Ready for malaria elimination: zero indigenous case reported in the People's Republic of China

Abstract

Background: Malaria was once one of the most serious public health problems in China. However, the disease burden has sharply declined and epidemic areas have shrunk after the implementation of an integrated malaria control and elimination strategy, especially since 2000. In this review, the lessons were distilled from the Chinese national malaria elimination programme and further efforts to mitigate the challenges of malaria resurgence are being discussed.

Methods: A retrospective evaluation was performed to assess the changes in malaria epidemic patterns from 1950 to 2017 at national level. The malaria data before 2004 were collected from paper-based annual reports. After 2004, each of the different cases from the Infectious Diseases Information Reporting Management System (IDIRMS) was closely examined and scrutinized. An additional documenting system, the National Information Management System for Malaria, established in 2012 to document the interventions of three parasitic diseases, was also examined to complete the missing data from IDIRMS.

Results: From 1950 to 2017, the occurrence of indigenous malaria has been steeply reduced, and malaria-epidemic regions have substantially shrunk, especially after the launch of the national malaria elimination programme. There were approximately 30 million malaria cases annually before 1949 with a mortality rate of 1%. A total of 5999 indigenous cases were documented from 2010 to 2016, with a drastic reduction of 99% over the 6 years (2010, n = 4262; 2016, n = 3). There were indigenous cases reported in 303 counties from 18 provinces in 2010, but only 3 indigenous cases were reported in 2 provinces nationwide in 2016. While in 2017, for the first time, zero indigenous case was reported in China, and only 7 of imported cases were in individuals who died of Plasmodium falciparum infection.

Conclusion: Malaria elimination in China is a country-led and country-owned endeavour. The country-own efforts were a clear national elimination strategy, supported by two systems, namely a case-based surveillance and response system and reference laboratory system. The country-led efforts were regional and inter-sectoral collaboration as well as sustained monitoring and evaluation. However, there are still some challenges, such as the maintenance of non-transmission status, the implementation of a qualified verification and assessment system, and the management of imported cases in border areas, through regional cooperation. The findings from this review can probably help improving malaria surveillance systems in China, but also in other elimination countries.

Keywords: China; Indigenous case; Malaria; Zero.

Fig. 1

Incidence of malaria in China, 1950–2017. The different control and elimination phases are shown in different colours. a Transmission not known (1949–1959); b outbreak and pandemic transmission (1960–1979); c decline with sporadic distribution (1980–1999); d low transmission with re-emergence in central China (2000–2009); and e the elimination phase (2010–2020). The indigenous and imported cases from 2002 to 2017 are shown in the right-hand column

Fig. 2

Indigenous malaria cases in China, 2010–2017. The red zones represent the areas where indigenous cases occur (the county level)

Fig. 3

The distribution of imported cases in China stratified by species (a) and origin of those imported cases (b) in 2017. The number of malaria cases using different colours to represent the imported cases distribution in China, as well as the origin of those cases. Each province in China and the origin country was marked with different colours on the map

Fig. 4

Sub-national malaria verification progress in China, 2012–2017. China has conducted sub-national verification of malaria elimination for all endemic provinces, and endemic provinces carry out county and prefecture malaria elimination verification by themselves. Similarly, a province/prefecture/county could conduct malaria elimination where no indigenous cases were reported in 3 consecutive years

Fig. 5

Documents developed to guide the national malaria control and elimination programme, 2005–2017