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Tajikistan reported just 7 local cases of malaria in 2013 and is on track to reach its goal of malaria elimination by 2015.

Overview Tajikistan has made tremendous progress in reducing malaria incidence, with reported malaria cases dropping from 19,064 in 2000 to just seven in 2013. The country is categorized in the elimination phase by the World Health Organization (WHO).1 Tajikistan has eliminated Plasmodium falciparum, and transmission is now due only to P. vivax. Primary malaria vectors in Tajikistan include Anopheles superpictus and An. pulcherimus, while An. maculipennis, An. hyrcanus, An. claviger, and An. artemievi are secondary vectors.2,3 Seasonal transmission of P. vivax malaria typically occurs between May and October, although duration of transmission varies geographically, with shorter seasons in mountainous areas and longer seasons of up to 6–8 months in the lowlands.4 In the spring, heavy rainfall and mild temperatures create ideal vector breeding grounds, and during the summer these breeding areas are sustained by an increase in rice cultiva-tion and agricultural land use changes.5 Southern Tajikistan is considered to be malaria endemic, whereas central and northern Tajikistan are prone to occasional outbreaks.3 There is no malaria in high altitude areas over 2,500 meters.4

Tajikistan was nearly successful in eliminating malaria in the mid-1970s, reducing local cases to only seven in 1974.6,7 Due mostly to the collapse of the Soviet Union and an ensuing civil war, malaria cases surged in the mid-1990s to an esti-mated 120,000 cases.1,6 Following this large outbreak, several interventions including indoor residual spraying (IRS) and mass drug administration with primaquine were introduced to bring the malaria situation under control. With only seven local cases of malaria in 2013, Tajikistan is once again close to interrupting transmission and is very likely to achieve its goal of eliminating malaria by the end of 2015.1,8

Progress Toward EliminationIn the early 1920s, malaria was a disease of considerable significance in Tajikistan; surveys revealed that entire popula-tions in the valley areas were affected.8 The first malaria

7

0

24

0.001

0.003

Local cases of malaria (100% P. vivax)

Deaths from malaria (Last death reported in 1997)

% population living in areas of active transmission (total population: 8.2 million)

Annual parasite incidence (cases/1,000 total population/year)

% slide positivity rate

At a Glance1

control campaign was launched in the 1930s when annual cases totaled more than 100,000.6,9 In response to this high caseload, health workers and malaria experts in Tajikistan led epidemiological assessments of the situation, established antimalaria field stations, and conducted routine examina-tions of individuals traveling from endemic areas. In addition, active case detection and treatment, vector control with IRS, anti-larval measures, and vector research studies were employed.10 By 1954, malaria incidence had fallen to five cases per 1,000 population. A malaria elimination campaign continued to reduce malaria cases, and between 1956 and 1960, malaria incidence dropped to less than one case per 1,000 population.11 The malaria burden remained at very low levels in the 1960s and early 1970s through the use of IRS, regular active case detection, and prompt treatment. By 1974, Tajikistan had nearly reached its goal of elimination, reporting only seven cases of malaria.5,6

In the late 1970s and early 1980s, the incidence of both P. vivax and P. falciparum began increasing in the southern areas bordering Afghanistan.5 Between 200 and 500 cases were recorded annually during this time. Local health services utilized a range of methods to control the increase in cases, including intensified active case detection, mass

TAJIKISTAN

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Eliminating malaria in Tajikistan

screen and treat campaigns, and additional trainings for health and laboratory personnel.5,9 Despite these efforts, cases in the southern areas of the country continued to slowly increase during the mid-1980s, largely a result of the Soviet-Afghan War (1979–1989), though control measures were successful enough that the number of annual cases stayed below one thousand.6,12

The malaria situation in Tajikistan quickly deteriorated fol-lowing the collapse of the Soviet Union in 1991, and was further impacted by a civil war (1992–1997). Malaria control operations and public health services were abandoned, and mass population movement to and from endemic areas in Afghanistan contributed to a steep rise in malaria cases.3,10

Between 1993 and 1997, reported cases increased dramati-cally from only 619 to nearly 30,000, though some estimates put the apex at more than 120,000.3 In 1997, the Republican Tropical Disease Center was created with the objectives of strengthening disease surveillance and management systems, increasing the availability of national health information, and deploying malaria control measures in focal areas.5 Other international partner organizations, such as the Agency for Technical Cooperation and Development (ACTED), Merlin, and UNICEF, began to launch malaria control interventions including vector control and support for health services, laboratory capacity-building, health education, and community engagement activities.5 By 1998, reported cases declined to approximately 19,000.12

Malaria Transmission Limits

0 250 500 Kilometres 0 250 500 Kilometres

Plasmodium falciparum Plasmodium vivax

P. falciparum/P. vivax malaria risk is classified into no risk, unstable risk of <0.1 case per 1,000 population (API) and stable risk of ≥0.1 case per 1,000 population (API). Risk was defined using health management information system data and the transmission limits were further refined using temperature and aridity data. Data from the international travel and health guidelines (ITHG) were used to identify zero risk in certain cities, islands and other administrative areas.

Water

P. falciparum free

Unstable transmission (API <0.1)

Stable transmission (≥0.1 API)

Water

P. vivax free

Unstable transmission (API <0.1)

Stable transmission (≥0.1 API)

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With the introduction of insecticide-treated bed nets by ACTED in 1998, along with IRS and community awareness efforts already in place, total cases decreased to fewer than 13,500 in 1999.5 Despite this downward trend, Tajikistan experienced an outbreak of P. falciparum malaria in 2000, accompanied by a sharp increase in P. vivax infections.13 With continued support provided by the international part-ner organizations to strengthen the capacity of the malaria program, cases steadily declined after the outbreak was contained.

In 2005, Tajikistan and nine neighboring malaria-endemic countries endorsed the Tashkent Declaration—the move from malaria control to elimination in the WHO European region—which marked Tajikistan’s political commitment to eliminate malaria.14 The WHO Regional Office for Europe and the Tajikistan Ministry of Health also signed a biennial collaborative agreement to support Tajikistan’s national ma-laria elimination campaign by providing technical assistance and building capacity within the malaria program, strength-ening cross-border collaboration with malaria-endemic Af-ghanistan, and supporting operational research on malaria.15

Goal:8 Halt malaria transmission by the end of 2015

Reported Malaria Cases*

Malaria incidence in Tajikistan increased in the 1990s as a result of civil war and disruption of health care services following the collapse of the Soviet Union. Cases declined in the 2000s as the country stabilized and strengthened its malaria control activities.

*Graph shows total reported cases from 1990–2005; as of 2006, only local cases are shown.

Source: World Health Organization, World Malaria Report 2014

0

5 000

10 000

15 000

20 000

25 000

30 000

35 000

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012

Num

ber

of

case

s

In 2006, Tajikistan received a five-year Round 5 Global Fund grant to strengthen the national malaria control program and general health services, improve access to early diagnosis and treatment of malaria, and support prevention activities, operational research, and community-based interventions with a goal to eliminate P. falciparum.16 Progress made with Global Fund support was significant: by 2008, Tajikistan re-ported only 318 malaria cases, an 87 percent reduction from 2005.1 In 2009, Tajikistan received a Round 8 Global Fund grant to build on the success achieved under Round 5, aimed at reducing the remaining local P. vivax transmission through IRS, distribution of insecticide-treated bed nets, and commu-nity education.8 The National Malaria Combating Programme then developed a 2011–2015 elimination strategy, focusing on capacity-building, strengthening of surveillance, improv-ing coverage and quality of early diagnosis and prompt treatment, promoting integrated vector management, and developing evidence-based interventions based on operational research.17 This strategy was endorsed by the government of Tajikistan in 2011, and its successful implementation has put the country within close reach of its 2015 elimination goal.

111 cases

65 cases

18 cases

7 cases

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GNI per capita (US$) $990

Country income classification Low income

Total health expenditure per capita (US$) $55

Total expenditure on health as % of GDP 6

Private health expenditure as % of total health expenditure

70

Eligibility for External Funding18–20

Economic Indicators21

The Global Fund to Fight AIDS, Tuberculosis and Malaria

Yes

U.S. Government’s President’s Malaria Initiative No

World Bank International Development Association Yes

Challenges to Eliminating MalariaMalaria importationImportation of malaria from Afghanistan poses a significant challenge for Tajikistan in its quest to achieve and maintain

Eliminating malaria in Tajikistan

elimination. The Ministries of Health for both countries are working together to provide diagnosis and treatment ser-vices along the border to prevent importation.16 Continued collaboration between the two countries will be critical in Tajikistan’s path to elimination.22

Human and financial resourcesInsufficient resources for malaria treatment and prevention activities are a barrier for Tajikistan’s malaria elimination program. Global Fund grants support many of the necessary resources, including training for health providers and malaria staff. However, many of the health providers are working within deficient health infrastructures and the salaries of com-munity workers are low, making it difficult to retain staff and keep them motivated.8

ConclusionFor Tajikistan to achieve and sustain zero malaria transmis-sion, maintaining surveillance and the capacity of primary health care facilities for effective case management and vector control will be critical. Tajikistan has confirmed its political commitment to increase cross-border collaboration with Afghanistan and is supported by the Global Fund to eliminate the remaining cases of P. vivax malaria. With only 7 local cases in 2013, Tajikistan is on track to attain its goal of interrupting malaria transmission by the end of 2015.

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1. Global Malaria Programme. World Malaria Report 2014. Geneva: World Health Organization; 2014.2. Gordeev MI, Zvantsov AB, Goryacheva II, Shaikevich EB, Ejov MN. Description of the new species Anopheles artemievi sp.n. (Diptera,

Culicidae) Med Parazitol (Mosk) 2005; (2): 4–5.3. Karimov S. Monitoring of malariological situation and evaluation of anti-malaria measures in the Republic of Tajikistan: Summary of the

PhD thesis. Dushanbe: 2005. 4. World Health Organization Regional Office for Europe. Potential malaria transmission areas in Tajikistan. 2011. [Available from: http://www.

euro.who.int/en/health-topics/communicable-diseases/vector-borne-and-parasitic-diseases/malaria/country-work/tajikistan/potential-malaria-transmission-areas-in-tajikistan].

5. Matthys B, Sherkanov T, Karimov S, Khabirov Z, Mostowlansky T, Utzinger J, et al. History of malaria control in Tajikistan and rapid malaria appraisal in an agro-ecological setting. Malar J 2008; 7(1): 217.

6. Manguin S, Carnevale P, Mouchet J, editors. Biodiversity of Malaria in the World. London: John Liebbey Eurotext; 2008.7. Lysenko AJ. Malariology. Geneva: World Health Organization; 1999. Report No: WHO/MAL/99.1089.8. National Coordination Committee on HIV/AIDS, Tuberculosis and Malaria. Global Fund Round 8: Malaria elimination project in Tajikistan

by 2014. Tajikistan: 2008.9. Aliev S, Saparova N. Current malaria situation and its control in Tadjikistan. Med Parazitol (Mosk) 2001; (1): 35–37.10. Pitt S, Pearcy BE, Stevens RH, Sharipov A, Satarov K, Banatvala N. War in Tajikistan and re-emergence of Plasmodium falciparum. Lancet

1998; 352(9136): 1279.11. Bruce-Chwatt LJ. Malaria Research and Eradication in the USSR: A Review of Soviet Achievements in the Field of Malariology. Bull Wld

Hlth Org 1959; 21: 737–772.12. Feachem RGA, Phillips AA, Targett GA, editors. Shrinking the Malaria Map: A Prospectus on Malaria Elimination. The Global Health

Group, Global Health Sciences, University California, San Francisco, 2009.13. World Health Organization. Roll Back Malaria in Central Asia and Kazakhstan. Geneva: World Health Organization; 2002. 14. World Health Organization Regional Office for Europe. The Tashkent Declaration: The Move from Malaria Control to Elimination.

Denmark: WHO EURO; 2005.15. World Health Organization Regional Office for Europe. Joint statement on cross-border cooperation on malaria in Tajikistan and

Afghanistan. Kurgan Tube: WHO EURO; 2010.16. National Coordination Committee on HIV/AIDS, Tuberculosis and Malaria. Global Fund Round 5: Malaria control in Tajikistan. Tajikistan; 2005.17. Country Coordinating Mechanism Tajikistan. Global Fund Transitional Funding Mechanism. Tajikistan; 2012.18. International Development Association. IDA Borrowing Countries. 2014. [Available from: http://www.worldbank.org/ida/borrowing-

countries.html].19. President’s Malaria Initiative. PMI Focus Countries. 2014. [Available from: http://www.pmi.gov/where-we-work].20. The Global Fund to Fight AIDS, Tuberculosis and Malaria. 2014 Eligibility List. 2014. [Available from: www.theglobalfund.org/documents/

core/eligibility/Core_EligibleCountries2014_List_en/].21. The World Bank. World Development Indicators Database. 2014. [Available from: http://data.worldbank.org/data-catalog/world-

development-indicators].22. World Health Organization Regional Office for Europe. Combating malaria remains a priority in Tajikistan and Afghanistan. Dushanbe;

2012. [Available from: http://www.euro.who.int/en/what-we-do/health-topics/communicable-diseases/malaria/news/news/2012/5/ combating-malaria-remains-a-priority-in-tajikistan-and-afghanistan].

Transmission Limits Maps SourcesGuerra CA, Gikandi PW, Tatem AJ, Noor AM, Smith DL, Hay SI and Snow RW. (2008). The limits and intensity of Plasmodium falciparum

transmission: implications for malaria control and elimination worldwide. Public Library of Science Medicine, 5(2): e38.

Guerra CA, Howe RE, Patil AP, Gething PW, Van Boeckel TP, Temperley WH, Kabaria CW, Tatem AJ, Manh BH, Elyazar IRF, Baird JK, Snow RW and Hay, SI. (2010). The international limits and population at risk of Plasmodium vivax transmission in 2009. Public Library of Science Neglected Tropical Diseases, 4(8): e774.

Sources

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About This BriefingThis Country Briefing was developed by the UCSF Global Health Group’s Malaria Elimination Initiative, in collaboration with the WHO Regional Office for Europe and Tajikistan’s Ministry of Health. Malaria transmission risk maps were provided by the Malaria Atlas Project. This document was produced by Gretchen Newby; to send comments or for additional information about this work, please email Gretchen.Newby@ucsf.edu.

m a l a r i a a t l a s p r o j e c t

The Malaria Atlas Project (MAP) provided the malaria transmission maps. MAP is committed to disseminating information on malaria risk, in partnership with malaria endemic countries, to guide malaria control and elimination globally. Find MAP online at: www.map.ox.ac.uk.

The Global Health Group at the University of California, San Francisco (UCSF) is an ‘action tank’ dedicated to translating new approaches into large-scale action that improves the lives of millions of people. Launched in 2007, the UCSF Global Health Group’s Malaria Elimination Initiative works at global, regional and national levels to accelerate progress towards eradication by conducting operational research to improve surveillance and response, strengthening political and financial commitment for malaria elimination, and collaborating with country partners to shrink the malaria map.