China eliminated malaria. Could it be a model for the rest of the world?

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Jun Cao has spent his entire career in the battle against malaria and witnessed the historic moment earlier this year when China was officially certified free of the mosquito-borne deadly disease.

But for public health experts such as Cao, who is deputy director of the Jiangsu Institute for Parasitic Diseases, passing that milestone simply means moving to a new phase in which China plays a different role: applying the Chinese experience in the global fight against malaria, particularly in Africa and the Greater Mekong Subregion.

Africa accounted for 94 per cent of the malaria cases and deaths worldwide in 2019, a year in which there were an estimated 229 million cases and 409,000 deaths from the disease.

But the Greater Mekong Subregion has also become a serious concern after it gave rise to several drug-resistant strains of malaria parasites.

“We used to receive help or technology from others, but in recent years we have been working more with less developed countries and taking on the role of exporting technology,” Cao said. “With domestic and international collaboration, we eliminated malaria in China, which I believe will free the world of malaria.”

In the annual Goalkeepers Report released by the Bill & Melinda Gates Foundation last week, China was praised for not stopping at its own accomplishment but going on to help other countries eliminate malaria, including adapting and sharing lessons learned, supplying antimalarial drugs and products, supporting Africa to establish a robust public health system and funding raw materials and technical support.

“China has enormous capacity and potential for innovation and a strong commitment to help address the health and development challenges facing developing countries,” said Yang Jianyue, deputy director of the Gates Foundation’s China office.

The foundation was working with two Chinese universities on biosynthetic artemisinin research which, if successful, could significantly bring down the price of artemisinin and ensure a continuous supply and greater access in low-income countries, Yang said.

The Chinese Academy of Sciences was also working to find new, safer and more environmentally friendly drugs to kill mosquitoes in response to the problem of insecticide resistance, she added.

Artemisinin was developed in China and first extracted from sweet wormwood in 1972 by Nobel Prize laureate Tu Youyou and her colleagues after years of experiments.

Today, artemisinin-based combination therapy is the best available treatment for malaria.

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Artemisinin-based drugs, together with other large prevention and control measures, helped China bring the incidence of malaria from 30 million cases a year in the 1940s to 30,000 a year in the late 1990s.

In 2010, a national action plan to eliminate the local transmission of malaria by the end of 2020 was made and soon a new surveillance and response strategy – known as the 1-3-7 approach – was imposed across the country.

The strategy requires reported malaria cases to be confirmed within one day, investigated by a local public health facility within three days and authorities to have control measures in place to prevent further transmission within seven days. China has not reported any local transmission since 2017.

Along the way during the anti-malaria struggle China has also benefited from international collaborations, including a U$100 million support provided by the Global Fund, which lasted from 2003 until 2013. Since then, China has become a donor and a strategic partner, ranking the 20th largest public donor to the Global Fund with US$63 million in contributions.

“Now we see China’s critical role in the wider global effort,” said Scott Filler, who heads the Global Fund’s malaria programme. “We’ve accumulated experience that we need to look at and learn from. We understand that producing technologies can be useful. We see this as innovation in antimalarial products. So, particularly all these efforts collectively can really help the global effort.”

Filler said the private sector in China could play a pivotal role in defeating malaria. The Global Fund had bought more than US$600 million worth of malaria drugs and bed nets from Chinese companies.

“It showed how critical this partnership is between private-sector manufacturers and the communities that we serve,” Filler said.

China could also help fill funding gaps in seasonal malaria chemoprevention, giving antimalarials to children in high transmission areas and applying the 1-3-7 approach in other places, he added.

The health care system and basic infrastructure are different in Africa and there are doubts whether health systems in Africa can carry out the 1-3-7 strategy.

However, Cao from the Jiangsu Institute for Parasitic Diseases said China’s experience of different disease control stages – including universal drug use, community participation, technical training, joint prevention and control measures in provinces where malaria was most prevalent – could still benefit African countries.

“The most valuable experience to Africa is … suiting measures to local conditions and giving guidance to different categories, because China had adopted recommendations by the World Health Organization and adapted them according to our actual situation. If Africa adapts China’s experience according to local conditions, it will achieve a better effect,” Cao said.

A pilot programme in Tanzania found the case review and epidemiological investigation – the three days of the 1-3-7 approach – was not possible with its allocation of local public health resources and skipped it, a strategy found to be better suited to that environment and significantly reduced the disease incidence.

The WHO is now trying to extend the 1-7 model to other areas with a higher malaria incidence, such as other parts of Tanzania, Zambia, Burkina Faso and Senegal. The approach was introduced by the WHO under a 2018 guideline to instruct malaria control programmes worldwide, especially in countries or regions where malaria was close to elimination.

“Even if the 1-3-7 approach isn’t exactly adapted, it embraces the public health notion of having a complex network where disease can be identified, recorded and reported, the appropriate response happening in a timely fashion, and these are the cornerstones of a public health response,” Filler said. “They are critical for malaria elimination. They’re important for Covid-19 and are responsible for any other disease state that we attack.”

In the Greater Mekong Subregion where resistant strains of the malaria parasite have been identified, the best way to get rid of resistant parasites is to get rid of all the parasites, but eliminating cross-border malaria could be complex, according to Filler.

“What we’re trying to learn from the lessons of China is not only getting rid of malaria within its areas but also helping its neighbouring countries too,” he said.

Helping in the global fight against malaria is in China’s interest, too, especially when the country’s focus shifts to around 3,000 imported cases a year.

“Border control is strictly regulated during the Covid-19 epidemic, but little can be done to stop mosquitoes from crossing the border, which has become a big challenge for China. There are also many cases of imported malaria that have been imported from Africa. With such a threat, malaria is likely to return,” Cao said.

The incidence of malaria was expected to rise significantly as soon as the malaria control project ceased, which had occurred in African nations as well as developed countries elsewhere, according to Cao.

“The only way to prevent such a resurgence is to work with the WHO [and] the Global Fund to strengthen malaria control, not only in the Greater Mekong Subregion, but also in Central Africa, so as to eliminate the threat of a resurgence [in China].”

This article was first published in South China Morning Post.