Malaria is an ancient disease with records that can be traced back to more than 3,500 years ago in oracle-bone inscriptions in China. The past centuries have witnessed several disasters by malaria-caused mortality and morbidity. In the early years after the founding of the People’s Republic of China, approximately 80% of the population was under malaria threat, and the disease was prevalent in nearly 70% of counties (2-5). In 1954, 6.97 million malaria cases represented a national incidence rate of 12.29 per 1,000 estimated (Figure 1). There were still more than 24 million cases in 1970 (6). In China’s malaria control campaign, concerted efforts for generations have led to an unprecedented descending incidence from 122.9/10,000 (6.97 million cases) in 1954 to 0.06/10,000 (7,855 cases) in 2010 (Figure 1). In response to the global malaria eradication initiative prompted by the Millennium Development Goals, China issued the National Action Plan for Malaria Elimination in China (2010–2020) in 2010: laying down the main objectives as eliminating malaria in most counties by 2015 and over the whole territory by 2020. In 2016, China was included by the WHO in the Elimination-2020 (E-2020) initiative as one of the 21 potential countries to reach malaria elimination by 2020. In 2017, for the first time, China reached the critical milestone of zero indigenous malaria cases (7). Zero indigenous transmission has been maintained for 4 consecutive years, achieving the goal proposed in the E-2020 initiative and the National Malaria Elimination Action Plan. Ultimately, on June 30, 2021, China was officially certified malaria-free by the WHO.
Malaria incidence in different periods and corresponding primary strategies in China.
Note: Focal investigation and prevention stage (1949–1959); Severe epidemic stage (1960–1979); Incidence declining stage (1980–1999); Control/pre-elimination stage (2000–2009); Malaria elimination stage (2010–2020).
During the focal investigation and prevention stage (1949–1959), in light of high morbidity and mortality, lack of professional agencies, and lack of baseline data, China instituted professional agencies nationally and conducted baseline investigations and field trials for the national malaria control program. Notably, China defined malaria as a notifiable disease in 1956, which highlighted the hazards and importance of the disease for the first time.
The severe epidemic stage (1960–1979) was characterized by vivax malaria pandemics in central China. Therefore, China conducted mass drug administration (MDA) with prophylactic and radical medications and initiated intranational cooperation mechanisms where the epidemic was unstable and endemic.
Through the comprehensive strategies in remote areas with severe outbreaks during the incidence declining stage (1980–1999), combined with prevention and control measures adopted in an earlier stage, malaria incidence declined continuously.
During the control/pre-elimination stage (2000–2009), despite case decline, China still faced severe issues in combating malaria: serious underreporting and high transmission in the Yunnan and Hainan provinces of southern China, and resurgence and outbreaks in central China. In response, China strengthened blood tests, early diagnosis, and appropriate treatment to solve these problems. Free mass distribution of long-lasting insecticide-treated nets (LLINs), health education, and monitoring and evaluation were also conducted with the support from the Global Fund, which offered important stimuli towards malaria elimination. More importantly, China established a timely, web-based reporting system and conducted targeted MDA in central China, which substantially reduced incidence to a record low: indicating the feasibility of eliminating malaria (5,7-8).
When China entered the malaria elimination stage (2010–2020), many institutions at the provincial or county levels still followed previously-used strategies. As a result, they overlooked the changes in concepts and methods necessary during the transition from the control to elimination stages. Consequently, the adaptation of alternative strategies at these governance levels was urgently needed. This involved setting priorities and operationalization based on local malaria epidemiology and robustness of the health system. These transitions required tailored responses, including an adaptive case- and focus-oriented comprehensive strategy and “1-3-7” approach, constructing and reinforcing elimination reporting systems, and implementing a diagnosis-reference laboratory network (7,9). Based on the successful experience of previous pilot trials on malaria control and elimination, Yunnan Province put forward and carried out a defensive 3-pronged strategy, as well as a “3+1” strategy (+1 was an extended buffer zone in Laiza City of Myanmar with a length of 20.5 km and a width of 2.5 km), in border areas to guarantee universal surveillance coverage and rapid response to any re-establishment of transmission (9-10).
In addition, regarding the management of imported malaria cases, an effective malaria detection and management system for migrant populations is essential: especially through multi-sectoral cooperation. Various capacity building and maintenance of malaria detection, diagnosis, treatment, and response are a fundamental components of keeping vigilance and the key to achieving elimination. Through these initiatives, China has continuously scaled up its efforts to realize its malaria-free status. Integrated cooperation, efficient information sharing, and action coordination between sectors, regions, and provinces fueled the progress in the last mile towards elimination in China.