Background: In 2021, the World Health Organization officially declared the People's Republic of China as malaria-free.However, despite this milestone achievement, the continued occurrence of severe and fatal cases of imported malaria in China,due to globalization and increased international communication, remains a significant public health concern. Objective: The aim of this study was to elucidate the epidemiological characteristics of imported malaria in 5 Chineseprovinces from 2014 to 2021 and to identify the factors that influence complications in imported malaria cases. The findingswill provide a basis for enhancing prevention and control measures, thereby consolidating China's achievements in malariaelimination. Methods: A case-based retrospective study was performed, using surveillance data collected from the representativeprovinces of China from 2014 to 2021. Epidemiological characteristics were analyzed using descriptive statistics. Logisticregression was used to identify the factors influencing the occurrence of complications. Results: A total of 5559 malaria cases were included during the study period. The predominant species was Plasmodiumfalciparum (3940/5559, 70.9%), followed by Plasmodium ovale (1054/5559, 19%), Plasmodium vivax (407/5559, 7.3%),Plasmodium malariae (157/5559, 2.8%), and 1 case of Plasmodium knowlesi. Most of the cases were male (5343/5559,96.1%). The complication rates for P falciparum and P ovale were 11.4% and 3.3%, respectively. Multivariate logisticregression analysis of the relevant factors of malaria complications revealed potential protective factors, including a previousinfection by Plasmodium (P<.001; odds ratio [OR] 0.512, 95% CI 0.422-0.621), and risk factors, including increased age(P=.004; OR 1.014, 95% CI 1.004-1.024), misdiagnosis at the first clinical visit (P<.001; OR 3.553, 95% CI 2.886-4.375), andthe time interval from onset to treatment (P=.001; OR 1.026, 95% CI 1.011-1.042). Subgroup analyses identified risk factorsassociated with P falciparum, which include advanced age (P=.004; OR 1.015, 95% CI 1.005-1.026), initial misdiagnosisduring the first clinical visit (P<.001; OR 3.549, 95% CI 2.827-4.455), the time interval from onset to treatment (P<.001; OR1.043, 95% CI 1.022-1.063), and a delay of more than 3 days from the first treatment to diagnosis (P<.001; OR 2.403, 95% CI 1.823-3.164). Additionally, the risk factors pertaining to P ovale involve misdiagnosis at the initial clinical visit (P=.01;OR 2.901, 95% CI 1.336-6.298), the time interval from onset to treatment (P=.002; OR 1.095, 95% CI 1.033-1.160), and theduration from the initial treatment to diagnosis (P=.43; OR 1.032, 95% CI 0.953-1.118). Previous infections can prevent theprogression of both P falciparum and P ovale. Conclusions: This study showed that the increasing proportion of P ovale in recent years should not be ignored. Furthermore,there is a need to improve diagnostic awareness, enhance the capacity of medical institutions, and provide health education forhigh-risk groups
