| Background:Malaria has been a major public health issue of global concern bringing a substantial disease burden to human society.According to the World Malaria Report 2020,from 2015 to 2019,no significant stride has been made in reducing malaria burden worldwide.The incidence of malaria has stagnated at 57 cases per thousand people at risk,and the decline of malaria mortality has also slowed down.Globally,there were an estimated 229 million of malaria cases and 409,000 related deaths in 2019.As the largest developing country in the world,China has achieved considerable progress in eliminating malaria since the launch of the National Malaria Elimination Action Plan(2010-2020)in 2010.Since 2017,in China,there have been no local infections for four consecutive years,meeting the World Health Organization’s criteria for certification of malaria elimination.However,with the advancement of globalization and more and more Chinese people go abroad for work,travel and participate in international activities,which makes imported malaria a main threat to malaria elimination in China.From 2010 to 2019,a total of 36,403 cases of malaria were reported nationwide,of which 30,392 cases(83.49%)were imported cases,notably higher than 5,998 locally infected cases(16.48%).Although a series of studies on the epidemiological characteristics of imported malaria have been carried out,few studies have focused on the financial burden exerted by imported malaria to the patients’ families and society at large.How to measure and cut the financial costs of imported malaria is an urgent issue to be addressed in the later stage of malaria elimination in China.Guangxi Zhuang Autonomous Region(Guangxi for short)is located in southern of China,it is one of the four areas with high malaria burden in southern China in history.During 2010-2019,imported malaria cases reported in Guangxi accounted for 10.70%(3 130/29 248)of the total imported malaria cases in China,and P.falciparum cases(72.88%,2 281/3 130)were the prominent cases.Therefore,economic burden evaluation based on imported malaria cases in Guangxi is of great significance for controlling and reducing the burden of malaria.Objective:1.To analyze the epidemiological characteristics of imported malaria in Guangxi from 2012 to 2019,and to provide decision-making basis for surveillance and response of imported malaria after elimination of malaria.2.To evaluate the economic burden caused by imported malaria cases in Guangxi and analyze the main influencing factors,so as to provide reference for reducing the economic burden of imported malaria cases.Methods:1.The information from Parasitic Disease Prevention and Control Information Management System on imported malaria cases in Guangxi from 2012 to 2019 were collected and a descriptive analysis about the epidemiological characteristics was run.2.Imported malaria cases diagnosed and reported by health institutions at all levels in Guangxi from January 1,2019 to December 31,2020 were collected,and economic burden related to malaria treatment was investigated for those cases confirmed by microscopic examination through hospital records collection,field visits and telephone interviews.The economic burden of imported malaria patients was described statistically,and univariate analysis and generalized additive model(GAM)were used to explore the influencing factors of the economic burden of malaria.Finally,based on the epidemiological data of imported malaria cases in Guangxi obtained in the first part,the overall economic burden of imported malaria in the whole region from 2017 to 2019 was calculated.Results:(1)Epidemiological characteristics of imported malariaA total of 3 011 imported malaria cases were reported in Guangxi from 2012 to 2019,including 3 005 confirmed cases(99.80%)and 6 clinically diagnosed cases(0.20%).Among the confirmed cases,there were 2 234 cases of P.falciparum malaria(74.34%),274 cases of P.vivax(9.12%),406 cases of P.ovale malaria(13.51%),38 cases of P.malariae(1.26%)and 55 cases of mixed infection(1.83%).The source of infection is concentrated in African countries(96.84%,2 788/2 879),with Ghana,Cameroon and Angola ranking the top three.Among all imported malaria cases in Guangxi from 2012 to 2019,there were 2 956 males(98.17%,2 956/3 011),and 55 females(1.83%,55/3 005).The age distribution was mainly from 30 to 49 years old,accounting for 66.76%(2 010/3 011)of the total cases.Most of the cases were migrant workers,accounting for 93%(2 671/2 884).Except for a cluster of imported malaria in Shanglin County in 2013,there was no obvious seasonal trend in the months of imported malaria cases reported in other years.Nanning,Hechi and Guilin were the three major cities with the highest number of imported malaria cases from 2012 to 2019,and Shanglin,Quanzhou and Dahua were the three counties with the highest number of imported malaria cases.Among the diagnostic units of imported malaria cases in Guangxi during 2012-2019,the county-level institutions accounted for the highest proportion(83.66%,2 519/3 011),followed by prefecture-level institutions,provincial institutions,township health centers,etc.The lowest median time to onset and diagnosis was 2d in 2013,and 3d in the other years.From 2017 to 2019,severe(inpatient)cases accounted for the highest proportion(75.91%,624/822),mild(outpatient)(22.75%,187/822)cases followed,and critical cases(1.34%,11/822)were the least.(2)Economic burden of imported malaria casesThis economic burden study included 202 imported malaria cases,of which 28 were outpatients,171 were inpatients,and 3 were critically ill.The median burden is 10.00 yuan;the median direct medical costs for hospitalized cases is 3 032.00 yuan,and the median direct non-medical costs for all cases is 160.00 yuan;The median direct medical costs of severe cases was 35,000.00 yuan,and the median direct non-medical costs of all the cases was 600.00 yuan.Univariate analysis showed that among hospitalized cases,the differences in direct medical economic burden and direct non-medical economic burden between different genders,different age groups,and different types of diseases were not statistically significant.The direct medical economic burden(P<0.01)and direct non-medical economic burden(P<0.01)of municipal hospitals is higher than that of county-level hospitals;the direct medical economic burden(P<0.01)and direct non-medical economic burden(P<0.01)of cases with hospitalization days≥4 days are both higher than those of cases with hospitalization days<4 days;The difference in the direct non-medical economic burden was not statistically significant for the cases where the medical economic burden exceeded the onset-diagnosis days of less than 3 days(P<0.01).The analysis of the composition of hospitalization expenses for imported malaria presented that laboratory test expenses(52.47%,1 515.75/2 888.81)accounted for the largest proportion of total hospitalization expenses,followed by drug expenses(21.68%,626.31/2 888.81)and examination expenses(10.68%,308.50/2 888.81),while diagnose expenses(2.08%,60.00/2888.81),injection fees(1.58%,45.65/2 888.81)and attendance fees(1.31%,38.00/2 888.81)accounted for a small proportion of county-level hospital hospitalization expenses.The indirect economic burden of outpatient cases was 353.13 yuan,the median indirect economic burden of hospitalized cases was 706.26 yuan,the median indirect economic burden of critical cases was 10 123.02 yuan.There were statistically significant differences in the indirect economic burden of inpatients between different hospitalization days(P<0.01),morbidity-diagnosis days(P<0.01),and hospital levels(P<0.01),while differences in gender,age,and disease types were not statistically significant.The general additive model results showed that the number of hospitalization days(P<0.01)and the number of days of onset-diagnosis(P<0.01)had an impact on the economic burden.From 2017 to 2019,the overall economic burden of imported malaria in Guangxi was 3250 375.22 yuan and the economic burden showed a decreasing trend year by year.Conclusion:1.Imported malaria mainly comes from African countries such as Ghana,Cameroon and Angola;imported cases were mostly P.falciparum(74.34%,2 234/3 005),and the majority of the cases were 30-49 years old(66.76%,2 010/3 011)and male(98.17%,2 956/3 011).The occupation were mainly migrant workers(92.61%,2 671/2 884).Cases of P.ovale are also growing year by year,exceeding the proportion of P.vivax.Most of the imported malaria cases were firstly diagnosed in county-level institutions,followed by prefecture-level and provincial-level institutions.Among imported malaria cases,severe(hospitalized)cases was an overwhelming majority,followed by mild(outpatient)cases and the least severe cases.2.In this study,it was found that the economic burden per capita of imported malaria outpatients was low,while the economic burden per capita of hospitalized cases and critical cases was heavy.The economic burden of critical cases exceeded the per capita disposable income in Guangxi in 2019,bringing heavy burden to the families and society of the patients.In hospitalization,assay cost,medicament and examination cost made up the greater part,while diagnose expenses,injection fees and attendance fees were the smaller part.The length of hospitalization and onset-diagnosis days were the main influencing factors of economic burden,that is,the longer the length of hospitalization days and onset-diagnosis time,the heavier the economic burden.3.From 2017 to 2019,with the annual downward of imported malaria cases,the overall economic burden in Guangxi also showed a decreasing trend year by year.To reduce the economic burden,patients should be found and confirmed as early as possible,and the length of hospitalization should be shortened scientifically and reasonably.At the same time,the current achievements in eliminating malaria should be consolidated to prevent the outbreak of imported malaria and the retransmission caused by imported malaria cases. |
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