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Dr Keith Carter led the mission of WHO’s Technical Advisory Group on Malaria Elimination and Certification to Azerbaijan from 3 to 14 October 2022. The team visited Baku, Azerbaijan’s capital city, and 3 other regions of the country: Lankaran, near the agricultural area on the south-east border with the Islamic Republic of Iran, Bilasuvar, also on the Iranian border, and Sabirabad in the centre of the country, which recorded its last malaria case in 2009.
What makes you confident that Azerbaijan has eliminated malaria?
For many decades there were 3 malaria parasites circulating in Azerbaijan, but Plasmodium falciparum and Plasmodium malariae transmission was interrupted in the 1960s. After that, Plasmodium vivax (P. vivax) remained the only parasite at the local transmission level. When we reviewed Azerbaijan’s history of malaria and the Government’s elimination efforts, we found that the last case of local P. vivax malaria transmission was in 2012. Since then, only a few imported cases have been detected.
We found no evidence of local malaria cases when we examined current data from its malaria detection and reporting surveillance systems. Azerbaijan is not a highly endemic malaria country, and the countries surrounding it – Türkiye, Georgia, Armenia, Russia, the Islamic Republic of Iran – do not have serious malaria problems. Except for the Islamic Republic of Iran in the south, which is also in the process of eliminating malaria, the threat of cases being imported to Azerbaijan by neighbouring countries is extremely low.
Our team found that Azerbaijan’s specimen collection system, network of laboratory services, data management system, and clinical infrastructure is very sound and efficient. It felt like we had seen enough positive outcomes to convince us that they have eliminated malaria.
What do you think Azerbaijan’s most effective strategies are for preventing malaria resurgence in the future?
In terms of resurgence, the most important thing the Government of Azerbaijan can do is ensure that their electronic surveillance system and health care services remain funded and in place, and we pointed this out to health and government officials during our meetings. As long as they don’t dismantle what is currently in place, we saw no problem.
The Ministry of Health registers all cases of infectious and parasitic diseases through Azerbaijan’s Electronic Integrated Disease Surveillance System (EIDSS). This system was introduced in 2010 alongside the national health infrastructure and its insurance system. It merges human and veterinary case data collection and is continuously synchronized among all EIDSS sites nationally. Data can be retrieved almost in real time, making malaria detection and treatment swift and accurate.
We were fortunate to meet with Dr Ahliman Amiraslanov, Chairman of the Committee of Health care of the Azerbaijani Parliament, and other members of the Parliamentary Health Committee responsible for overall governance of the health sector in the country. The committee has ensured a budget to support efforts to eliminate malaria, and will continue providing funding to prevent re-establishment of the disease. The budget specifically allocated for activities to prevent malaria re-establishment is approximately US$ 700 000 annually.
Of the many interventions employed throughout Azerbaijan to eliminate malaria, what impressed you the most and why?
In the capital and beyond we were quite impressed with the people met and the sites visited. While in Baku, we met with staff from the Republican Center for Hygiene and Epidemiology, and parliamentarians responsible for maintaining national malaria control funding and operations as well as training institutions. Later we had the opportunity to travel outside the city to local hospitals, primary care health outposts, laboratories, and the malaria operation centres. During these visits we reviewed data, surveillance and reporting systems, and equipment and procedures for vector control.
We found no problems with the hospitals and health outposts or with the treatment and laboratory facilities that we visited. We also inspected the university and training institutes where doctors, parasitologists and other public health workers learn how to implement prevention strategies and reactive protocols in case of a resurgence. In addition, we found that the epidemiological and entomological supervision systems are working well together to identify vectors and parasites active in the country.
What role has a stable economy and peacetime played in malaria elimination in Azerbaijan?
In terms of malaria, there are a few things to remember: you have the parasites, you have the vectors, and you have the humans that are susceptible to disease. As economies stabilize, governments can invest more in health, diagnostic and treatment centres. They can also adequately fund water management programmes that reduce potential mosquito breeding sites.
For example, in the case of poor-quality housing, a stable economy allows you to, over time, make improvements to housing and prevent the breeding of mosquitoes around people’s homes because you can afford to build proper drainage and irrigation. Economic development means significant reductions in malaria transmission, and that is the situation in Azerbaijan.
From 1993–1996 there was a malaria outbreak in Azerbaijan and approximately 13 000 P. vivax malaria cases were detected. The most explosive outbreak was due to armed conflict with Armenia that disrupted health services and exacerbated malaria transmission, especially among refugees.
Close to a million refugees and internally displaced people were forced to live in tents in open areas where mosquitoes would breed and bite, and health care staff were unable to work. People in need of medical attention could not access appropriate care and the number of malaria infections swelled. When vectors are not detected and people who are infected cannot be diagnosed and treated, it results in an outbreak, which is exactly what happened in Azerbaijan in the 1990s.
Azerbaijan law guarantees health care access as a right to all citizens. How well is Azerbaijan doing in terms of ensuring universal access to health care for all?
We did not survey the entire national health care apparatus, per se, but during our time in the Sabirabad Region we visited a health service outpost and accompanied a nurse practitioner in Garalar village on her door-to-door home visits. She told us that all pregnant women receive prenatal care and appropriate vaccines, enquires for persons with fever, the main symptom of malaria and anyone who needs medical attention can receive it at the clinic or in their homes.
The best-case scenario in any country is a health care service that can provide diagnosis for patients when they walk through the door, and that those cases can be detected and treated quickly. In countries where finances are strong this scenario is available – but in resource poor countries, access to these kinds of health services are much more of a problem.
Azerbaijan is a wealthy enough nation that can afford to implement vector control through insecticide indoor residual spraying, for example, and proper water management practices. It can afford to maintain and sustain diagnostic and treatment facilities. It has access to laboratories with microscopes, and antimalarial drugs, including chloroquine, primaquine, and artemisinin-based combination therapies. Economic prosperity prevents malaria transmission.
Is there a particular malaria elimination intervention that you found is unique to Azerbaijan compared to other malaria endemic countries?
Azerbaijan is an upper middle class income nation, by comparison, to many others and its road systems are excellent and well maintained. This means anyone that is sick can easily reach local health centres close to where they live.
In poorer countries with compromised road and transport systems it is more difficult for patients to reach health centres to receive proper care. Many people end up walking or pedalling a bike for miles to a clinic. Once they do arrive, the health facility may not be equipped with laboratories and microscopes for blood sampling, or the appropriate antimalarial drugs may not be readily available.
Azerbaijan’s Government has been working toward malaria elimination since the 1930s, so today it is a question of maintaining services and funding systems that are already in place. For many years now the country has abided by the WHO’s malaria elimination guidelines, and in the past, it adhered to prevention protocols like the use of bed nets and insecticide spraying, as well as other measures.
Did you observe if the COVID pandemic interrupted or bolstered malaria prevention efforts, and if so, in what way?
When we arrived in October 2022 the railroads were closed due to COVID. We did meet with the airline and railroad industries, and with state customs officials, to discuss travel risks. Both the airlines and railroads were engaged in tracking for potential imported malaria or COVID cases coming into the country. They told us that at airports anyone coming in from overseas with a fever was tested for COVID.
Everyone across multiple sectors was involved in these efforts. At the university and training institutes, we observed how doctors, parasitologists, epidemiologists, and entomologists were being trained to identify and treat malaria and viral diseases. Everyone was on board with malaria and COVID prevention protocols and understood what needed to be done during the pandemic. The systems were clearly in place.
What kinds of prevention efforts did you observe the government is providing to protect agricultural workers from malaria transmission?
Azerbaijan’s agricultural sector includes many cotton and rice plantations that employ large number of workers. These crops, in particular, rely on standing water reservoirs for irrigation purposes, which can become breeding sites for mosquitoes that transmit malaria if they are not managed well. As a result, agricultural workers, in particular, can be at higher risk of malaria.
We had the opportunity to meet with representatives from the Azerbaijan Amelioration and Water Management group in the capital, Baku, that oversees and coordinates irrigation practices from their headquarters, and from satellite offices in the outlying districts. The group works in close collaboration with the Regional and District Centers of Hygiene and Epidemiology to reduce mosquito proliferation in the plantation regions. Their cooperative efforts include monitoring water collectors and drainage systems, and clearing vegetation from channels to prevent mosquito eggs and larvae from growing.
During our visit to farming areas near the Iranian border, we found the health service system was fully equipped to reach agricultural workers if there was a need for care. Protocols call for them to immediately test, diagnose and treat workers with appropriate antimalarial drugs, and to monitor and assess environmental, entomological and epidemiological risk factors. Health workers also conduct malaria prevention education and determine whether insecticide use and water management interventions need to be bolstered.
The citizens of Azerbaijan have endured malaria for decades. Can you briefly discuss any public health education strategies that you felt were effective in harnessing public support and adherence to testing and treatment?
Health care in Azerbaijan is free for everyone in the country, and the fact is that people take advantage of a free health care system. They do go to the district health centres and they do access appropriate treatment when they need it. They get tested and they get vaccinated.
The public’s utilization of services reflects the people’s trust in the public health sector and the officials who lead it. Some of Azerbaijan’s current health infrastructure is built upon the foundation of the Soviet health system that was put in place years ago. People began relying on the health care system then, and they continue to rely on it now. It is free for all citizens in Azerbaijan and the people believe in the information they receive and comply with public health guidelines.