**2. Malaria elimination strategy in China**

The national malaria elimination strategy was developed based on the malaria control situation and response to the Global Eradication of Malaria Initiative proposed by the United Nation Millennium Development Goals (MDGs) in September 2000 [5, 17, 18]. The overall strategy comprised specific objectives and key measures taking into account the different epidemiological contexts and diversity of malaria transmission models all over the country. The overall goals of malaria elimination in China were set to achieve zero indigenous cases in the country by 2015, leaving apart the border areas of Yunnan Province with Myanmar and Tibet Autonomous Region with India to achieve complete elimination in the country by 2020.

#### **2.1. Intermediate objectives**

*Anopheles*

**Sibling species** 

**Species** 

**Breeding habitats**

**Feeding behavior** 

**Resting** 

**Insecticide susceptibility status**

**Distribution** 

**range**

**behavior**

**(peak biting** 

**activity)**

**identification** 

**prevalent in** 

**the People's** 

**tools**

**Republic of** 

**China**

*Anopheles* 

—

Morphological

Rice field, canal,

Zoophily

Exophily

Resistance to organochlorine,

Latitude below

234 Towards Malaria Elimination - A Leap Forward

33°N

dichloro-diphenyl-trichloroethane (DDT),

and deltamethrin in some provinces

(first option)

Anthropophily

(second option)

ditch, pond

characters

*sinensis*

*Anopheles* 

*An. minimus*,

Morphological

Heliophobic

Zoophily/

Endophily

Sensitive to all insecticides used currently

32.5°N

Latitude below

anthropophily

(reported only in

Hainan Province)

stream, canal,

ditch, rice field

characters; PCR

*An. harrisoni*

*minimus* s.l.

*Anopheles* 

—

Morphological

Heliophobic, canal,

Anthropophily

Endophily

Sensitive to all insecticides used currently

Latitude

22°N~33°N

ditch, rice field,

filter well

characters; PCR

*lesteri*

*Anopheles* 

*An. dirus*, *An.* 

Morphological

Heliophobic,

Anthropophily

Exophily

Sensitive to all insecticides used currently

23°N

Latitude below

stream in forest,

pit with water,

footprint of cattle

Bionomical characteristics of malaria vectors in the People's Republic of China (reference [14]).

characters; PCR

*dirus* s.l.

**Table 1.**

*baimaii*

**species/**

**taxa**

The strategy and key measures for malaria elimination in China were developed in line with the WHO guidelines [19]. However, counties had variable endemicity based on which a classification

<sup>1</sup> *Botswana, Cabo Verde, South Africa, Swaziland, Costa Rica, Ecuador, El Salvador, Mexico, Saudi Arabia, Timor-Leste, Malaysia.* 2 *Botswana, South Africa, Swaziland, Ecuador, Saudi Arabia.*

was established according to the different types of area and intensity of malaria transmission. According to the magnitude of transmission and incidence, all counties were classified into 4 types, including Type I, local transmission and incidence ≥1/10,000 over the past 3 years; Type II, local transmission and incidence <1/10,000 over the past 3 years; Type III, no indigenous cases reported over the past 3 years but still with risk of transmission; and Type IV, malaria-free [20]. The classification of malaria-endemic areas is presented in **Figure 1** [17, 20].

*2.2.1. Strengthening control and management of infectious sources*

• **Timely surveillance and response to all malaria cases** [20, 21]

be collected and kept for verification.

○ Full dose and **whole medication**<sup>3</sup>

the whole course of treatment.

first-line treatment to treat uncomplicated falciparum malaria.

*2.2.2. Strengthening vector control*

• **Treatment**

3

• **Timely malaria case detection**. Both public and private clinics and health facilities at all levels should take blood samples from patients including clinical diagnosed malaria cases, suspected malaria cases and febrile patients without confirmed origin of infection. Blood smear for microscopic tests or auxiliary detection using Rapid Diagnosis Test (RDT) kits should be carried out with blood samples. For RDT-positive samples, blood smears must

Malaria Elimination in the People's Republic of China: Current Progress, Challenges, and Prospects

http://dx.doi.org/10.5772/intechopen.77282

237

○ **Strengthening malaria case reporting.** Public or private clinics and health facilities at all levels have the responsibility to report malaria cases within 24 hours (**1 day**) after diagnosis. This is a requirement from the law on the Prevention and Control of Infectious Diseases in the People's Republic of China (http://www.gov.cn/banshi/2005-08/01/content\_19107.htm).

○ **Case verification.** Centers for Disease Control and Prevention (CDCs) at the county level are made responsible for the verification of individual cases reported through the information system and for laboratory test assessment (RDT and microscope). Case investigation and verification are required to be accomplished within **3 days** after reporting. ○ **Management of malaria foci.** CDCs at the county level are responsible for investigation on identified malaria foci and further disposal within **7 days** after index case reporting. A reactive case detection must be carried out by collecting blood samples from inhabitants around the index case (fever displayed over the last 2 weeks). Collected blood samples must be analyzed by microscope or RDT. Meanwhile, vector control measures (i.e., indoor residual spraying (IRS)) must be implemented, and information materials for public awareness and health education must be provided to all families in different foci.

the national guidelines. Public or private clinics and health facilities at all levels should treat all the detected malaria patients according to the national guidelines for anti-malarial drug use, issued by the Ministry of Health. All patients must be followed up across

○ **Anti-relapse treatment.** In non-transmission malaria season, patients diagnosed with

• **Anti-mosquito interventions.** During the malaria transmission season, it is encouraged to transform and improve the environment so as to reduce the number of breeding sites and

Whole medication refers to the 8-day treatment for vivax malaria with primaquine (total dose 180 mg over 8 days) and chloroquine (total dose 1200 mg over 3 days) as first-line drugs. Artemisinin combination therapy (ACT) was used as

*vivax* malaria during the previous year must be given anti-relapse treatment.

should be given to treat malaria patients according to

**Figure 1.** Stratification of malaria-endemic areas for data based on 2010 (references [5, 17]).

Several intermediate progress objectives were also set in a graduated way depending on the type of area. By 2015, (i) all Type III counties should achieve the objective of malaria elimination; (ii) at the same time, Types I and II counties, except Yunnan border counties, are expected to report zero indigenous malaria cases; (iii) the incidence of indigenous malaria cases in Type I counties located in the Yunnan border areas should be reduced to <1/10,000; (iv) it is expected that by 2017, no indigenous cases should be reported in the whole country; (v) by the year 2018, all Types I and II counties, except Yunnan border counties, must have fully achieved malaria elimination; and (vi) malaria elimination should be achieved all over the country by the year 2020.

#### **2.2. Implementation requirements for malaria elimination**

In order to achieve malaria elimination, specific requirements were assigned depending upon the type of county. The Type I counties should strengthen the management of infectious source and implement vector control measures to reduce the incidence of malaria. The Type II counties should eliminate the infectious source of malaria to interrupt local malaria transmission. The Type III counties should enhance the monitoring and disposition of the imported cases to prevent the secondary transmission. The Type IV counties should deal appropriately with imported cases. These requirements were also made flexible enough to be adjusted according to the control process and changes in the dynamics of the disease. These requirements were based on specific and standardized key measures [17].

#### *2.2.1. Strengthening control and management of infectious sources*

	- **Strengthening malaria case reporting.** Public or private clinics and health facilities at all levels have the responsibility to report malaria cases within 24 hours (**1 day**) after diagnosis. This is a requirement from the law on the Prevention and Control of Infectious Diseases in the People's Republic of China (http://www.gov.cn/banshi/2005-08/01/content\_19107.htm).
	- **Case verification.** Centers for Disease Control and Prevention (CDCs) at the county level are made responsible for the verification of individual cases reported through the information system and for laboratory test assessment (RDT and microscope). Case investigation and verification are required to be accomplished within **3 days** after reporting.
	- **Management of malaria foci.** CDCs at the county level are responsible for investigation on identified malaria foci and further disposal within **7 days** after index case reporting. A reactive case detection must be carried out by collecting blood samples from inhabitants around the index case (fever displayed over the last 2 weeks). Collected blood samples must be analyzed by microscope or RDT. Meanwhile, vector control measures (i.e., indoor residual spraying (IRS)) must be implemented, and information materials for public awareness and health education must be provided to all families in different foci.

#### • **Treatment**

was established according to the different types of area and intensity of malaria transmission. According to the magnitude of transmission and incidence, all counties were classified into 4 types, including Type I, local transmission and incidence ≥1/10,000 over the past 3 years; Type II, local transmission and incidence <1/10,000 over the past 3 years; Type III, no indigenous cases reported over the past 3 years but still with risk of transmission; and Type IV, malaria-free [20].

Several intermediate progress objectives were also set in a graduated way depending on the type of area. By 2015, (i) all Type III counties should achieve the objective of malaria elimination; (ii) at the same time, Types I and II counties, except Yunnan border counties, are expected to report zero indigenous malaria cases; (iii) the incidence of indigenous malaria cases in Type I counties located in the Yunnan border areas should be reduced to <1/10,000; (iv) it is expected that by 2017, no indigenous cases should be reported in the whole country; (v) by the year 2018, all Types I and II counties, except Yunnan border counties, must have fully achieved malaria elimination; and (vi) malaria elimination should be achieved all over the country by the year 2020.

In order to achieve malaria elimination, specific requirements were assigned depending upon the type of county. The Type I counties should strengthen the management of infectious source and implement vector control measures to reduce the incidence of malaria. The Type II counties should eliminate the infectious source of malaria to interrupt local malaria transmission. The Type III counties should enhance the monitoring and disposition of the imported cases to prevent the secondary transmission. The Type IV counties should deal appropriately with imported cases. These requirements were also made flexible enough to be adjusted according to the control process and changes in the dynamics of the disease. These requirements were

**2.2. Implementation requirements for malaria elimination**

based on specific and standardized key measures [17].

The classification of malaria-endemic areas is presented in **Figure 1** [17, 20].

236 Towards Malaria Elimination - A Leap Forward

**Figure 1.** Stratification of malaria-endemic areas for data based on 2010 (references [5, 17]).


#### *2.2.2. Strengthening vector control*

• **Anti-mosquito interventions.** During the malaria transmission season, it is encouraged to transform and improve the environment so as to reduce the number of breeding sites and

<sup>3</sup> Whole medication refers to the 8-day treatment for vivax malaria with primaquine (total dose 180 mg over 8 days) and chloroquine (total dose 1200 mg over 3 days) as first-line drugs. Artemisinin combination therapy (ACT) was used as first-line treatment to treat uncomplicated falciparum malaria.

decrease the density of mosquitoes in combination with the patriotic health movement4 and new rural village development [22]. Measures of IRS and insecticide-treated net (ITN) are required to be applied in malaria foci.

• **Strengthening malaria control and prevention among expatriates**. China is involved in many large construction projects in malaria epidemic areas in different countries, e.g., Ethiopia and Zambia in Africa, Myanmar and Indonesia in Southeast Asia. Some of the projects like road, railway, or dam constructions involve high malaria risk exposure. CDCs provide appropriate information and training to the personnel employed in these projects before expatriates' deployment. The management and registration of malaria cases among expatriates are conducted locally in coordination with health agencies and CDCs. Public security departments provide assistance to investigate malaria cases among expatriates as

Malaria Elimination in the People's Republic of China: Current Progress, Challenges, and Prospects

http://dx.doi.org/10.5772/intechopen.77282

239

• **Strengthening capacity building for malaria diagnosis.** The National Institute of Parasitic Diseases, China CDC is responsible for managing national malaria diagnosis reference laboratory. Its mandate is to provide a final laboratory confirmation and identify the source of any malaria case. Reference laboratories at all levels should regularly assess the skills of

• **Malaria surveillance in the post-elimination stage.** The status of malaria-free area must be maintained in counties having achieved malaria elimination, as well as in previously nonendemic provinces. This must be done through regular training of the medical personnel in malaria diagnosis and treatment. Prevention of re-establishment of malaria transmission is also required and must be conducted by intensifying the monitoring of imported cases.

A total of 28,886 malaria cases were reported in Mainland China (excluding Hong Kong, Macau, and Taiwan) from 2010 to 2016 (**Table 2**) [9, 10, 23–26]. During this period, indigenous cases, as well as the number of areas with local transmission, were substantially reduced. There were 40 indigenous cases reported from 10 counties in 2015, a decrease of 99.06% from 2010. By 2015, all Type III counties had achieved malaria elimination goals (no occurrence of indigenous cases for at least 3 consecutive years). Except for border counties in Yunnan, 96.43% (54/56) of the Type I counties reported no indigenous case over the same period. The malaria incidence in 19 Type I counties in Yunnan border area was lower than 10/100,000. All positive cases were reported through the China Information System for Disease Control and Prevention (CISDCP). The increase in incidence and number of detected cases after 6 years of implementation of the malaria elimination program was linked to the large number of imported cases, while the number of indigenous cases was reduced by 99.93% between 2010 and 2016 (**Table 2**) [8, 27–30]. The number of provinces with imported cases increased from 22 in 2010 to 30 (all the provinces in Mainland China except Tibet) in 2015. A total of 3318 imported cases were reported in 2016 (**Table 2**). The top 5 countries of origin of the imported cases were Myanmar (15.9%), Angola (12.5%), Nigeria (7.7%), Equatorial Guinea (7.5%),

test and conduct quality control to ensure operation of the laboratory network.

**3.1. Status after seven years of implementation of malaria elimination program**

requested by the Department of Health.

**3. Progress on malaria elimination in China**

*2.2.5. Improving malaria surveillance*

• **Strengthening personal protection**. To prevent or minimize mosquito bites during the malaria transmission season, personal protective measures must be implemented such as repellents, mosquito-repellent incense, mosquito nets, wire mesh screening of doors and windows, *etc*.

### *2.2.3. Strengthening health education*


#### *2.2.4. Strengthening malaria control in mobile/migrant populations*

• **Strengthening the management of malaria among travelers**. The Department of Health and Exit & Entry Administration should regularly release public information about the world malaria situation and related information inside the country. Tourism departments should release such information to tourists too. The Department of Tourism and Commerce has the obligation to aid the Department of Health in providing information to people traveling to malaria-endemic areas, as well as track information on malaria patients. Mechanism for shared information should be established among different sectors. This cross sector mechanism is responsible for increasing the anti-malaria public awareness, for providing consultation services to cross-border populations, for screening individuals with fever who have been traveling to malaria-endemic areas, and for reporting the detected malaria cases.

<sup>4</sup> The patriotic health movement is referring to a community-based health movement focusing on cleaning, pest control, environment reforming, and other health-related activities, with the aim of preventing infectious diseases.

• **Strengthening malaria control and prevention among expatriates**. China is involved in many large construction projects in malaria epidemic areas in different countries, e.g., Ethiopia and Zambia in Africa, Myanmar and Indonesia in Southeast Asia. Some of the projects like road, railway, or dam constructions involve high malaria risk exposure. CDCs provide appropriate information and training to the personnel employed in these projects before expatriates' deployment. The management and registration of malaria cases among expatriates are conducted locally in coordination with health agencies and CDCs. Public security departments provide assistance to investigate malaria cases among expatriates as requested by the Department of Health.

#### *2.2.5. Improving malaria surveillance*

decrease the density of mosquitoes in combination with the patriotic health movement4 and new rural village development [22]. Measures of IRS and insecticide-treated net (ITN)

• **Strengthening personal protection**. To prevent or minimize mosquito bites during the malaria transmission season, personal protective measures must be implemented such as repellents, mosquito-repellent incense, mosquito nets, wire mesh screening of doors and windows, *etc*.

• **Strengthening people awareness.** Mass media such as newspapers, radio, TV, and internet posts should cover "World Malaria Day and National Malaria Day" activities and implement various ways to widely broadcast knowledge on malaria and the malaria elimination policy to improve public awareness and motivate community participation in malaria con-

• **Strengthening health education for primary and junior high school students.** Education department should deploy and arrange the primary and junior high school health education. CDCs should strengthen the technical support to health education on malaria in these schools. Primary and junior high schools in Types I and II counties should keep malaria and malaria control awareness as a recurrent topic in regular health education courses or theme activities. They should encourage pupils to pass such awareness to their family

• **Strengthening health education at the community level.** In Types I and II counties, the local CDCs should organize and support malaria public awareness by the way of advertisements and regularly update posted news in hospital waiting rooms, community health service centers, rural hospitals, village clinics, and large construction sites. They should

• **Strengthening the management of malaria among travelers**. The Department of Health and Exit & Entry Administration should regularly release public information about the world malaria situation and related information inside the country. Tourism departments should release such information to tourists too. The Department of Tourism and Commerce has the obligation to aid the Department of Health in providing information to people traveling to malaria-endemic areas, as well as track information on malaria patients. Mechanism for shared information should be established among different sectors. This cross sector mechanism is responsible for increasing the anti-malaria public awareness, for providing consultation services to cross-border populations, for screening individuals with fever who have been traveling to malaria-endemic areas, and for reporting the detected

The patriotic health movement is referring to a community-based health movement focusing on cleaning, pest control,

environment reforming, and other health-related activities, with the aim of preventing infectious diseases.

are required to be applied in malaria foci.

members by the way of "child educate adult."

also develop awareness material in minority nations' language.

*2.2.4. Strengthening malaria control in mobile/migrant populations*

*2.2.3. Strengthening health education*

238 Towards Malaria Elimination - A Leap Forward

trol and elimination.

malaria cases.

4

