Distribution of malaria patients seeking care in different types of health facilities during the implementation of National Malaria Elimination Programme

Malaria is one of the most prevalent mosquito-borne infectious diseases in the world, which can have a damaging impact on society and the economy [1‐3]. According to the latest available data, an estimated 228 million malaria cases occurred worldwide, and 405,000 deaths associated with malaria were reported in 2018 [4, 5]. Malaria had been prevalent since the foundation of the People’s Republic of China [6]. After the Chinese government put a great deal of efforts into the control of malaria epidemics, the morbidity and mortality rates of malaria had reached their lowest level historically in the late twentieth century [7]. However, after 2000, a malaria resurgence occurred in China, and peaked in 2006 with approximately 64,178 malaria cases reported [8‐10]. China immediately launched the National Malaria Control Programme (2006–2015) with the partnership of the Global Fund project [11, 12]. With the effective implementation of measures, such as multi-sectorial cooperation and communication strategy, the incidence of autochthonous malaria cases had declined sharply during the period 2006–2010 in China [13‐15].

After 2010, the epidemiology of malaria was different from that in the past. Almost all cases were imported cases due to the increasing number of immigrant workers and foreign travellers [16]. At the same time, the area where malaria transmission was occurring during this period in China had expanded from 24 traditional malaria-endemic provinces to 31 provinces across the country. Most patients suffering from malaria were low-literacy labourers from rural areas, and their awareness of being infected with malaria was low. Despite they were suffering from malaria, the initial symptoms of these patients were fever, chills, and sweating [17]. They always sought care at a grassroots medical institution nearby with symptoms of cold. Some previous studies also reported deaths from malaria patients who developed severe illnesses due to misdiagnosis by grassroots medical institutions [18, 19]. In 2010, in order to enable malaria patients to receive timely treatment within the county area and reduce delays, the Chinese government also had launched the National Malaria Elimination Programme (NMEP) (2010–2020) [3, 8, 20]. Through this action plan, the government had strengthened the training of malaria diagnosis and treatment for clinicians in different types of health facilities to achieve the goal that all health facilities had the ability to diagnose malaria along with the hospitals at all levels, which had the ability to treat malaria by 2015 [21, 22]. In China, the Centers for Disease Control and Prevention (CDCs) provide malaria diagnostic services and free anti-malarial medications; clinics, township hospitals, and hospitals at all levels perform both diagnostic and treatment services [23]. If the township hospital failed to treat malaria patients after making an exact diagnosis, patients would be referred to county-level or higher-level hospitals [24].

As a category B notifiable infectious disease in China, health facilities at all levels have the responsibility to report malaria cases within 24 h after diagnosis according to the law on the Prevention and Control of Infectious Diseases [25]. In a way, if patients were diagnosed as malaria, their visits to health facilities would be recorded. Some studies have also described the distribution of malaria patients seeking care in different types of health facilities based on the reporting data [26]. However, there are few studies focus on the proportions of malaria patients seeking care in hospitals within county-level or prefecture-level areas. To address this knowledge gap, this study describes the distribution of malaria patients in different types of health facilities, and the proportions of patients seeking care in hospitals within county and prefectural administrative area in the context of the eradication phase of malaria.

This study presents the distribution of malaria patients seeking care in different types of health facilities and describes that most patients seeking care in provincial-level and prefecture-level hospitals were from areas where they lived far away from hospitals they visited. In this study, it was found that most malaria patients sought care in hospitals, followed by township hospitals and CDCs. This may be due to the fact that most patients were imported Plasmodium falciparum during post-stage of malaria elimination [32]. Patients with falciparum malaria were often in poor health, and needed timely medical first aid. Therefore, hospitals were playing an increasingly important role in the reporting, diagnosis, and treatment for them [33]. Compared with other provinces, the proportion of patients seeking care in township hospitals was slightly lower than the proportion of patients seeking care in hospitals in Yunnan, at 43.3%, which was much higher than that in other provinces. Yunnan province has international borders with Myanmar, Vietnam, and Laos, where malaria had been endemic. Most cases in Yunnan had been imported from these countries. The number of malaria cases in Yunnan once ranked first historically [34, 35]. Because malaria was a common disease in Yunnan, clinicians at local township hospitals had experience in treating malaria.

For patients seeking care in hospitals, it could be seen that proportions of patients seeking care in tertiary hospitals were much higher than any other two types of hospitals in most provinces except Yunnan province. One question was whether it was because these patients had more convenient access to tertiary hospitals that led to a higher proportion of that. It was found that the proportion of within county patients in tertiary hospitals in Yunnan was only 13.6%, which meant that most patients in tertiary hospitals came from other counties where far away from the tertiary hospitals. In China, each county generally has one or more county-level hospitals, and these hospitals usually belong to secondary hospitals. Why did they not go to the secondary hospital? There were maybe two reasons. One reason was that maybe clinicians in secondary hospitals failed to make an exact diagnosis as malaria, and then they referred patients to higher-level hospitals. Another reason was that patients might think that tertiary hospitals could provide better treatment services, and they would like to seek care in tertiary hospitals directly [36, 37]. The fact is that many patients would seek care in tertiary hospitals directly. However, the proportions of patients seeking care in hospitals within county-level areas were also low. It is speculated that maybe clinicians in secondary hospitals could not make a malaria diagnosis and treatment [24].

However, the proportions of patients seeking care within prefecture-level areas were relatively high in most provinces. It seemed that most malaria cases could be treated in prefecture-level areas. Compared with patients who sought care outside their prefecture-level areas, patients who sought care within prefecture-level areas would save time and prevent the delay and deterioration of the disease [38]. In the post-malaria eradication phase, it may be necessary to designate a hospital for malaria treatment in each prefecture-level area [39].

The characteristics of the distribution of patients seeking care in different types of hospitals between provinces varied greatly. As for Jiangsu province, both the proportions of patients seeking care within county-level areas and the proportions of patients seeking care within prefecture-level areas were much higher than that in other provinces. This meant that most malaria patients could be treated in hospitals within the prefecture-level and county-level areas, which was the goal that NMEP set. The measures taken by Jiangsu province to control the malaria epidemic were unique. The number of imported malaria cases in Jiangsu had been ranked third nationwide, and the number of falciparum malaria cases ranked first in the nation [40, 41]. The Jiangsu government put great importance on the elimination of malaria, and Jiangsu took the lead in putting forward the “1-3-7” approach: case reporting within 1 day, case investigation within 3 days, and case investigation and disposal of the epidemic within 7 days [42]. Meanwhile, various forms of technical training were carried out annually, and almost all staffs in various health facilities mastered the malaria Rapid Diagnostic Tests (RDTs) [43‐45]. As a result, patients could be diagnosed and treated within county-level and prefecture-level areas.

This study has at least three limitations. First, the number of cases reported by the sample hospitals and the location of the sample hospitals were considered in the selection of sample hospitals. Hospitals with a small number of reported malaria cases were not be prioritized for inclusion. Second, the actual sample cases were lower than expected due to the reluctance of sampled hospital staff or the loss of cases due to the renewal of the electronic case system. For example, only 41 cases were collected in Anhui Province, which would lead to unstable analysis results in Anhui. Third, this study focused on the hospitals reporting the cases. There may be some patients who went to other hospitals for medical services before they were diagnosed in the hospitals reporting the cases.

This study described the distribution of malaria patients in different types of health facilities, and the proportions of patients seeking care in hospitals within county and prefectural administrative areas during the implementation of National Malaria Elimination Programme. During the implementation of the NMEP, malaria patients tended to seek care in tertiary hospitals and prefecture-level hospitals, and most patients could be treated in hospitals within prefecture-level areas. A lower proportion of patients seeking care within county-level areas reminded that the diagnosis and treatment capacity of county-level hospitals may be insufficient, which may lead to delays in malaria treatment, resulting in life-threatening and huge economic burden. In the elimination stage of malaria, the scope and extent of the malaria epidemic has fallen to its lowest level in history. Local governments should formulate corresponding prevention and control strategies according to their regional realities. It is necessary to continue to strengthen the monitoring of fever symptoms in people entering the epidemic areas [46], and consolidate the ability of clinicians in grassroots medical institutions to carry out RDTs and microscopic examination, and establish referral system from grassroots medical institutions to hospitals designated for malaria treatment.