Network based systems

Role of the International Network on Surveillance and Response System Leading to Malaria Elimination: China’s Engagement in Global Health | Infectious diseases of poverty


Malaria, an ancient killer disease transmitted by mosquitoes, continues to threaten people’s health and livelihoods. Momentum towards a renewed response to malaria around the world has been building since the turn of the new century, following the failure of the first global malaria eradication program in the mid-20th century [1]. Renewed political commitment, increased investment in research and innovation, and the creation of new funding mechanisms are enabling unprecedented progress, with the number of global malaria deaths steadily declining from 896,000 in 2000 to 627 000 in 2020 [2]. Malaria eradication is back on the table, as global stakeholders such as the World Health Organization (WHO), the Rolling Back Malaria Partnership to End Malaria [3]the Global Fund to Fight AIDS, Tuberculosis and Malaria, the U.S. President’s Malaria Initiative, the Bill & Melinda Gates Foundation and many others believe that ending malaria is within reach through concerted efforts [4]. A set of overarching strategies and a potential timeline have been proposed [1]. Notably, the Global Technical Strategy for Malaria 2016-2030 (GTS) and the Action and Investment to Defeat Malaria 2016-2030 were adopted in 2015, setting the ambitious new goal to reduce the global burden of malaria. 90% by 2030. [3, 5].

Despite major achievements over the past two decades, the past 4 years have seen the world stuck in a plateau. According to the World Malaria Report 2021, an estimated 241 million cases of malaria occurred, resulting in 627,000 deaths in 2020, most severely affecting sub-Saharan Africa [2]. Additionally, the future of malaria looks bleak under the COVID-19 pandemic, which is straining malaria interventions around the world. Gains made saving lives over the past 20 years could be lost unless all WHO guidelines against the COVID-19 pandemic and malaria are followed [6].

Surveillance and response have been recognized as crucial steps for effective control and elimination of tropical diseases, including malaria [7]. Malaria surveillance has transformed and become a key intervention under Pillar 3 – transforming malaria surveillance into a core intervention according to GTS [5]. By providing timely and specific data and information at the national level or in certain geographical areas, the surveillance system is essential to enable a more targeted response to malaria. [8].

China has made tremendous progress towards eliminating malaria. China was certified as a malaria-free country by WHO on June 30, 2021. With a robust and improved malaria surveillance and response system network, both domestically and internationally, China is able to not only ensure and sustain a malaria-free future within its borders, but also has enormous potential to contribute to global malaria elimination efforts [8, 9]. This is a review of the China-led International Network on SRS and its implications for malaria elimination.

The role of SRS in eliminating malaria

Infectious disease surveillance is recognized as the cornerstone of public health decision-making and practice. The weakness of the surveillance system constitutes one of the challenges for the elimination of malaria. Malaria surveillance has been defined to collect data in a systematic way, consolidate information and disseminate it rapidly to guide decision-making towards malaria prevention and control actions. [10]. In recent years, even though surveillance systems in most high-burden countries have been significantly improved, they still fail to capture essential malaria data in a complete, accurate and timely manner, making it difficult to optimize of the response plan, assessment of disease trends, inequities and response gaps, and responding to outbreaks [11]. A robust SRS can effectively identify specific high-risk populations, determine their size, and track them over time with adequate representativeness to accurately assess infection rates and the use of preventive measures. Surveillance may work most intensively as an intervention when the program is closest to elimination and effective surveillance is required at all stages of the path to elimination.

China’s surveillance-response towards a malaria-free future

With 30 million cases of the disease a year in the 1940s and no cases of indigenous malaria since 2017, China has become the 40th and most populous country to be certified malaria-free by the WHO. [12, 13]. Practices and experiences in building and improving malaria SRS in China’s 70-year effort could be shared with malaria epidemic countries that face gaps in surveillance coverage, l health information architecture, data capture, etc. [14].

In China, SRS has been well integrated into its public health system [15]. Since the start of the national malaria control program in the 1950s, a national malaria surveillance system was gradually set up and then reinforced in 2005 when 62 sentinel sites were set up. [16]. As China entered the phase of malaria elimination in 2010, surveillance and response focused on individual cases and foci. In 2012, national surveillance systems were launched, which include routine surveillance and sentinel surveillance [17]. For routine surveillance, a national case reporting and case management network is formed from county level, municipal level, provincial level to national level, while entomological surveillance, antimalarial drug resistance surveillance , surveillance of the population at risk are conducted as sentinel surveillance. The “1-3-7” standard (case notification within 1 day, case investigation within 3 days and focus elimination within 7 days) has been adopted to rapidly detect and identify all malaria infections and ensure appropriate treatment above all case of secondary or local infection. transmission may occur. The national deployment of the “1-3-7” standard has performed well, with all cases reported within 24 hours of diagnosis, 97.9% (2619/2674) of them investigated for epidemiology within 3 days, and 2326 outbreaks identified, investigation and response within 7 days in 2019 [18]. Recognized by WHO, the “1-3-7” standard has been recommended as a surveillance and response strategy in the Greater Mekong Sub-region, including Cambodia and Thailand, and has been modified as a test community reactive to 1,7-malaria. and response approach in the context of Tanzania [19, 20].

The surveillance and response network in China plays a crucial role in identifying public health problems, determining the distribution and epidemic dynamics of malaria nationwide, detecting outbreaks and epidemic anomalies, the evaluation of the effects of on-site interventions and the identification of risk factors as well as the populations and regions at risk.

A case study of the International Forum on SRS

China’s engagement in global health has gained solid momentum. Following the establishment of a public health network for cooperation opportunities launched in 2017 at the Belt and Road High-Level Meeting, the Institutional Network of China-Africa Malaria Elimination Cooperation (INCAM) was founded during the High Level Meeting on China. Health cooperation in Africa the following year. China has begun collaborating with the international community to call for a broader network on SRS, given its experience in applying innovative genetics-based approaches and tools that could offer breakthrough results when they are applied to other settings of ongoing transmission, and even on the path to malaria elimination [21]. As a WHO Collaborating Center for Tropical Diseases, the National Institute of Parasitic Diseases (NIPD) of the China Centers for Disease Control and Prevention (China CDC) has played an important role in organizing and coordinating activities of the national and international network on SRS [22].

The International Forum on Surveillance-Response System Leading to the Elimination of Tropical Diseases (ISRS) is an exemplary event in promoting the international SRS malaria network. Bringing together scientists from research, public health and health policy, this forum is jointly supported by the NIPD at China CDC, the Swiss Tropical and Public Health Institute and the WHO. The SSRI aims to share knowledge and experiences related to the control, prevention and elimination of major tropical diseases and to discuss new approaches for the establishment of an integrated surveillance platform and network. and response, where malaria is high on the agenda. An in-depth discussion took place on current challenges, opportunities and measures to foster reliable and effective SRS as a strategic key for endemic countries moving towards elimination. After the first SSRI in 2012, participants suggested that the forum be convened every 2 years, to keep abreast of the latest research priorities and discuss the challenges of implementing local, national or regional SRS.

In 2020, a total of five SSRIs were organized, which have gained increasing attention and impact within the international malaria and NTD community. The number of stakeholders who participated in the SSRI is estimated to have increased tenfold, from around 100 in 10 countries in 2012 to 1000 in 40 countries in 2020. The influx of participants at the last forum mainly contributed to the dissemination live accordingly. of the COVID-19 pandemic, which has allowed SSRI to reach a wider range of participants. The agenda for discussions on the malaria SRS in each SSRI closely followed the mandates and echoed the initiatives of important international cooperation channels such as Brazil, Russian Federation, Summit India, China and South Africa (BRICS) and the China-Africa Forum. Cooperation, in addition to regular updates (Table 1). The agenda items also took into consideration the current global situation such as the COVID-19 pandemic and quickly started a conversation on how to address the dual challenges facing humans. In addition, ISRS has provided an institution-focused platform to exchange ideas and generate new collaborations and partnerships on malaria, through which several MoUs have been signed between NIPD at China CDC and its counterparts. Bilateral and multilateral international cooperation has also been consolidated and expanded, including pilot malaria control cooperation projects in Tanzania and Papua New Guinea. The scientific outputs of SSRI included publications on the topics of SRS nationally, regionally and internationally as one of the key indicators to promote the control and elimination of tropical diseases. Additionally, Infectious Diseases of Poverty, a unique journal that bridges this communication gap between developing and developed countries and encourages breakthroughs in surveillance and response research, was first featured through of the SSRI.

Table 1 An overview of five SSRIs

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