Establishment of a provincial network to improve the ‘1-3-7’ approach

Jiangsu Province has established a network of malaria surveillance and response system for malaria case finding, notification through CRDSIS within one day, epidemiological investigation within three days and disposal of homes/homes within seven days. The system network covers provincial, prefectural, county and township levels for medical institutions and healthcare providers (Fig. 1). In 2012, the Reference Laboratory for Malaria Diagnosis of Jiangsu Province was established. The reference laboratory confirms Plasmodium species designations of all reported and suspected malaria cases and publishes a monthly feedback report. In Jiangsu Province, medical institutions above the county level perform microscopy using blood smears of malaria cases. CDC staff at different administrative levels are responsible for the operation of the “1-3-7” approach and the steps involved in the network system.

Fig. 1

Malaria Surveillance and Response Network in Jiangsu Province, China. CDC Center for Disease Control and Prevention; TOR rapid diagnostic tests; vpn virtual private network

Population health education to improve health care seeking behavior

Following the guidelines of the Administrative Department of Health in combination with the annual National Malaria Day publicity activities on April 26, local CDC staff conducted population-level health education campaigns about malaria by designing slogans, displaying posters, broadcasting audiovisual material and distributing leaflets. and traditional informational brochures aimed at residents and high-risk populations such as laborers engaged in outdoor work including infrastructure construction, loggers and truck drivers in African and Asian countries from the South East. Simultaneously, and in conjunction with multisectoral cooperation, knowledge on malaria control and prevention was disseminated through newspapers, radio, television and other multimedia media. 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 the “1-3-7” approach from 2012 to 2020, approximately 61.57 million people have benefited from it 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/TV spots aired on anti-malaria knowledge malaria, 2,548 malaria-related articles were published in newspapers, 23,745 billboard exhibits were displayed, and 49,994 billboards were displayed. A total of 8,023,732 leaflets were printed and 1,201,076 brochures were distributed to residents. In-person education opportunities included 28,172 malaria knowledge consultation sessions by CDC staff and 6,384 malaria training courses were held for medical facility staff and CDC staff, which benefited 61.57 million people across the province (Table 1) over the period 2012-2020. Since 2012, the Jiangsu Institute of Parasitic Diseases (JIPD) has designed and distributed 27 kinds of publicity materials, including flyers, posters, and mugs with printed information on malaria prevention and control for potentially at-risk populations. high risk and local residents.

Table 1 Advertising activities on the annual National Malaria Day in Jiangsu Province, 2012-2020

Timing of care-seeking and malaria diagnosis of imported cases

Among the 2,423 malaria cases imported between 2012 and 2020, the mean and interquartile range of days from symptom onset to initial health care seeking was 1.29 days (range 0.3). For malaria cases seeking health services, 687 (28.4%) and 1,104 (45.6%) cases visited the hospital on days zero and two after symptom onset, respectively. Of the 2,423 cases, 632 went to hospital more than three days after the onset of symptoms (632/2,423; 26.1%). Over 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 seeing healthcare, respectively. For malaria cases seeking health care services on the same day of symptom onset, significant differences were identified over the nine-year study period (χ2 = 27.27, P = 0.001) (Table 2).

Table 2 Timing of health care seeking and malaria diagnosis of imported cases in Jiangsu province, 2012-2020

Diagnosis of malaria in different medical structures

According to the surveillance and response procedures and the “1-3-7” approach in Jiangsu province, trainings on malaria diagnosis and treatment and the use of rapid diagnostic tests (RDTs) for establishments of health were strengthened during the study period. Between 2012 and 2020, 2,423 imported cases of malaria were reported via CRIDIS. Of the total, 1,820 (75.1%) malaria patients were diagnosed at all levels of medical institutions, and 562 (23.2%) cases were diagnosed at CDCs, including 41 (1.7% ) cases diagnosed at the China Entry-Exit Inspection and Quarantine Bureau (CIQ, China Customs). No cases of malaria were diagnosed by village clinics or private clinics (Table 3). The mean and interquartile interval of days from initial health care seeking to diagnosis of malaria was 2.13 days (range: 0 to 3) during the study period. For diagnosis on the same day or within two days of onset of symptoms by medical institutions, 1,502 (61.9%) and 540 (22.3%) cases were identified, respectively. Of the 2,423 imported cases, only 381 (15.7%) were diagnosed three days or later. Between 2012 and 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 the onset of symptoms, significant differences were observed between years (χ2= 27.75, P= 0.001). For CDC malaria diagnosis, the proportion of malaria cases diagnosed by CDC professional staff decreased over the year (χ2= 171.35, Pχ2= 144.93, P

Table 3 Malaria diagnosis in different medical institutions in Jiangsu Province, 2012-2020

Indicators of the ‘1-3-7’ approach

In order to improve the quality of implementation of the “1-3-7” approach, table-top exercises were conducted on eliminating malaria foci to assess the performance of CDC staff and the staff at local medical facilities regarding the indicators of the “1-3-7” approach. Since 2012, 100.0% of malaria cases have been reported via CRDSIS by local medical facility staff within a day (24 h) of case presentation. More than 99.4% of malaria cases were individually epidemiologically investigated by local CDC staff at the county level within three days and more than 98.3% were cleared within seven days (table 4). The proportion of outbreaks investigated within seven days fell to 90.0% in 2020.

Table 4 Indicators of the “1-3-7” approach in Jiangsu province, 2012-2020

Progress of Malaria Elimination in Jiangsu Province

From 2001 to 2020, a total of 4,877 indigenous malaria cases and 5,002 imported cases were reported in Jiangsu Province (Fig. 2). The majority of malaria cases reported between 2001 and 2010 were indigenous cases (69.0%, or 4,864 cases); 1,615 cases (22.9%) were imported from other provinces of China and 568 cases (8.1%) were imported from other countries. From 2011 to 2020, a total of 2,797 cases of malaria have been reported. Among them, 2,784 cases were imported from other countries and only 13 of them were due to indigenous diseases. Plasmodium vivaxin Jiangsu Province (all in 2011). In 2012, indigenous cases of vivax malaria were eliminated, and since then all malaria cases in Jiangsu Province have been imported from overseas. Over the past decade, there have been 91 cases of severe malaria and eight malaria deaths, all of which were imported. There were no cases of malaria introduced into Jiangsu province during the study period.

Figure 2
Figure 2

The evolution of the malaria situation between 2001 and 2020 in Jiangsu province, China

Beginning in 2012, Jiangsu Province launched a county-level evaluation strategy of malaria elimination progress. All 100 counties in Jiangsu Province were individually monitored and evaluated on their progress towards malaria elimination, of which Sheyang County and Liyang County first met the elimination criteria and passed the evaluation. By the end of 2016, all 100 counties in Jiangsu Province had passed the county-level assessment. In 2017, all 13 prefectural cities of Jiangsu Province passed the municipal assessment of malaria elimination, and the whole province achieved the malaria elimination target which has been maintained ever since (Fig. 3).

Figure 3
picture 3

Malaria elimination progress from 2011 to 2020 in Jiangsu Province, China