Shrinking the malaria map in China: measuring the progress of the National Malaria Elimination Programme

Background:Remarkable progress has been made towards the elimination of malaria in China since the National Malaria Elimination Programme(NMEP)was launched in 2010.The incidence of locally-acquired malaria cases has declined rapidly and endemic areas have also dramatically shrunk.In total,3078 malaria cases were reported in 2014,but only 56 cases were indigenous.In order to further promote the elimination programme,we reviewed the progress of and experiences associated with malaria elimination in China,and identified the challenges and priorities for the next stage of the programme.Methods:Data were collected from the web-based China Information System for Disease Control and Prevention,and the China Annual Report of Malaria Elimination.The progress towards the elimination of malaria from 2010 to 2014 was measured.Results:During the implementation of the NMEP from 2010 to 2014,local malaria incidence has declined continuously,only remaining in the Yunnan Province and Tibet Autonomous Region in 2014.By the end of 2015,75.6%(1636/2163)of the malaria-endemic counties passed the sub-national elimination assessment.The main challenges are cases of border malaria and imported malaria from other countries.Sustainable support and investment from the government,the establishment of an effective surveillance and response system,and risk assessments for the potential reintroduction of malaria are priorities for the next stage of the elimination programme.Conclusions:The NMEP in China has been successfully implemented thus far and the malaria map has shrunk dramatically.The priorities for malaria elimination are interventions to block transmission at border areas,management of imported malaria cases,preventing malaria reintroduction,capacity building,and sustainability of malaria surveillance and response.

Laboratory diagnosis for malaria in the elimination phase in China:efforts and challenges

Malaria remains a global health challenge,although an increasing number of countries will enter pre-elimination and elimination stages.The prompt and precise diagnosis of symptomatic and asymptomatic carriers of Plasmodium parasites is the key aspect of malaria elimination.Since the launch of the China Malaria Elimination Action Plan in 2010,China has formulated clear goals for malaria diagnosis and has established a network of malaria diagnostic laboratories within medical and health institutions at all levels.Various external quality assessments were implemented,and a national malaria diagnosis reference laboratory network was established to strengthen the quality assurance in malaria diagnosis.Notably,no indigenous malaria cases have been reported since 2017,but the risk of re-establishment of malaria transmission cannot be ignored.This review summarizes the lessons about malaria diagnosis in the elimination phase,primarily including the establishments of laboratory networks and quality control in China,to better improve malaria diagnosis and maintain a malaria-free status.A reference is also provided for countries experiencing malaria elimination.

China’s 1-3-7 surveillance and response strategy for malaria elimination: Is case reporting, investigation and foci response happening according to plan?

Background:The China’s 1-3-7 strategy was initiated and extensively adopted in different types of counties(geographic regions)for reporting of malaria cases within 1 day,their confirmation and investigation within 3 days,and the appropriate public health response to prevent further transmission within 7 days.Assessing the level of compliance to the 1-3-7 strategy at the county level is a first step towards determining whether the surveillance and response strategy is happening according to plan.This study assessed if the time-bound targets of the 1-3-7 strategy were being sustained over time.Such information would be useful to improve implementation of the 1-3-7 strategy in China.Methods:This cross-sectional study involved country-wide programmatic data for the period January 1st 2013 to June 30th 2014.Data variables were extracted from the national malaria information system and included socio-demographic information,type of county,date of diagnosis,date of reporting,date of case investigation,case classification(indigenous,or imported,or unknown),focus investigation,date of reactive case detection(RACD),and date of indoor residual spraying(IRS).Summary statistics and proportions were used and comparisons between groups were assessed using the chi-square test.Level of significance was set at a P-value≤0.05.Results:Of a total of 5,688 malaria cases from 731 counties,there were 55(1%)indigenous cases(only in Type 1 and Type 2 counties)and 5,633(99%)imported cases from all types of counties.There was no delay in reporting malaria cases by type of county.In terms of case investigation,97.5%cases were investigated within 3 days with the proportion of delays(1.5%)in type 2 counties,being significantly lower than type 1 counties(4.1%).Regarding active foci,96.4%were treated by RACD and/or IRS.Conclusions:The performance of 1-3-7 strategy was encouraging but identified some challenges that if addressed can further improve implementation.

Poverty and malaria in the Yunnan province, China

Poverty and malaria appear to have an intertwined link.This paper aims to define the relationship between poverty and malaria in Yunnan,China,and to make recommendations for future research in this important area.Data on malaria prevalence and the population’s income in each county between 2005 and 2010 were obtained from the Yunnan Center for Disease Control and Prevention and the Yunnan Bureau of Statistics,respectively.Geographic mapping shows an apparent spatial convergence of poverty and the incidence of malaria at a county level,and suggests that poverty may be one of the drivers of malaria transmission in Yunnan.Future research should focus on:1.measuring and quantifying the relationship between poverty and the malaria burden at the individual,community,county and regional level in Yunnan;and 2.developing the GIS-based spatial decision support system(SDSS)framework in malaria endemic areas,particularly along the border areas in Yunnan.

Are malaria elimination efforts on right track?An analysis of gains achieved and challenges ahead

Background:Malaria causes significant morbidity and mortality each year.In the past few years,the global malaria cases have been declining and many endem ic countries are heading towards malaria elimination.Nevertheless,reducing the number of cases seems to be easy than sustained elimination.Therefore to achieve the objective of com plete elimination and maintaining the elimination status,it is necessary to assess the gains made during the recent years.Main text:With inclining global support and World Health Organisation(WHO)efforts,the control programmes have been im plem ented effectively in many endemic countries.Given the aroused interest and investments into malaria elimination program m es at global level,the am bitious goal o f elimination appears feasible.Sustainable interventions have played a pivotal role in malaria contraction,however drug and insecticide resistance,social,dem ographic,cultural and behavioural beliefs and practices,and unreformed health infrastructure could drift back the progress attained so far.Ignoring such im peding factors coupled with certain region specific factors may jeopardise our ability to abide righteous track to achieve global elimination of malaria parasite.Although support beyond the territories is important,but well managed integrated vector managem ent approach at regional and country level using scrupulously selected area specific interventions targeting both vector and parasite along with the com m unity involvem ent is necessary.A brief incline in malaria during 2016 has raised fresh perturbation on whether elimination could be achieved on time or not.Conclusions:The intervention tools available currently can most likely reduce transmission but clearing of malaria epicentres from where the disease can flare up any time,is not possible without involving local population.Nevertheless maintaining zero malaria transmission and checks on malaria import in declared malaria free countries,and further speeding up of interventions to stop transmission in elimination countries is most desirable.Strong collaboration backed by adequate political and financial support am ong the countries with a common objective to eliminate malaria must be on top priority.The present review attempts to assess the progress gained in malaria elimination during the past few years and highlights some issues that could be important in successful malaria elimination.

Malaria elimination in Lao PDR:the challenges associated with population mobility

Although the Lao People’s Democratic Republic(Lao PDR)is comparatively small landlocked country with patterns of both in-and out-migration,its human migration situation has been poorly studied.This is despite all of the country’s 18 provinces sharing both official and unofficial border checkpoints with neighboring countries.Economic reforms in the last decade have seen a gradual increase in the promotion of foreign investment,and main towns and transportation networks have been expanding thus offering new opportunities for livelihoods and economic activities.In the last decade,there has also been a significant reduction of reported malaria cases in Lao PDR and while this is an important prerequisite for eliminating malaria in the country,malaria outbreaks reported in the last four years suggest that population mobility,particularly in the south,is an important factor challenging current control efforts.Bolder investment in social sector spending should be geared towards improving health service provision and utilization,ensuring equitable access to primary health care(including malaria)through efforts to achieve universal health coverage targets.This should be extended to populations that are mobile and migrants.The local government plays a critical role in supporting policy and enforcement issues related to private sector project development in the provinces.Cross-border initiatives with neighboring countries,especially in terms of data sharing,surveillance,and response,is essential.Mechanisms to engage the private sector,especially the informal private sector,needs to be explored within the context of existing regulations and laws.Existing and new interventions for outdoor transmission of malaria,especially in forest settings,for high-risk groups including short-and long-term forest workers and their families,mobile and migrant populations,as well as the military must be combined into integrated packages with innovative delivery mechanisms through social marketing approaches.This should happen at multiple points in the mobility pathway and involve the private sector rather than being fully reliant on the national malaria vertical program This article based on the review of existing literature from abstracts and full texts,includes published,peer-reviewed English language literature sourced through PubMed and grey literature sources through Google and Google Scholar.The review included also case reports,sector reports,conference proceedings,research reports,epidemiology studies,qualitative studies,and census reports in both Lao and English languages.The authors used the search terms:malaria and mobile populations,malaria control program and elimination,health system performance,malaria outbreak,Lao PDR;and included articles published until June 2015.

Challenges in early phase of implementing the 1-3-7 surveillance and response approach in malaria elimination setting:A field study from Myanmar

Background:The National Plan for Malaria Elimination(NPME)in Myanmar(2016–2030)aims to eliminate indigenous Plasmodium falciparum malaria in six states/regions of low endemicity by 2020 and countrywide by 2030.To achieve this goal,in 2016 the National Malaria Control Program(NMCP)implemented the“1-3-7”surveillance and response strategy.This study aims to identify the barriers to successful implementation of the NPME which emerged during the early phase of the“1-3-7”approach deployment.Methods:A mixed-methods study was conducted with basic health staff(BHS)and Vector Born Disease Control Program(VBDC)staff between 2017 and 2018 in six townships of six states/regions targeted for sub-national elimination by 2020.A self-administered questionnaire,designed to assess the knowledge required to implement the“1-3-7”approach,was completed by 544 respondents.Bivariate analysis was performed for quantitative findings and thematic analysis was conducted for qualitative findings using Atals.ti software.Results:Although 83%of participants reported performing the key activities in the“1-3-7”surveillance and response approach,less than half could report performing those activities within 3 days and 7 days(40 and 43%,respectively).Low proportion of BHS correctly identified six categories of malaria cases and three types of foci(22 and 26%,respectively).In contrast,nearly 80%of respondents correctly named three types of case detection methods.Most cited challenges included‘low community knowledge on health’(43%),‘inadequate supplies’(22%),and‘transportation difficulty’(21%).Qualitative data identified poor knowledge of key surveillance activities,delays in reporting,and differences in reporting systems as the primary challenges.The dominant perceived barrier to success was inability to control the influx of migrant workers into target jurisdictions especially in hard-to-reach areas.Interviews with township medical officers and the NMCP team leaders further highlighted the necessity of refresher training for every step in the“1-3-7”surveillance and response approach.Conclusions:The performance of the“1-3-7”surveillance and response approach in Myanmar delivers promising results.However,numerous challenges are likely to slow down malaria elimination progress in accordance with the NPME.Multi-stakeholder engagement and health system readiness is critical for malaria elimination at the subnational level.

Malaria epidemiology and stratification of incidence in the malaria elimination setting in Harari Region,Eastern Ethiopia

Background: Ethiopia has shown notable progress in reducing the burden of malaria over the past two decades.Because of this progress,the country has shifted efforts from control to elimination of malaria.This study was conducted to analyse the malaria epidemiology and stratification of incidence in the malaria elimination setting in eastern Ethiopia.Methods:: A retrospective study was conducted to analyse the epidemiology of malaria by reviewing the district health office data from 2013 to 2019 in Harari Region.In addition,three years of sub-district level malaria data were used to stratify the malaria transmission intensity.Malaria interventions(Long-lasting insecticidal nets[LLIN]and indoor residual spraying[IRS])employed were reviewed to analyse the intervention coverage at the Regional level.Descriptive statistics were used to show the malaria transmission in terms of years,season and species of the malaria parasite.Incidence rate per 1000 population and death rate per 1000000 population at risk were computed using the total population of each year.Results: In the Harari Region,malaria incidence showed a more pronounced declining trend from 2017 to 2019.Plasmodium falciparum,P.vivax and mixed infections accounted for 69.2%,30.6%and 0.2%of the cases,respectively.There was an increment in malaria intervention coverage and improved malaria diagnosis.In the year 2019 the coverage of LLIN and IRS in the Region were 93.4%and 85.1%respectively.The annual malaria incidence rate dropped from 42.9 cases per 1000 population in 2013 to 6.7 cases per 1000 population in 2019.Malaria-related deaths decreased from 4.7 deaths per 1000000 people annually in 2013 to zero,and there have been no deaths reported since 2015.The malaria risk appears to be heterogeneous and varies between districts.A higher number of malaria cases were recorded in Erer and Jenella districts,which constitute 62%of the cases in the Region.According to the sub-district level malaria stratification,there was shrinkage in the malaria transmission map and about 70%of the sub-districts have achieved elimination targets.Conclusions: In the Harari Region,malaria morbidity and mortality have been significantly declined.Thus,if this achievement is sustained and scaling-up of the existing malaria prevention and control strategies by focusing on those populations living in the higher malaria transmission districts and sub-districts,planning of malaria elimination from the study area might be feasible.

Cost-effectiveness analysis of malaria rapid diagnostic test in the elimination setting

Background:As more and more countries approaching the goal of malaria elimination,malaria rapid diagnostic tests(RDT)was recomendated to be a diagnostic strategy to achieve and maintain the statute of malaria free,as it’s less requirments on equipment and experitise than microscopic examination.But there are very few economic evaluations to confirm whether RDT was cost-effective in the setting of malaria elimination.This research aimed to offer evidence for helping decision making on malaria diagnosis strategy.Methods:A cost-effectiveness analysis was conducted to compare RDT with microscopy examination for malaria diagnosis,by using a decision tree model.There were three strategies of malaria diagnostic testing evaluated in the model,1)microscopy,2)RDT,3)RDT followed by microscopy.The effect indicator was defined as the number of malaria cases treated appropriately.Based on the joint perspective of health sector and patient,costs data were collected from hospital information systems,key informant interviews,and patient surveys.Data collection was conducted in Jiangsu from September 2018 to January 2019.Epidemiological data were obtained from local malaria surveillance reports.A hypothetical cohort of 300000 febrile patients were simulated to calculate the total cost and effect of each strategy.One-way,two-way,and probabilistic sensitivity analysis were performed to test the robustness of the result.Results:The results showed that RDT strategy was the most effective(245 cases)but also the most costly(United States Dollar[USD]4.47 million)compared to using microscopy alone(238 cases,USD 3.63 million),and RDT followed by microscopy(221 cases,USD 2.75 million).There was no strategy dominated.One-way sensitivity analysis reflected that the result was sensitive to the change in labor cost and two-way sensitivity analysis indicated that the result was not sensitive to the proportion of falciparum malaria.The result of Monte Carlo simulation showed that RDT strategy had higher effects and higher cost than other strategies with a high probability.Conclusions:Compared to microscopy and RDT followed by microscopy,RDT strategy had higher effects and higher cost in the setting of malaria elimination.

Long-lasting microbial larvicides for controlling insecticide resistant and outdoor transmitting vectors:a cost-effective supplement for malaria interventions

The issues of pyrethroid resistance and outdoor malaria parasite transmission have prompted the WHO to call for the development and adoption of viable alternative vector control methods.Larval source management is one of the core malaria vector interventions recommended by the Ministry of Health in many African countries,but it is rarely implemented due to concerns on its cost-effectiveness.New long-lasting microbial larvicide can be a promising cost-effective supplement to current vector control and elimination methods because microbial larvicide uses killing mechanisms different from pyrethroids and other chemical insecticides.It has been shown to be effective in reducing the overall vector abundance and thus both indoor and outdoor transmission.In our opinion,the long-lasting formulation can potentially reduce the cost of larvicide field application,and should be evaluated for its cost-effectiveness,resistance development,and impact on non-target organisms when integrating with other malaria vector control measures.In this opinion,we highlight that long-lasting microbial larvicide can be a potential cost-effective product that complements current front-line long-lasting insecticidal nets(LLINs)and indoor residual spraying(IRS)programs for malaria control and elimination.Microbial larviciding targets immature mosquitoes,reduces both indoor and outdoor transmission and is not affected by vector resistance to synthetic insecticides.This control method is a shift from the conventional LLINs and IRS programs that mainly target indoor-biting and resting adult mosquitoes.

Priorities of China’s participation in global malaria elimination:the perspective of malaria endemic countries

Background:Malaria is one of the major diseases afecting global health,while progress in malaria control and elimination has stagnated in some endemic countries.China has been certifcated malaria free by World Health Organization in 2021,and will get more involved on global malaria elimination.Further discussion is needed on how to collaborate with the malaria endemic countries and provide efective help.This study was to investigate the perceptions of malaria endemic countries on China’s contribution to global malaria elimination and to lay a foundation for further action.Methods:Semi-structured interviews were conducted with key informants including national malaria project managers and technicians from malaria endemic countries.Thematic framework approach was used to analyze the data.Results:Malaria endemic countries now face challenges in insufcient funds,technique,products,public health systems and inadequacy of international assistance.They hold a positive attitude towards cooperation with China and identifed experience and technique exchange,personnel training,system building and scientifc research cooperation as prioritized areas.Conclusions:China could make full use of its own advantages in technique transfer,health system improvement,information system construction,and health human resource training and take an active part in global malaria elimination.