Development of human resources in malaria microscopy during and after the malaria elimination phase in China

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Therefore, this paper presents the efforts made, achievements attained, and future prospects regarding the development of human resources in malaria microscopy during and after the malaria elimination phase in China. Methods To confirm the competence of malaria microscopists at the national level, six rounds of the External Competence Assessment of Malaria Microscopists (ECAMM) courses, developed and administered by the World Health Organization (WHO), were conducted in China from 2017 to 2024. The number and frequency of certified microscopists participating in the WHO-ECAMM courses were retrospectively reviewed. To support the establishment of core groups at sub-national levels, a model course for the National Competency Assessment of Malaria Microscopists (NCAMM) was revised in accordance with WHO guidelines and implemented from 2019 to 2024. The course schedule and scoring system were detailed, including improvements in evaluation metrics. Participants' competency levels (A, B, C, and D) were determined based on standardized criteria. The relationship between participants' competency levels and their age or years of experience in malaria microscopy, as well as variations in their scores, was analyzed. To guide the future qualification of microscopists in peripheral areas, a proposed framework for human resource development of malaria microscopists was presented, based on the current malaria situation in China. Results A total of 64 microscopists participated in the six WHO-ECAMM courses. The average age of these participants is 41.1 years. Among them, 29 individuals certified at Level 1 and 17 individuals at Level 2 covered NIPD as well as 29 out of 31 provinces. In addition, among the 72 participants who attended the six NCAMM courses, 10 were certified at Level A (the highest level), and 33 at Level B. Factors such as age, place of employment, educational background, and gender did not show a significant impact on participants' competence in malaria microscopy (n = 72; ρ = 0.2, P > 0.05). However, the number of years of experience in malaria microscopy demonstrated a moderate positive correlation with competence levels(n = 72; ρ = 0.4, P < 0.01). Notably, scores for species identification (SI) improved significantly (Z = −7.3, P < 0.01). The proposed structure for human resource development of malaria microscopists includes three core groups operating at the national, sub-national (provincial), and sub-provincial levels. This structure recommends the application of four models for assessing microscopists’ competence. Discussion and Conclusion Based on six WHO-ECAMM courses, the national core group of malaria microscopists was re-affirmed. The NCAMM courses conducted in China have demonstrated sufficient effectiveness as both an evaluation system and a refresher training model. They are expected to be widely implemented at both national and subnational levels to support the development of human resources in malaria microscopy. The predefined structure for human resource development of malaria microscopists provides a systematic framework for assessing and defining the competencies of microscopists in peripheral areas. Health sciences/Diseases Health sciences/Health care Health sciences/Medical research National Competency Assessment of Malaria Microscopists (NCAMM) Slide Preparation (SP) Parasite Detection (PD) Parasite Species Identification (SI) Parasite Counting (PC) Figures Figure 1 Figure 2 Figure 3 1 Background Since 2015, nine countries, including China, have been officially certified as malaria-free by the World Health Organization (WHO) [ 1 ]. Although global malaria elimination programs have made significant progress in recent years, malaria remains a substantial public health challenge worldwide. In 2023, approximately 263 million individuals were infected with malaria, resulting in an estimated 597,000 deaths [ 1 ]. China maintains regular communication with other countries and regions. According to official statistics, China processed approximately 610 million entries and exits of individuals in 2024, of which 291 million involved mainland residents traveling in and out of the country [ 2 ]. On average, around 3,000 malaria cases were reported annually across 31 provinces in China since 2011, corresponding to an incidence rate of approximately 2.1 cases per million population (3,000/1.4 billion). Despite this relatively low incidence, the disease resulted in a significant number of severe cases and a case fatality rate of 4.8 per thousand (n = 8, ± 1.8‰, 95% CI: 3.3–6.3‰). Furthermore, imported Plasmodium vivax cases and its primary vector, Anopheles sinensis , are widely present in malaria-endemic provinces of China [ 3 – 8 ]. Therefore, China continues to face a risk of malaria resurgence. To prevent severe malaria, malaria-related fatalities, and the re-transmission of malaria in malaria-free regions, the principles of early detection, early diagnosis, and early treatment—collectively referred to as the "Three Early" strategy—are widely recognized as essential global practices. However, given the persistently low incidence of malaria during and after its elimination in China, large-scale, comprehensive resource allocation—including specialized testing reagents, materials, and human resources—is clearly impractical. Nevertheless, shortages in these areas have led to misdiagnoses and delayed diagnoses, serving as notable warnings [ 9 ]. Among the available diagnostic methods for malaria—Rapid Diagnostic Tests (RDT), Nucleic Acid Testing (NAT), and microscopy—microscopy remains the gold standard and is considered the most feasible option for monitoring malaria cases at health institutions of various levels including county and even some township under the current epidemiological context in China. This principle is reflected in the National Surveillance Program during the Post-Malaria Elimination Period (2025 Edition) (NSP-2025). Therefore, to ensure the effective implementation of the "Three Early" strategy and to uphold the high-quality execution of the NSP-2025, it is essential to maintain a sufficient number of qualified microscopists across the country. Simultaneously, establishing effective mechanisms to sustain their diagnostic competence is equally critical. The External Competence Assessment of Malaria Microscopists (WHO-ECAMM), developed and implemented by the World Health Organization (WHO), serves as a well-established model for evaluating the competence of malaria microscopists and has been widely adopted by malaria-endemic countries globally [ 10 – 11 ]. Microscopists qualified in WHO-ECAMM courses are the best proof of a strong surveillance system required to certify and sustain malaria elimination [ 12 ]. The National Institute of Parasitic Diseases (NIPD) under the China Center for Disease Control and Prevention (CDC), which oversees the national malaria control program, has organized ten WHO-ECAMM courses between 2009 and 2024. However, due to the limitation that no more than one microscopist per province could participate every three years, the demand for certified malaria microscopists remains largely unfulfilled in China, particularly at the subnational level [ 13 – 14 ]. The National Competency Assessment of Malaria Microscopists (NCAMM) is another model proposed by WHO, specifically designed to support domestic external competence assessments in malaria microscopy. To date, however, no NCAMM implementation has been reported globally. In 2018, three Chinese facilitators were jointly trained and certified by the WHO Western Pacific Region Office, the Asian Collaborative Training Network for Malaria, and NIPD. Based on WHO guidelines, these facilitators successfully conducted six updated NCAMM courses between 2019 and 2024. This document presents the efforts and achievements in human resource development for malaria microscopists in China, along with future prospects. First, it summarizes the certified malaria microscopists assessed through WHO-ECAMM courses in China. Next, it introduces the updated NCAMM courses, supported by an analysis of assessment data. Finally, it proposes a conceptual framework for the future development of human resources for malaria microscopists in China. 2 Methods 2.1 Certified Malaria Microscopists in WHO-ECAMM Courses Between 2017 and 2024 in China Data on participants who attended the WHO-ECAMM courses between 2017 and 2024 in China were collected. The number and distribution of certified microscopists across different levels were calculated at the provincial level. 2.2 NCAMM Courses Implemented Between 2019 and 2024 2.2.1 Organization of Six NCAMM Courses and Collection of Participants’ Information NIPD, either independently or in collaboration with provincial CDCs, organized six NCAMM courses. Each course was conducted with the support of one to three certified facilitators. Comprehensive data were systematically collected regarding participants’ affiliated institutions, gender, educational background, age, and years of experience in malaria microscopy. 2.2.2 NCAMM Course Schedule and Scoring System The NCAMM course is a structured five-day training program that includes a theoretical examination, pre-assessment, and final evaluation (as detailed in Table 1 ), all of which align with WHO’ s guidelines [ 10 – 11 ]. The key distinction between the assessments was that the theoretical and skill-based presentations were scheduled toward the end of the program in the earlier versions. Table 1 Agenda of NCAMM course D1 0800–0915 0915–0945 0945–1215 1215–1300 1300–1330 1330–1545 1545–1700 (Presentation) Registration Introduction of ECAMM, Theory Test & Feedback Pretest: Slide making (5/7 Slides) Pretest: Slide Examination (9 slides) Lunch Pretest: Slides Staining Pretest: Slide Examination (9 slides) 1.Slides preparation and assessment criteria 2. Blood elements & artefacts and skills of malaria microscopy (simple version) D2 0800–0915 0915–0945 0945–1215 1215–1300 1300–1330 1330–1545 1545–1700 Answer feedback and slides Review Final test: Slide making (5/7 Slides) Final test: Slide Examination (10 slides) Lunch Final test: Slides Staining Final test: Slide Examination (9 slides) 1.Blood elements & artefacts and skills of malaria microscopy (detailed version) 2.Skills of parasite counting D3 0800–0915 0915–0945 0945–1215 1215–1300 1300–1330 1330–1545 1545–1700 Answer feedback and slides Review Final test: Slide making (5/7 Slides) Final test: Slide Examination (10 slides) Lunch Final test: Slides Staining Final test: Slide Examination (9 slides) 1.Skills of collecting blood from finger and making slides 2.Establishment of malaria slide Bank(changeable) D4 0800–0915 0915–0945 0945–1215 1215–1300 1300–1330 1330–1545 1545–1700 Answer feedback and slides Review Final test: Slide making using Finger blood (3/5 Slides) Final test: Slide Examination (10 slides) Lunch Final test: Slide Staining Final test: Slide Examination (8 slides) QA in Malaria Laboratory Diagnosis (changeable) D5 0800–0915 0915–1045 1100–1200 1200–1300 1300–1600 Announcement of results and slides review Clinical diagnosis, treatment and case sharing (changeable) Course conclusion and award ceremony Lunch Departure For the Slide Preparation (SP) grading, a total of 13 quality criteria are evaluated (as detailed in Table 2 ). These criteria have been updated since their initial establishment in 2019 [ 15 ]. Each criterion is scored as either "Yes" (1 point) or "No" (0 points), with one point allocated per criterion. The total score for each prepared slide is calculated, and slides achieving 12 or more points out of 13 are considered qualified. The percentage of qualified slides prepared by each participant during the final assessment period (Days 2–4) serves as one of the key indicators for determining participants’ competence levels. From Days 1 to 3, participants are provided with seven blank slides daily for blood film preparation. Each day, the five best-prepared slides from each participant are evaluated against the established quality criteria. On Day 4, participants are given five blank slides, and three thick and thin smears prepared from freshly collected finger-prick blood samples are assessed using the same evaluation criteria. Table 2 Criteria items for slides preparation Criteria Items for SP Yes/No 1 The blood smear is unique labeled and the label is located at the end near the thick film 2 Diameter of thick film is 10 ~ 12mm , even and more than 90% is intact 3 The thick film is adequate thickness. Averagely 10 ~ 20 white blood cells per f ield 4 The position of thick film is right (Distance from center of thick film to the nearest short edge ≥ 30mm) 5 There are three parts of thin films, head, body and tail with no waves 6 There are adequate space between thick and thin films (≥ 5mm) 7 There are adequate space between thin film and edges of slide (≥ 5mm short edge, ≥1mm long edge) 8 The thin film is adequate size (len gth and width are both ≧ 20mm) 9 The white blood cells are properly stained (nucleus is purple to black) 10 The red cells are completely lyzed in thick films (Diameter of lyzed area is more than 8mm) 11 Red cells show single layer towards the feathered edge 12 The red blood cells are properly stained(grey to pink) 13 The films are clearly and no debris. The background is transparent Yes for 1 point, No for 0 point; Slides with ≥ 12 points is qualified. The composition of the NCAMM slide panels is largely consistent with the methodology employed by the WHO-ECAMM [ 10 – 11 ], with the exception of slides including two species (two slides in total in the final test) and non-falciparum species (eight slides in the final test). These components can be tailored according to the local malaria epidemiological profile. For the parasite counting test, which comprises 14 slides in the final assessment, six slides with parasite densities ranging from 800 to 6,000 parasites/µL are included. The highest parasite density category, represented by two slides, is defined as 12,000–20,000 parasites/µL rather than 40,000–100,000 parasites/µL due to limitations in slide availability. At least 16 falciparum slides with low parasite density (200–700 parasites/µL) are selected for species identification (n = 10) and counting (n = 6). The slide panels used in the pre-test are identical to those used in the WHO-ECAMM [ 10 – 11 ]. Two to three slides may be repeated between the pre-test and the final test. Participants are evaluated based on their accuracy in malaria parasite detection (PD), species identification (SI), and parasite counting (PC). Scoring is calculated using the following equations: PD (%) = \(\:\frac{\text{T}\text{h}\text{e}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{p}\text{o}\text{s}\text{i}\text{t}\text{i}\text{v}\text{e}\text{s}\:\text{n}\text{o}\text{t}\text{e}\text{d}\:\text{b}\text{y}\:\text{t}\text{h}\text{e}\:\text{p}\text{a}\text{r}\text{t}\text{i}\text{c}\text{i}\text{p}\text{a}\text{n}\text{t}\text{s}}{\text{T}\text{h}\text{e}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{a}\text{l}\text{l}\:\text{t}\text{r}\text{u}\text{e}\:\text{p}\text{o}\text{s}\text{i}\text{t}\text{i}\text{v}\text{e}\text{s}}\) ×100% SI (%) = \(\:\frac{\text{T}\text{h}\text{e}\:\text{t}\text{o}\text{t}\text{a}\text{l}\:\text{p}\text{o}\text{i}\text{n}\text{t}\text{s}\:\text{o}\text{b}\text{t}\text{a}\text{i}\text{n}\text{e}\text{d}\:\text{b}\text{y}\:\text{t}\text{h}\text{e}\:\text{p}\text{a}\text{r}\text{t}\text{i}\text{c}\text{i}\text{p}\text{a}\text{n}\text{t}}{2\times\:\:\text{T}\text{h}\text{e}\:\text{t}\text{o}\text{t}\text{a}\text{l}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{s}\text{l}\text{i}\text{d}\text{e}\text{s}\:\text{f}\text{o}\text{r}\:\text{s}\text{p}\text{e}\text{c}\text{i}\text{e}\text{s}\:\text{i}\text{d}\text{e}\text{n}\text{t}\text{i}\text{f}\text{i}\text{e}\text{d}}\) ×100% PC (%) = \(\:\frac{\text{T}\text{h}\text{e}\:\text{t}\text{o}\text{t}\text{a}\text{l}\:\text{p}\text{o}\text{i}\text{n}\text{t}\text{s}\:\text{o}\text{b}\text{t}\text{a}\text{i}\text{n}\text{e}\text{d}\:\text{b}\text{y}\:\text{t}\text{h}\text{e}\:\text{p}\text{a}\text{r}\text{t}\text{i}\text{c}\text{i}\text{p}\text{a}\text{n}\text{t}}{3\times\:\:\text{T}\text{h}\text{e}\:\text{t}\text{o}\text{t}\text{a}\text{l}\:\text{n}\text{u}\text{m}\text{b}\text{e}\text{r}\:\text{o}\text{f}\:\text{s}\text{l}\text{i}\text{d}\text{e}\text{s}\:\text{f}\text{o}\text{r}\:\text{p}\text{a}\text{r}\text{a}\text{s}\text{i}\text{t}\text{e}\:\text{c}\text{o}\text{u}\text{n}\text{t}\text{i}\text{n}\text{g}}\) ×100% For the SI component, the final test consists of a total of 22 positive slides. Two points are awarded for accurate identification. If only one species is identified in a mixed infection scenario, one point is given, whereas zero points are assigned if two species are reported when only one is present. Furthermore, three points are awarded if the participant's count is within 25% of the actual count, one point if the count falls within 50% but not within 25%, and zero points if the count is less than 50% of the true value. 2.2.3 Assessment of Competence Level in Malaria Microscopy Participants are classified into Competence Levels A, B, C, or D based on the scoring criteria for PD, SI, and PC, as outlined in WHO's documentation (Table 3 ) [ 11 ]. Table 3 Standards to certifying participants’ different competence of malaria microscopy [ 11 ] Levels PD (%) SI (%) PC(%) SP(%) A 90 ~ 100 90 ~ 100 50 ~ 100 90 ~ 100 B 80 ~ 89 80 ~ 89 40 ~ 49 80 ~ 89 C 70 ~ 79 70 ~ 79 30 ~ 39 70 ~ 79 D 0 ~ 69 0 ~ 69 0 ~ 29 0 ~ 69 2.2.5 Data Analysis 2.2.5 Data Analysis Data were analyzed using SPSS Statistics 23. Initial normality tests were conducted to assess the distribution of the data. Results are presented as means with standard deviation and medians with interquartile ranges (25th and 75th percentiles). For data that were not normally distributed, the Wilcoxon test and Fisher’s exact test (α = 0.05) were used. An ordinal regression analysis was conducted, incorporating Spearman’s correlation coefficient, to examine the relationship between participants’ competence levels in malaria microscopy and their age or years of experience in malaria microscopy. 2.3 Pre-assumed Structure of Human Resource Development for Malaria Microscopists in China Based on the spatial distribution of malaria cases at provincial, sub-provincial, and county levels in 2023 and 2024, as well as the requirements outlined in the NSP-2025, a pre-assumed structure for the development of human resources for malaria microscopists at different administrative levels in China is proposed. 3 Results 3.1 Malaria microscopists certified in WHO-ECAMM courses between 2017 and 2024 In total, 64 microscopists participated in the six WHO-ECAMM courses conducted in China between 2017 and 2024. Prior to China being certified as malaria-free in 2021, four of these courses were held between 2017 and 2019. Participants in these courses were selected from NIPD and 31 provinces across the country. In 2024, two additional courses were conducted to reassess the participants and evaluate newly nominated microscopists, particularly those from provinces with relatively low malaria incidence between 2019 and 2023. Among the 31 provinces, 21 were granted two opportunities to nominate microscopists for participation in the WHO-ECAMM courses, three provinces were given one opportunity, six provinces were provided three opportunities, and one province was given four opportunities (see Table 4 ). Among the 64 microscopists, 57 participated once, six participated twice, and one participated three times. Of these individuals, 29 were certified at level 1, 17 at level 2, and 18 at level 3 or 4. Microscopists Table 4 Microscopists certified in different provinces between 2017 and 2024 Chances Competence levels Once Twice Tree times Four times 1 2 Others No. of microscopists 57 6 1 None 29 17 18 No. of Provinces 3 21 6 1 22 14 11 certified at level 1 or 2 represented the NIPD and 29 provinces (see Table 4 ). Among them, 15 were male and 31 were female. Currently, the average age of these microscopists is 41.1 years (n = 46; ±8.7; median = 41.0 [36.0 ~ 46.0]). If we consider participation starting from 2012, seven participants attended the courses twice and seven attended three times. All of them have been engaged in malaria microscopy over the past decade. Most of them (13 out of 14) demonstrated improvement in their competence or maintained a high level of proficiency. The detailed outcomes are as follows: four were certified at level 1 three times, one was certified at level 1 twice, one was certified at level 2 twice, one improved from level 2 to level 1, four improved from level 3 or 4 to level 2 or 1 either directly or stepwise, one decreased from level 1 to level 2, and one decrease from level 1 to level 3. 3.2 Findings of NCAMM courses in China Among the 72 participants in six NCAMM courses, 48 were female and 24 were male; 36 were from provincial-level units and 36 from sub-provincial-level units. With regard to educational background, 32 participants held master’s degrees and 40 held bachelor’s degrees (see Table 5 ). The majority of Table 5 Six NCAMM courses in China and participants’ basic information Order Time Organizers Participants’ units Sex Education degree Provincial Units Sub-provincial Units Female Male Master Bachelor 1st 2019 NIPD 9 3 8 4 8 4 2nd 2021 Province 1 2 10 11 1 4 8 3rd 2023 Province 1 4 8 7 5 8 3 4th 2023 Province 2 3 9 8 4 3 9 5th 2024 Province 3 6 6 5 7 2 10 6th 2024 NIPD 12 0 9 3 6 6 Total 36 36 48 24 32 40 participants were aged between 35.0 and 40.0 years (n = 72; mean age = 36.3 ± 5.9 years; median = 35.0 years [32.0 ~ 40.0]). Additionally, all participants had more than 6 years of experience in malaria microscopy (n = 72; mean = 6.7 ± 5.0 years; median = 6.5 years [2.0 ~ 10.0]). In total, 10 out of 72 participants were certified at Level A, 33 at Level B, and 28 at Level C or D. In the second and fourth courses, a higher proportion of participants achieved Level A and B certifications compared to those in the remaining courses (Fisher's exact test: df = 3; χ² = 7.8, 7.9, 11.8, 11.8; P < 0.01 or P < 0.05; χ² = 8.4, 10.3, 8.5; P = 0.01 or P < 0.05). No statistically significant differences were found among the outcomes of participants enrolled in the first, third, fifth, and sixth courses (Fisher's exact test: df = 3; χ² = 2.5, 1.6, 3.1, 4.2, 3.1, 1.3; P > 0.05) (see Table 6 ). Statistical analysis revealed that demographic variables such as age, workplace, educational background, Table 6 Results and comparison of 6 NCAMM courses Courses Organizers No. of participants Fisher's Exact Test between different courses A B C D 2nd 3rd 4th 5th 6th 1st NIPD 0 6 3 3 χ 2 = 7.8 P 0.05 χ 2 = 8.4 P 0.05 χ 2 = 3.1 P > 0.05 2nd Province 1 2 10 0 0 / χ 2 = 7.9 P 0.05 χ 2 = 11.8 P < 0.01 χ 2 = 11.8 P 0.05 χ 2 = 4.2 P > 0.05 χ 2 = 3.1 P > 0.05 4th Province 2 5 6 1 0 / / / χ 2 = 10.3 P = 0.01 χ 2 = 8.5 P 0.05 6th NIPD 1 3 6 2 / / / / / Total 10 33 18 11 / and gender did not significantly affect participants' competence in malaria microscopy (n = 72; ρ = 0.2, P > 0.05; Fisher's exact test: χ² = 1.2, 1.2, 1.7; df = 3; P > 0.05) (Tables 7 – 8 ). In contrast, the number of years of experience in malaria microscopy showed a moderate positive correlation with competence levels (n = 72; ρ = 0.4, P < 0.01) (see Table 8 ). All 72 participants scored above the minimum threshold required for their respective certification levels in PD, PC, and SP. Table 7 Participants’ competence comparison of participants with different background Factors No. of Participants with Different Competence of Malaria Microscopy Total Fisher's Exact Test A(n = 10) B(n = 33) C(n = 18) D(n = 11) Units Provincial level 5 13 13 5 36 χ 2 = 5.1 P > 0.05 Sub-provincial level 5 20 5 6 36 Education Degree Master 4 13 9 6 32 χ 2 = 1.2 P > 0.05 Bachelor 6 20 9 5 40 Sex Female 7 24 10 7 48 χ 2 = 1.7 P > 0.05 Male 3 9 8 4 24 Table 8 Relevance between participants’ competence and their ages or years serving for malaria microscopy Items Factors Ages Years of service in malaria microscopy Mean Median Mean Median Participants’ Competence of Malaria Microscopy A(n = 10) 37.6 ± 1.9 35.0[34.0 ~ 39.3] 9.4 ± 1.5 9.0[6.5 ~ 13.0] B(n = 33) 37.2 ± 1.0 35.0[32.0 ~ 42.5] 7.7 ± 0.8 8.0[4.0 ~ 10.0] C(n = 18) 34.4 ± 1.4 33.0[31.0 ~ 36.5] 4.4 ± 1.1 3.0[1.0 ~ 5.3] D(n = 11) 35.2 ± 1.8 36.0[30.0 ~ 40.0] 4.7 ± 1.4 2.0[0.5 ~ 10.0] Total 36.3 ± 5.9 35.0[32.0 ~ 40.0] 6.7 ± 5.0 6.5[2.0 ~ 10.0] Correlation Coefficient(ρ) 0.2 0.4 Sig. (2-tailed) P > 0.05 P < 0.01 Scores for SI improved significantly in the final test (n = 72; mean = 80.0 ± 11.0]; median = 82.0 [74.0 ~ 88.0]) compared to the pre-test (n = 72; mean = 62.0 ± 19.0; median = 62.0 [50.0 ~ 77.0]) (Z = − 7.3, P < 0.01). Furthermore, participants demonstrated a significant improvement in competence following the WHO-ECAMM course (n = 23; Z = − 2.4, P < 0.05; Z = − 3.0, P < 0.01; Z = − 3.9, P < 0.01) after completing the NCAMM courses (n = 23; mean = 75.4 ± 8.9; median = 75.0 [67.0 ~ 82.0]) compared to both the pre-test (n = 23; mean = 82.8 ± 12.1; median = 88.0 [76.0 ~ 92.0]) and the final test (n = 23; mean = 88.6 ± 8.9; median = 93.0 [83.0 ~ 95.0]) (Table 9 ). Table 9 Comparison of participants’ SI scores between different periods* Courses Scores Paired T-test NCAMM- Final-test ECAMM-Final test NCAMM- Pre-test (n = 72) Mean 62.0 ± 19.0 Z=-7.3 P < 0.01 / Median 62.0[50.0 ~ 77.0] NCAMM-Final test (n = 72) Mean 80.0 ± 11.0 / / Median 82.0[74.0 ~ 88.0] NCAMM-Final test (n = 23) Mean 75.4 ± 8.9 / Z=-3.9 P < 0.01 Median 75.0[67.0 ~ 82.0] ECAMM- Pre-test (n = 23) Mean 82.8 ± 12.1 Z=-2.4 P < 0.05 Z=-3.0 P < 0.01 Median 88.0[76.0 ~ 92.0] ECAMM-Final test (n = 23) Mean 88.6 ± 8.9 / / Median 93.0[83.0 ~ 95.0] * 23 participants took part in both NCAMM and WHO-ECAMM successively. 3.3 Pre-assumed structure of human resource development of malaria microscopists in China The spatial distribution patterns of malaria cases in China in 2023 and 2024 indicate that all provinces have reported occurrences. A majority of provinces (21–22 out of 31) reported cases in more than 60% of their sub-provincial regions, while nearly half of the provinces (14–16 out of 31) reported cases in fewer than 20% of their counties (see Figs. 1 – 2 ). Therefore, it is recommended that core groups composed of highly competent malaria microscopists be established at the national, provincial, and most sub-provincial levels. At the county level, staffing strategies may vary depending on the local malaria situation. The proposed human resource structure for malaria microscopists includes three core groups operating at the national, sub-national (provincial), and sub-provincial levels. This structure suggests the application of four models for assessing microscopists’ competence (see Fig. 3 ). The national core group consists of microscopists employed in national and provincial laboratories. All members should currently hold a certification of Level 1 or Level 2 in the WHO-ECAMM courses. In provinces where malaria cases have been reported in five or more sub-provincial areas over the past three years, it is recommended that microscopists in the provincial core group be certified at least at Level A or B in the NCAMM courses. In provinces where malaria cases have been reported in zero to four sub- provincial areas during the same period, microscopists certified at Level A or B in the NCAMM courses are considered acceptable. Alternatively, those who have been assessed as qualified malaria microscopists through other provincial competence assessment mechanisms (PCAMM) are also acceptable. The provincial core group is composed of microscopists working in provincial and sub-provincial laboratories. At the county level, qualified malaria microscopists trained through PCAMM courses are essential in counties that have reported malaria cases in the past three years. In counties where no malaria cases have been reported for at least five consecutive years, greater emphasis should be placed on the microscopists’ ability to prepare blood smears and maintain awareness for malaria case screening, rather than on the precise identification of parasite species. This objective can be achieved through Basic Training Courses (BTC) conducted by sub-provincial or provincial institutions. Ideally, the core group at the sub-provincial level should consist of microscopists who have been certified through either PCAMM or BTC training programs. 4 Discussion and Conclusion The WHO-ECAMM course in previous studies has demonstrated dual functions in both assessing and training microscopy skills [ 14 ]. Among the four fundamental components of malaria microscopy, the scores on species identification (SI) were found to have the most significant impact on determining participants’ overall competence in the six NCAMM courses conducted in China. All 72 participants showed improvement in their SI scores from the pre-test to the final test. Furthermore, among the 23 participants who had also completed the WHO-ECAMM course, additional improvements in SI scores were observed. Therefore, the NCAMM model can serve as a robust and effective tool for enhancing the competence of malaria microscopists. Correlation analysis of data from the six NCAMM courses revealed no significant relationship between participants’ competence and factors such as institutional hierarchy, educational background, gender, or age. However, the number of years of experience in malaria microscopy was identified as a key determinant of proficiency. Given that malaria microscopy is a skill largely dependent on accumulated experience, the assessment outcomes from the six NCAMM courses appear to consistently reflect the actual competence levels of microscopists. This suggests that the NCAMM course effectively serves as an assessment tool for microscopy competence. Since NCAMM courses conducted in China demonstrate sufficient efficacy as both an evaluation system and a refresher training model, they can be and are expected to be widely implemented at both national and sub-national levels to enhance the human resource capacity of microscopists. Furthermore, the model may serve as a reference for other countries or regions that are either historically malaria-free or have achieved malaria-free certification. Additionally, several recommendations can be made that differ from those of the WHO-ECAMM courses [ 10 – 11 ]. First, new criteria for SP were developed based on previous national and WHO guidelines [ 13 – 16 ], which were issued in 2019 [ 15 ]. The skill levels of SP are assessed in the WHO-ECAMM course but not in the NCAMM course. Furthermore, there are currently no internationally recognized standards for evaluating SP competence. The Chinese model used in the National Technical Competition for Diagnosis of Parasitic Diseases is relatively subjective due to time constraints, as SP competence is primarily assessed based on the appearance of blood smears [ 14 ], using indicators such as "correct size," "somewhat incorrect size," and "incorrect size." Drawing from the initial version and experiences gained during NCAMM implementation, a total of 13 criteria items were ultimately included. Among these, items 2 (diameter of thick film is 10–12 mm, even, and more than 90% intact), 3 (thick film has adequate thickness, with an average of 10–20 white blood cells per field), and 8 (size of thin film is adequate; length and width are both ≥ 20 mm) were revised, while item 4 (position of thick film is correct, with a distance from the center of the thick film to the nearest short edge ≥ 30 mm) was newly added compared to the first version [ 15 ]. These criteria can also be effectively applied in quality assurance (QA) programs. Secondly, within the NCAMM course, the criteria for assessing competence in parasite counting (PC) were based on the WHO/WPRO/RITM External Quality Assessment (EQA) Program for Malaria Microscopy, which differ from those used in the WHO-ECAMM framework [ 10 – 11 ]. According to the WHO-ECAMM standards, participants receive full credit if their count falls within ± 25% of the reference value; otherwise, no points are awarded. PC is widely recognized as the most challenging component of malaria microscopy. Therefore, the NCAMM program introduced a modified scoring criterion, whereby participants receive one point if their count lies between 25% and 50% of the reference count. This adjustment is intended to encourage participants to improve their ability to recognize and identify parasites, thereby enhancing their overall proficiency in PC. Finally, since the integration of SP assessment into the NCAMM curriculum, the original schedule based on the WHO-ECAMM framework proved insufficient for maintaining a balanced approach between theoretical instruction and practical skill development. To resolve this issue, theoretical sessions and skill-based presentations were strategically moved to the end of the agenda. This adjustment offers an additional advantage: facilitators can gain preliminary insights into participants' strengths and weaknesses during earlier activities, enabling them to tailor and emphasize key content in subsequent presentations. As a result, participants benefit from a more conducive learning environment, allowing them to consolidate knowledge and skills after a full day of hands-on practice. Consequently, the NCAMM course demonstrates enhanced effectiveness compared to its predecessor, particularly as a refresher training program. Based on six WHO-ECAMM courses, the national core group of malaria microscopists was re-affirmed. Although level-1 certified microscopists from eight provinces were not reassessed in the past three years, their competence remains credible, as they have consistently maintained their roles in malaria microscopy since certification, both during and after the malaria elimination phase. The assessment results of those who participated in the WHO-ECAMM courses on multiple occasions further support this conclusion. To ensure the quality assurance (QA) of malaria diagnosis, the National Reference Laboratory Network for Malaria Diagnosis (NRLNMD) was established during the elimination phase in China [ 16 ]. Certified microscopists in WHO-ECAMM courses served as the core workforce responsible for operating the NRLNMD and implementing QA activities. For instance, they were entrusted with the final responsibility for species identification of malaria parasites, participated in the drafting of national and provincial microscopy standards, trained fresh microscopists, and contributed to various other malaria control initiatives [ 15 , 17 – 26 ]. The NCAMM course was developed and implemented in China as a standardized model to assess the competence of microscopists in provincial core groups. Provincial-level personnel certified at level A or B were also authorized to make final species identification decisions. It was expected that all members of these core groups would support the development of microscopist teams at the county and township levels nationwide, thereby facilitating the expansion of the NRLNMD and the implementation of QA activities. Certified microscopists through the WHO-ECAMM and NCAMM programs have made significant contributions and instilled confidence in the QA system. Their achievements have inspired the concept of defining and evaluating the competence of malaria microscopists working at peripheral levels. The framework for human resource development of malaria microscopists present in this file offers programmatic guidance to this concept. However, unified standards and practical procedures for certifying microscopists at sub-provincial and county levels remain under development. In fact, various PCAMM courses have been implemented across 31 provinces to train and assess microscopists, although few results have been reported [ 17 – 18 ]. It is evident that uniform cutoff standards are needed to validate these training programs and ensure that certified microscopists are capable of detecting and diagnosing malaria as early and accurately as possible. A prototype of harmonized cutoff standards has therefore been proposed for discussion, based on the minimum competence levels for peripheral-level microscopists outlined in the WHO guidelines [ 11 ]. The concept of BTC was first introduced in China. Given the context of a low incidence rate, this initiative is based on the establishment of national and provincial core teams of highly competent microscopists, as well as the feasibility of rapid, remote malaria diagnosis through internet-based sharing using computers or mobile devices. Under such situation, a microscopist, who can distinguish unusual exogenous organisms in peripheral blood, with consciousness and ability to screen malaria cases and to prepare blood films is enough to surveil malaria. The training costs is much less than training him/her to be an expert in malaria microscopy. However, the implementation schedule and evaluation criteria must be finalized following comprehensive field investigations, practical trials, and discussions. This project has been incorporated into the routine work plan of NIPD in recent years. The NRLNMD has played a crucial role in ensuring the accuracy and reliability of Plasmodium diagnosis in healthcare facilities [ 19 – 23 ]. In the near future, with continued development of human resources and the training of qualified microscopists, an expanded NRLNMD is expected to further contribute to achieving the "Three Early" of malaria prevention and control. Meanwhile, targeted activities within RLNMD and the QA system can be designed in response to fluctuations in the malaria situation and human resource availability. Furthermore, the performance monitoring and active participation in NRLNMD and QA activities serve as effective strategies for sustaining and enhancing microscopists’ diagnostic competence. 5 Limitation The limited sample size represents the first limitation of this study. Organizing training courses is generally resource-intensive, requiring substantial time, effort, and financial investment. As a result, data were collected from only six WHO-ECAMM courses and six NCAMM courses in total. Secondly, participants’ scores on SP (Standardized Patient) assessments from pre- to post-training are not presented here. Based on observations, most participants were able to produce 100% qualified recordings, as additional skill training and practice prior to the post-assessment improved their competence. Thirdly, the results of the anonymous satisfaction surveys conducted after each NCAMM course, which included ten questions regarding course content and delivery, were not included in the manuscript, as all participants provided high evaluation scores. Declarations Ethics statement This study was reviewed and approved by the Ethics Committee of the National Institute of Parasitic Diseases, China CDC. All participates in this study provided informed consent to participate. we confirm that consent was obtained from all human participants involved in the research. This declaration has been clearly included in the revised manuscript. Data availability The data and materials used in this study can be obtained by contacting Dr. Mei Li at [email protected] . Funding The budget organizing WHO-ECAMM courses and NCAMM courses were supported by the Chinese National Malaria Program. Authorship contributions Li M, as the initiator of the NCAMM courses in China, has organized seven WHO-ECAMM courses, established the assessment criteria, designed and conducted nine NCAMM courses, processed all samples, analyzed the data, and drafted the manuscript. Liu H and Wang ZY assisted in finalizing the assessment criteria and course design and participated in one to two courses as facilitators. Wang YB, Yan G, Zhou RM, Deng Y, Liu H and Deng Y served as organizers of NCAMM courses in province 1, 2 and 3 respectively, and provided valuable suggestions for the implementation of NCAMM. Li M and Xia ZG served as organizers of the first and sixth NCAMM courses. Xia ZG also dispatched facilitators to the six NCAMM courses. Wang SQ and Dai YQ assisted in the sixth NCAMM course. Zhou XN and Li SZ were responsible for signing participants’ certificates. All authors reviewed and approved the final version of the manuscript. Conflicts of Interest The authors declare no conflicts of interest. Acknowledgments We extend our appreciation to LetPub (www.letpub.com.cn) for its professional linguistic assistance during the preparation of this manuscript. Information of all authors Dr. Li Mei [email protected] National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008-8405 Mr. Yongbin Wang [email protected] Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong Institute of Parasitic Diseases Control No.11 Taibailou Middle Road, Rencheng District Jining, Shandong, 271096, China 0537-2312938 Prof. Ruimin Zhou [email protected] Insitution of Parasite Disease Prevention and Control, Henan Center for Disease Prevention and Control No. 105 Nongyenan Road, Zhengzhou, Henan, 450016, China 0371-65589001 Prof. Hui Liu [email protected] Yunnan Institute of Parasitic Diseases No. 827 Huitong Road, Chenggong District, Kunming, Yunnan, 650500, China 0871-65234001 Dr. Zhigui Xia [email protected] National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008 Mr. Ge Yan [email protected] Shandong First Medical University & Shandong Academy of Medical Sciences, Shandong Institute of Parasitic Diseases Control No.11 Taibailou Middle Road, Rencheng District Jining, Shandong, 271096, China 0537-2312938 Prof. Yan Deng [email protected] Insitution of Parasite Disease Prevention and Control,Henan Center for Disease Prevention and Control No. 105 Nongyenan Road Zhengzhou, Henan, 450016, China 0371-65589001 Prof. Yan Deng [email protected] Yunnan Institute of Parasitic Diseases No. 827 Huitong Road, Chenggong District Kunming, Yunnan, 650500, China 0871-65234001 Prof. Zhenyu Wang [email protected] No.1380 Zhongshan West Road，Changning District Shanghai, 200336, China 021-62758710 Miss Siqi Wang wangsq@ nipd.chinacdc.cn National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008 Mr. Yuqi Dai [email protected] National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008 Prof. Xiaonong Zhou [email protected] National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008 Dr. Shizhu Li [email protected] National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention No. 207, Ruijin Er Road, Huangpu District Shanghai, 200025, China 021-64377008 References World Health Organization. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7483997","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":521670086,"identity":"8bac39ea-9f2c-4cb5-a3b5-62b19915e8bf","order_by":0,"name":"Mei Li","email":"","orcid":"","institution":"National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Chinese Center for Tropical Diseases Research, Ministry of Health, Ministry of Science and 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07:12:49","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":146623,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7483997/v1/9abd5d73c3195917f0f98a99.html"},{"id":92474587,"identity":"2da3c565-7d52-4e9e-a87d-dc1c6f059f84","added_by":"auto","created_at":"2025-09-30 07:12:49","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":57625,"visible":true,"origin":"","legend":"\u003cp\u003eThe spatial distribution patterns of malaria cases in sub-provincial level in China in 2023 and 2024\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7483997/v1/c75816d8e562e0817e6509df.png"},{"id":92478306,"identity":"39985812-9e4b-4f96-8b12-7392ee51d1b6","added_by":"auto","created_at":"2025-09-30 07:28:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":63998,"visible":true,"origin":"","legend":"\u003cp\u003eThe spatial distribution patterns of malaria cases in county level in China in 2023 and 2024\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7483997/v1/7adcc2d1258f500e82afb0a8.png"},{"id":92474589,"identity":"e21ac4e8-ef25-4b64-91c5-8ba5711bed60","added_by":"auto","created_at":"2025-09-30 07:12:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":67695,"visible":true,"origin":"","legend":"\u003cp\u003ePre-assumed structure of human resource development of malaria microscopists in China\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7483997/v1/619aa1fdd6e39e98f393ae7b.png"},{"id":92480872,"identity":"dfa422f2-9368-40ec-aacb-8b4843c49f2f","added_by":"auto","created_at":"2025-09-30 07:44:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1514776,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7483997/v1/469b8e83-d3b1-4ce6-b0b7-35bb42b6b619.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of human resources in malaria microscopy during and after the malaria elimination phase in China","fulltext":[{"header":"1 Background","content":"\u003cp\u003eSince 2015, nine countries, including China, have been officially certified as malaria-free by the World Health Organization (WHO) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Although global malaria elimination programs have made significant progress in recent years, malaria remains a substantial public health challenge worldwide. In 2023, approximately 263\u0026nbsp;million individuals were infected with malaria, resulting in an estimated 597,000 deaths [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. China maintains regular communication with other countries and regions. According to official statistics, China processed approximately 610\u0026nbsp;million entries and exits of individuals in 2024, of which 291\u0026nbsp;million involved mainland residents traveling in and out of the country [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. On average, around 3,000 malaria cases were reported annually across 31 provinces in China since 2011, corresponding to an incidence rate of approximately 2.1 cases per million population (3,000/1.4\u0026nbsp;billion). Despite this relatively low incidence, the disease resulted in a significant number of severe cases and a case fatality rate of 4.8 per thousand (n\u0026thinsp;=\u0026thinsp;8, \u0026plusmn;\u0026thinsp;1.8\u0026permil;, 95% CI: 3.3\u0026ndash;6.3\u0026permil;). Furthermore, imported \u003cem\u003ePlasmodium vivax\u003c/em\u003e cases and its primary vector, \u003cem\u003eAnopheles sinensis\u003c/em\u003e, are widely present in malaria-endemic provinces of China [\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Therefore, China continues to face a risk of malaria resurgence.\u003c/p\u003e\u003cp\u003eTo prevent severe malaria, malaria-related fatalities, and the re-transmission of malaria in malaria-free regions, the principles of early detection, early diagnosis, and early treatment\u0026mdash;collectively referred to as the \"Three Early\" strategy\u0026mdash;are widely recognized as essential global practices. However, given the persistently low incidence of malaria during and after its elimination in China, large-scale, comprehensive resource allocation\u0026mdash;including specialized testing reagents, materials, and human resources\u0026mdash;is clearly impractical. Nevertheless, shortages in these areas have led to misdiagnoses and delayed diagnoses, serving as notable warnings [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Among the available diagnostic methods for malaria\u0026mdash;Rapid Diagnostic Tests (RDT), Nucleic Acid Testing (NAT), and microscopy\u0026mdash;microscopy remains the gold standard and is considered the most feasible option for monitoring malaria cases at health institutions of various levels including county and even some township under the current epidemiological context in China. This principle is reflected in the National Surveillance Program during the Post-Malaria Elimination Period (2025 Edition) (NSP-2025). Therefore, to ensure the effective implementation of the \"Three Early\" strategy and to uphold the high-quality execution of the NSP-2025, it is essential to maintain a sufficient number of qualified microscopists across the country. Simultaneously, establishing effective mechanisms to sustain their diagnostic competence is equally critical.\u003c/p\u003e\u003cp\u003eThe External Competence Assessment of Malaria Microscopists (WHO-ECAMM), developed and implemented by the World Health Organization (WHO), serves as a well-established model for evaluating the competence of malaria microscopists and has been widely adopted by malaria-endemic countries globally [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Microscopists qualified in WHO-ECAMM courses are the best proof of a strong surveillance system required to certify and sustain malaria elimination [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. The National Institute of Parasitic Diseases (NIPD) under the China Center for Disease Control and Prevention (CDC), which oversees the national malaria control program, has organized ten WHO-ECAMM courses between 2009 and 2024. However, due to the limitation that no more than one microscopist per province could participate every three years, the demand for certified malaria microscopists remains largely unfulfilled in China, particularly at the subnational level [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe National Competency Assessment of Malaria Microscopists (NCAMM) is another model proposed by WHO, specifically designed to support domestic external competence assessments in malaria microscopy. To date, however, no NCAMM implementation has been reported globally. In 2018, three Chinese facilitators were jointly trained and certified by the WHO Western Pacific Region Office, the Asian Collaborative Training Network for Malaria, and NIPD. Based on WHO guidelines, these facilitators successfully conducted six updated NCAMM courses between 2019 and 2024.\u003c/p\u003e\u003cp\u003eThis document presents the efforts and achievements in human resource development for malaria microscopists in China, along with future prospects. First, it summarizes the certified malaria microscopists assessed through WHO-ECAMM courses in China. Next, it introduces the updated NCAMM courses, supported by an analysis of assessment data. Finally, it proposes a conceptual framework for the future development of human resources for malaria microscopists in China.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Certified Malaria Microscopists in WHO-ECAMM Courses Between 2017 and 2024 in China\u003c/h2\u003e\u003cp\u003eData on participants who attended the WHO-ECAMM courses between 2017 and 2024 in China were collected. The number and distribution of certified microscopists across different levels were calculated at the provincial level.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 NCAMM Courses Implemented Between 2019 and 2024\u003c/h2\u003e\u003cdiv id=\"Sec5\" class=\"Section3\"\u003e\u003ch2\u003e2.2.1 Organization of Six NCAMM Courses and Collection of Participants\u0026rsquo; Information\u003c/h2\u003e\u003cp\u003eNIPD, either independently or in collaboration with provincial CDCs, organized six NCAMM courses. Each course was conducted with the support of one to three certified facilitators. Comprehensive data were systematically collected regarding participants\u0026rsquo; affiliated institutions, gender, educational background, age, and years of experience in malaria microscopy.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section3\"\u003e\u003ch2\u003e2.2.2 NCAMM Course Schedule and Scoring System\u003c/h2\u003e\u003cp\u003eThe NCAMM course is a structured five-day training program that includes a theoretical examination, pre-assessment, and final evaluation (as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), all of which align with WHO\u0026rsquo; s guidelines [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The key distinction between the assessments was that the theoretical and skill-based presentations were scheduled toward the end of the program in the earlier versions.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAgenda of NCAMM course\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0800\u0026ndash;0915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0915\u0026ndash;0945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0945\u0026ndash;1215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1215\u0026ndash;1300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1300\u0026ndash;1330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1330\u0026ndash;1545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1545\u0026ndash;1700\u003c/p\u003e\u003cp\u003e(Presentation)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRegistration\u003c/p\u003e\u003cp\u003eIntroduction of ECAMM, Theory Test \u0026amp; Feedback\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePretest:\u003c/p\u003e\u003cp\u003eSlide making\u003c/p\u003e\u003cp\u003e(5/7 Slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePretest:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(9 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLunch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePretest:\u003c/p\u003e\u003cp\u003eSlides Staining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003ePretest:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(9 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.Slides preparation and assessment criteria\u003c/p\u003e\u003cp\u003e2. Blood elements \u0026amp; artefacts and skills of malaria microscopy (simple version)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eD2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0800\u0026ndash;0915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0915\u0026ndash;0945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0945\u0026ndash;1215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1215\u0026ndash;1300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1300\u0026ndash;1330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1330\u0026ndash;1545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1545\u0026ndash;1700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnswer feedback and slides Review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide making\u003c/p\u003e\u003cp\u003e(5/7 Slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(10 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLunch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlides Staining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination (9 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.Blood elements \u0026amp; artefacts and skills of malaria microscopy (detailed version)\u003c/p\u003e\u003cp\u003e2.Skills of parasite counting\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eD3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0800\u0026ndash;0915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0915\u0026ndash;0945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0945\u0026ndash;1215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1215\u0026ndash;1300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1300\u0026ndash;1330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1330\u0026ndash;1545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1545\u0026ndash;1700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnswer feedback and slides Review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide making\u003c/p\u003e\u003cp\u003e(5/7 Slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(10 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLunch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlides Staining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(9 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.Skills of collecting blood from finger and making slides 2.Establishment of malaria slide Bank(changeable)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eD4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0800\u0026ndash;0915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0915\u0026ndash;0945\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0945\u0026ndash;1215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1215\u0026ndash;1300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1300\u0026ndash;1330\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1330\u0026ndash;1545\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1545\u0026ndash;1700\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnswer feedback and slides Review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide making using Finger blood\u003c/p\u003e\u003cp\u003e(3/5 Slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(10 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eLunch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Staining\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eFinal test:\u003c/p\u003e\u003cp\u003eSlide Examination\u003c/p\u003e\u003cp\u003e(8 slides)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eQA in Malaria Laboratory Diagnosis (changeable)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eD5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0800\u0026ndash;0915\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0915\u0026ndash;1045\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1100\u0026ndash;1200\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1200\u0026ndash;1300\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003e1300\u0026ndash;1600\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnnouncement of results and slides review\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eClinical diagnosis, treatment and case sharing (changeable)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCourse conclusion and award ceremony\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eLunch\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e\u003cp\u003eDeparture\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eFor the Slide Preparation (SP) grading, a total of 13 quality criteria are evaluated (as detailed in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). These criteria have been updated since their initial establishment in 2019 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Each criterion is scored as either \"Yes\" (1 point) or \"No\" (0 points), with one point allocated per criterion. The total score for each prepared slide is calculated, and slides achieving 12 or more points out of 13 are considered qualified. The percentage of qualified slides prepared by each participant during the final assessment period (Days 2\u0026ndash;4) serves as one of the key indicators for determining participants\u0026rsquo; competence levels. From Days 1 to 3, participants are provided with seven blank slides daily for blood film preparation. Each day, the five best-prepared slides from each participant are evaluated against the established quality criteria. On Day 4, participants are given five blank slides, and three thick and thin smears prepared from freshly collected finger-prick blood samples are assessed using the same evaluation criteria.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCriteria items for slides preparation\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCriteria Items for SP\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eYes/No\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe blood smear is unique labeled and \u003cb\u003ethe label is located at the end near the thick film\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eDiameter of thick film is \u003cb\u003e10\u0026thinsp;~\u0026thinsp;12mm\u003c/b\u003e, \u003cb\u003eeven\u003c/b\u003e and more than 90% is intact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe thick film is adequate thickness. Averagely \u003cb\u003e10\u0026thinsp;~\u0026thinsp;20 white blood cells per f\u003c/b\u003eield\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eThe position of thick film is right\u003c/b\u003e (Distance from center of thick film to the nearest short edge\u0026thinsp;\u0026ge;\u0026thinsp;30mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eThere are three parts of thin films, head, body and tail with no waves\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eThere are adequate space between thick and thin films (\u0026ge;\u0026thinsp;5mm)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eThere are adequate space between thin film and edges of slide (\u0026ge;\u0026thinsp;5mm short edge, \u0026ge;1mm long edge)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe thin film \u003cb\u003eis adequate size (len\u003c/b\u003egth and width are both ≧\u0026thinsp;20mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe white blood cells are properly stained (nucleus is purple to black)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe red cells are completely lyzed in thick films (Diameter of lyzed area is more than 8mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRed cells show single layer towards the feathered edge\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe red blood cells are properly stained(grey to pink)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eThe films are clearly and no debris. The background is transparent\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003eYes for 1 point, No for 0 point; Slides with \u0026ge;\u0026thinsp;12 points is qualified.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe composition of the NCAMM slide panels is largely consistent with the methodology employed by the WHO-ECAMM [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], with the exception of slides including two species (two slides in total in the final test) and non-falciparum species (eight slides in the final test). These components can be tailored according to the local malaria epidemiological profile. For the parasite counting test, which comprises 14 slides in the final assessment, six slides with parasite densities ranging from 800 to 6,000 parasites/\u0026micro;L are included. The highest parasite density category, represented by two slides, is defined as 12,000\u0026ndash;20,000 parasites/\u0026micro;L rather than 40,000\u0026ndash;100,000 parasites/\u0026micro;L due to limitations in slide availability. At least 16 falciparum slides with low parasite density (200\u0026ndash;700 parasites/\u0026micro;L) are selected for species identification (n\u0026thinsp;=\u0026thinsp;10) and counting (n\u0026thinsp;=\u0026thinsp;6). The slide panels used in the pre-test are identical to those used in the WHO-ECAMM [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Two to three slides may be repeated between the pre-test and the final test. Participants are evaluated based on their accuracy in malaria parasite detection (PD), species identification (SI), and parasite counting (PC). Scoring is calculated using the following equations:\u003c/p\u003e\u003cp\u003ePD (%) = \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\text{T}\\text{h}\\text{e}\\:\\text{n}\\text{u}\\text{m}\\text{b}\\text{e}\\text{r}\\:\\text{o}\\text{f}\\:\\text{p}\\text{o}\\text{s}\\text{i}\\text{t}\\text{i}\\text{v}\\text{e}\\text{s}\\:\\text{n}\\text{o}\\text{t}\\text{e}\\text{d}\\:\\text{b}\\text{y}\\:\\text{t}\\text{h}\\text{e}\\:\\text{p}\\text{a}\\text{r}\\text{t}\\text{i}\\text{c}\\text{i}\\text{p}\\text{a}\\text{n}\\text{t}\\text{s}}{\\text{T}\\text{h}\\text{e}\\:\\text{n}\\text{u}\\text{m}\\text{b}\\text{e}\\text{r}\\:\\text{o}\\text{f}\\:\\text{a}\\text{l}\\text{l}\\:\\text{t}\\text{r}\\text{u}\\text{e}\\:\\text{p}\\text{o}\\text{s}\\text{i}\\text{t}\\text{i}\\text{v}\\text{e}\\text{s}}\\)\u003c/span\u003e\u003c/span\u003e\u0026times;100%\u003c/p\u003e\u003cp\u003eSI (%) = \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\text{T}\\text{h}\\text{e}\\:\\text{t}\\text{o}\\text{t}\\text{a}\\text{l}\\:\\text{p}\\text{o}\\text{i}\\text{n}\\text{t}\\text{s}\\:\\text{o}\\text{b}\\text{t}\\text{a}\\text{i}\\text{n}\\text{e}\\text{d}\\:\\text{b}\\text{y}\\:\\text{t}\\text{h}\\text{e}\\:\\text{p}\\text{a}\\text{r}\\text{t}\\text{i}\\text{c}\\text{i}\\text{p}\\text{a}\\text{n}\\text{t}}{2\\times\\:\\:\\text{T}\\text{h}\\text{e}\\:\\text{t}\\text{o}\\text{t}\\text{a}\\text{l}\\:\\text{n}\\text{u}\\text{m}\\text{b}\\text{e}\\text{r}\\:\\text{o}\\text{f}\\:\\text{s}\\text{l}\\text{i}\\text{d}\\text{e}\\text{s}\\:\\text{f}\\text{o}\\text{r}\\:\\text{s}\\text{p}\\text{e}\\text{c}\\text{i}\\text{e}\\text{s}\\:\\text{i}\\text{d}\\text{e}\\text{n}\\text{t}\\text{i}\\text{f}\\text{i}\\text{e}\\text{d}}\\)\u003c/span\u003e\u003c/span\u003e\u0026times;100%\u003c/p\u003e\u003cp\u003ePC (%) = \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:\\frac{\\text{T}\\text{h}\\text{e}\\:\\text{t}\\text{o}\\text{t}\\text{a}\\text{l}\\:\\text{p}\\text{o}\\text{i}\\text{n}\\text{t}\\text{s}\\:\\text{o}\\text{b}\\text{t}\\text{a}\\text{i}\\text{n}\\text{e}\\text{d}\\:\\text{b}\\text{y}\\:\\text{t}\\text{h}\\text{e}\\:\\text{p}\\text{a}\\text{r}\\text{t}\\text{i}\\text{c}\\text{i}\\text{p}\\text{a}\\text{n}\\text{t}}{3\\times\\:\\:\\text{T}\\text{h}\\text{e}\\:\\text{t}\\text{o}\\text{t}\\text{a}\\text{l}\\:\\text{n}\\text{u}\\text{m}\\text{b}\\text{e}\\text{r}\\:\\text{o}\\text{f}\\:\\text{s}\\text{l}\\text{i}\\text{d}\\text{e}\\text{s}\\:\\text{f}\\text{o}\\text{r}\\:\\text{p}\\text{a}\\text{r}\\text{a}\\text{s}\\text{i}\\text{t}\\text{e}\\:\\text{c}\\text{o}\\text{u}\\text{n}\\text{t}\\text{i}\\text{n}\\text{g}}\\)\u003c/span\u003e\u003c/span\u003e\u0026times;100%\u003c/p\u003e\u003cp\u003eFor the SI component, the final test consists of a total of 22 positive slides. Two points are awarded for accurate identification. If only one species is identified in a mixed infection scenario, one point is given, whereas zero points are assigned if two species are reported when only one is present. Furthermore, three points are awarded if the participant's count is within 25% of the actual count, one point if the count falls within 50% but not within 25%, and zero points if the count is less than 50% of the true value.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section3\"\u003e\u003ch2\u003e2.2.3 Assessment of Competence Level in Malaria Microscopy\u003c/h2\u003e\u003cp\u003eParticipants are classified into Competence Levels A, B, C, or D based on the scoring criteria for PD, SI, and PC, as outlined in WHO's documentation (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eStandards to certifying participants\u0026rsquo; different competence of malaria microscopy [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLevels\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePD (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSI (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003ePC(%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSP(%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u0026thinsp;~\u0026thinsp;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e90\u0026thinsp;~\u0026thinsp;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e50\u0026thinsp;~\u0026thinsp;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90\u0026thinsp;~\u0026thinsp;100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e80\u0026thinsp;~\u0026thinsp;89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80\u0026thinsp;~\u0026thinsp;89\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e40\u0026thinsp;~\u0026thinsp;49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e80\u0026thinsp;~\u0026thinsp;89\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e70\u0026thinsp;~\u0026thinsp;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70\u0026thinsp;~\u0026thinsp;79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e30\u0026thinsp;~\u0026thinsp;39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e70\u0026thinsp;~\u0026thinsp;79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u0026thinsp;~\u0026thinsp;69\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section3\"\u003e\u003ch2\u003e2.2.5 Data Analysis\u003c/h2\u003e\u003c/div\u003e\u003cdiv id=\"Sec9\" class=\"Section3\"\u003e\u003ch2\u003e2.2.5 Data Analysis\u003c/h2\u003e\u003cp\u003eData were analyzed using SPSS Statistics 23. Initial normality tests were conducted to assess the distribution of the data. Results are presented as means with standard deviation and medians with interquartile ranges (25th and 75th percentiles). For data that were not normally distributed, the Wilcoxon test and Fisher\u0026rsquo;s exact test (α\u0026thinsp;=\u0026thinsp;0.05) were used. An ordinal regression analysis was conducted, incorporating Spearman\u0026rsquo;s correlation coefficient, to examine the relationship between participants\u0026rsquo; competence levels in malaria microscopy and their age or years of experience in malaria microscopy.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Pre-assumed Structure of Human Resource Development for Malaria Microscopists in China\u003c/h2\u003e\u003cp\u003eBased on the spatial distribution of malaria cases at provincial, sub-provincial, and county levels in 2023 and 2024, as well as the requirements outlined in the NSP-2025, a pre-assumed structure for the development of human resources for malaria microscopists at different administrative levels in China is proposed.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Malaria microscopists certified in WHO-ECAMM courses between 2017 and 2024\u003c/h2\u003e\u003cp\u003eIn total, 64 microscopists participated in the six WHO-ECAMM courses conducted in China between 2017 and 2024. Prior to China being certified as malaria-free in 2021, four of these courses were held between 2017 and 2019. Participants in these courses were selected from NIPD and 31 provinces across the country. In 2024, two additional courses were conducted to reassess the participants and evaluate newly nominated microscopists, particularly those from provinces with relatively low malaria incidence between 2019 and 2023.\u003c/p\u003e\u003cp\u003eAmong the 31 provinces, 21 were granted two opportunities to nominate microscopists for participation in the WHO-ECAMM courses, three provinces were given one opportunity, six provinces were provided three opportunities, and one province was given four opportunities (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAmong the 64 microscopists, 57 participated once, six participated twice, and one participated three times. Of these individuals, 29 were certified at level 1, 17 at level 2, and 18 at level 3 or 4. Microscopists\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMicroscopists certified in different provinces between 2017 and 2024\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eChances\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eCompetence levels\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOnce\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eTwice\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTree times\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eFour times\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of microscopists\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e57\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo. of Provinces\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003ecertified at level 1 or 2 represented the NIPD and 29 provinces (see Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). Among them, 15 were male and 31 were female. Currently, the average age of these microscopists is 41.1 years (n\u0026thinsp;=\u0026thinsp;46; \u0026plusmn;8.7; median\u0026thinsp;=\u0026thinsp;41.0 [36.0\u0026thinsp;~\u0026thinsp;46.0]). If we consider participation starting from 2012, seven participants attended the courses twice and seven attended three times. All of them have been engaged in malaria microscopy over the past decade. Most of them (13 out of 14) demonstrated improvement in their competence or maintained a high level of proficiency. The detailed outcomes are as follows: four were certified at level 1 three times, one was certified at level 1 twice, one was certified at level 2 twice, one improved from level 2 to level 1, four improved from level 3 or 4 to level 2 or 1 either directly or stepwise, one decreased from level 1 to level 2, and one decrease from level 1 to level 3.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Findings of NCAMM courses in China\u003c/h2\u003e\u003cp\u003eAmong the 72 participants in six NCAMM courses, 48 were female and 24 were male; 36 were from provincial-level units and 36 from sub-provincial-level units. With regard to educational background, 32 participants held master\u0026rsquo;s degrees and 40 held bachelor\u0026rsquo;s degrees (see Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The majority of\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSix NCAMM courses in China and participants\u0026rsquo; basic information\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrder\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTime\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrganizers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eParticipants\u0026rsquo; units\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e\u003cp\u003eEducation degree\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eProvincial Units\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eSub-provincial Units\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMaster\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2019\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNIPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2021\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvince 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvince 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2023\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvince 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProvince 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2024\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNIPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eparticipants were aged between 35.0 and 40.0 years (n\u0026thinsp;=\u0026thinsp;72; mean age\u0026thinsp;=\u0026thinsp;36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9 years; median\u0026thinsp;=\u0026thinsp;35.0 years [32.0\u0026thinsp;~\u0026thinsp;40.0]). Additionally, all participants had more than 6 years of experience in malaria microscopy (n\u0026thinsp;=\u0026thinsp;72; mean\u0026thinsp;=\u0026thinsp;6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0 years; median\u0026thinsp;=\u0026thinsp;6.5 years [2.0\u0026thinsp;~\u0026thinsp;10.0]).\u003c/p\u003e\u003cp\u003eIn total, 10 out of 72 participants were certified at Level A, 33 at Level B, and 28 at Level C or D. In the second and fourth courses, a higher proportion of participants achieved Level A and B certifications compared to those in the remaining courses (Fisher's exact test: df\u0026thinsp;=\u0026thinsp;3; χ\u0026sup2; = 7.8, 7.9, 11.8, 11.8; P\u0026thinsp;\u0026lt;\u0026thinsp;0.01 or\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05; χ\u0026sup2; = 8.4, 10.3, 8.5; P\u0026thinsp;=\u0026thinsp;0.01 or P\u0026thinsp;\u0026lt;\u0026thinsp;0.05). No statistically significant differences were found\u003c/p\u003e\u003cp\u003eamong the outcomes of participants enrolled in the first, third, fifth, and sixth courses (Fisher's exact test: df\u0026thinsp;=\u0026thinsp;3; χ\u0026sup2; = 2.5, 1.6, 3.1, 4.2, 3.1, 1.3; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (see Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eStatistical analysis revealed that demographic variables such as age, workplace, educational background,\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eResults and comparison of 6 NCAMM courses\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"11\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCourses\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eOrganizers\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eNo. of participants\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\u003cp\u003eFisher's Exact Test between different courses\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2nd\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003e3rd\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003e4th\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003e5th\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c11\"\u003e\u003cp\u003e6th\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1st\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNIPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7.8\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;2.5 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.4\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.6 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.1 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2nd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;7.9 P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.1 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;11.8 P\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;11.8\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3rd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince 1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.7 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;4.2 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;3.1 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince 2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;10.3 P\u0026thinsp;=\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;8.5 P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvince 3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.3 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6th\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNIPD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c11\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eand gender did not significantly affect participants' competence in malaria microscopy (n\u0026thinsp;=\u0026thinsp;72; ρ\u0026thinsp;=\u0026thinsp;0.2, P\u0026thinsp;\u0026gt;\u0026thinsp;0.05; Fisher's exact test: χ\u0026sup2; = 1.2, 1.2, 1.7; df\u0026thinsp;=\u0026thinsp;3; P\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Tables\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). In contrast, the number of years of experience in malaria microscopy showed a moderate positive correlation with competence levels (n\u0026thinsp;=\u0026thinsp;72; ρ\u0026thinsp;=\u0026thinsp;0.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) (see Table\u0026nbsp;\u003cspan refid=\"Tab8\" class=\"InternalRef\"\u003e8\u003c/span\u003e). All 72 participants scored above the minimum threshold required for their respective certification levels in PD, PC, and SP.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipants\u0026rsquo; competence comparison of participants with different background\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eNo. of Participants with Different Competence of Malaria Microscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eFisher's Exact Test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eA(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eB(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eC(n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eD(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eUnits\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProvincial level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;5.1 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSub-provincial level\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eEducation Degree\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaster\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.2 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBachelor\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eχ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;1.7 P\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab8\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 8\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelevance between participants\u0026rsquo; competence and their ages or years serving for malaria microscopy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" morerows=\"2\" nameend=\"c2\" namest=\"c1\" rowspan=\"3\"\u003e\u003cp\u003eItems\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e\u003cp\u003eFactors\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eAges\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eYears of service in malaria microscopy\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e\u003cp\u003eParticipants\u0026rsquo; Competence of Malaria Microscopy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eA(n\u0026thinsp;=\u0026thinsp;10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.0[34.0\u0026thinsp;~\u0026thinsp;39.3]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e9.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.0[6.5\u0026thinsp;~\u0026thinsp;13.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eB(n\u0026thinsp;=\u0026thinsp;33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e37.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.0[32.0\u0026thinsp;~\u0026thinsp;42.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e7.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e8.0[4.0\u0026thinsp;~\u0026thinsp;10.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eC(n\u0026thinsp;=\u0026thinsp;18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33.0[31.0\u0026thinsp;~\u0026thinsp;36.5]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3.0[1.0\u0026thinsp;~\u0026thinsp;5.3]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eD(n\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e36.0[30.0\u0026thinsp;~\u0026thinsp;40.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.7\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e2.0[0.5\u0026thinsp;~\u0026thinsp;10.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eTotal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36.3\u0026thinsp;\u0026plusmn;\u0026thinsp;5.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e35.0[32.0\u0026thinsp;~\u0026thinsp;40.0]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e6.7\u0026thinsp;\u0026plusmn;\u0026thinsp;5.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.5[2.0\u0026thinsp;~\u0026thinsp;10.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eCorrelation Coefficient(ρ)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003e0.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eSig. (2-tailed)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eP\u0026thinsp;\u0026gt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eScores for SI improved significantly in the final test (n\u0026thinsp;=\u0026thinsp;72; mean\u0026thinsp;=\u0026thinsp;80.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0]; median\u0026thinsp;=\u0026thinsp;82.0 [74.0\u0026thinsp;~\u0026thinsp;88.0]) compared to the pre-test (n\u0026thinsp;=\u0026thinsp;72; mean\u0026thinsp;=\u0026thinsp;62.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0; median\u0026thinsp;=\u0026thinsp;62.0 [50.0\u0026thinsp;~\u0026thinsp;77.0]) (Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;7.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01). Furthermore, participants demonstrated a significant improvement in competence following the WHO-ECAMM course (n\u0026thinsp;=\u0026thinsp;23; Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;2.4, P\u0026thinsp;\u0026lt;\u0026thinsp;0.05; Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.0, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01; Z\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;3.9, P\u0026thinsp;\u0026lt;\u0026thinsp;0.01) after completing the NCAMM courses (n\u0026thinsp;=\u0026thinsp;23; mean\u0026thinsp;=\u0026thinsp;75.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9; median\u0026thinsp;=\u0026thinsp;75.0 [67.0\u0026thinsp;~\u0026thinsp;82.0]) compared to both the pre-test (n\u0026thinsp;=\u0026thinsp;23; mean\u0026thinsp;=\u0026thinsp;82.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1; median\u0026thinsp;=\u0026thinsp;88.0 [76.0\u0026thinsp;~\u0026thinsp;92.0]) and the final test (n\u0026thinsp;=\u0026thinsp;23; mean\u0026thinsp;=\u0026thinsp;88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9; median\u0026thinsp;=\u0026thinsp;93.0 [83.0\u0026thinsp;~\u0026thinsp;95.0]) (Table\u0026nbsp;\u003cspan refid=\"Tab9\" class=\"InternalRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab9\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 9\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eComparison of participants\u0026rsquo; SI scores between different periods*\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eCourses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c3\" namest=\"c2\" rowspan=\"2\"\u003e\u003cp\u003eScores\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003ePaired T-test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNCAMM- Final-test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eECAMM-Final test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNCAMM-\u003c/p\u003e\u003cp\u003ePre-test (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.0\u0026thinsp;\u0026plusmn;\u0026thinsp;19.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ=-7.3\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e62.0[50.0\u0026thinsp;~\u0026thinsp;77.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNCAMM-Final test (n\u0026thinsp;=\u0026thinsp;72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e80.0\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.0[74.0\u0026thinsp;~\u0026thinsp;88.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eNCAMM-Final test (n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.4\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ=-3.9\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.0[67.0\u0026thinsp;~\u0026thinsp;82.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eECAMM- Pre-test\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ=-2.4\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eZ=-3.0\u003c/p\u003e\u003cp\u003eP\u0026thinsp;\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.0[76.0\u0026thinsp;~\u0026thinsp;92.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eECAMM-Final test\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMean\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e88.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e/\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMedian\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e93.0[83.0\u0026thinsp;~\u0026thinsp;95.0]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e* 23 participants took part in both NCAMM and WHO-ECAMM successively.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3 Pre-assumed structure of human resource development of malaria microscopists in China\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eThe spatial distribution patterns of malaria cases in China in 2023 and 2024 indicate that all provinces have reported occurrences. A majority of provinces (21\u0026ndash;22 out of 31) reported cases in more than 60% of their sub-provincial regions, while nearly half of the provinces (14\u0026ndash;16 out of 31) reported cases in fewer than 20% of their counties (see Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Therefore, it is recommended that core groups composed of highly competent malaria microscopists be established at the national, provincial, and most sub-provincial levels. At the county level, staffing strategies may vary depending on the local malaria situation. The proposed human resource structure for malaria microscopists includes three core groups operating at the national, sub-national (provincial), and sub-provincial levels. This structure suggests the application of four models for assessing microscopists\u0026rsquo; competence (see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe national core group consists of microscopists employed in national and provincial laboratories. All members should currently hold a certification of Level 1 or Level 2 in the WHO-ECAMM courses. In provinces where malaria cases have been reported in five or more sub-provincial areas over the past three years, it is recommended that microscopists in the provincial core group be certified at least at Level A or B in the NCAMM courses. In provinces where malaria cases have been reported in zero to four sub- provincial areas during the same period, microscopists certified at Level A or B in the NCAMM courses are\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003econsidered acceptable. Alternatively, those who have been assessed as qualified malaria microscopists through other provincial competence assessment mechanisms (PCAMM) are also acceptable. The provincial core group is composed of microscopists working in provincial and sub-provincial laboratories.\u003c/p\u003e\u003cp\u003eAt the county level, qualified malaria microscopists trained through PCAMM courses are essential in counties that have reported malaria cases in the past three years. In counties where no malaria cases have been reported for at least five consecutive years, greater emphasis should be placed on the microscopists\u0026rsquo; ability to prepare blood smears and maintain awareness for malaria case screening, rather than on the precise identification of parasite species. This objective can be achieved through Basic Training Courses (BTC) conducted by sub-provincial or provincial institutions. Ideally, the core group at the sub-provincial level should consist of microscopists who have been certified through either PCAMM or BTC training programs.\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion and Conclusion","content":"\u003cp\u003eThe WHO-ECAMM course in previous studies has demonstrated dual functions in both assessing and training microscopy skills [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Among the four fundamental components of malaria microscopy, the scores on species identification (SI) were found to have the most significant impact on determining participants\u0026rsquo; overall competence in the six NCAMM courses conducted in China. All 72 participants showed improvement in their SI scores from the pre-test to the final test. Furthermore, among the 23 participants who had also completed the WHO-ECAMM course, additional improvements in SI scores were observed. Therefore, the NCAMM model can serve as a robust and effective tool for enhancing the competence of malaria microscopists. Correlation analysis of data from the six NCAMM courses revealed no significant relationship between participants\u0026rsquo; competence and factors such as institutional hierarchy, educational background, gender, or age. However, the number of years of experience in malaria microscopy was identified as a key determinant of proficiency. Given that malaria microscopy is a skill largely dependent on accumulated experience, the assessment outcomes from the six NCAMM courses appear to consistently reflect the actual competence levels of microscopists. This suggests that the NCAMM course effectively serves as an assessment tool for microscopy competence.\u003c/p\u003e\u003cp\u003eSince NCAMM courses conducted in China demonstrate sufficient efficacy as both an evaluation system and a refresher training model, they can be and are expected to be widely implemented at both national and sub-national levels to enhance the human resource capacity of microscopists. Furthermore, the model may serve as a reference for other countries or regions that are either historically malaria-free or have achieved malaria-free certification. Additionally, several recommendations can be made that differ from those of the WHO-ECAMM courses [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eFirst, new criteria for SP were developed based on previous national and WHO guidelines [\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], which were issued in 2019 [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The skill levels of SP are assessed in the WHO-ECAMM course but not in the NCAMM course. Furthermore, there are currently no internationally recognized standards for evaluating SP competence. The Chinese model used in the National Technical Competition for Diagnosis of Parasitic Diseases is relatively subjective due to time constraints, as SP competence is primarily assessed based on the appearance of blood smears [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e], using indicators such as \"correct size,\" \"somewhat incorrect size,\" and \"incorrect size.\" Drawing from the initial version and experiences gained during NCAMM implementation, a total of 13 criteria items were ultimately included. Among these, items 2 (diameter of thick film is 10\u0026ndash;12 mm, even, and more than 90% intact), 3 (thick film has adequate thickness, with an average of 10\u0026ndash;20 white blood cells per field), and 8 (size of thin film is adequate; length and width are both \u0026ge;\u0026thinsp;20 mm) were revised, while item 4 (position of thick film is correct, with a distance from the center of the thick film to the nearest short edge\u0026thinsp;\u0026ge;\u0026thinsp;30 mm) was newly added compared to the first version [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. These criteria can also be effectively applied in quality assurance (QA) programs.\u003c/p\u003e\u003cp\u003eSecondly, within the NCAMM course, the criteria for assessing competence in parasite counting (PC) were based on the WHO/WPRO/RITM External Quality Assessment (EQA) Program for Malaria Microscopy, which differ from those used in the WHO-ECAMM framework [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. According to the WHO-ECAMM standards, participants receive full credit if their count falls within \u0026plusmn;\u0026thinsp;25% of the reference value; otherwise, no points are awarded. PC is widely recognized as the most challenging component of malaria microscopy. Therefore, the NCAMM program introduced a modified scoring criterion, whereby participants receive one point if their count lies between 25% and 50% of the reference count. This adjustment is intended to encourage participants to improve their ability to recognize and identify parasites, thereby enhancing their overall proficiency in PC.\u003c/p\u003e\u003cp\u003eFinally, since the integration of SP assessment into the NCAMM curriculum, the original schedule based on the WHO-ECAMM framework proved insufficient for maintaining a balanced approach between theoretical instruction and practical skill development. To resolve this issue, theoretical sessions and skill-based presentations were strategically moved to the end of the agenda. This adjustment offers an additional advantage: facilitators can gain preliminary insights into participants' strengths and weaknesses during earlier activities, enabling them to tailor and emphasize key content in subsequent presentations. As a result, participants benefit from a more conducive learning environment, allowing them to consolidate knowledge and skills after a full day of hands-on practice. Consequently, the NCAMM course demonstrates enhanced effectiveness compared to its predecessor, particularly as a refresher training program.\u003c/p\u003e\u003cp\u003eBased on six WHO-ECAMM courses, the national core group of malaria microscopists was re-affirmed. Although level-1 certified microscopists from eight provinces were not reassessed in the past three years, their competence remains credible, as they have consistently maintained their roles in malaria microscopy since certification, both during and after the malaria elimination phase. The assessment results of those who participated in the WHO-ECAMM courses on multiple occasions further support this conclusion.\u003c/p\u003e\u003cp\u003eTo ensure the quality assurance (QA) of malaria diagnosis, the National Reference Laboratory Network for Malaria Diagnosis (NRLNMD) was established during the elimination phase in China [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Certified microscopists in WHO-ECAMM courses served as the core workforce responsible for operating the NRLNMD and implementing QA activities. For instance, they were entrusted with the final responsibility for species identification of malaria parasites, participated in the drafting of national and provincial microscopy standards, trained fresh microscopists, and contributed to various other malaria control initiatives [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20 CR21 CR22 CR23 CR24 CR25\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The NCAMM course was developed and implemented in China as a standardized model to assess the competence of microscopists in provincial core groups. Provincial-level personnel certified at level A or B were also authorized to make final species identification decisions. It was expected that all members of these core groups would support the development of microscopist teams at the county and township levels nationwide, thereby facilitating the expansion of the NRLNMD and the implementation of QA activities.\u003c/p\u003e\u003cp\u003eCertified microscopists through the WHO-ECAMM and NCAMM programs have made significant contributions and instilled confidence in the QA system. Their achievements have inspired the concept of defining and evaluating the competence of malaria microscopists working at peripheral levels. The framework for human resource development of malaria microscopists present in this file offers programmatic guidance to this concept. However, unified standards and practical procedures for certifying microscopists at sub-provincial and county levels remain under development. In fact, various PCAMM courses have been implemented across 31 provinces to train and assess microscopists, although few results have been reported [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. It is evident that uniform cutoff standards are needed to validate these training programs and ensure that certified microscopists are capable of detecting and diagnosing malaria as early and accurately as possible. A prototype of harmonized cutoff standards has therefore been proposed for discussion, based on the minimum competence levels for peripheral-level microscopists outlined in the WHO guidelines [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe concept of BTC was first introduced in China. Given the context of a low incidence rate, this initiative is based on the establishment of national and provincial core teams of highly competent microscopists, as well as the feasibility of rapid, remote malaria diagnosis through internet-based sharing using computers or mobile devices. Under such situation, a microscopist, who can distinguish unusual exogenous organisms in peripheral blood, with consciousness and ability to screen malaria cases and to prepare blood films is enough to surveil malaria. The training costs is much less than training him/her to be an expert in malaria microscopy. However, the implementation schedule and evaluation criteria must be finalized following comprehensive field investigations, practical trials, and discussions. This project has been incorporated into the routine work plan of NIPD in recent years.\u003c/p\u003e\u003cp\u003eThe NRLNMD has played a crucial role in ensuring the accuracy and reliability of Plasmodium diagnosis in healthcare facilities [\u003cspan additionalcitationids=\"CR20 CR21 CR22\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In the near future, with continued development of human resources and the training of qualified microscopists, an expanded NRLNMD is expected to further contribute to achieving the \"Three Early\" of malaria prevention and control. Meanwhile, targeted activities within RLNMD and the QA system can be designed in response to fluctuations in the malaria situation and human resource availability. Furthermore, the performance monitoring and active participation in NRLNMD and QA activities serve as effective strategies for sustaining and enhancing microscopists\u0026rsquo; diagnostic competence.\u003c/p\u003e"},{"header":"5 Limitation","content":"\u003cp\u003eThe limited sample size represents the first limitation of this study. Organizing training courses is generally resource-intensive, requiring substantial time, effort, and financial investment. As a result, data were collected from only six WHO-ECAMM courses and six NCAMM courses in total. Secondly, participants\u0026rsquo; scores on SP (Standardized Patient) assessments from pre- to post-training are not presented here. Based on observations, most participants were able to produce 100% qualified recordings, as additional skill training and practice prior to the post-assessment improved their competence. Thirdly, the results of the anonymous satisfaction surveys conducted after each NCAMM course, which included ten questions regarding course content and delivery, were not included in the manuscript, as all participants provided high evaluation scores.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eEthics statement\u003c/p\u003e\n\u003cp\u003eThis study was reviewed and approved by the Ethics Committee of the National Institute of Parasitic Diseases, China CDC. All participates in this study provided informed consent to participate. we confirm that consent was obtained from all human participants involved in the research. This declaration has been clearly included in the revised manuscript.\u003c/p\u003e\n\u003cp\u003eData availability\u003c/p\u003e\n\u003cp\u003eThe data and materials used in this study can be obtained by contacting Dr. Mei Li at [email protected]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe budget organizing WHO-ECAMM courses and NCAMM courses were supported by the Chinese National Malaria Program. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthorship contributions\u003c/p\u003e\n\u003cp\u003eLi M, as the initiator of the NCAMM courses in China, has organized seven WHO-ECAMM courses, established the assessment criteria, designed and conducted nine NCAMM courses, processed all samples, analyzed the data, and drafted the manuscript. Liu H and Wang ZY assisted in finalizing the assessment criteria and course design and participated in one to two courses as facilitators. Wang YB, Yan G, Zhou RM, Deng Y, Liu H and Deng Y\u0026nbsp;served as organizers of NCAMM courses in province 1, 2 and 3 respectively, and provided valuable suggestions for the implementation of NCAMM. Li M and Xia ZG served as organizers of the first and sixth NCAMM courses. Xia ZG also dispatched facilitators to the six NCAMM courses. Wang SQ and Dai YQ assisted in the sixth NCAMM course. Zhou XN and Li SZ were responsible for signing participants\u0026rsquo; certificates. All authors reviewed and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003eConflicts of Interest\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWe extend our appreciation to LetPub (www.letpub.com.cn) for its professional linguistic assistance during the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eInformation of all authors\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Li Mei \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008-8405\u003c/p\u003e\n\u003cp\u003eMr. Yongbin Wang\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eShandong First Medical University \u0026amp; Shandong Academy of Medical Sciences, Shandong Institute of Parasitic Diseases Control \u003c/p\u003e\n\u003cp\u003eNo.11 Taibailou Middle Road, Rencheng District\u003c/p\u003e\n\u003cp\u003eJining, Shandong, 271096, China\u003c/p\u003e\n\u003cp\u003e0537-2312938\u003c/p\u003e\n\u003cp\u003eProf. Ruimin Zhou\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eInsitution of Parasite Disease Prevention and Control, Henan Center for Disease Prevention and Control\u003c/p\u003e\n\u003cp\u003eNo. 105 Nongyenan Road, \u003c/p\u003e\n\u003cp\u003eZhengzhou, Henan, 450016, China\u003c/p\u003e\n\u003cp\u003e0371-65589001\u003c/p\u003e\n\u003cp\u003eProf. Hui Liu \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eYunnan Institute of Parasitic Diseases\u003c/p\u003e\n\u003cp\u003eNo. 827 Huitong Road, Chenggong District, \u003c/p\u003e\n\u003cp\u003eKunming, Yunnan, 650500, China\u003c/p\u003e\n\u003cp\u003e0871-65234001\u003c/p\u003e\n\u003cp\u003eDr. Zhigui Xia\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008\u003c/p\u003e\n\u003cp\u003eMr. Ge Yan\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eShandong First Medical University \u0026amp; Shandong Academy of Medical Sciences, Shandong Institute of Parasitic Diseases Control \u003c/p\u003e\n\u003cp\u003eNo.11 Taibailou Middle Road, Rencheng District\u003c/p\u003e\n\u003cp\u003eJining, Shandong, 271096, China\u003c/p\u003e\n\u003cp\u003e0537-2312938\u003c/p\u003e\n\u003cp\u003eProf. Yan Deng \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eInsitution of Parasite Disease Prevention and Control,Henan Center for Disease Prevention and Control\u003c/p\u003e\n\u003cp\u003eNo. 105 Nongyenan Road \u003c/p\u003e\n\u003cp\u003eZhengzhou, Henan, 450016, China\u003c/p\u003e\n\u003cp\u003e0371-65589001\u003c/p\u003e\n\u003cp\u003eProf. Yan Deng \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eYunnan Institute of Parasitic Diseases\u003c/p\u003e\n\u003cp\u003eNo. 827 Huitong Road, Chenggong District\u003c/p\u003e\n\u003cp\u003eKunming, Yunnan, 650500, China\u003c/p\u003e\n\u003cp\u003e0871-65234001\u003c/p\u003e\n\u003cp\u003eProf. Zhenyu Wang \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNo.1380 Zhongshan West Road，Changning District\u003c/p\u003e\n\u003cp\u003eShanghai, 200336, China\u003cbr\u003e 021-62758710\u003c/p\u003e\n\u003cp\u003eMiss Siqi Wang\u003c/p\u003e\n\u003cp\u003ewangsq@ nipd.chinacdc.cn\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008\u003c/p\u003e\n\u003cp\u003eMr. Yuqi Dai \u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008\u003c/p\u003e\n\u003cp\u003eProf. Xiaonong Zhou\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008\u003c/p\u003e\n\u003cp\u003eDr. Shizhu Li\u003c/p\u003e\n\u003cp\[email protected]\u003c/p\u003e\n\u003cp\u003eNational Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention \u003c/p\u003e\n\u003cp\u003eNo. 207, Ruijin Er Road, Huangpu District\u003c/p\u003e\n\u003cp\u003eShanghai, 200025, China\u003c/p\u003e\n\u003cp\u003e021-64377008\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. World malaria report. Geneva, 2024: 6-29.\u003c/li\u003e\n\u003cli\u003eNational Immigration Administration Government transparency, statistical data: 610 million people entering and leaving the country in 2024, a year-on-year increase of 43.9% [EB/OL] https://www.nia.gov.cn/n741440/n741567/c1693512/content.html. 2025-01-14\u003c/li\u003e\n\u003cli\u003eFeng J, Zhang L, Huang F, Yin JH, Tu H, Xia ZG, Zhou SS, Xiao N, Zhou XN. Ready for malaria elimination: zero indigenous case reported in the People\u0026apos;s Republic of China. Malar J. 2018, 29;17(1):315.\u003c/li\u003e\n\u003cli\u003eYin JH, Zhang L, Yi BY, Zhou SS, Xia ZG. Imported malaria from land bordering countries in China: A challenge in preventing the reestablishment of malaria transmission. Travel Med Infect Dis. 2023, 53:102575.\u003c/li\u003e\n\u003cli\u003eZhang L, Xia ZG, Li SZ. Epidemiological characteristics of malaria in China, 2024[J]. 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Developing standards for malaria microscopy: external competency assessment for malaria microscopists in the Asia-Pacific[J]. Malar J. 2012,11:352.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Malaria microscopy quality assurance manual. Version 2. Geneva:World Health Organization; 2016.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Global technical strategy for mal aria 2016\u0026ndash;2030. Geneva, 2021: 9-18.\u003c/li\u003e\n\u003cli\u003eYin J, Yan H, Li M, et al. Competency and challenges in malaria microscopy in China[J].Bioscience Trends, 2018, 11(6):702-705.\u003c/li\u003e\n\u003cli\u003eLi M, Zhou HJ, Yan H, et al. Analysis on external competency assessment for malaria microscopists in China[J].Malaria journal, 2019, 18(1):366.\u003c/li\u003e\n\u003cli\u003eLi M, Zhou HJ, Xia ZG, et al. Quality evaluation on the preparation of the malaria blood smears at the national level in 2019[J]. Chin J Parasitol Parasit Dis, 2022, 40(6): 754-759.\u003c/li\u003e\n\u003cli\u003eYin J H , Yan H , Huang F ,et al.Establishing a China malaria diagnosis reference laboratory network for malaria elimination[J].Malaria Journal, 2015, 14(1):40.DOI:10.1186/s12936-015-0556-z.\u003c/li\u003e\n\u003cli\u003eFei L, Shuang Z, Yi Y, et al. Assessment of Malaria Microscopy Competency at Primary Health Institutions in the Chongqing Municipality[J].Frontiers in Medicine, 2021, 8:602442. \u003c/li\u003e\n\u003cli\u003eNing W , Zhuang S F , Wen L ,et al. Evaluating ECAMM-based training efficacy for malaria microscopists in Hunan Province, China[J].Frontiers in Public Health, 2025. 1598917.\u003c/li\u003e\n\u003cli\u003eZou Y, Li L, Yu T, Ge L, Huo F, Liu Y. Analysis of laboratory re-examination results in Sichuan Provincial Malaria Diagnostic Reference Laboratory from 2014 to 2020[J]. Chin J Schisto Control. 2021, 33(5):496-500. 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Results of microscopic examinations and blood slide re-examinations of malaria elimination evaluation in ten prefectures of Yunnan Province[J]. Chin J Schisto Control. 2019 Jan 5;31(5):543-545. (Chinese).\u003c/li\u003e\n\u003cli\u003eLi M, Huang F, Yin J, Yan H, Zhou S, Xia Z. Malaria Microscopy Competency in the Subnational Verification, China: Implications for Malaria Elimination and the Prevention of Malaria Reestablishment[J]. Can J Infect Dis Med Microbiol. 2022:8003845. \u003c/li\u003e\n\u003cli\u003eYan H, Li M, Xia ZG, Yin JH. Competency of malaria laboratory diagnosis at national and provincial levels at the beginning of malaria post-elimination phase, China[J]. Malar J. 2024, 26;23(1):58. \u003c/li\u003e\n\u003cli\u003eDing G, Zhu G, Cao C, Miao P, Cao Y, Wang W, Gu Y, Xu S, Wang S, Zhou H, Cao J. The challenge of maintaining microscopist capacity at basic levels for malaria elimination in Jiangsu Province, China[J]. BMC Public Health. 2018,18(1):489. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"National Competency Assessment of Malaria Microscopists (NCAMM), Slide Preparation (SP), Parasite Detection (PD), Parasite Species Identification (SI), Parasite Counting (PC)","lastPublishedDoi":"10.21203/rs.3.rs-7483997/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7483997/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUnder the context of sustained low malaria incidence in China, maintaining an adequate number of qualified microscopists remains a critical component to ensure and sustain the success of malaria elimination. Therefore, this paper presents the efforts made, achievements attained, and future prospects regarding the development of human resources in malaria microscopy during and after the malaria elimination phase in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo confirm the competence of malaria microscopists at the national level, six rounds of the External Competence Assessment of Malaria Microscopists (ECAMM) courses, developed and administered by the World Health Organization (WHO), were conducted in China from 2017 to 2024. The number and frequency of certified microscopists participating in the WHO-ECAMM courses were retrospectively reviewed. To support the establishment of core groups at sub-national levels, a model course for the National Competency Assessment of Malaria Microscopists (NCAMM) was revised in accordance with WHO guidelines and implemented from 2019 to 2024. The course schedule and scoring system were detailed, including improvements in evaluation metrics. Participants' competency levels (A, B, C, and D) were determined based on standardized criteria. The relationship between participants' competency levels and their age or years of experience in malaria microscopy, as well as variations in their scores, was analyzed. To guide the future qualification of microscopists in peripheral areas, a proposed framework for human resource development of malaria microscopists was presented, based on the current malaria situation in China.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 64 microscopists participated in the six WHO-ECAMM courses. The average age of these participants is 41.1 years. Among them, 29 individuals certified at Level 1 and 17 individuals at Level 2 covered NIPD as well as 29 out of 31 provinces. In addition, among the 72 participants who attended the six NCAMM courses, 10 were certified at Level A (the highest level), and 33 at Level B. Factors such as age, place of employment, educational background, and gender did not show a significant impact on participants' competence in malaria microscopy (n = 72; ρ = 0.2, P \u0026gt; 0.05). However, the number of years of experience in malaria microscopy demonstrated a moderate positive correlation with competence levels(n = 72; ρ = 0.4, P \u0026lt; 0.01). Notably, scores for species identification (SI) improved significantly (Z = −7.3, P \u0026lt; 0.01). The proposed structure for human resource development of malaria microscopists includes three core groups operating at the national, sub-national (provincial), and sub-provincial levels. This structure recommends the application of four models for assessing microscopists’ competence.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiscussion and Conclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on six WHO-ECAMM courses, the national core group of malaria microscopists was re-affirmed. The NCAMM courses conducted in China have demonstrated sufficient effectiveness as both an evaluation system and a refresher training model. They are expected to be widely implemented at both national and subnational levels to support the development of human resources in malaria microscopy. The predefined structure for human resource development of malaria microscopists provides a systematic framework for assessing and defining the competencies of microscopists in peripheral areas.\u003c/p\u003e","manuscriptTitle":"Development of human resources in malaria microscopy during and after the malaria elimination phase in China","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-30 07:12:44","doi":"10.21203/rs.3.rs-7483997/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-30T07:11:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-28T14:20:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-22T13:48:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52652867651354091852849915030725068111","date":"2026-04-02T09:11:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"221291065003505572636106851549189824381","date":"2026-04-01T17:27:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"115428399072487846438293281964255985758","date":"2026-03-10T09:56:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140388210349969044940937239329816917813","date":"2026-03-09T13:47:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-08T04:00:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316357346468917399093705040847445804353","date":"2026-01-08T03:41:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"266712988047634225323041420312193262460","date":"2025-12-13T06:39:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"235178505165662421579994000376147425349","date":"2025-11-13T07:16:33+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-18T05:37:48+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-11T06:08:04+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-08T02:41:52+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-04T05:57:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-09-04T05:54:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"5ee7a83b-7d56-471e-8245-4f5ebf648a14","owner":[],"postedDate":"September 30th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[{"id":55448058,"name":"Health sciences/Diseases"},{"id":55448059,"name":"Health sciences/Health care"},{"id":55448060,"name":"Health sciences/Medical research"}],"tags":[],"updatedAt":"2026-05-15T06:38:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-30 07:12:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7483997","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7483997","identity":"rs-7483997","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}