What is a WHO certification of malaria elimination?
Certification of malaria elimination is the official recognition by WHO of a country’s malaria-free status. WHO grants this certification when a country has demonstrated, with rigorous, credible evidence, that the chain of local transmission of\r\n all human malaria parasites has been interrupted nationwide for at least the past 3 consecutive years, and that a fully functional surveillance and response system that can prevent re-establishment of indigenous transmission is in place.
The malaria elimination certification process is voluntary and can only be initiated when a country submits an official request to the WHO Director-General. China initiated the process in November 2020 after reporting 4 consecutive years of zero indigenous\r\n malaria cases.
What process did WHO follow to verify China’s malaria-free status?
WHO has an established process for certifying a country’s malaria-free status. The process is explained briefly on this webpage and in greater detail in the publication Preparing for certification of malaria \r\nelimination. This same process is followed for all countries that request a malaria elimination certification from WHO.
The Malaria\r\n Elimination Certification Panel (MECP), an independent WHO advisory body, is tasked with verifying a country’s malaria-free status. After reviewing evidence submitted by countries, analysing independent sources and conducting on-site evaluation\r\n missions, the panel makes a recommendation to WHO to either certify a country as malaria-free or to postpone certification.
What were the overall impressions of MECP members and their key findings?
The MECP evaluation team found that staff at all levels of China’s health system have a sound knowledge of malaria diagnosis and management, reinforced by regular training. They noted that China provides a high quality of care for patients with\r\n malaria, as well as appropriate treatment regimens.
The evaluation team found that China has a strong malaria surveillance system capable of reliably detecting imported cases of the disease, together with other measures to reduce the risk of a re-establishment of malaria along its shared border with Myanmar,\r\n where the disease remains endemic. China’s strong commitment from both the central and provincial governments to maintaining zero malaria cases was also recognized.
Which sectors of government – beyond the health sector – contributed to this achievement?
Through an agreement signed in 2010, 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\r\n – joined forces to end malaria nationwide. Together, they formulated the \"China Malaria Elimination Action Plan (2010-2020)\", which initiated the national malaria elimination programme.
“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,” notes He Qinghua, Deputy Director-General of the Bureau of Disease Prevention and Control\r\n at China’s National Health Commission.
Working under the guidance of the provincial, county and township administrators, this multisectoral partnership contributed effectively to the elimination of malaria and will continue to play a critical role in the prevention of re-establishment of malaria\r\n transmission in China.
What innovative tools or strategies were critical for China to achieve malaria elimination?
Over the course of its 7-decade response to malaria, China has been at the forefront of innovation in new tools and strategies for beating back the disease.\r\n
In 1967, the Chinese Government launched the “523 Project”, a research programme aimed at finding new treatments for malaria. This nation-wide effort, involving more than 500 scientists from 60 institutions, led to the discovery in the 1970s\r\n of artemisinin – the core compound of ACTs (artemisinin-based combination therapies), the most effective antimalarial drugs used today. In recognition of her contributions to the discovery of artemisinin, Chinese Professor Youyou Tu was awarded\r\n the Nobel Prize in Physiology or Medicine in 2015.
Beginning in the 1980s, China was one of the first countries to extensively field test insecticide-treated nets, well before they became a WHO-recommended intervention for malaria control. The use of such nets, mainly in the provinces of Sichuan, Guangdong,\r\n Henan and Jiangsu, led to substantial reductions in malaria incidence in areas where they were deployed.\r\n
In recent years, China also created and rolled out a highly effective surveillance strategy. Known as “1-3-7”, the strategy includes strict timelines over the course of 7 days to stop malaria in its tracks and prevent onward transmission of\r\n the disease.
What were some of the other key elements behind China’s success story?
Underpinning China’s malaria elimination success was an unwavering political commitment, at all levels of government, to ending the disease over a 70-year period. China’s first malaria control strategy, issued in 1951, noted that Government\r\n should consider malaria control a “central task” of its administration, and that it should do all it could to reduce the country’s burden of the disease.
In 1956, the goal of national malaria elimination was included in the country’s agriculture and development strategies. By 1957, malaria control stations had been established in 70 counties and cities and pilot malaria control programmes were conducted\r\n in some provinces.
The country’s poverty reduction programme, which resulted in significant improvements in housing, living conditions, communications and access to health facilities, also played an important role in this story, particularly in rural areas. The programme\r\n was launched when the People’s Republic of China was founded in 1949, and further expanded in the late 1970s. Efforts to accelerate poverty reduction have intensified in recent years.
China’s commitment to universal health coverage has also been key to success. The country provides a basic public health service package for its residents free of charge; as part of this package, everyone has access to affordable services for the\r\n diagnosis and treatment of malaria, regardless of legal or financial status.
As stated in “Strategies of Healthy China 2030”, a document launched by the State Council in 2016, China will continue to improve access to preventive and curative services by reducing out-of-pocket expenditures and through further investment\r\n in public health services as well as the strengthening of health personnel training.
In recent years, why has Yunnan Province in south-western China been disproportionately affected by malaria?
When China announced a national policy to eliminate malaria in 2010, Yunnan Province had the greatest number of counties considered at risk for the disease. The province offers fertile breeding grounds for mosquitoes during the rainy season and is home\r\n to a number of species of the mosquito that are vectors for malaria parasites.
Yunnan Province also shares a border with 3 malaria-endemic countries: Lao People’s Democratic Republic, Myanmar and Viet Nam. Myanmar, in particular, carries a substantial malaria burden; during the period 2011-2019, Myanmar was the source of more\r\n imported malaria cases in China (nearly 5000) than any other country.
Over the last decade, under the leadership of the National Health Commission and the Yunnan provincial government, the Yunnan Institute for Parasitic Diseases has worked successfully with the local Chinese Center for Disease Control and Prevention to\r\n stamp out indigenous cases of the disease across the province.\r\n
What cross-border efforts have been put in place to prevent re-establishment of the disease?
Although China has eliminated malaria, the risk of imported cases of the disease remains a key concern, particularly in southern Yunnan Province. To prevent re-establishment of the disease, the country has stepped up its malaria surveillance in at-risk\r\n zones and has engaged actively in regional malaria control initiatives.
At border crossing points to neighbouring countries where malaria is still present, advocacy boards or banners are put up to warn people of the risk of malaria, and leaflets concerning malaria, dengue and other infectious diseases have been made widely\r\n available. Information on malaria is included in the curriculum of school children, especially in border provinces such as Yunnan.
Through cross-government agreements, health professionals in China have also collaborated with neighbouring countries to expand support to communities living on the other side of border.
China also faces the challenge of imported malaria cases among Chinese nationals returning from sub-Saharan Africa and other malaria-endemic regions. The country’s primary strategy against imported malaria is the maintenance of an effective surveillance\r\n system that allows for early detection of cases and an appropriate response.
How did WHO support China’s malaria elimination effort?
Since 2017, WHO has supported a group of 21 malaria-eliminating countries, including China, through a special initiative called the “E-2020”. A\r\n recent report,\r\n published in April 2021, charts their progress towards a common goal: eliminating malaria within the 2020 timeline.
To guide countries in their elimination journeys, WHO developed the 2017\r\n Framework for malaria elimination,\r\n which outlines the critical requirements needed to achieve and maintain elimination, such as national case-based surveillance systems, quality data management, and robust human and financial resources.
The Framework introduced, for the first time, the concept of verification of subnational malaria elimination, which is particularly relevant for large countries like Brazil, China and Mexico. It also offers guidance on setting targets and systems to verify\r\n malaria-free areas within a country’s borders, which can help countries prepare for national certification.
To prepare for its certification, China initiated in 2017 a subnational process whereby individual provinces were verified by the Government as malaria-free. By 2020, all 24 provinces and autonomous regions that were previously malaria endemic had received national recognition of malaria\r\n elimination.\r\n
