WHO certifies that Uzbekistan has eliminated malaria
12/12/2018 09:02
WHO certifies that Uzbekistan has eliminated malaria
12/12/2018 09:02
Tashkent, Uzbekistan (UzDaily.com) -- Here’s a lesson for the next textbook on malaria: If at first you succeed, don’t rest on your laurels or become complacent. Put your head down and keep working.
Public health officials in the Republic of Uzbekistan learned that lesson the hard way after they emerged victorious more than half a century ago in their battle against malaria. The Central Asian nation of 32 million people, which gained independence from the Union of Soviet Socialist Republics in 1991, first eliminated the disease in 1961. But that success didn’t last.
After enduring a decades-long return of the malaria parasite, Uzbekistan eliminated malaria for a second time, in 2010. Now, the country has gone one step further, securing the official WHO certification of malaria-free status.
“In eliminating malaria, Uzbekistan has taken a big step forward in protecting the health of its people,” said WHO Director-General Tedros Adhanom Ghebreyesus, who recently signed a certificate attesting that the country had eliminated indigenous transmission of the disease from within its borders. “This is a spectacular achievement.”
Uzbekistan’s malaria-free certification brings to 19 the number of countries in the European Region that have received the WHO certification. The European Region as a whole was declared as having interrupted indigenous malaria transmission in 2016.
Malaria was once widespread in Uzbekistan
Uzbekistan’s relationship with malaria has been a longstanding one. The region’s climate and topography are welcoming to malaria-carrying mosquitoes; its malaria season lasts about 7 months. From 1892 to 1905, malaria killed nearly 40 000 people in the capital’s Tashkent District – one eleventh of the population there. In one settlement, it killed more than a third of the population.
But it was not until 1921, when Turkestan – which then included Uzbekistan – recorded more than 200 000 malaria cases that the public health effort against the disease began in earnest.
The response was swift and wide-ranging. Government efforts focused on expanding access to health care in general and anti-malarial medicines (quinine) in particular; taking preventive measures, like draining or filling in the standing bodies of water that serve as incubators for mosquito larvae; and training health professionals on how to prevent, recognize and treat the disease.
Initial efforts resulted in a dip in the number of cases. However, the case load roared back during World War II, when the war effort siphoned off resources that had previously been directed against malaria; in 1943, nearly 1 in 10 people contracted the malaria parasite.
Woman preparing a bed with mosquito net in Uzbekistan
After the war, the government returned its focus to malaria-elimination efforts. By 1952, nearly 500 physicians and more than 1500 nurses were working at anti-malarial facilities; thousands of hectares of swamps had been drained; powerful insecticides like DDT and hexachlorane were widely used in the form of indoor spraying; and bodies of water conducive to the growth of mosquito larvae were treated with chemicals in some cases and stocked with mosquito-eating gambusia fish in others.
The results showed an increasing impact: In 1953, nearly 20 000 malaria cases were detected in more than 2800 (27.9%) settlements; in 1959, just 49 cases were detected in 30 (0.3%) settlements; and, in 1961, no indigenous cases of malaria were detected in the Republic.
Landlocked Uzbekistan’s borders prove porous to malaria
Uzbeks’ freedom from malaria proved short-lived. Across the borders of the landlocked country, the parasite was thriving. Soon, cases traced to Afghanistan and Tajikistan appeared in Uzbekistan.
By 1966, an outbreak of malaria was registered in the Boysun district of the Surkhandarya Province in the south, where 58 people fell ill in 14 settlements. During the 1980s, the epidemiological situation worsened as soldiers from Afghanistan entered Uzbekistan, spreading malaria there. By the mid-1980s, cases of indigenous malaria were registered in the Namangan region in the east and the Termez region in the south.
By 1999, cases acquired by local transmission of the parasite were spreading in the south, along the border with Tajikistan. A year later, 125 cases, 46 of them indigenous, had been identified.
Getting to zero
Once again, the government took swift action. “In 2000, the Ministry of Health set up a national programme for malaria surveillance and control to reduce malaria transmission and limit its distribution,” said Dr Inna Tyo, who leads a parasitic diseases unit at Uzbekistan’s Republican Centre of State Sanitary-Epidemiological Surveillance. “A variety of interventions resulted in a steady, dramatic decrease in the malaria burden.”
By this time, some of the tools had changed; DDT could no longer be used, but widespread use of indoor spraying with other insecticides was proving effective. The government also increased the number of personnel at health clinics in border areas and strengthened surveillance.
Through the 2005 Tashkent Declaration, noted Dr Tyo, Uzbekistan and 8 other malaria-affected countries in the region – Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan, Turkey, Turkmenistan – pledged to eliminate malaria by 2015.
Malaria cases in Surkhandarya Province – Uzbekistan’s most heavily affected area – dropped from 81 in 2007 to 0 in 2011–2014. The last three locally acquired cases anywhere in the country were detected in 2010.
Much credit goes to the government, which understood that malaria affects economic health as well as personal health, said Dr Anatoly Kondrashin, who recently travelled to Uzbekistan to verify, as a member of WHO’s Malaria Elimination Certification Panel, that zero local transmission had been sustained for the prior 3 years.
“The government kept a clear understanding that the malaria problem was an obstacle to the implementation of the national plan of development of Uzbekistan,” Dr Kondrashin said. That understanding led the government to maintain its support of the nation’s primary health care system – the backbone of the malaria response – even during the economic crisis that gripped the country during the 1990s, he added.
A ‘holistic approach’
The government’s health system was not acting alone, said Dr Kondrashin, citing support from other ministries – agriculture, education and transportation – as well as from non-governmental organizations and other partners.
He also noted the establishment of checkpoints along Uzbekistan’s borders with Tajikistan and Afghanistan, where health workers checked everyone seeking to enter the country for symptoms of malaria before allowing them passage.
“The most remarkable thing is there was a holistic approach towards early detection, diagnosis and efficacious treatment of malaria patients – free of charge and irrespective of nationality,” he added.
Keeping track of progress proved key. Data were carefully compiled, for example, on breeding sites for the mosquitoes that spread the malaria parasite so that anti-malaria activities could be targeted precisely in areas where they would be most useful.
“Uzbekistan is a country that kept malaria at bay through years of hard work and painstaking effort, and this achievement is highly commendable,” said Dr Nedret Emiroglu, Director of Health Emergencies and Communicable Diseases at WHO Regional Office for Europe. “Two years after the regional malaria-free declaration, the official certification is further proof of the country’s success in maintaining zero malaria.”
The WHO Regional Office for Europe supported Uzbekistan’s Ministry of Health in developing a technically sound national malaria strategy. Through regular country visits, WHO personnel assisted the government in its efforts to strengthen national capacities to combat the disease and monitor disease trends.
The Global Fund also played a critical role. Dr Kondrashin credited the Global Fund for providing the money needed to ensure there were enough insecticide-treated bednets, spraying equipment, training activities, medicines, transportation for drugs and laboratory equipment – tools needed to eliminate the disease.
The Global Fund bankrolls some 60% of international funding for malaria programmes – more than US$ 1.2 billion each year; it has spent more than US$ 159 million fighting diseases – including malaria – in Uzbekistan alone.
Preventing a resurgence
Now that malaria has been eliminated in Uzbekistan, the government and national malaria partners are committed to preventing the disease from again taking root over the long term.
Continued areas of focus include early detection and timely treatment; monitoring of mosquito populations; preparedness of the surveillance system for outbreaks; rapid response if indigenous transmission recurs; trans-border cooperation on malaria prevention; and ongoing training of specialists.
In April 2017, representatives from Turkey, the Russian Federation, Uzbekistan and 7 other countries in Central Asia and the Caucasus − Armenia, Azerbaijan, Georgia, Kazakhstan, Kyrgyzstan, Tajikistan and Turkmenistan – reaffirmed their commitment to preventing the re-establishment of malaria by signing the Ashgabat Statement. The statement recognizes the need for sustained political commitment, an adequate level of financing, and investment in health systems strengthening to maintain the malaria-free status of countries in the WHO European Region.
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