The People's Republic of China

Programme goal

National goal: to eliminate malaria by 2020.1
Sub-national goal: no indigenous cases outside of Yunnan province by 2015.1

Epidemiological context

  • Major plasmodium species: P. falciparum (58%), P. vivax (42%).2
  • Major anopheles species: An. sinensis, anthropophagus, dirus, minimus.2
  • Malaria attributed deaths in 2012: 14.2
  • Malaria endemicity by population: It is estimated that 42% of the population in China live in low transmission areas and 58% of the population live in malaria-free areas.2 Malaria transmission limits are illustrated below.3
  • Indigenous and imported malaria: Malaria transmission in China is focused in 2 provinces. In 2012, Hainan province reported no indigenous cases and 13 imported cases, and Yunnan province reported 853 malaria cases and 679 imported cases.4
  • P. falciparum transmission limits in China 2010, Malaria Atlas Project
  • P. vivax transmission limits in China 2010, Malaria Atlas Project

Elimination strategy

Details of China's malaria elimination strategy are given in the APMEN publication,5 here we provide an overview some of the elements of the approach.

  • G6PD: pilot testing of G6PD deficiency screening is ongoing and roll‐out of G6PD screening to be implemented in all P. vivax endemic areas with high prevalence of G6PD deficiency pending results of pilot tests.
  • Drug strategy: focused Mass Drug Administration (MDA) 'Spring Treatment' program provides 180 mg primaquine over 8 days for patients who had P. vivax in the year prior, close contacts of positive P.vivax cases in the year prior, and occasionally entire villages; efficacy of this program is currently under study.6
  • Vector control strategyindoor residual spraying is used at all foci with any malaria incidence.
  • Surveillance-response: '1-3-7' strategy, based on the national web-based case reporting system, reporting malaria cases within 1 day, confirmation and investigation within 3 days, and appropriate public health response to prevent further transmission within 7 days.7 All residents in the village of a confirmed case are screened with microscopy or PCR, plus GPS to record the locations of positive cases.
  • Entomological surveillancevector species identification, density, and insecticide resistance are monitored at sentinel sites.
  • High risk populationshigh risk populations identified are poor ethnic groups, forest workers, ethnic minority groups, highly mobile populations and adult males (because of work context and propensity to sleep outside without a bednet). Mobile medical teams are used to improve malaria treatment to migrant workers and local residents at Myanmar border. Targeted interventions planned to increase coverage of high risk populations by 2015: Border crossers at Yunnan/Myanmar border - distribute 'malaria packs' of LLINs, prophylactic medications, behaviour change communication materials; Hainan Forest Workers - behaviour change communication materials and extra LLINs for use overnight in forest; Anhui Migrant workers: provide BCC materials through peer groups; ethnic minority groups with higher G6PD deficiency prevalence - modify case management policy as appropriate after screening test piloted; pregnant women and children: distribute LLINs through antenatal clinics.
  • Private sectorapprox. 80% of malaria cases are diagnosed in the private sector, usually in the villages. Strengthening diagnosis, treament and reporting is planned.
  • Advocacy and education: health education and BCC is provided to school students and is to be strengthened; high-risk groups (forest workers, migrants workers) receive BCC from peer groups and NGOs; and Chinese nationals who travel to endemic countries receive pre-departure information, text message campaigns during transmission season, and are screened and treated at airports upon return. 
  • Chain of events conducted within the 1-3-7 surveillance-response time windows. 4
  • Data reporting and feedback system for 1-3-7 surveillance-response in China. 4

Operational research portfolio

  • Operational research to characterize the distribution and types of G6PD deficiency.8
  • Comparing the efficacy of the Chinese primaquine regimen with the WHO recommended regimen.8
  • Molecular studies to better understand the epidemiology of P. vivax relapses versus re-infections.8
  • Use of molecular epidemiology techniques in concert with spatio-temporal data for the identification of the origin of the parasite.8

Challenges

  • Anopheles sinensis is the primary P. vivax vector in China and climate change may contribute to improving its efficiency and lifespan by increasing temperatures.5
  • Populations at risk of malaria including people who are crossing the Yunnan/Myanmar border, forest workers, migrant worker pose a challenge to the malaria programme since they are often hard to reach. China's elimination strategy includes numerous plans to implement targeted delivery of health services and supplies (as outlined above).5
  • Imported malaria infection is a challenge in China.4,5

Lessons learnt

  • Surviellance is a core intervention in China's elimination strategy.
  • 'Spring treament' as a focal MDA strategy using primaquine has been used and the program is under study.6

References

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