1. Turkmenistan case study Outbreak 2002-2003 Identification of actions to strenghten the health system

2. System Ministry of Health Primary health care institutions, pharmaceutical services, hospital and outpatient services, hospitals, research centres etc., Nongovernmental organizations, professional societies etc.

3. Public health care delivery system Administrative structure: Primary – district level Intermediate – province level Central – government level At each admin level a network exist, which include : Hospitals Health centres Infectious diseases isolation units Laboratories Sanitory epidemiological services, including antimalarial interventions

4. Primary care services ”Health houses”: – Diagnostic procedures – Treatment of common illnesses – Curative and preventive measures against parasitic diseases and other diseases – immunization – Community awareness and health education

5. Outbreak in 2003 P. vivax oubreak detected in April 2003 The suspected index case was an oil and gas worker living in a farm, close to the Afghanistan border The patient fell ill twice, malaria was not suspected (”pneumonia”), despite the high risk of malaria to be suspected due to travel close to Afghanistan The episode occured prior to the peak transmission season, indicating a relapsing case without Two housewifes in the same farm were revealed also to have been diagnosed in 2002, who had not travelled Resulted in an outbreak with 48 autochthonous cases detected

6. Outbreak 2003 Outbreak in Maru province, three districts primarily affected DistrictTotal casesOil/gas workersOthers Yoloten3015 Serhetabad422 Tagtabazar11 0 Turkmengala220 Mary City110 Total483117

7. Containment actions done Improved case follow up actions in 2003 16 brigades engaged in ACD by daily house-to- house visits in all malaria foci in the villages Radical treatment provided Epidemiological investigations of cases and foci Full IRS in all transmission foci Raising community awareness regarding malaria

8. Weak points Lack of awareness of malaria No malaria testing done - even in the hospital Weak malaria surveillance and reporting system Inadequate response system Outbreak also overlooked by local health facilities Weak epidemiological investigations

9. Required actions Improved malaria awareness among health workers, in particular in districts where many oil and gas workers reside Proper case follow-up including radical treatment Epidemiological investigations to be done routinely Improved communication and surveillance Cross-border collaboration and communication between Afghanistan and Turkmenistan