From 30 million to zero: China creates a malaria-free future
China is celebrating a major health achievement: the country has not recorded a single indigenous case of malaria since August 2016. This is a notable feat in a place where the disease has historically taken a huge toll. In the 1940s, there were an estimated 30 million cases of malaria and 300 000 deaths each year.
“I come from a village where malaria epidemics were common,” recalls Professor Yang Henglin, who is now a senior advisor on malaria at the Yunnan Institute of Parasitic Diseases. “Among my father’s generation, I had 2 older uncles who died probably as a result of severe malaria infection.”
Professor Yang has been involved in malaria control for 45 years. His work directing the malaria elimination strategy in Yunnan Province has helped lead to a dramatic drop in indigenous malaria cases: from 400 000 in 1953 to zero in 2016.
In 1955, China established a National Malaria Control Programme. Communities rallied to improve irrigation, reduce mosquito breeding grounds, use insecticide spraying and sleep under bed nets. Health authorities worked to locate and stop the spread of outbreaks.
Progress was steady. By the end of 1990, the total number of cases nationwide had plummeted to some 117 000, and malaria-related deaths were reduced by 95%.1
With support from the Global Fund to Fight AIDS, Tuberculosis and Malaria, beginning in 2003, China stepped up the training, staffing, laboratory equipment, medicines and mosquito control measures that were needed to quickly find, treat and prevent malaria cases.
Global Fund support totalling over US$ 100 million was disbursed over a 10-year period to help end malaria in 762 counties. In that time, the number of malaria cases fell to fewer than 5000 per year.
Setting the elimination goal
In 2010, China set an ambitious target: to eliminate malaria by 2020. This was a response to the country’s progress in malaria control and to the malaria target of the 2000 Millennium Development Goals, which called for halting and reversing the incidence of the disease by the year 2015.
Through a sweeping agreement, 13 ministries – including those representing health, education, finance, research and science, development, public security, the army, police, commerce, industry and information technology, media and tourism – joined forces to end the risk of malaria nationwide.
“We realized that it was necessary to cooperate with all relevant departments and involve the whole of society in order to achieve the malaria goals,” says He Qinghua, Deputy Director-General of the Bureau of Disease Prevention and Control at China’s National Health Commission.
One feature of China’s way of working is the replication of ministries and departments from the capital through to the provinces, prefectures, counties, townships and villages. If Beijing makes a policy, each level follows.
In Meng La County, on the border with the Lao People's Democratic Republic (PDR), it’s easy to find national policies translated into local action. Ms Yi Yue, Deputy Director of the county People’s Congress, explains how local ministries work closely together.
“Every year, we host a working group meeting with the 13 ministries, including the Ministries of Health and Finance, she said. “We discuss what we achieved, the current challenges, and plan strategies for the coming year. In this way, we work efficiently to achieve the goal of malaria elimination.”
In recent years, China has also fully invested in national efforts to stamp out the disease. Since 2014, the country has paid for its entire malaria elimination programme through domestic resources.
“The Government has demonstrated its commitment to malaria elimination by dedicating funding,” says Professor Yang Henglin. “Government commitment, together with the dedication of Chinese malaria experts, and the early support – in particular from the Global Fund – has led to success here.”
Ms Yi also notes that the Meng La County allots some of its own budget to the programme, as do other priority counties.
The “1-3-7” strategy
China has also implemented a highly effective surveillance strategy to find and stop malaria rapidly – before cases spread. Known as “1-3-7,” the strategy includes strict timelines to be followed to the hour.
Within 1 day, any malaria case must be reported. By the end of Day 3, the county Center for Disease Control and Prevention (known as the CDC) will have confirmed and investigated the case and determined if there is a risk of spread.
By the end of Day 7, the county CDC will have taken measures to ensure no further spread, including by testing members of the community where the malaria case was found.
Strategies lead to success
Since 2010, China has classified its 2858 mainland counties according to “types” based on the malaria burden. Each year, the number of “Type 1” and “Type 2” counties – those with malaria transmission in the last 3 years – has steadily declined to zero.
In 2016 there were only 3 indigenous cases of the disease reported nationwide.2 By 2017 and 2018, there were none. And, so far in 2019, the progress holds with zero indigenous cases reported across the country.
Continued success requires continued vigilance. Yunnan Province, which borders 3 malaria-endemic countries: Lao PDR, Myanmar and Viet Nam, will remain vigilant against imported cases of the disease.
Extra teams are trained to respond to any case of malaria using the “1-3-7” approach. The province’s 68 malaria posts are another line of defence; they are equipped with staff and microscopes to rapidly examine blood samples and report cases. China is also offering technical assistance to bordering countries, including Lao PDR and Myanmar, to help reduce malaria transmission.
In order to sustain malaria elimination, all of these measures must continue. “The threat of imported malaria will remain for a long time,” explains Professor Yang. “If we don’t maintain our efforts, it may come back.”