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Background  Following initiation of China’s National Malaria Elimination Action Plan in 2010, indigenous malaria infections in Jiangsu Province decreased significantly. Meanwhile imported  Plasmodium  infections have increased substantially, particularly  Plasmodium ovale  and  Plasmodium malariae . Given the risk for malaria resurgence, there is an urgent need to understand the increase in imported  P. ovale  and  P. malariae  infections as China works to achieve national malaria elimination.    Methods  An observational study of imported malaria cases in Jiangsu Province, China was carried out for the period of 2011–2014.    Results  A total of 1268 malaria cases were reported in Jiangsu Province from 2011 to 2014. Although imported  Plasmodium falciparum  cases (n = 1058) accounted for 83.4 % of all reported cases in Jiangsu,  P. ovale  cases (14, 19, 30, and 46) and their proportion (3.7, 9.6, 8.8, and 13.0 %) of all malaria cases increased over the 4 years. Similarly,  P. malariae  cases (seven, two, nine, and 10) and proportion (1.9, 1.0, 2.6, and 2.8 %) of all malaria cases increased slightly during this time. A total of 98 cases of  Plasmodium ovale curtisi  (47/98, 48 %) and  Plasmodium ovale wallikeri  (51/98, 52 %) were identified as well. Latency periods were significant among these  Plasmodium  infections (p = 0.00). Also, this study found that the latency periods of  P. ovale  sp. , P. malariae  and  Plasmodium vivax  were significantly longer than  P. falciparum . However, for both  P. ovale curtisi  and  P. ovale wallikeri  infections, the latency period analysis was not significant (p = 0.81). Misdiagnosis of both  P. ovale  and  P. malariae  was greater than 71.5 and 71.4 %, respectively. The  P. ovale  cases were misdiagnosed as  P. falciparum  (35 cases, 32.1 %),  P. vivax  (43 cases, 39.4 %) by lower levels of CDCs or hospitals. And, the  P. malariae  cases were misdiagnosed as  P. falciparum  (ten cases, 35.7 %),  P. vivax  (nine cases, 32.1 %) and  P. ovale  sp. (one case, 3.6 %). Geographic distribution of imported  P. ovale  sp. and  P. malariae  cases in Jiangsu Province mainly originated from sub-Saharan Africa such as Equatorial Guinea, Nigeria, and Angola.    Conclusions  Although the vast majority of imported malaria cases were due to  P. falciparum , the increase in other rare  Plasmodium  species originating from sub-Saharan Africa and Southeast Asia should be closely monitored at all levels of health providers focusing on diagnosis and treatment of malaria. In addition to a receptive vector environment, long latency periods and misdiagnosis of  P. malariae  and  P. ovale  sp. increase the risk of re-introduction of malaria in China.

malaria journal

The increasing importance of Plasmodium ovale and Plasmodium malariae in a malaria elimination setting: an observational study of imported cases in Jiangsu Province, China, 2011–2014