Malaria burden and treatment targets in Kachin Special Region II, Myanmar from 2008 to 2016: A retrospective analysis
Malaria burden and treatment targets in Kachin Special Region II, Myanmar from 2008 to 2016: A retrospective analysis
Hui Liu 0 1
Jian-Wei Xu 0 1
Yaw Bi 1
0 Yunnan Institute of Parasitic Diseases, Yunnan Provincial Centre of Malaria Research, Yunnan Provincial Key Laboratory of Vector-borne Diseases Control and Research, Yunnan Provincial Collaborative Innovation Center for Public Health and Disease Prevention and Control , Pu'er City , China , 2 Laiza City Hospital , Laiza City, Kachin Special Region II , Myanmar
1 Editor: Laurent ReÂnia, Agency for Science, Technology and Research - Singapore Immunology Network , SINGAPORE
Data Availability Statement: All relevant data are
within the paper and its Supporting Information
Funding: National Natural Science Foundation of
China (NSFC/81560543) funded to collect and
analyse the data. Dr Liu received the grant.
Funder's website: https://isisn.nsfc.gov.cn/
egrantweb/. The funders had no role role in study
design, data collection and analysis, decision to
publish, or preparation of the manuscript.
Although drug-based treatment is the primary intervention for malaria control and
elimination, optimal use of targeted treatments remains unclear. From 2008 to 2016, three targeted
programs on treatment were undertaken in Kachin Special Region II (KR2), Myanmar.
Program I (2008±2011) treated all confirmed, clinical and suspected cases; program II (2012±
2013) treated confirmed and clinical cases; and program III (2014±2016) targeted confirmed
cases only. This study aims to evaluate the impacts of the three programs on malaria burden
individually based on the annual parasite incidence (API), slide positivity rate (SPR) and
their relative values. The API is calculated from original collected data and the incidence
rate ratio (IRR) for each year is calculated by using the first-year API as a reference in each
program phase across the KR2. Same method is applied to calculate SPR and risk ratio
(RR) at the sentinel hospital too. During program I (2008±2011), malaria burden was
reduced by 61% (95%CI: 58%-74%) and the actual API decreased from 9.8 (95%CI: 9.6±
10.1) per 100 person-years in 2008 to 3.8 (3.6±4.1) per 100 person-years in 2011. Amid
program II (2012±2013), the malaria burden increased by 33% (95%CI: 22%-46%) and the
actual API increased from 2.1(95%CI: 2.0±2.3) per 100 person-years in 2012 to 2.8 (95%CI:
2.7±2.9) per 100 person-years in 2013. During program III (2014±2016) the malaria burden
increased furtherly by 60% (95%CI: 51% - 69%) and the actual API increased from 3.2(95%
CI: 3.0±3.3) per 100 person-years in 2014 to 5.1 (95%CI: 4.9±5.2) per 100 person-years in
2016. Results of the slide positivity of the sentinel hospital also confirm these results.
Resurgence of malaria was mainly due to Plasmodium vivax during program II and III. This study
indicates that strategy adopted in program I (2008±2011) should be more appropriate for
the KR2. Quality-assured treatment of all confirmed, clinical and suspected malaria cases
may be helpful for the reduction of malaria burden.
Malaria is identified by the World Health Organization (WHO) in the World Malaria Report
2015 as a disease that continues to threaten human health globally [
]. In the year of 2015
alone, malaria caused 429 000 deaths and affected 212 million people [
]. The WHO plans to
eliminate P. falciparum malaria by 2025 and turn all Greater Mekong Subregion (GMS)
countries into non indigenous malaria by 2030 [
]. Drug-based treatment (henceforth calling
treatment) is the primary interventional measure that is widely applied to fulfill successful malaria
]. However, optimal use of mass or targeted treatments remains unclear [
While the resistance of artemisinin and partner drug is also one of the factors that threatens
the control and elimination of malaria, especially in the GMS [
], it is critical to accelerate
malaria elimination before the failure of available antimalarial drugs.
Kachin Special Region II (KR2) is one of the malaria hot spots along China-Myanmar
border (S1 Fig). Integrate-intervention strategy, including treatment, bednet distribution and
health education, was adopted and implemented in KR2 from 2008 to 2016 but still end up on
the losing side of malaria control [
]. Although a range of studies have been conducted in the
KR2, few studies focused on malaria-treatment targets [6±11]. Three targeted programs on
treatment were undertaken from 2008 to 2016. The sixth and tenth Rounds of China's Global
Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) projects covered the KR2 from July
2007 to December 2013. From 2008 to 2011(Program I), the sixth round of China's GFATM
project aimed at treating all confirmed, clinical and suspected cases across the KR2. In 2012
and 2013(Program II), the first two years of the tenth round of China's GFATM project turned
to confirmed and clinical cases [
]. The second phase of the tenth round of China's
GFATM project was consolidated into Global Fund New Funding Model (GFNFM) to
intensify malaria control in Myanmar since 2014, and then from 2014 to 2016 (Program III), only
malaria cases confirmed by microscopy or rapid diagnostic test (RDT) are eligible to be treated
based on the guidelines for malaria treatment in Myanmar. To understand the impacts
bringing by the three treatment programs, this paper offers the first publicly available retrospective
analysis of the impacts of eight-year treatment since 2008.
To explore the impacts of the three treatment strategies, this research uses a statistical analysis
of routine data from malaria control programme. The Health Department of Kachin Special
Region II of Myanmar has approved the access and collection of the data. All data has been
fully anonymized before accessing. All data analysis processes have been approved by the
Ethics Committees of the Yunnan Institute of Parasitic Diseases. In the case of anonymity,
requirements on informed consent have been waived.
The KR2 is one of the malaria hyperendemic areas in the northern Myanmar (S1 Fig). Total
population of KR2 is about 60,000 and most people are Kachin Ethnic Minority (known as
Jinghpaw in China). Hot climate, adequate precipitation and lush forest of KR2 provide a
suitable environment for the growth and reproduction of mosquitoes and also for the
transmission of malaria. With a complex vector community, Anopheles dirus and Anopheles minimus
have been identified as two primary vectors [
]. In year-round malaria's transmission, all of
the parasite species (i.e. P. falciparum, P. vivax, P. malariae and P. ovale) exist in the area [
]. To provide basic health service, Kachin Independent Organization (KIO) established a
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primary health care system with the support of international non-governmental organizations
(NGOs). In the KR2, this primary health care system is continuously carrying out malaria
control activities even in the context of war.
Case definition and treatment
This study applies microscopy to detect parasites at malaria diagnosis and treatment stations
(MDT). Rapid diagnostic test (RDT) is used by Village malaria workers (VMW), outreach
teams and selected private clinics as a supplement. In this paper, a confirmed case is that of
being tested as positivity by microscopic or RDT; a clinical case is the case that was not
confirmed by any laboratory tests but with regular symptoms of fever, chills and sweating; and a
suspected case is that the patient has a fever for less than 48 hours.
Confirmed falciparum malaria cases were treated with artemisinin-based combination
therapy (ACT) for three days. ACT drugs used were mainly dihydroartemisinin- piperaquine
(DP) (total dosage 2880mg [320mg D + 2560mg P] for an adult) from 2008 to 2013 and
artemether-lumefantrine (total dosage 3360mg [480mg A+ 2880mg L] for an adult) from 2014 to
2016. Based on the Chinese guideline for malaria treatment, confirmed vivax malaria cases
were given chloroquine (CQ) once a day for three days (total dosage 1200mg for an adult) and
a total dosage 180mg of primaquine (PQ) once a day for eight days (22.5mg /day for an adult)
from 2008 to 2013. The same dosage of CQ and a total dosage 210 mg of PQ for 14 days (15mg
/day for a 50kg adult) were given during 2014±2016 according to the guideline of Myanmar.
Infected children were dosed based on their body weight. From 2008 to 2013, ACT was
administered for clinical and suspected cases in P. falciparum and mixed parasite prevalent areas
accompanying with the adoption of CQ/PQ in single P. vivax prevalent areas. Although
directly observed treatment (DOT) was not used, health staffs were required to inform
caregivers or family members of patients to urge treatments.
Data resources and collection
In this study, data was collected in two approaches: (1) Through health information system
(HIS), established and maintained by the GFATM projects, number of malaria cases and
treatment regimens administered monthly across the KR2 were captured [
]; and (2) from the
records of microscopy at Laiza City Hospital, which is the Headquarter Hospital of the KIO
and also a sentinel hospital for malaria surveillance in the KR2.
Annual parasite incidence (API) and slide positivity rate (SPR) were chosen as the indicators
of malaria burden in our study. First, we calculated the API per 100 person-years with 95%
confidence interval (CI). Second, we took the first-year API as the reference to calculate API
rate ratios (IRR) with 95%CI for the following years of each program phase. Third, we worked
out slide positivity rate (SPR) with 95%CI and took the first-year SPR as the reference to
calculate risk ratio (RR) with 95%CI for microscopy's data in sentinel hospital. Fourth, we adopted
monthly slide positivity rates of the sentinel hospital to diagrammatize the seasonal fluctuation
of malaria: 2006 representing for the malaria risk prior to systemic interventions of the
GFATM projects, 2009 for treatment program I (2008±2011), 2013 for II (2012±2013) and
2015 for III (2014±2016). Finally, we combined the results of the IRR, RR and seasonal
fluctuation of slide positivity to evaluate the impacts of the three treatment programs.
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Total 88 547 treatment courses (52 552 ACT and 35 995 CQ/PQ) were administered during
program I (2008±2011). Only in 2010, total 37 646 courses (22 457 ACT and 15 189 CQ/PQ)
were delivered. We selected the API of the first year of this phase (2008) as the baseline of the
phase. The IRR of the last year (2011) of this phase was 0.39 (0.36±0.42) that equates to a
reduction of the malaria burden by 61% (95%CI: 58% - 74%) (S1 Table). The actual API was
reduced from 9.8 (95%CI: 9.6±10.1) per 100 person-years in 2008 to 3.8 (3.6±4.1) per 100
person-years in 2011(S1 Table, S2 Fig). As the SPR of the first year (2008) of this phase was took
as the control, the RR of the last year (2011) of this phase was 0.23 (95%CI: 0.19±0.28) that
equates to a reduction by 77% (72% - 81%). The actual SPR of the sentinel hospital was
decreased from 21.8% (95%CI: 19.4%-24.3%) in 2008 to 5.0% (95%CI: 4.2% - 5.9%) in 2011
Total 3 586 treatment courses (1 458 ACT and 2 128CQ/PQ) were administered during
program II (2012±2013). As the API of the first year (2012) of this phase was used as the
reference, the IRR of the last year (2013) was 1.33 (95%CI: 1.22±1.46) that equates to an increase of
the malaria burden by 33% (95%CI: 22% - 46%) (S1 Table). The actual API increased from 2.1
(95%CI: 2.0±2.3) per 100 person-years in 2012 to 2.8(95%CI: 2.7±2.9) per 100 person-years in
2013 (S1 Table, S2 Fig). As the SPR of the first year (2012) was took as the control, the RR of
the last year (2013) was1.27 (95%CI: 1.04±1.56) that equates to an increase of 27% (95%CI: 4%
- 56%) (S2 Table). The actual SPR of the sentinel hospital increased from 5.7% (95%CI: 4.8%
6.7%) in 2012 to 7.3% (95%CI: 6.4% - 8.2%) in 2013 (S2 Table).
Total 7 521 treatment courses (8 85 ACT and 6 636CQ/PQ) were administered during
program III (2014±2016). As the API of the first year (2014) of this phase was used as the baseline,
the IRR of the last year (2016) was 1.60 (95%CI: 1.51±1.69) that equates to an increase of the
malaria burden by 60% (95%CI: 51% - 69%) (S1 Table). The actual API increased from 3.2
(95%CI: 3.0±3.3) per 100 person-years in 2014 to 5.1 (95%CI: 4.9±5.2) per 100 person-years in
2016 (S1 Table, S2 Fig). As the SPR of the first year (2014) was used as the control, the RR
associated with slide positivity of the last year (2016) was 3.02 (95%CI: 2.70±3.39) that equates to
an increase of 202% (170% - 339%). The actual SPR of the sentinel hospital increased from
8.4% (95%CI: 7.5% - 9.3%) in 2014 to 25.3% (95%CI: 24.1% -26.5%) in 2016 (S2 Table).
The total incidence of P. falciparum malaria decreased from 3 827 (67.0% of total confirmed
cases, 95%CI: 65.7%-68.2%) in 2008 to 134 (4.1%, 95%CI: 3.4%-4.8%) in 2016 (S1 Table). The
slide positivity number of P. falciparum reduced from 64 (25.9% of total slide positivity, 95%
CI: 20.6% -31.8%) in 2008 to 19 (1.5%, 95%CI: 0.9% - 2.4%) in 2016 at the sentinel hospital (S2
Table). Comparing with 2006 (prior to the systemic interventions), the slide positivity rates of
the sentinel hospital decreased in most of the months of 2009 (program I), 2013(program II)
and 2015(program III). The months for slide positivity peak were March (48.9%) and June
(49.3%) in 2006 (two peaks), July (32.5%) in 2009, June (19.2%) in 2013 and May (30.9%) in
2015. Although the monthly distribution of peaks above shows that the peak is shrinking and
moving from 2006 to 2015, the slide positivity rates were resurging again from 2012 to 2016
(S2 Table, S3 Fig).
The purpose of this paper is to evaluate the impacts of the three targeted treatment programs
on malaria burden across the KR2, Myanmar. Malaria burden was reduced by 61% during
treatment program I (2008±2011) that targeted all confirmed, clinical and suspected cases. The
incidence of P. falciparum malaria continuously decreased but the overall malaria burden
increased because of increasing P. vivax incidence during treatment program II (2012±2013)
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that targeted confirmed and clinical cases and program III (2014±2016) that only targeted
confirmed cases. The failure of the program II and III indicates the challenges in treatment and
control of P. vivax.
In western Thailand, the results of quantitative-PCR documented that more than 90% of
Plasmodium spp. infections were asymptomatic and submicroscopic within the studied
community, where a high proportion of clinically febrile patients were misdiagnosed and
]. Accurateness of microscopy largely relies on the capacity, carefulness and
responsibilities of microscopists. The best expert microscopists have the ability of a detection
limit > 4 p/ul and the capacity of most expert microscopists should be > 30 p/ul. RDT has
limitations in specificity, sensitivity and quality. The detection limit of RDT is between 100 and
200 p/ul and current mainstream available RDT is more sensitive in detecting P.falciparum
than detecting P. vivax. The PCR can detect < 4 p/ul but is difficult to operate in the field [16±
19]. Thus, the application of RDT in the program III (2014±2016) suggests that a high
proportion of Plasmodium spp. infections may be missed. Another problem is that most cases do not
have regular symptoms of fever, chills and sweating . Therefore, the same story may
happen in the program II (2012±2013). Passive detections and treatments are not sufficient for the
quickly elimination of malaria because they cannot detect asymptomatic carriers. However,
submicroscopic and asymptomatic carriers could still be treated if they have clinical attacks.
Thus, immediate administration of antimalarial drugs to all confirmed, clinical and suspected
cases can help cut off the transmission of malaria. As with the help of other interventions,
malaria transmission can be interrupted finally. To eradicate malaria, administration of
antimalarial drugs to all confirmed, clinical and suspected cases should be considered into the
treatment strategies in hyperendenic areas like the KR2. On the other hand, comparing with
mass drug administration (MDA), this strategy may also help reduce the risk of drug's adverse
effects and the cost of drugs together with their administration.
High coverage of malaria intervention is crucial at any stage of malaria control and
]. Malaria elimination is steadily implemented in China now [
]. In 2016, only three
indigenous malaria cases were reported in the region of China by adopting high coverage of
treatment programs. In Jiangsu Province, from 1973 to 1983, MDA with pyrimethamine and
primaquine was used extensively and with up to 30 million people in target counties covered
in a peak year (50% of the population size). Thus, the annual incidence has decreased 56.7%
(95% CI: -75.5% to -23.7%) from 1973 to1976 and decreased 12.4% (95% CI: -24.7% to 2.0%)
from 1976 to 1983 [
]. Yunnan Province used to be an important malaria endemic area.
From 2006 to 2009, treatment targeted all confirmed, clinical and suspected malaria cases. A
total of 334 316 courses (56 272 ACT and 278 044 CQ/PQ) were administered to febrile
patients. The number of the courses is 13.3 times of the confirmed malaria cases (in total 25
070). Besides, a total of 250 456 PQ eight-day courses were provided for radical cure treatment
in low transmitting season. As a result, the API was reduced by 77.9%, from 2.80 per 10 000
person-years in 2006 to 0.62 per 10 000 person-years in 2009[
]. Since 2010, China has
switched from malaria control to elimination. In 2010, assuming there is no repeat medication
within individuals, we administered 37 646 courses (22 457 ACT and 15 189 CQ/PQ) in the
KR2, which is 62.6% (95%CI: 62.2±63.0) of the total population (i.e. 60 123). The API was
reduced by 50%, from 6.4 (95%CI: 6.2±6.6) per 100 person-years in 2009 to 3.2 (3.1±3.4) per
100 person-years in 2010 (S1 Table, S2 Fig). This success also documented the importance of
high access and coverage of treatment in malaria control.
The population size, genetic diversity, multi-clonal infections and transmission intensity of
malaria parasites are associated with the spread of anti-malarial resistance [
]. Resistance is
most likely to occur in patients with high numbers of parasites . Not only can
qualityassured diagnosis and treatment help patients improving outcome, but also limit the drug
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resistance . The ACT watch group reported that the structure of anti-malarial market,
constituted by community health workers, general retailers, itinerant drug vendors, pharmacies
and private for-profit facilities in Myanmar. Oral artemisinin monotherapy (AMT) was
available in 27.7% of private sector outlets. Less than 20% across the private sector could correctly
state the national first-line treatment for uncomplicated falciparum and vivax malaria [
The private sector outlets distributed the oral AMT. The median number of oral AMT tablets
was two tablets (about one tenth of a full adult dosage) [
]. P. falciparum malaria was reduced
by 96.5% across the KR2, from 3 827 cases in 2008 to 134 cases in 2016. Besides, the result of
our resistance surveillance illustrates that the ACT was still efficacious for the treatment of
falciparum malaria [
]. Nowadays, there is not a single promising method to eliminate
artemisinin resistant P. falciparum malaria foci. As a result, a multipronged approach, including the
MDA and other expanded treatment (e.g. administration of all confirmed, clinical and
suspected cases), is adopted to contain artemisinin resistance [
]. A high coverage of
qualityassured treatment could be one of the strategies that prevent the development and spread of
In the GFATM supported projects, all positive blood slides and 10% of negative slides were
sampled and sent to expert microscopists to reread for lab quality assurance. Results from the
experts confirmed that there was an increase in P. vivax in the KR2, rather than the
misjudgement-detection experiences as in Cambodia [
The increase in P. vivax in the KR2 reveals that the control and elimination of P. vivax
malaria is much more difficult than P. falciparum. Vector control may be less effective in
cutting off the transmission of P. vivax parasites than P. falciparum because mosquitoes bite early
in the evening, obtain blood meals outdoors and rest outdoors in various areas [
the KR2 had a high coverage and usage rate of insecticide-treated nets (ITNs), especially
among the children and pregnant women [
], the incidence of P. viax malaria still increased
from 286 cases in 2012 to 3168 in 2016 after the targets varying from program I to II and III
(S1 Table). Other challenges on P. viax malaria control are: 1) blood-stage P. vivax often occurs
with low parasite densities with gametocytes thus may be misdiagnosed by routine microscopy
or RDT as negative; and 2) dormant hypnozoite stage can cause multiple relapses.
Furthermore, current diagnostic methods cannot detect the hypnozoites in liver cells and gametocytes
of P. vivax are frequently produced and transmitted to the mosquito before symptoms
]. Primaquine is the sole available option for killing gametocytes and treating the liver
stage parasite but it can cause acute haemolytic anaemia in patients accompanying with severe
forms of glucose-6-phosphate dehydrogenase (G6PD) deficiency and cannot be administered
to the children under six months of age or pregnant women [
]. Quality assured
treatment of all confirmed, clinical and suspected cases can kill dormant hypnozoites and
submicroscopic parasites with gametocytes. It may be the main reason that program I (2008±2011)
reduced reported P. vivax malaria from 1 889 cases in 2008 to 400 in 2011.
Two slide positivity peaks occurred in March and June in 2006 while there is only one peak
from 2009 to 2015 (from May to July). The change shows that the peak is shrinking and
moving. Increasing slide positivity indicates that resurging parasite prevalence is from 2012 to 2016
(S2 Table, S3 Fig). The baseline survey of the sixth GFATM project detected that 17.1% (95%
CI: 15.0%-19.2%) of parasite prevalence occurred among community residents [
] and the
systemic intervention of the GFATM projects began in early 2008 [
]. In 2006, the first slide
positivity peak in March may be the outcome of originally high parasite prevalence. In the
area, the population of anopheline mosquitoes starts to boom with rising temperature since
April every year. However, breeding sites for An. minimus is flushed by torrential rain after
July decreasing the density of primary vector and reducing the possibility of transmission.
Thus, true intensive transmission happens from May to July [
]. After the success of program
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I (2008±2011) in decreasing the originally high parasite prevalence, the peak of slide positivity
turned to high transmission season (i.e. from May to July) in 2009, 2013 and 2015 (see S3 Fig).
Unavoidably, the accuracy of this retrospective research is weakened by a range of factors
together with denied access to more abundant data resources. First, the study cannot exclude
the impacts of other interventions on malaria burden in the KR2. The ratio of bed net to
person reached 1:1.96 (i.e. more than one net for every two people) while the ratio of long-lasting
insecticidal net (LLIN) to person was 1:2.52 and 76.1% of people sleeping in LLINs the prior
night in 2013 [
]. However, the bed net is not effective in preventing the transmission of P.
vivax due to the barriers mentioned above in the control of P. vivax malaria [
]. Second, the
increasingly unstable political context may also have affected malaria transmission and
intervention activities. Since May 12th of 2012, there have been fierce conflicts and struggles
between Kachin Independent Army and National Defense Army. It is an ethnical conflict
between Kachin ethnics and the mainstream Burmese people. Due to the conflicts, Kachin
people left their land and moved to the internally displaced person (IDP) camps next to
China-Myanmar borderline. The affected people have nowhere to go but stay in the place due
to the inland ethnical conflicts of Myanmar and also the strict border control of China. People
moved from a place that had higher levels of malaria transmission could bring parasites with
them into the IDP camps. The tenth GFATM project and the department of health of the KIO
have set up health facilities while establishing the IDP campus. Although a literature reported
that malaria incidence in the IDP camps was significantly lower than the surrounding villages
], it still seems impossible to totally stop the influx of the political unrest on malaria burden.
Third, results of microscopy and RDT were not arbitrated by PCR but only by expert
microscopists. But the impacts are even throughout time-series analysis so that the results are still
comparable. Fourth, only P. falciparum and P. vivax can be defined and discussed in this paper
from routine malaria diagnosis, treatment and surveillance because the microscopists who
work in routine health facilities have no capacity to accurately identify P. malariae and P.
ovale. Moreover, the adopted RDT is only able to detect P. falciparum and P. vivax. Plus, some
P. malariae and P. ovale identified by microscopists in lab quality control were included the
analysis of P. vivax. Fifth, this study has not considered whether the patients take medication
as required but the compliance of patient is essential to long-treatment course for primaquine.
In the GFATM supported projects, directly observed treatment (DOT) was not carried out but
health staffs let the caregivers or family members monitoring patients to take drugs in time.
An eight day regimen of primaquine (22.5mg/day for adult) was used from 2008 to 2013 and a
14 day regimen of primaquine (15mg/day for adult) was used from 2014 to 2016. Usually,
longer medications mean poorer compliance on drugs [
]. Thus, further studies should
consider this issue when interpreting the results.
The results of study demonstrate the importance of high-coverage treatment in the control and
elimination of malaria. Treatment scenario adopted in the program I (2008±2011) might be the
best in all of the three. A confirmed case-targeted treatment program may miss the infections of
submicroscopic parasites, especially for P. vivax, and then finally fails to treat asymptomatic
parasite carriers. Thus, quality-assured treatment of all confirmed, clinical and suspected malaria
cases may be helpful for reducing malaria burden and drug resistance of antimalarial drugs.
S1 Fig. Location of study site.
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S2 Fig. Number of persons treated and annual parasite incidence from 2008 to 2016. API.
Annual parasite incidence. AFI. Annual P. falciparum incidence. AVI. Annual P. vivax
incidence. I. Start of all confirmed, clinical and suspected cases treated. II. Start of confirmed and
clinical cases treated. III. Start of only confirmed cases treated.
S3 Fig. Seasonal fluctuation of slide positivity in 2006, 2009, 2013 and 2015.
S1 Table. Changes of malaria burden and treatment targeted in Kachin Special Region II,
Myanmar from 2008 to 2016.
S2 Table. Changes of slide positivity of febrile patients at Laiza Hospital, Kachin Special
Region II, Myanmar from 2008 to 2016.
We would like to thank Health Poverty Action (an UK-based NGO) and Health Department
of Kachin Special Region II (HDKR2) for their continuous malaria control activities in this
hard setting. We are also grateful to the collaboration of HDKR2 in the data collection process
and the approval of analyzing the data and reporting the results from Ethics Committees of the
Yunnan Institute of Parasitic Diseases. We thank Mr Hongzhang Xu and Ms Mengxi Lei from
the Australian National University for their comments and copyediting. The opinions
expressed are those of the authors and do not necessarily reflect those of the above
organizations and people.
Conceptualization: Hui Liu, Jian-Wei Xu.
Data curation: Hui Liu, Yaw Bi.
Formal analysis: Jian-Wei Xu.
Funding acquisition: Hui Liu.
Investigation: Hui Liu, Yaw Bi.
Methodology: Jian-Wei Xu.
Resources: Yaw Bi.
Writing ± review & editing: Jian-Wei Xu.
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