Table 2

Primary challenges on the way to malaria elimination and corresponding strategies in China

Stage (year)	Primary challenges	Strategies coping with challenges
The focal investigation and prevention stage (1949–1959)	High morbidity and mortality Lack of professional agencies Lack of baseline data	Establish professional agencies Carry out baseline investigation and field trials Initiate National Malaria Control Programme Notifiable disease enrolment
The severe epidemic stage (1960–1979)	Vivax malaria pandemics in central China	Mass drug administration (MDA) with prophylactic and radical medications Mass protection Initiate intranational cooperation mechanisms
The continuous incidence declining stage (1980–1999)	Severe epidemic in remote areas Unstable epidemic	Comprehensive measures based on vector habits in receptive areas with different Anopheles spp.
The control/pre-elimination stage (2000–2009)	Serious under-reporting of malaria High transmission in Yunnan and Hainan in southern China Resurgence and outbreaks in central China	Strengthen blood test, early diagnosis and appropriate treatment, LLINs (Long-lasting insecticide impregnated nets)/ITNs distribution, health education, and monitoring and evaluation with support from the Global Fund Establish web-based reporting system Target MDA in central China
The elimination stage	Lack of changes in concepts and strategies from control to elimination Border malaria Imported malaria Long-term no malaria case debilitates the health workers’ capacity	Adaptive case-centric and focus-centric comprehensive strategy and 1-3-7 approach Construction and re-inforcement of elimination-specific reporting system and diagnosis reference laboratory network Three defensive lines strategy and ‘3+1’ strategy in border areas of Yunnan province Imported malaria management through multisectoral cooperation Various capacity-building and maintenance measures