China’s road to malaria elimination
China, the world’s most populous nation, has recorded zero indigenous cases of malaria since August 2016 and will soon be eligible to apply for official WHO malaria-free certification. This photo essay shows how Yunnan Province – the area of China most challenged by malaria in the recent past – has conquered this ancient disease.
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Yunnan Province in south-west China is known for its dramatic mountain scenery, verdant tea plantations, healthy rice paddies and delicious produce. The region also offers fertile breeding grounds for mosquitoes in the rainy season, including several species of Anopheles mosquitoes, which can harbour and transmit malaria. When China announced a national policy to eliminate malaria in 2010, Yunnan Province had the greatest number of counties considered at high risk for the disease.
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Over the last decade, the Yunnan Institute for Parasitic Diseases has worked hand-in-hand with the local Chinese Center for Disease Control and Prevention (CDC) to stamp out indigenous cases of the disease across the province. Here, a medical entomologist at the Yunnan Institute reaches for an Anopheles mosquito specimen. Yunnan Province is home to 8 species of this mosquito that are a vector for malaria parasites.
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China’s “1-3-7” strategy is at the core of its successful malaria elimination effort. The strategy refers to the diagnosis, investigation and follow-up of cases that must occur within 1, 3 and 7 days. On Day 1, any malaria case, confirmed by a rapid diagnostic test or microscopy and treated, must be reported to the local CDC. Here, a laboratory specialist at the Yunnan Institute for Parasitic Diseases holds blood smears that she will examine under a microscope for malaria parasites.
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By the end of Day 3, the county CDC must confirm and investigate the case and determine if there is a risk of spread. Investigators ask the person with malaria where they think they were infected, when they became sick with fever, where they have spent time, and who they have travelled with.
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By the end of Day 7, the county CDC manages any malaria risks in the areas where the person with malaria has spent time. This includes testing community members for malaria using rapid diagnostic tests or microscopy; identifying the malaria type; treating anyone with malaria; raising awareness in the community; investigating the species of mosquitoes; and reducing their numbers, including through indoor spraying of insecticides.
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A staff member from the Meng La County CDC, pictured here, demonstrates how insecticides are prepared for use in indoor residual spraying. Through this mosquito control measure, trained technicians spray the insecticide on the inside walls of people’s homes. After biting a person, Anopheles mosquitoes rest on those walls, absorb the insecticide and die.
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As a result of strict adherence to the “1-3-7” strategy, Yunnan has not had a single local malaria case for several years. But the province still faces major risks as it borders 3 malaria-endemic countries: the Lao People’s Democratic Republic (PDR), Myanmar and Viet Nam. People travel in and out of Yunnan from these countries constantly and, as a result, the province reports about 300 imported cases of malaria each year.
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When there is an imported case of malaria, health authorities must work quickly to stop it from infecting anyone locally. Additional infections can lead to a resurgence of the disease. Bai Jinhua, the head of microbiology at the People's Hospital in Meng La County, stands ready to examine any blood smears for malaria. This station is one of 68 established by Yunnan Province in border towns and villages to help rapidly identify any imported cases of the disease.
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Cooperation with neighbouring countries is another important strategy to prevent imported cases of malaria. Here, dancers mark World Malaria Day on 25 April 2019 in an event coordinated with the Lao PDR at the Mohan border crossing in Meng La County, Yunnan Province.
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The World Malaria Day event was organized by the China CDC, the Yunnan Institute of Parasitic Diseases, the People’s Government of Mengla County and the Health Bureau of Mengla County. Chen Shimei (in red), who has been working for the CDC in Meng La county on malaria elimination for 19 years, and her colleagues hold fans that explain why it is important to control malaria at the borders.
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“Every year, we see many migrant workers and tourists passing through this border,” Chen Shimei says. “We make sure people receive information booklets, and if someone is sick with malaria, we even treat them on site.” In recent months, there has been only 1 imported case of malaria identified in Meng La County. She says these educational efforts must continue to help sustain malaria elimination.