Huang et al. Infect Dis Poverty (2020) 9:158 https://doi.org/10.1186/s40249-020-00777-1 RESEARCH ARTICLE Open Access From control to elimination: a spatial-temporal analysis of malaria along the China-Myanmar border Fang Huang1, Li Zhang1, Jing‑Bo Xue1, Hong‑Ning Zhou2, Aung Thi3, Jun Zhang4, Shui‑Sen Zhou1, Zhi‑Gui Xia1* and Xiao‑Nong Zhou1* Abstract Background: Malaria cases have declined signifcantly along the China‑Myanmar border in the past 10 years and this region is going through a process from control to elimination. The aim of this study is to investigate the epidemiology of malaria along the border, will identify challenges in the progress from control to elimination. Methods: National reported malaria cases from China and Myanmar, along with the data of 18 Chinese border counties and 23 townships in Myanmar were obtained from a web‑based diseases information reporting system in China and the national malaria control program of Myanmar, respectively. Epidemiological data was analyzed, includ‑ ing the number of reported cases, annual parasite index and proportion of vivax infection. Spatial mapping of the annual parasite index (API) at county or township level in 2014 and 2018 was performed by ArcGIS. The relationship of malaria endemicity on both sides of the border was evaluated by regression analysis. Results: The number of reported malaria cases and API declined in the border counties or townships. In 2014, 392 malaria cases were reported from 18 Chinese border counties, including 8.4% indigenous cases and 91.6% imported cases, while the highest API (0.11) was occurred in Yingjiang County. There have been no indigenous cases reported since 2017, but 164 imported cases were reported in 2018 and 97.6% were imported from Myanmar. The average API in 2014 in 23 Myanmar townships was signifcantly greater than that of 18 Chinese counties (P < 0.01). However, the API decreased signifcantly in Myanmar side from 2014 to 2018 (P < 0.01). The number of townships with an API between 0 and 1 increased to 15 in 2018, compared to only fve in 2014, while still four townships had API > 10. Plas- modium vivax was the predominant species along the border. The number of reported malaria cases and the propor‑ tion of vivax infection in the 18 Chinese counties were strongly correlated with those of the 23 Myanmar townships (P < 0.05). Conclusions: Malaria elimination is approaching along the China‑Myanmar border. However, in order to achieve the malaria elimination in this region and prevent the re‑establishment of malaria in China after elimination, continued political, fnancial and scientifc commitment is required. *Correspondence: [email protected]; [email protected] 1 National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Chinese Center for Tropical Diseases Research, WHO Collaborating Center for Tropical Diseases, National Centre for International Research on Tropical Diseases, Ministry of Science and Technology, Key Laboratory of Parasite and Vector Biology, Ministry of Health, Shanghai 200025, China Full list of author information is available at the end of the article © The Author(s) 2021. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Huang et al. Infect Dis Poverty (2020) 9:158 Page 2 of 13 Keywords: Malaria, Control, Elimination, China–Myanmar border Background Eliminate Malaria in the Greater Mekong Subregion by Malaria is a life-threatening disease caused by Plasmo- 2030” in 2018 [7]. dium parasites that are transmitted to human through Historically, malaria was one of the most serious infec- the bites of infected female Anopheles mosquitoes. It tious diseases in China [8]. During the past six decades, remains one of the most common infectious diseases in China has made great contributions towards malaria the world, with the number of confrmed cases estimated control [8]. In 2010, the Chinese government launched at 228 million with 405 000 deaths in 2018, compared the National Malaria Elimination Programme (NMEP) with 416 000 estimated deaths in 2017 and 585 000 in 2010–2020 with the goal of eliminating malaria by 2020, 2010 [1]. Te emergence and spread of artemisinin resist- sustaining a malaria-free status and prevent re-estab- ant Plasmodium falciparum has become one of the great- lishment beyond 2020 (Fig. 1) [9, 10]. Over the follow- est challenges to malaria control and elimination in the ing 5 years, malaria cases decreased substantially. In Greater Mekong Subregion (GMS) [2–5]. Recent eforts 2017, no indigenous malaria cases were reported for the to fght malaria in the GMS have yielded impressive frst time [11]. In 2020, China is close to malaria elimi- results. According to the latest World Health Organiza- nation nationwide. However, Yunnan Province in south- tion (WHO) estimates, the reported number of malaria ern China, which borders Myanmar, Vietnam and Laos, cases fell by 76% between 2010 and 2018, and malaria remains the key focus of the NMEP. deaths fell by 95% over the same period [1]. Driven by the Myanmar has the highest malaria burden and is a major artemisinin resistance, WHO has implemented a strat- source of malaria exportation in the GMS [12, 13]. In the egy to eliminate P. falciparum from six countries in the past decade, Myanmar has made signifcant progress in GMS by 2025, in response to the threat of an untreatable reducing malaria morbidity and mortality with the fnan- multi-drug resistant parasite [6]. Representatives from cial support for major improvements in access to early six countries signed the “Ministerial Call for Action to diagnosis and appropriate treatment. Malaria morbidity Fig. 1 Timeline and milestones of malaria elimination in China and Myanmar. NMEP National Malaria Elimination Programme Huang et al. Infect Dis Poverty (2020) 9:158 Page 3 of 13 was reduced by 72% in 2016 compared with 2012 and remarkably and the progress was made possible through there was a 95% reduction in malaria deaths within the greater access to efective malaria control tools, particu- same period [14]. However, Myanmar was still reported larly artemisinin-based combination therapies (ACTs) to account for the majority of malaria cases and deaths in for malaria treatment, rapid diagnostic tests (RDTs), and the GMS [7, 15, 16]. Meanwhile, confict-afected settings insecticide-treated nets (ITNs). Terefore, we undertook and regions with high population mobility have enhanced a spatial and temporal analysis to investigate the chang- the programmatic challenges of moving towards elimi- ing pattern of malaria along this border and identify the nation [17–19]. Following the recommendation by the key priorities and challenges in the progress from malaria WHO Malaria Policy Advisory Group to eliminate P. control to elimination. falciparum malaria in the GMS by 2030 in 2014, which was technically, operationally and fnancially feasible, in Methods 2016 the National Malaria Control Programme (NMCP) Study site in Myanmar set the goal of eliminating P. falciparum Te study areas include 18 counties in Yunnan Province, malaria by 2025 and eliminating malaria in all states and China and 23 townships in Kachin, North Shan and East regions by 2030 (Fig. 1) [20]. Shan states of Myanmar (Fig. 2). A total of 18 counties in Yunnan Province, China and Yunnan Province, located in the southern China, 23 townships in Myanmar share the border of 1997 km. spans approximately 394 000 km2 with a population Te border areas on both sides are outlying, hard to reach of 48.3 million. Yunnan has high mountains border- and poverty-stricken inhabited by the minority nationali- ing Tibet and Sichuan in the west, a hilly plateau in the ties [21]. Currently, there are 13 national and provincial east bordering Guangxi and Guizhou provinces/auton- frontier ports, 427 passageways and countless shortcuts omous regions, and a tropical zone in the south shar- along the border. Te climate, landscape and vectors of ing the border with Vietnam, Laos, and Myanmar. Te malaria transmission on both sides of the border are sim- average daily high temperature is around 24° centigrade ilar. In the last 10 years, malaria incidence has declined and the climate is almost moderate, but also ofers a Fig. 2 Map of the borders between the China and Myanmar. The China map is from National Geomatics Center of China with the link https:// www. ngcc. cn/ ngcc/. And the map is correct by checking with that from the web link: https:// bzdt. ch. mnr. gov. cn/ Huang et al. Infect Dis Poverty (2020) 9:158 Page 4 of 13 few sultry months with high humidity and high temper- Data analysis atures. In the western Yunnan, it has distinct dry and Data analysis was processed using Microsoft Excel 2017 rainy seasons. A total of 18 counties lie along the bor- and SAS software (SAS Institute Inc, Version 9.2, Cary, der with Myanmar.