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

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

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%),


**Table 2.**Malaria-attributable morbidity in the People's Republic of China during 2010–2016°. and Cameroon (7.1%). In response to the increasing risk from imported cases, joint coordination and transfer of information were established among different agencies, in particular between China CDC and port quarantines. The latter are responsible for frontline screening and detection providing timely reports of positive cases. Clinics and hospitals are in charge of case treatment, while CDCs must follow up all the reported cases and carry out the individual case investigation. A successful example of such organization is given by the Shanglin County, Guangxi [31], for reporting 1,052 imported malaria cases in 2013, all of which were successfully treated and no death cases occurred. Furthermore, although *Anopheles* mosquitoes were present [14], no second-

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Along the border between China and countries of the Greater Mekong Subregion (GMS) (Myanmar, Lao PDR, and Vietnam), 3 frontline barriers were established jointly by CDCs and port quarantines [32]. These 3 barriers consisted of (i) a strengthened health system in all 25 border counties with a capacity to immediate and comprehensive response to each malaria case (first line), (ii) establishment of 68 malaria service points at the border to provide consultation and screening to the migrant/mobile population (MMP) (second line), and (iii) a coordination process for response to malaria along the international borders between China, Myanmar, Lao PDR, and

The main risks clearly identified after implementation of the national malaria elimination program were re-introduction through imported cases and the associated secondary transmission by local malaria vectors. Sustainable vector control is therefore essential. With the support from the national malaria surveillance system and national malaria diagnosis reference laboratory network, all the confirmed malaria cases were examined, including a total number of 2,215 foci investigated within 7 days after case detection and verification (**Table 3**). Long-lasting insecticidal net (LLIN) or ITN was delivered to the communities with high malaria incidence and presence of highly efficient malaria vectors, such as *Anopheles dirus* s.l. or *Anopheles minimus* s.l. [14]. IRS was carried out in active malaria foci (the definition of active foci is given in Ref. [19, 33]). In 2015, a total number of 29,611 LLIN/ITN were delivered, and 1,697,188 persons were protected by IRS in response to malaria foci (**Table 4**). Another key element in the protection of people against imported malaria was the training and education of the personnel. Annual joint health training workshops were carried out by the Departments of Health, Education, and Inspection and Quarantine on the National Malaria Day (April 26th) since 2008. Altogether, 74.9 million educational documents were delivered during workshops from 2010 to 2015 (**Table 5**). To these, one must add all posters and flyers delivered through port quarantines. Capacity building for health professional personnel corresponded to 464,500 working days in CDCs; 848,764 working days for clinical doctors; and 186,368 working days for microscopists during 2010–2015 (**Table 5**). With respect to port quarantines, 16,141 working days of training were accomplished with a malaria awareness rate of 100%.

A key issue in successful implementation of a program relies on the governmental commitment and support for sustained allocation of resources. The government at all levels has adopted malaria elimination as a component of the socioeconomic strategy. A national action plan for malaria elimination was issued jointly by 13 ministries in 2010 with clear goals and strategy, followed by a sustainable budget plan to ensure the financial support for malaria elimination. As a

Vietnam covering 42 border counties (20 in Yunnan and 22 in the 3 other countries).

ary transmission occurred.

\*\*Before 2013, the data recorded in the annual reporting system did not separate *P. malariae* and *P. ovale.*

and Cameroon (7.1%). In response to the increasing risk from imported cases, joint coordination and transfer of information were established among different agencies, in particular between China CDC and port quarantines. The latter are responsible for frontline screening and detection providing timely reports of positive cases. Clinics and hospitals are in charge of case treatment, while CDCs must follow up all the reported cases and carry out the individual case investigation. A successful example of such organization is given by the Shanglin County, Guangxi [31], for reporting 1,052 imported malaria cases in 2013, all of which were successfully treated and no death cases occurred. Furthermore, although *Anopheles* mosquitoes were present [14], no secondary transmission occurred.

Along the border between China and countries of the Greater Mekong Subregion (GMS) (Myanmar, Lao PDR, and Vietnam), 3 frontline barriers were established jointly by CDCs and port quarantines [32]. These 3 barriers consisted of (i) a strengthened health system in all 25 border counties with a capacity to immediate and comprehensive response to each malaria case (first line), (ii) establishment of 68 malaria service points at the border to provide consultation and screening to the migrant/mobile population (MMP) (second line), and (iii) a coordination process for response to malaria along the international borders between China, Myanmar, Lao PDR, and Vietnam covering 42 border counties (20 in Yunnan and 22 in the 3 other countries).

The main risks clearly identified after implementation of the national malaria elimination program were re-introduction through imported cases and the associated secondary transmission by local malaria vectors. Sustainable vector control is therefore essential. With the support from the national malaria surveillance system and national malaria diagnosis reference laboratory network, all the confirmed malaria cases were examined, including a total number of 2,215 foci investigated within 7 days after case detection and verification (**Table 3**). Long-lasting insecticidal net (LLIN) or ITN was delivered to the communities with high malaria incidence and presence of highly efficient malaria vectors, such as *Anopheles dirus* s.l. or *Anopheles minimus* s.l. [14]. IRS was carried out in active malaria foci (the definition of active foci is given in Ref. [19, 33]). In 2015, a total number of 29,611 LLIN/ITN were delivered, and 1,697,188 persons were protected by IRS in response to malaria foci (**Table 4**). Another key element in the protection of people against imported malaria was the training and education of the personnel. Annual joint health training workshops were carried out by the Departments of Health, Education, and Inspection and Quarantine on the National Malaria Day (April 26th) since 2008. Altogether, 74.9 million educational documents were delivered during workshops from 2010 to 2015 (**Table 5**). To these, one must add all posters and flyers delivered through port quarantines. Capacity building for health professional personnel corresponded to 464,500 working days in CDCs; 848,764 working days for clinical doctors; and 186,368 working days for microscopists during 2010–2015 (**Table 5**). With respect to port quarantines, 16,141 working days of training were accomplished with a malaria awareness rate of 100%.

A key issue in successful implementation of a program relies on the governmental commitment and support for sustained allocation of resources. The government at all levels has adopted malaria elimination as a component of the socioeconomic strategy. A national action plan for malaria elimination was issued jointly by 13 ministries in 2010 with clear goals and strategy, followed by a sustainable budget plan to ensure the financial support for malaria elimination. As a

**Year**

**Total** 

**Local cases**

**Imported cases**

**No. of** 

**death** 

**cases**

**reported** 

**Clinical** 

*P. vivax*

*P.* 

**Mix**

**Subtotal**

**Clinical** 

*P.* 

*P.* 

*P.* 

*P.* 

**Mix**

**Subtotal**

**diagnosis**

*vivax*

*falciparum*

*malariae*

*ovale*

*falciparum*

**diagnosis**

**cases**

2010 2011 2012 2013 2014 2015 2016

3321

0

3 °The number of malaria cases reported in 2017 will be published by the end of 2018.

\*NA indicates that data were not available in the annual reporting system.

\*\*Before 2013, the data recorded in the annual reporting system did not separate *P. malariae* and *P. ovale.*

Malaria-attributable morbidity in the People's Republic of China during 2010–2016°.

**Table 2.**

0

0

3

15

709

2158

64

311

61

3318

15

3288

1

38

1

0

40

22

840

1991

76

272

47

3248

20

3078

5

45

6

0

56

20

798

1876

52

232

44

3022

25

4128

6

77

9

0

92

29

859

2899

51

133

65

4036

23

2718

32

228

16

5

281

35

900

1403

60\*\*

0

39

2437

15

4498

364

885

56

3

1308

372

1253

1468

62\*\*

0

35

3190

33

240 Towards Malaria Elimination - A Leap Forward

7855

0

4165

97

0

4262

NA\*

NA

1161

NA

NA

NA

3593

19


\*1-3-7 model is referring to case reported within **1 day** (24 hours), case verification and investigation within **3 days**, and foci investigation and disposal within **7 days**. This is summarized as work model for malaria surveillance and response for malaria elimination program [20, 21].

key player in malaria elimination in the central government, the National Health Commission (NHC, previously known as the Ministry of Health before 2011 and National Health and Family Planning Commission during 2011–2018) has established a multidisciplinary technical committee

**Total 29,611 1,697,188**

**Table 4.** Progress indicators of vector control measures in 2015.

\*Vector control measures mainly implemented in malaria foci for targeting population at risk.

**Province Number of delivered LLIN/ITN Number of people protected by IRS/house\***

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Beijing 0 0 Tianjin 0 0 Hebei 6 353 Shanxi 0 188 Inner Mongolia 0 0 Liaoning 0 1120 Jilin 0 0 Heilongjiang 0 0 Shanghai 0 301 Jiangsu 0 7299 Zhejiang 0 1850 Anhui 207 1094 Fujian 180 535 Jiangxi 0 11,142 Shandong 0 336 Henan 2096 17,814 Hubei 79 918 Hunan 4 408 Guangdong 1552 1,327,650 Guangxi 10 1961 Hainan 6910 20,106 Chongqing 2 45,280 Sichuan 7 11,248 Guizhou 7418 12,771 Yunnan 628 229,535 Tibet 10,000 1537 Shaanxi 512 3546 Gansu 0 196 Qinghai 0 0 Ningxia 0 0 Xinjiang 0 0

**Table 3.** Progress indicators of 1-3-7\* model in 2015.

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\*Vector control measures mainly implemented in malaria foci for targeting population at risk.

**Table 4.** Progress indicators of vector control measures in 2015.

**Province Cases reported within 24 h Case investigation within 3 days Number of foci** 

\*1-3-7 model is referring to case reported within **1 day** (24 hours), case verification and investigation within **3 days**, and foci investigation and disposal within **7 days**. This is summarized as work model for malaria surveillance and response

**Investigated cases within 3 days**

**Proportion of reported cases**

Beijing 89 89 100% 89 100% 0 Tianjin 17 17 100% 17 100% 0 Hebei 44 44 100% 44 100% 21 Shanxi 12 12 100% 12 100% 15 Inner Mongolia 6 6 100% 1 16.67% 0 Liaoning 65 65 100% 65 100% 62 Jilin 21 21 100% 21 100% 0 Heilongjiang 8 8 100% 8 100% 0 Shanghai 42 42 100% 42 100% 29 Jiangsu 408 408 100% 408 100% 408 Zhejiang 195 195 100% 195 100% 160 Anhui 129 129 100% 129 100% 117 Fujian 94 94 100% 94 100% 12 Jiangxi 52 52 100% 52 100% 43 Shandong 219 219 100% 217 99.09% 199 Henan 185 185 100% 184 99.46% 180 Hubei 125 125 100% 122 97.60% 12 Hunan 129 129 100% 128 99.22% 46 Guangdong 155 155 100% 144 92.90% 1 Guangxi 236 236 100% 236 100% 33 Hainan 14 14 100% 14 100% 12 Chongqing 33 33 100% 31 93.94% 26 Sichuan 294 294 100% 292 99.32% 272 Guizhou 17 17 100% 17 100% 0 Yunnan 622 622 100% 618 99.36% 481 Tibet 8 8 100% 8 100% 0 Shaanxi 81 81 100% 81 100% 80 Gansu 22 22 100% 21 95.45% 6 Qinghai 1 1 100% 0 0 0 Ningxia 6 6 100% 6 100% 0 Xinjiang 4 4 100% 4 100% 0 **Total 3333 3333 100% 3300 99.01% 2215**

**Total reported cases**

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for malaria elimination program [20, 21].

**Table 3.** Progress indicators of 1-3-7\* model in 2015.

**Reported cases within 24 h** **investigated and disposed within** 

**7 days**

**Proportion of investigated cases**

> key player in malaria elimination in the central government, the National Health Commission (NHC, previously known as the Ministry of Health before 2011 and National Health and Family Planning Commission during 2011–2018) has established a multidisciplinary technical committee


comprising malaria experts, i.e., epidemiologists, entomologists, clinical doctors, parasitologists, program managers, *etc*. With the support of this committee, NHC has issued a series of guidelines and standards adapting and updating the WHO guidelines [2, 19, 33, 34], such as technical guidelines for malaria elimination, malaria treatment and anti-malarial drug use, standards for malaria

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A working model, named 1-3-7, for malaria surveillance and response was implemented as a

• "1," within 1 day (24 hours): all malaria cases must be reported to the Chinese Information System for Disease Control and Prevention (CISDCP), an internet-based reporting system. The case information will be notified through a four-level system "county→ prefecture→ province→ national." The response at different levels is implemented according to national guidelines. Malaria is classified as a category B notifiable infectious disease, and case reporting through CISDCP has been implemented since 2004 [35]. All private and public registered clinics and hospitals must report malaria cases through CISDCP after diagnosis. CDCs are the key operators of CISDCP (**Figure 2**). This ensures that malaria case informa-

• "3," within 3 days: all the reported malaria cases should be confirmed and visited by CDCs' staffs at the county level to verify the infectious origin of the cases (whether imported or locally acquired). Meanwhile, blood samples of patients are taken and sent to the reference

**Figure 2.** Vertical reporting structure of the China information system for disease control and prevention (CISDCP)

control and elimination, and malaria diagnosis, to cite a few [18].

national malaria program. The definition of "1-3-7" is as follow:

tion is timely transmitted from bottom to top.

laboratory for further verification.

(CDC, Centers for Disease Control and Prevention).

**3.2. Successful implementation**

**Table 5.** Progress indicators of health education and capacity building during 2010–2015.

comprising malaria experts, i.e., epidemiologists, entomologists, clinical doctors, parasitologists, program managers, *etc*. With the support of this committee, NHC has issued a series of guidelines and standards adapting and updating the WHO guidelines [2, 19, 33, 34], such as technical guidelines for malaria elimination, malaria treatment and anti-malarial drug use, standards for malaria control and elimination, and malaria diagnosis, to cite a few [18].

#### **3.2. Successful implementation**

**Province Number of trained people (person/time) Number of delivered health** 

Beijing 208 0 176 185,000 Tianjin 240 300 300 25,700 Hebei 41,499 95,926 10,652 3,064,121 Shanxi 596 0 871 57,000 Inner Mongolia 204 408 204 3200 Liaoning 7554 88,609 5835 143,600 Jilin 226 0 226 4000 Heilongjiang 0 0 0 0

Shanghai 21,516 48,584 9377 1,246,268 Jiangsu 26,415 23,963 16,468 7,365,562 Zhejiang 11,447 19,304 8749 1,676,164 Anhui 59,229 42,417 18,671 14,323,973 Fujian 7653 8777 3095 556,489 Jiangxi 12,696 24,829 9272 1,621,293 Shandong 34,624 56,382 15,494 7,040,504 Henan 62,005 183,085 19,486 7,968,270 Hubei 27,199 38,291 10,062 4,078,954 Hunan 22,018 46,761 11,666 4,722,609 Guangdong 737 375 1008 429,401 Guangxi 23,682 57,461 10,914 4,505,439 Hainan 10,838 5288 2607 2,058,430 Chongqing 1027 0 235 0 Sichuan 1900 0 825 372,200 Guizhou 21,643 28,120 8827 3,342,021 Yunnan 28,962 35,103 7479 4,200,909 Tibet — — — — Shaanxi 21,951 34,313 10,970 3,615,648 Gansu 12,851 9136 2178 1,631,944 Qinghai — — — — Ningxia 469 0 144 0 Xinjiang 5111 1332 577 670,755 Total 464,500 848,764 186,368 74,909,454

**Clinical doctors Microscopists**

**Malaria health workers**

244 Towards Malaria Elimination - A Leap Forward

Note: "-" denotes data not available.

**Table 5.** Progress indicators of health education and capacity building during 2010–2015.

**education materials**

A working model, named 1-3-7, for malaria surveillance and response was implemented as a national malaria program. The definition of "1-3-7" is as follow:

• "1," within 1 day (24 hours): all malaria cases must be reported to the Chinese Information System for Disease Control and Prevention (CISDCP), an internet-based reporting system. The case information will be notified through a four-level system "county→ prefecture→ province→ national." The response at different levels is implemented according to national guidelines. Malaria is classified as a category B notifiable infectious disease, and case reporting through CISDCP has been implemented since 2004 [35]. All private and public registered clinics and hospitals must report malaria cases through CISDCP after diagnosis. CDCs are the key operators of CISDCP (**Figure 2**). This ensures that malaria case information is timely transmitted from bottom to top.

**Figure 2.** Vertical reporting structure of the China information system for disease control and prevention (CISDCP) (CDC, Centers for Disease Control and Prevention).

• "3," within 3 days: all the reported malaria cases should be confirmed and visited by CDCs' staffs at the county level to verify the infectious origin of the cases (whether imported or locally acquired). Meanwhile, blood samples of patients are taken and sent to the reference laboratory for further verification.

• "7," within 7 days: the outbreak focus should be investigated, and vector control and health promotion measures must be implemented. Vector control measures need to be conducted in active foci only, which are considered to have potential risk of onward transmission. The scope of investigation is the household of the reported patient and neighboring households. However, it can be expanded, if necessary.

mobile/migrant populations. Five provinces in Central China, i.e., Jiangsu, Shandong, Henan, Anhui, and Hubei, and 3 provinces in Southern China, i.e., Guangdong, Guangxi, and Hainan, coordinated their actions at all levels (**Figure 4**). This joint coordination efficiently contributed to control malaria outbreaks and reduce malaria incidence [40, 41]. **The last aspect** to be considered is international collaboration. Malaria elimination cannot be achieved through the efforts of few countries only. It must be a general and coordinated international effort. In this respect, China has received support from international agencies such as WHO and Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to conduct this international collaboration [42]. At the same time, China developed international collaborations with African and GMS countries to implement a coordinated strategy for controlling and eliminating malaria [43, 44], and Chinese

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**Figure 4.** Cross province coordination mechanism for malaria control based on national mechanisms established since

the 1950s–1970s. At that time, few population movements were occurring in the Yunnan Province.

Following the implementation of this 1-3-7 model, local malaria transmission was interrupted effectively in most parts of China, which accelerated the malaria elimination process [20, 21, 36]. Based on this success, the 1-3-7 model was recommended by WHO as an example for malaria surveillance model at elimination stage, in "Strategy for malaria elimination in the Greater Mekong Subregion: 2015-2030" and "Malaria surveillance, monitoring & evaluation: a reference manual" [37, 38].

However, the 1-3-7 strategy is not sufficient to successfully achieve malaria elimination. Other aspects must be considered. **The first aspect** to consider is the establishment of a network of malaria surveillance and diagnosis reference laboratories. After the launch of the malaria elimination program in 2010, and following the suggestions from the WHO guidelines [2, 19, 33, 34], a network for malaria diagnosis reference labs was gradually established [39]. By 2015, 23 provinces were enrolled into the National Reference Laboratory Network (NRLN). Laboratories at all levels worked together to ensure the quality of malaria diagnosis all over the country in a bottom-up approach (**Figure 3**) [39]. **Another key aspect** to consider is the involvement of communities. The community level is essential for a successful implementation. In addition to cross sector coordination, information was shared with different subnational divisions and in particular the community level. This is especially important when managing malaria cases among

**Figure 3.** Structure of the National Reference Laboratory Network (QA, quality assurance).

mobile/migrant populations. Five provinces in Central China, i.e., Jiangsu, Shandong, Henan, Anhui, and Hubei, and 3 provinces in Southern China, i.e., Guangdong, Guangxi, and Hainan, coordinated their actions at all levels (**Figure 4**). This joint coordination efficiently contributed to control malaria outbreaks and reduce malaria incidence [40, 41]. **The last aspect** to be considered is international collaboration. Malaria elimination cannot be achieved through the efforts of few countries only. It must be a general and coordinated international effort. In this respect, China has received support from international agencies such as WHO and Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) to conduct this international collaboration [42]. At the same time, China developed international collaborations with African and GMS countries to implement a coordinated strategy for controlling and eliminating malaria [43, 44], and Chinese

• "7," within 7 days: the outbreak focus should be investigated, and vector control and health promotion measures must be implemented. Vector control measures need to be conducted in active foci only, which are considered to have potential risk of onward transmission. The scope of investigation is the household of the reported patient and neighboring house-

Following the implementation of this 1-3-7 model, local malaria transmission was interrupted effectively in most parts of China, which accelerated the malaria elimination process [20, 21, 36]. Based on this success, the 1-3-7 model was recommended by WHO as an example for malaria surveillance model at elimination stage, in "Strategy for malaria elimination in the Greater Mekong Subregion: 2015-2030" and "Malaria surveillance, monitoring & evaluation:

However, the 1-3-7 strategy is not sufficient to successfully achieve malaria elimination. Other aspects must be considered. **The first aspect** to consider is the establishment of a network of malaria surveillance and diagnosis reference laboratories. After the launch of the malaria elimination program in 2010, and following the suggestions from the WHO guidelines [2, 19, 33, 34], a network for malaria diagnosis reference labs was gradually established [39]. By 2015, 23 provinces were enrolled into the National Reference Laboratory Network (NRLN). Laboratories at all levels worked together to ensure the quality of malaria diagnosis all over the country in a bottom-up approach (**Figure 3**) [39]. **Another key aspect** to consider is the involvement of communities. The community level is essential for a successful implementation. In addition to cross sector coordination, information was shared with different subnational divisions and in particular the community level. This is especially important when managing malaria cases among

**Figure 3.** Structure of the National Reference Laboratory Network (QA, quality assurance).

holds. However, it can be expanded, if necessary.

a reference manual" [37, 38].

246 Towards Malaria Elimination - A Leap Forward

**Figure 4.** Cross province coordination mechanism for malaria control based on national mechanisms established since the 1950s–1970s. At that time, few population movements were occurring in the Yunnan Province.

students are being trained in Europe on molecular approaches applied on *Anopheles* mosquitoes [13–15]. These international collaborations on malaria and vector control toward elimination provided strong support to reduce malaria incidence in China and will be the basis for sustaining malaria elimination efforts.

in global health governance [58], but a higher level of involvement is now expected, and the Chinese experience in malaria elimination will definitely be put at use within the "One Belt and One Road Initiative" [59]. Several platforms are currently under development, such as the Malaria Elimination Network in Lancang-Mekong Region (MENLMR) and the China-Africa Cooperation Program. Both GMS and sub-Saharan Africa are strongly affected by malaria, including drug resistance [60–62], high disease burden [1], and low level of resources [1, 3, 34]. They are thus primary targets for focused interventions enabling malaria elimination. Furthermore, these countries are experiencing innumerable challenges to achieve their planned malaria elimination program and in dire need of international support to bridge the funding gap [1–3, 37]. Although China has applied a successful model and did significant progress on malaria elimination, the Chinese model and experience cannot directly be implemented in these countries. Evaluation and field tests are needed as preliminary steps for operational feasibility. Pilot areas have been identified, and demonstrative projects have been therefore launched jointly by China and the targeted countries to assess the level of feasibility. These preliminary projects will provide evidence-based suggestions to develop a suitable strategy

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and model for each country to realize the ultimate goal of malaria elimination.

China has made substantial progress on malaria elimination and is on the way to achieve the elimination goal on time by 2020. The lessons drawn based on experiences in China will make a good reference for the countries aiming at malaria elimination. Challenges identified in the malaria elimination process in China might help other countries formulating appropriate strategies in time and place. International collaboration is strongly advocated to achieve the

All the staffs in 31 provincial CDCs who have provided support to the data collection are

global issue to eliminate the most important infectious disease of the current times.

acknowledged. This study was supported by TDR training grant (B40084).

The authors declare jointly that there is no conflict of interest.

CDC Centers for Disease Control and Prevention

ACT Artemisinin combination therapy

**6. Conclusions**

**Acknowledgements**

**Conflict of interest**

**Acronyms**
