Establishment of provincial network to improve the ‘1-3-7’ approach
Jiangsu Province has established a malaria surveillance and response system network for malaria case finding, reporting via CRDSIS within one day, epidemiological investigation within three days, and focal/foci disposition within seven days. The system network covers provincial, prefectural, county and township levels for medical facilities and health providers (Fig. 1). In 2012, the Jiangsu provincial malaria diagnosis reference laboratory was established. The reference laboratory confirms Plasmodium species designations of all reported and suspected malaria cases and issues a monthly feedback report. In Jiangsu Province, medical facilities above the county level carry out microscopy using blood smears of malaria cases. The CDC personnel in different administrative levels are responsible for the functioning of the ‘1-3-7’ approach and the steps involved in the network system.
Population health education to improve healthcare seeking behavior
Following the guidance of the Health Administrative Department in combination with annual publicity activities of National Malaria Day on April 26, local CDC staffs conducted population-level health education campaigns on malaria by designing slogans, displaying posters, broadcasting audio-visual materials, and distributing leaflets and traditional informational pamphlets to residents and high-risk populations such as laborers engaged in outdoor work including as infrastructure construction, lumberjacks, and truck drivers in African and Southeast Asian countries. Simultaneously, and jointly with multi-sector cooperation, malaria control and prevention knowledge was disseminated through newspapers, radio, television, and other multimedia outlets. In recent years, popular social media platforms such as WeChat and Weibo have been widely used to disseminate malaria related knowledge.
Throughout the implementation of ‘1-3-7’ approach from 2012 to 2020, an estimated 61.57 million individuals have benefited in Jiangsu Province. During the annual National Malaria Week in April, public health education campaigns were carried out including: 10,483 educational DVDs distributed, 9,446 radio/television ads displayed on knowledge of malaria control, 2,548 malaria control-related articles were published in newspapers, 23,745 pieces of exhibition boards were displayed, and 49,994 bulletin boards were posted. A total of 8,023,732 leaflets were printed and 1,201,076 brochures were distributed to residents. In-person educational opportunities included 28,172 malaria knowledge consultation sessions by CDC personnel and 6,384 malaria training courses were held for medical facilities’ staff and CDC’s personnel which benefited 61.57 million people across whole province (Table 1) during the 2012–2020 period. Since 2012, the Jiangsu Institute of Parasitic Diseases (JIPD) has designed and distributed 27 types of publicity materials, including leaflets, posters, and mugs with printed malaria prevention and control information for potentially high-risk populations and local residents.
Time of healthcare seeking and malaria diagnosis of imported cases
Among the 2,423 imported malaria cases during 2012–2020, the mean and inter-quartile range of days elapsing between symptom onset and initial healthcare seeking was 1.29 days (range 0, 3). For malaria cases seeking healthcare services, 687 (28.4%) and 1,104 (45.6%) cases visited hospitals on day zero and two after symptom onset, respectively. Of the 2,423 cases, 632 visited hospitals more than three days after symptom onset (632/2,423; 26.1%). During the nine-year period, 55 (27.8%), 82 (24.1%), 88 (24.8%), 136 (33.6%), 63 (20.5%), 72 (30.1%), 83 (34.1%), 76 (31.1%) and 31 (34.4%) patients were diagnosed on day zero after seeking healthcare, respectively. For malaria cases seeking healthcare services on the same day of symptom onset, significant differences were identified during the nine year study period (χ2 = 27.27, P = 0.001) (Table 2).
Malaria diagnosis in different medical facilities
According to the surveillance and response procedures and ‘1-3-7’ approach in Jiangsu Province, malaria trainings on diagnosis and treatment, and rapid diagnostic test (RDT) usage for health facilities strengthened during the study period. Between 2012 and 2020, 2,423 imported malaria cases were reported via CRIDIS. Of the total, 1,820 (75.1%) malaria patients were diagnosed in all levels of medical facilities, and 562 (23.2%) cases were diagnosed in CDCs, including 41 (1.7%) cases diagnosed in China’s Entry-Exit Inspection and Quarantine Bureau (CIQ, China Customs). No malaria cases were diagnosed by village clinics or private clinics (Table 3). The mean and inter-quartile range of days between initially seeking healthcare and malaria diagnosis was 2.13 days (range: 0–3) during the study period. For diagnosis the same day or within two days of symptom onset by medical facilities, 1,502 (61.9%) and 540 (22.3%) cases were identified, respectively. Of the 2,423 imported cases, only 381 (15.7%) were diagnosed at three days or later. Between 2012 to 2020, a total of 1,502 (61.9%) patients were diagnosed on day zero after symptom onset, respectively. For the percentage of malaria cases confirmed on the same day as symptom onset, significant differences were observed between years (χ2 = 27.75, P = 0.001). For malaria diagnosis in the CDCs, the proportion of malaria cases diagnosed by CDCs professional personnel decreased over the year (χ2 = 171.35, P < 0.001). On the contrary, the proportion of malaria cases diagnosed by all levels of hospitals increased yearly (χ2 = 144.93, P < 0.001) (Table 3).
Indicators of the ‘1-3-7’ approach
In order to improve the implementation quality of ‘1-3-7’ approach, tabletop exercises were conducted on malaria foci disposal to evaluate the performance of CDC personnel and local medical facility staff related to the ‘1-3-7’ approach indicators. Since 2012, 100.0% of malaria cases were reported via CRDSIS by local medical facility staff within one day (24 h) of case presentation. More than 99.4% of malaria cases received individual epidemiological investigations by local CDC staff at the county level within three days and more than 98.3% were disposed of within seven days (Table 4). The proportion of foci investigated within seven days decreased to 90.0% in 2020.
Progress of malaria elimination in Jiangsu Province
From 2001 to 2020, a total of 4,877 indigenous and 5,002 imported malaria cases were reported in Jiangsu Province (Fig. 2). The majority of malaria reported between 2001 to 2010 were indigenous cases (69.0%, or 4,864 cases); 1,615 cases (22.9%) were imported from other provinces within China, and 568 cases (8.1%) were imported from other countries. From 2011 to 2020, the total of 2,797 malaria cases were reported. Of them, there were 2,784 cases were imported from other countries and only 13 of them were due to indigenous Plasmodium vivax in Jiangsu Province (all in 2011). In 2012, indigenous vivax malaria cases were eliminated, and since then all malaria cases in Jiangsu Province were imported from abroad. In the recent decade, there have been 91 severe malaria cases and eight malaria deaths, all of which were imported. There have been no introduced malaria cases in Jiangsu Province during the study period.
Beginning in 2012, Jiangsu Province initiated a county-level assessment strategy of malaria elimination progress. All 100 counties in Jiangsu Province were individually monitored and assessed on their progress toward malaria elimination, of which, Sheyang county and Liyang county first achieved the criteria for elimination and passed the assessment. By the end of 2016, all 100 counties in Jiangsu Province passed the county-level assessment. In 2017, all 13 prefectural cites in Jiangsu Province passed the municipal-level assessment of malaria elimination, and the whole province achieved the goal of malaria elimination which has since been maintained since (Fig. 3).