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Spatiotemporal Trends of Malaria in Relation to Economic Development and Cross-Border Movement Along the China–Myanmar Border in Yunnan Province

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Spatiotemporal Trends of Malaria in Relation to Economic Development and Cross-Border Movement Along the China–Myanmar Border in Yunnan Province ISSN (Print) 0023-4001 ISSN (Online) 1738-0006 Korean J Parasitol Vol. 58, No. 3: 267-278, June 2020 ▣ ORIGINAL ARTICLE https://doi.org/10.3347/kjp.2020.58.3.267 Spatiotemporal Trends of Malaria in Relation to Economic Development and Cross-Border Movement along the China–Myanmar Border in Yunnan Province Xiaotao Zhao1,2, Weerapong Thanapongtharm3, Siam Lawawirojwong4, Chun Wei2, Yerong Tang2, Yaowu Zhou2, 2 5 1, Xiaodong Sun , Jestumon Sattabongkot , Jaranit Kaewkungwal * 1Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; 2Yunnan Institute of Parasitic Diseases, Puer, Yunnan, China; 3Veterinary Epidemiological Center, Bureau of Disease Control and Veterinary Services, Department of Livestock Development, Bangkok, Thailand; 4Geo-Informatics and Space Technology Development Agency, Bangkok, Thailand; 5Mahidol Vivax Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Abstract: The heterogeneity and complexity of malaria involves political and natural environments, socioeconomic devel- opment, cross-border movement, and vector biology; factors that cannot be changed in a short time. This study aimed to assess the impact of economic growth and cross-border movement, toward elimination of malaria in Yunnan Province during its pre-elimination phase. Malaria data during 2011-2016 were extracted from 18 counties of Yunnan and from 7 villages, 11 displaced person camps of the Kachin Special Region II of Myanmar. Data of per-capita gross domestic prod- uct (GDP) were obtained from Yunnan Bureau of Statistics. Data were analyzed and mapped to determine spatiotemporal heterogeneity at county and village levels. There were a total 2,117 malaria cases with 85.2% imported cases; most im- ported cases came from Myanmar (78.5%). Along the demarcation line, malaria incidence rates in villages/camps in Myanmar were significantly higher than those of the neighboring villages in China. The spatial and temporal trends sug- gested that increasing per-capita GDP may have an indirect effect on the reduction of malaria cases when observed at macro level; however, malaria persists owing to complex, multi-faceted factors including poverty at individual level and cross-border movement of the workforce. In moving toward malaria elimination, despite economic growth, cooperative efforts with neighboring countries are critical to interrupt local transmission and prevent reintroduction of malaria via im- ported cases. Cross-border workers should be educated in preventive measures through effective behavior change com- munication, and investment is needed in active surveillance systems and novel diagnostic and treatment services during the elimination phase. Key words: Malaria, spatiotemporal trend, economic development, cross-border movement, China–Myanmar border INTRODUCTION the border areas of Yunnan Province during its pre-elimination phase. The heterogeneity and complexity of malaria involves the Several studies have noted that it is important to fully un- political and natural environments, socioeconomic develop- derstand the complex pathways between poverty and malaria ment, transportation and cross-border movement, access to so as to develop effective strategies for sustainable malaria health care services, and vector biology, factors that cannot be control [8-11]. One study on malaria and poverty suggested a changed in a short time [1-7]. This study aimed to assess the potential bidirectional relationship: poverty as a cause of ma- impact of 2 facets, economic growth and cross-border move- laria and malaria as a cause of poverty. Poverty sustains the ment, in moving toward malaria elimination in the remaining conditions in which malaria thrives, and malaria impedes eco- highly endemic areas along the China–Myanmar border, in nomic growth and keeps communities in poverty [9]. Another study reviewing the published and grey literature on malaria Received 24 September 2019, revised 2 March 2020, accepted 6 April 2020. and poverty reported that the quality of the literature examin- • Corresponding author ([email protected]) * ing this issue is highly variable, with many different measures © 2020, Korean Society for Parasitology and Tropical Medicine of socioeconomic status [11]. In assessing the economic bur- This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0) den of malaria, 2 different approaches have typically been fol- which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. lowed. i.e., the perspectives of microeconomics and macroeco- 267 268 Korean J Parasitol Vol. 58, No. 3: 267-278, June 2020 nomics. Microeconomics studies assess the direct costs of ma- ter returning. An indigenous case is a patient whose malaria in- laria prevention and treatment at individual, household, and fection was acquired from local transmission by Anopheles health service levels, with or without the estimated indirect mosquitoes within China, including malaria cases with no cost of lost work time. Macroeconomics studies assess the clear evidence of being imported from outside the country. long-term economic growth and development of malaria at As malaria is considered to be related to poverty and eco- larger scale (e.g., provincial, country level) [9]. nomic inequality, and poverty is often an underlying factor for Studies at country level examining the gross domestic prod- migration, the specific objectives of the present study were to uct (GDP) of poor countries have revealed that malaria im- examine the spatial and temporal trends of indigenous and pedes economic growth in these countries. The loss of GDP imported cases of malaria in relation to economic growth (per owing to malaria in Uganda during 2003 was equivalent to capita GDP) in the 18 border counties of Yunnan Province USD 11 million (about USD 0.43 per capita) whereas almost during the malaria pre-elimination phase and rapid economic 1.1% of GDP (about USD 2.2 per capita) is devoted to dealing development in China during 2011-2016. In addition, the spa- with malaria in Tanzania [9]. In China, Yunnan Province lags tiotemporal patterns of malaria at hotspots in adjacent areas behind other provinces in social and economic development. between Yingjiang County of China and the Kachin Special Its GDP per capita ranks 29th of 31 provinces [12]. One study Region II (KSR II) of Myanmar was analysed to examine in Yunnan noted that poverty and malaria appear to have a changes in the persistently high incidence of border malaria clear inverse relationship, with residents living along the bor- during the same period. der experiencing greater degrees of poverty and malaria infec- tion than those in other regions of this province [10]. MATERIALS AND METHODS The challenge of countries nearing malaria elimination is of- ten owing to international borders with countries that have not Study area yet achieved substantial reductions in malaria transmission Yunnan shares a long border with 3 malaria-endemic coun- [12]. Cross-border movement of infected individuals from en- tries: Myanmar, Laos, and Vietnam. The study area in the pres- demic areas to neighboring countries has been recognized as a ent investigation refers to 18 border counties within Yunnan contributor to the spread of malaria in Asia and Africa [1,13- Province in China and one special region in Myanmar. The 15]. Cross-border malaria transmission and reintroduction is border area on the Myanmar side includes internally displaced the main challenge for China as it shares 4,060 km of porous populations fleeing war. The 18 counties along the China– international borders with Greater Mekong Subregion (GMS) Myanmar border in Yunnan share a 2,185-km land border. countries. The China–Myanmar border is particularly challeng- This area had an annual average total population of 4.8 mil- ing owing to ongoing conflict on the Myanmar side of the bor- lion during the years 2011-2016. The elevation varies greatly, der, resulting in uninterrupted disease transmission [16-22]. from 210 m to 4,878 m. Cross-border trade, logging, quarry- Yunnan faces a problem similar to most GMS countries in that ing, mining, and plantation work are frequent labor activities border malaria is a major source of disease transmission, and performed at the border regions, and it is difficult to manage malaria parasites are introduced via porous borders by highly these mobile populations of workers [10,32]. mobile human populations [13,23-25]. In 2011-2013, import- Specifically, the study explored adjacent areas in the 2 coun- ed malaria infections accounted for more than 70% of all cases tries, Yingjiang County of China and the KSR II of Myanmar of malaria in Yunnan [26-29]. Another threat of malaria intro- (Fig. 1). Yingjiang County is located in the western part of duction is owing to internally displaced persons (IDPs) from Yunnan Province and shares a 214.6-km border with Kachin neighboring Myanmar, where the malaria situation is far worse State in western Myanmar. The county’s land area is 4,429 km2 than that in Yunnan [30,31]. The Technical Scheme of China and features mountains and alluvial plains, with elevations Malaria Elimination defined malaria cases as “indigenous case” ranging from 210 m to 3,404.6 m. The climate is subtropical. or “imported case”. An imported case is a patient who diag- Yingjiang County has 15 townships, 103 village committees, nosed with malaria with a history of travelling to overseas ma- 1,148 natural villages, and a total population of 310,000. Nine laria-endemic areas during the malaria-transmission season, townships border Myanmar. KSR II has a land area of about and the onset of malaria symptoms was less than 1 month af- 287 km2 with a total population of around 60,000; most local Zhao et al.: Spatiotemporal trends of malaria along China–Myanmar border 269 Study Area Average GDP Indigenous case Imported case Total case 4,000 700 3,500 600 No. of malaria cases 3,000 500 2,500 400 2,000 300 1,500 200 1,000 Per capita GOP (US$) 100 500 0 0 2011 2012 2013 2014 2015 2016 A B Fig.
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