China's 1-3-7 surveillance and response strategy for malaria elimination: Is case reporting, investigation and foci response happening according to plan?

Reducing Malaria Transmission through Reactive Indoor Residual Spraying: A Systematic Review

In the final stages of malaria elimination, interventions to reduce malaria transmission are often centered around a confirmed case of malaria, as cases tend to cluster together at very low levels of transmission. The WHO commissioned a systematic review of the literature and synthesis of evidence for reactive indoor residual spraying (IRS) to develop official recommendations for countries. Several electronic databases were searched in November 2020. A total of 455 records were identified and screened; 20 full-text articles were assessed for eligibility. Two cluster-randomized trials met the inclusion criteria for epidemiological outcomes. Risk of bias was assessed using standard criteria. Because one study was a superiority trial in which the comparator included reactive case detection or mass drug administration and the other was a noninferiority trial in which the comparator was proactive, focal IRS, results could not be pooled. In the superiority trial, reactive IRS reduced malaria prevalence by 68% (risk ratio [RR]: 0.32; 95% CI: 0.13-0.80; certainty of evidence: HIGH) compared with no reactive IRS. No difference was observed for clinical malaria (RR: 0.65; 95% CI: 0.38-1.11; certainty of evidence: MODERATE). In the noninferiority study, the mean difference in incidence between reactive IRS and proactive IRS was 0.10 additional case per 1,000 person-years, which was within the prespecified noninferiority bound (95% CI: -0.38 to 0.58; certainty of evidence: MODERATE). The evidence indicates that reactive IRS may be a cost-effective tool for the prevention of malaria in elimination settings. As only two cluster-randomized controlled trials from sub-Saharan Africa were found, additional high-quality studies should be encouraged.

Impact of 1,7-malaria reactive community-based testing and response (1,7-mRCTR) approach on malaria prevalence in Tanzania

BACKGROUND

Progress in malaria control has stalled in recent years and innovative surveillance and response approaches are needed to accelerate malaria control and elimination efforts in endemic areas of Africa. Building on a previous China-UK-Tanzania pilot study on malaria control, this study aimed to assess the impact of the 1,7-malaria Reactive Community-Based Testing and Response (1,7-mRCTR) approach implemented over two years in three districts of Tanzania.

METHODS

The 1,7-mRCTR approach provides community-based malaria testing via rapid diagnostic tests and treatment in villages with the highest burden of malaria incidence based on surveillance data from health facilities. We used a difference-in-differences quasi-experimental design with linear probability models and two waves of cross-sectional household surveys to assess the impact of 1,7-mRCTR on malaria prevalence. We conducted sensitivity analyses to assess the robustness of our results, examined how intervention effects varied in subgroups, and explored alternative explanations for the observed results.

RESULTS

Between October 2019 and September 2021, 244,771 community-based malaria rapid tests were completed in intervention areas, and each intervention village received an average of 3.85 rounds of 1-7mRCTR. Malaria prevalence declined from 27.4% at baseline to 11.7% at endline in the intervention areas and from 26.0% to 16.0% in the control areas. 1,7-mRCTR was associated with a 4.5-percentage-point decrease in malaria prevalence (95% confidence interval: - 0.067, - 0.023), equivalent to a 17% reduction from the baseline. In Rufiji, a district characterized by lower prevalence and where larviciding was additionally provided, 1,7-mRCTR was associated with a 63.9% decline in malaria prevalence.

CONCLUSIONS

The 1,7-mRCTR approach reduced malaria prevalence. Despite implementation interruptions due to the COVID-19 pandemic and supply chain challenges, the study provided novel evidence on the effectiveness of community-based reactive approaches in moderate- to high-endemicity areas and demonstrated the potential of South-South cooperation in tackling global health challenges.

The contribution of active case detection to malaria elimination in Thailand

INTRODUCTION

Thailand's malaria surveillance system complements passive case detection with active case detection (ACD), comprising proactive ACD (PACD) methods and reactive ACD (RACD) methods that target community members near index cases. However, it is unclear if these resource-intensive surveillance strategies continue to provide useful yield. This study aimed to document the evolution of the ACD programme and to assess the potential to optimise PACD and RACD.

METHODS

This study used routine data from all 6 292 302 patients tested for malaria from fiscal year 2015 (FY15) to FY21. To assess trends over time and geography, ACD yield was defined as the proportion of cases detected among total screenings. To investigate geographical variation in yield from FY17 to FY21, we used intercept-only generalised linear regression models (binomial distribution), allowing random intercepts at different geographical levels. A costing analysis gathered the incremental financial costs for one instance of ACD per focus.

RESULTS

Test positivity for ACD was low (0.08%) and declined over time (from 0.14% to 0.03%), compared with 3.81% for passive case detection (5.62%-1.93%). Whereas PACD and RACD contributed nearly equal proportions of confirmed cases in FY15, by FY21 PACD represented just 32.37% of ACD cases, with 0.01% test positivity. Each geography showed different yields. We provide a calculator for PACD costs, which vary widely. RACD costs an expected US$226 per case investigation survey (US$1.62 per person tested) or US$461 per mass blood survey (US$1.10 per person tested).

CONCLUSION

ACD yield, particularly for PACD, is waning alongside incidence, offering an opportunity to optimise. PACD may remain useful only in specific microcontexts with sharper targeting and implementation. RACD could be narrowed by defining demographic-based screening criteria rather than geographical based. Ultimately, ACD can continue to contribute to Thailand's malaria elimination programme but with more deliberate targeting to balance operational costs.

Exploring activities and behaviours potentially increases school-age children's vulnerability to malaria infections in south-eastern Tanzania

BACKGROUND

Strengthening malaria control activities in Tanzania has dramatically declined human malaria infections. However, there is an increasing epidemiological shift in the burden on school-age children. The underlying causes for such an epidemiological shift remain unknown in this context. This study explored activities and behaviours that could increase the vulnerability of school-age children to transmission risk to provide insight into protection gap with existing interventions and opportunities for supplementary interventions.

METHODS

This cross-sectional study conducted twenty-four focus group discussions (FGDs) in three districts of Rufiji, Kibiti and Kilwa in south-eastern Tanzania. Sixteen FGDs worked with school-age children (13 to 18 years) separating girls and boys and eight FGDs with their parents in mixed-gender groups. A total of 205 community members participated in FGDs across the study area. Of them, 72 participants were parents, while 133 were school-age children (65 boys and 68 girls).

RESULTS

Routine domestic activities such as fetching water, washing kitchen utensils, cooking, and recreational activities such as playing and watching television and studying were the reported activities that kept school-age children outdoors early evening to night hours (between 18:00 and 23:00). Likewise, the social and cultural events including initiation ceremonies and livelihood activities also kept this age group outdoors from late evening to early night and sometimes past midnight hours. Parents migrating to farms from December to June, leaving behind school-age children unsupervised affecting their net use behaviour plus spending more time outdoors at night, and the behaviour of children sprawling legs and hands while sleeping inside treated bed nets were identified as potential risks to infectious mosquito bites.

CONCLUSION

The risky activities, behaviours, and social events mostly occurring outdoors might increase school-age children's vulnerability to malaria infections. The findings provide preliminary insight on potential risk factors for persisting transmission. Further studies to quantify the risk behaviour and activities are recommended to establish the magnitude and anticipated impact on supplementary control strategies to control infection in school-age children.

1-3-7 surveillance and response approach in malaria elimination: China's practice and global adaptions

There has been a significant reduction in malaria morbidity and mortality worldwide from 2000 to 2019. However, the incidence and mortality increased again in 2020 due to the disruption to services during the COVID-19 pandemic. Surveillance to reduce the burden of malaria, eliminate the disease and prevent its retransmission is, therefore, crucial. The 1-3-7 approach proposed by China has played an important role in eliminating malaria, which has been internationally popularized and adopted in some countries to help eliminate malaria. This review summarizes the experience and lessons of 1-3-7 approach in China and its application in other malaria-endemic countries, so as to provide references for its role in eliminating malaria and preventing retransmission. This approach needs to be tailored and adapted according to the region condition, considering the completion, timeliness and limitation of case-based reactive surveillance and response. It is very important to popularize malaria knowledge, train staff, improve the capacity of health centres and monitor high-risk groups to improve the performance in eliminating settings. After all, remaining vigilance in detecting malaria cases and optimizing surveillance and response systems are critical to achieving and sustaining malaria elimination.

Establishing and applying an adaptive strategy and approach to eliminating malaria: practice and lessons learnt from China from 2011 to 2020

ABSTRACTOn 30 June 2021, China was certified malaria-free by the World Health Organization. In this study, the evolution, performance, outcomes, and impact of China's adaptive strategy and approach for malaria elimination from 2011 to 2020 were analysed using 10-year data. The strategy and approach focused on timely detection and rapid responses to individual cases and foci. Indigenous cases declined from 1,308 in 2011 to 36 in 2015, and the last one was reported from Yunnan Province in April 2016, although thousands of imported cases still occur annually. The "1-3-7" approach was implemented successfully between 2013 and 2020, with 100% of cases reported within 24 h, 94.5% of cases investigated within three days of case reporting, and 93.4% of foci responses performed within seven days. Additionally, 81.6% of patients attended the first healthcare visit within 1-3 days of onset and 58.4% were diagnosed as malaria within three days of onset, in 2017-2020. The adaptive strategy and approach, along with their universal implementation, are most critical in malaria elimination. In addition to strengthening surveillance on drug resistance and vectors and border malaria collaboration, a further adapted three-step strategy and the corresponding "3-3-7" model are recommended to address the risks of re-transmission and death by imported cases after elimination. China's successful practice and lessons learnt through long-term efforts provide a reference for countries moving towards elimination.

The impact of reactive case detection on malaria transmission in Zanzibar in the presence of human mobility

Malaria persists at low levels on Zanzibar despite the use of vector control and case management. We use a metapopulation model to investigate the role of human mobility in malaria persistence on Zanzibar, and the impact of reactive case detection. The model was parameterized using survey data on malaria prevalence, reactive case detection, and travel history. We find that in the absence of imported cases from mainland Tanzania, malaria would likely cease to persist on Zanzibar. We also investigate potential intervention scenarios that may lead to elimination, especially through changes to reactive case detection. While we find that some additional cases are removed by reactive case detection, a large proportion of cases are missed due to many infections having a low parasite density that go undetected by rapid diagnostic tests, a low rate of those infected with malaria seeking treatment, and a low rate of follow up at the household level of malaria cases detected at health facilities. While improvements in reactive case detection would lead to a reduction in malaria prevalence, none of the intervention scenarios tested here were sufficient to reach elimination. Imported cases need to be treated to have a substantial impact on prevalence.

Case-based malaria surveillance and response: implementation of 1-3-7 approach in Jiangsu Province, China

Following initiation of China's National Malaria Elimination Action Plan (NMEAP) in 2010, China's 1-3-7 surveillance and response approach was developed and rolled out in China to facilitate the malaria control programme and accelerate the progress of malaria elimination. Innovative strategies and interventions have been developed and implemented in Jiangsu Province to facilitate case-based malaria surveillance and response. A total of 9879 malaria cases were reported in Jiangsu Province from 2001 to 2020. Since 2012, no indigenous malaria cases have been reported in Jiangsu Province. However, in recent years, there has been a substantial increase of imported cases from abroad. To continue improving the malaria surveillance and response system, Jiangsu Province has conducted population-based health education to improve the healthcare seeking behaviour of malaria patients, strengthened the capacity of health facilities to improve the performance of malaria diagnosis and treatment, and strengthened health workforce capacity to improve the implementation of 1-3-7 approach. Continually improving surveillance and response system can play a critical role in the early detection and rapid response of individual malaria cases and prevent the re-establishment of malaria.

Developing sero-diagnostic tests to facilitate Plasmodium vivax Serological Test-and-Treat approaches: modeling the balance between public health impact and overtreatment

BACKGROUND

Eliminating Plasmodium vivax will require targeting the hidden liver-stage reservoir of hypnozoites. This necessitates new interventions balancing the benefit of reducing vivax transmission against the risk of over-treating some individuals with drugs which may induce haemolysis. By measuring antibodies to a panel of vivax antigens, a strategy of serological-testing-and-treatment (PvSeroTAT) can identify individuals with recent blood-stage infections who are likely to carry hypnozoites and target them for radical cure. This provides a potential solution to selectively treat the vivax reservoir with 8-aminoquinolines.

METHODS

PvSeroTAT can identify likely hypnozoite carriers with ~80% sensitivity and specificity. Diagnostic test sensitivities and specificities ranging 50-100% were incorporated into a mathematical model of vivax transmission to explore how they affect the risks and benefits of different PvSeroTAT strategies involving hypnozoiticidal regimens. Risk was measured as the rate of overtreatment and benefit as reduction of community-level vivax transmission.

RESULTS

Across a wide range of combinations of diagnostic sensitivity and specificity, PvSeroTAT was substantially more effective than bloodstage mass screen and treat strategies and only marginally less effective than mass drug administration. The key test characteristic determining of the benefit of PvSeroTAT strategies is diagnostic sensitivity, with higher values leading to more hypnozoite carriers effectively treated and greater reductions in vivax transmission. The key determinant of risk is diagnostic specificity: higher specificity ensures that a lower proportion of uninfected individuals are unnecessarily treated with primaquine. These relationships are maintained in both moderate and low transmission settings (qPCR prevalence 10% and 2%). Increased treatment efficacy and adherence can partially compensate for lower test performance. Multiple rounds of PvSeroTAT with a lower performing test may lead to similar or higher reductions in vivax transmission than fewer rounds with a higher performing test, albeit with higher rate of overtreatment.

CONCLUSIONS

At current performance, PvSeroTAT is predicted to be a safe and efficacious option for targeting the hypnozoite reservoir towards vivax elimination. P. vivax sero-diagnostic tests should aim for both high performance and ease of use in the field. The target product profiles informing such development should thus reflect the trade-offs between impact, overtreatment, and ease of programmatic implementation.

Improving the surveillance and response system to achieve and maintain malaria elimination: a retrospective analysis in Jiangsu Province, China

Background

Following initiation of China’s National Malaria Elimination Action Plan (NMEAP) in 2010, the ‘1-3-7’ approach was developed and rolled out in China to facilitate the malaria elimination programme and accelerate malaria elimination. This study aims to summarize and condense these experiences through a retrospective analysis in Jiangsu Province, which could be adapted and applied in other malaria elimination settings worldwide.

Methods

A retrospective analysis of imported malaria cases into China identified through an improved surveillance and response system in Jiangsu Province was carried out for the period of 2001–2020. To improve the malaria surveillance and response system, Centers for Diseases Control and Prevention from the prefectures and counties in Jiangsu province conducted population-level health education to improve healthcare seeking behavior, strengthened capacity of health facilities to improve performance of malaria diagnosis and treatment, and raised the capacity of public health providers to improve implementation of the ‘1-3-7’ approach. Categorical variables were carried out by Chi square tests with Fisher’s exact correction.

Results

From 2001 to 2020, a total of 9,879 malaria cases were reported in Jiangsu Province. Since 2012, no indigenous malaria cases have been reported in Jiangsu Province. However, in recent years, there has been a substantial increase of imported falciparum malaria cases. Between 2012 and 2020, an estimated 61.57 million individuals have benefited from population-level health education in Jiangsu Province. For healthcare-seeking services among the 2,423 imported malaria cases, 687 (28.4%) and 1,104 (45.6%) cases visited hospitals on the first day and the second day from symptom onset, respectively. A total of 1,502 (61.9%) cases were diagnosed on the first day at medical facilities. Jiangsu Province achieved 100%, 99.4% and 98.3% completion rate in terms of case detection and notification (within one day), case investigation (within three days) and foci response and disposition (within seven days), respectively. The improved surveillance and response system in Jiangsu Province plays an important role in preventing the re-introduction of malaria and maintaining the malaria-free status.

Conclusions

Jiangsu Province has maintained its malaria-free status since 2012. The continuous improvement of a surveillance and response system plays an important role in the early detection and rapid response of potential malaria-related outbreaks in Jiangsu, China, and has important lessons for other malaria eliminating settings. Remaining vigilant in the detection of imported malaria cases and maintaining an active surveillance and response system is critical to sustain the success of malaria elimination.

Graphic Abstract

A malaria-free China: global importance and key experience

Malaria has a worldwide distribution and is the world's deadliest mosquito-borne disease. The goal of malaria elimination is also reflected in the United Nations Sustainable Development Goals and the Global Technical Strategy for Malaria 2016-2030 issued by the World Health Organization (WHO). China succeeded in its malaria elimination programme after being certified as malaria-free by the WHO on 30 June 2021. Therefore, we document some of the key lessons learnt in the course of the malaria elimination effort in China in this special volume, showing how different strategies made elimination feasible in different subregions of China with different epidemiological and socioeconomic characteristics, in order to present strong signals to other malaria-endemic countries that malaria elimination is feasible within one generation.

Effectiveness of joint 3 + 1 malaria strategy along China-Myanmar cross border areas

BACKGROUND

Cross-border malaria in Laiza City of Myanmar seriously affected Yingjiang County of China and compromised reaching the goal of malaria elimination by 2020. Since 2017, a pilot project on 3 + 1 strategy of joint cross-border malaria prevention and control was carried out for building a malaria buffer in these border areas. Here, 3 were the three preventive lines in China where different focalized approaches of malaria elimination were applied and + 1 was a defined border area in Myanmar where the integrated measures of malaria control were adopted.

METHODS

A 5-year retrospective analysis (2015 to 2019) was conducted that included case detection, parasite prevalence and vector surveillance. Descriptive statistics was used and the incidence or rates were compared. The annual parasite incidence and the parasite prevalence rate in + 1 area of Myanmar, the annual importation rate in Yingjiang County of China and the density of An. minimus were statistically significant indictors to assess the effectiveness of the 3 + 1 strategy.

RESULTS

In + 1 area of Myanmar from 2015 to 2019, the averaged annual parasite incidence was (59.11 ± 40.73)/1000 and Plasmodium vivax accounted for 96.27% of the total confirmed cases. After the pilot project, the annual parasite incidence dropped 89% from 104.77/1000 in 2016 to 12.18/1000 in 2019, the microscopic parasite prevalence rate dropped 100% from 0.34% in 2017 to zero in 2019 and the averaged density of An. Minimus per trap-night dropped 93% from 1.92 in June to 0.13 in September. The submicroscopic parasite prevalence rate increased from 1.15% in 2017 to 1.66% in 2019 without significant difference between the two surveys (P = 0.084). In Yingjiang County of China, neither indigenous nor introduced case was reported and 100% cases were imported from Myanmar since 2017. The averaged annual importation rate from 2015 to 2019 was (0.47 ± 0.15)/1000. After the pilot project, the annual importation rate dropped from 0.59/1000 in 2016 to 0.28/1000 in 2019 with an overall reduction of 53% in the whole county. The reduction was 67% (57.63/1000 to 18.01/1000) in the first preventive line, 52% (0.20/1000 to 0.10/1000) in the second preventive line and 36% (0.32/1000 to 0.22/1000) in the third preventive line. The averaged density of An. Minimus per trap-night in the first preventive line dropped 94% from 2.55 in June to 0.14 in September, without significant difference from that of + 1 area of Myanmar (Z value = - 1.18, P value = 0.24).

CONCLUSION

The pilot project on 3 + 1 strategy has been significantly effective in the study areas and a buffer zone of border malaria was successfully established between Laiza City of Myanmar and Yingjiang County of China.

What sub-Saharan African countries can learn from malaria elimination in China

Malaria is one of the most devastating diseases plaguing the sub-Saharan African region since time immemorial. In spite of a global reduction in mortality rates, a significant proportion of deaths due to malaria is still accounted for in the region. China recently joined the 40 countries declared malaria free by the World Health Organization and became the first country in the WHO Western Pacific Region to be awarded the certification. We commented on the strategies employed by China to eliminate malaria, address challenges facing malaria control in sub-Saharan Africa, and derive lessons that could be learned in the sub-Saharan African context.

Epidemiologic Analysis of Efforts to Achieve and Sustain Malaria Elimination along the China-Myanmar Border

Malaria cases have dramatically declined in China along the Myanmar border, attributed mainly to adoption of the 1-3-7 surveillance and response approach. No indigenous cases have been reported in China since 2017. Counties in the middle and southern part of the border area have a higher risk for malaria importation and reestablishment after elimination.

Malaria Elimination in India: Bridging the Gap Between Control and Elimination

India observed a significant reduction in malaria cases in the previous year, reaffirming our trust and efficiency of the existing tools to achieve malaria elimination. On 25 April, 2019, countries around the world marked World Malaria Day under the theme “Zero malaria starts with me”. This provides an opportunity to rejoice the success and re-evaluate ongoing challenges in the fight against this preventable and treatable parasitic disease. We highlight the potential gaps in the malaria elimination program, and underscore potential solutions and strategies to implement, improve and intensify the success of the national goal of malaria elimination by 2030.

Implementation and success factors from Thailand's 1-3-7 surveillance strategy for malaria elimination

Thailand’s National Malaria Elimination Strategy 2017–2026 introduced the 1-3-7 strategy as a robust surveillance and response approach for elimination that would prioritize timely, evidence-based action. Under this strategy, cases are reported within 1 day, cases are investigated within 3 days, and foci are investigated and responded to within 7 days, building on Thailand’s long history of conducting case investigation since the 1980s. However, the hallmark of the 1-3-7 strategy is timeliness, with strict deadlines for reporting and response to accelerate elimination. This paper outlines Thailand’s experience adapting and implementing the 1-3-7 strategy, including success factors such as a cross-sectoral Steering Committee, participation in a collaborative regional partnership, and flexible local budgets. The programme continues to evolve to ensure prompt and high-quality case management, capacity maintenance, and adequate supply of lifesaving commodities based on surveillance data. Results from implementation suggest the 1-3-7 strategy has contributed to Thailand’s decline in malaria burden; this experience may be useful for other countries aiming to eliminate malaria.

Spatial patterns of <em>Plasmodium vivax</em> transmission explored by multivariate auto-regressive state-space modelling - A case study in Baoshan Prefecture in southern China

The transition from the control phase to elimination of malaria in China through the national malaria elimination programme has focussed attention on the need for improvement of the surveillance- response systems. It is now understood that routine passive surveillance is inadequate in the parasite elimination phase that requires supplementation by active surveillance in foci where cluster cases have occurred. This study aims to explore the spatial clusters and temporal trends of malaria cases by the multivariate auto-regressive state-space model (MARSS) along the border to Myanmar in southern China. Data for indigenous cases spanning the period from 2007 to 2010 were extracted from the China's Infectious Diseases Information Reporting Management System (IDIRMS). The best MARSS model indicated that malaria transmission in the study area during 36 months could be grouped into three clusters. The estimation of malaria transmission patterns showed a downward trend across all clusters. The proposed methodology used in this study offers a simple and rapid, yet effective way to categorize patterns of foci which provide assistance for active monitoring of malaria in the elimination phase.

Seven decades towards malaria elimination in Yunnan, China

BACKGROUND

Yunnan Province was considered the most difficult place in China for malaria elimination because of its complex malaria epidemiology, heterogeneous ecological features, relatively modest economic development, and long, porous border with three malaria endemic countries: Lao People's Democratic Republic, Myanmar, and Viet Nam.

METHODS

Academic publications and grey literature relevant to malaria elimination in Yunnan covering the period from 1950 until 2020 inclusive were considered. The following academic indexes were searched: China Science Periodical Database, China National Knowledge Infrastructure Database, and MEDLINE. Grey literature sources were mainly available from the National Institute of Parasitic Diseases (NIPD), the Chinese Center for Diseases Control and Prevention, and the Yunnan Institute of Parasitic Diseases (YIPD).

RESULTS

A malaria elimination campaign in the 1950-1960s, based mainly on mass administration of antimalarial drugs and large-scale vector control, reduced morbidity and mortality from malaria and interrupted transmission in some areas, although elimination was not achieved. Similar strategies were used to contain outbreaks and a resurgence of disease during the 1970s, when malaria services were discontinued. From the 1980s, malaria incidence declined, despite the challenges of large numbers of mobile and migrant populations and an unstable primary health care system in rural areas following economic transformation. Launch of the national malaria elimination programme in 2010 led to adoption of the '1-3-7' surveillance and response strategy specifying timely detection of and response for every case, supported by the establishment of a real-time web-based disease surveillance system and a new primary health care system in rural areas. Border malaria was addressed in Yunnan by strengthening the surveillance system down to the lowest level, cross-border collaboration with neighbouring countries and non-governmental organizations, and the involvement of other sectors.

CONCLUSIONS

Seven decades of work to eliminate malaria in Yunnan have shown the importance of political commitment, technically sound strategies with high quality implementation, a robust surveillance and response system at all levels, community participation and effective management of border malaria. The experiences and lessons learned from elimination remain important for prevention re-establishment of malaria transmission in the Province.

Choosing interventions to eliminate forest malaria: preliminary results of two operational research studies inside Cambodian forests

BACKGROUND

Rapid elimination of Plasmodium falciparum malaria in Cambodia is a goal with both national and international significance. Transmission of malaria in Cambodia is limited to forest environments, and the main population at risk consists of forest-goers who rely on forest products for income or sustenance. The ideal interventions to eliminate malaria from this population are unknown.

METHODS

In two forested regions of Cambodia, forest-goers were trained to become forest malaria workers (FMWs). In one region, FMWs performed mass screening and treatment, focal screening and treatment, and passive case detection inside the forest. In the other region, FMWs played an observational role for the first year, to inform the choice of intervention for the second year. In both forests, FMWs collected blood samples and questionnaire data from all forest-goers they encountered. Mosquito collections were performed in each forest.

RESULTS

Malaria prevalence by PCR was high in the forest, with 2.3-5.0% positive for P. falciparum and 14.6-25.0% positive for Plasmodium vivax among forest-goers in each study site. In vectors, malaria prevalence ranged from 2.1% to 9.6%, but no P. falciparum was observed. Results showed poor performance of mass screening and treatment, with sensitivity of rapid diagnostic tests equal to 9.1% (95% CI 1.1%, 29.2%) for P. falciparum and 4.4% (95% CI 1.6%, 9.2%) for P. vivax. Malaria infections were observed in all demographics and throughout the studied forests, with no clear risk factors emerging.

CONCLUSIONS

Malaria prevalence remains high among Cambodian forest-goers, but performance of rapid diagnostic tests is poor. More adapted strategies to this population, such as intermittent preventive treatment of forest goers, should be considered.

Reactive Case Detection (RACD) and foci investigation strategies in malaria control and elimination: a review

Background

Reactive case detection (RACD) and foci investigation are key strategies in malaria elimination and prevention of its re-establishment. They are a key part of surveillance that has been recommended by the World Health Organization (WHO) to be considered as a core intervention and as one of the three pillars of the Global Technical Strategy for Malaria 2016–2030.

Methods

A search using the key words “Reactive Case Detection”, “RACD”, “RCD” and “Malaria” was carried out in PubMed, Scopus, Taylor and Francis online databases for studies published until 31st July 2019. The inclusion criteria for selection of articles for review included (1) how RACD is implemented in each country; (2) challenges faced in RACD implementation; (3) suggestions on how the effectiveness of RACD process can be improved.

Results

411 titles were identified, 41 full text articles were screened and 29 were found eligible for inclusion in the review. Published literature on RACD, and case and foci investigations has mostly assessed the process of the activity. Most studies have documented that the yield of positives in RACD has been highest in the index case’s household and the immediate neighbourhood of the index case. Microscopy and RDTs are the common tests used in RACD. The guidelines for case and foci investigation, and RACD and PACD, are not universally adopted and are country-specific. Some of the limitations and challenges identified include lack of proper guidelines, logistic issues and problems with public compliance.

Conclusions

Although there is no documented evidence that RACD is useful in malaria elimination settings, most authors have opined that RACD is necessary for malaria elimination. Lack of knowledge in the target populations, a target radius and how to carry out the RACD process is a major challenge in the decision-making process.

Effectiveness of the innovative 1,7-malaria reactive community-based testing and response (1, 7-mRCTR) approach on malaria burden reduction in Southeastern Tanzania

BACKGROUND

In 2015, a China-UK-Tanzania tripartite pilot project was implemented in southeastern Tanzania to explore a new model for reducing malaria burden and possibly scaling-out the approach into other malaria-endemic countries. The 1,7-malaria Reactive Community-based Testing and Response (1,7-mRCTR) which is a locally-tailored approach for reporting febrile malaria cases in endemic villages was developed to stop transmission and Plasmodium life-cycle. The (1,7-mRCTR) utilizes existing health facility data and locally trained community health workers to conduct community-level testing and treatment.

METHODS

The pilot project was implemented from September 2015 to June 2018 in Rufiji District, southern Tanzania. The study took place in four wards, two with low incidence and two with a higher incidence. One ward of each type was selected for each of the control and intervention arms. The control wards implemented the existing Ministry of Health programmes. The 1,7-mRCTR activities implemented in the intervention arm included community testing and treatment of malaria infection. Malaria case-to-suspect ratios at health facilities (HF) were aggregated by villages, weekly to identify the village with the highest ratio. Community-based mobile test stations (cMTS) were used for conducting mass testing and treatment. Baseline (pre) and endline (post) household surveys were done in the control and intervention wards to assess the change in malaria prevalence measured by the interaction term of 'time' (post vs pre) and arm in a logistic model. A secondary analysis also studied the malaria incidence reported at the HFs during the intervention.

RESULTS

Overall the 85 rounds of 1,7-mRCTR conducted in the intervention wards significantly reduced the odds of malaria infection by 66% (adjusted OR 0.34, 95% CI 0.26,0.44, p < 0001) beyond the effect of the standard programmes. Malaria prevalence in the intervention wards declined by 81% (from 26% (95% CI 23.7, 7.8), at baseline to 4.9% (95% CI 4.0, 5.9) at endline). In villages receiving the 1,7-mRCTR, the short-term case ratio decreased by over 15.7% (95% CI - 33, 6) compared to baseline.

CONCLUSION

The 1,7-mRCTR approach significantly reduced the malaria burden in the areas of high transmission in rural southern Tanzania. This locally tailored approach could accelerate malaria control and elimination efforts. The results provide the impetus for further evaluation of the effectiveness and scaling up of this approach in other high malaria burden countries in Africa, including Tanzania.

Epidemiological big data and analytical tools applied in the control programmes on parasitic diseases in China: NIPD's sustained contributions in 70 years

The analysis of epidemiological data has played an important role for the academic research carried out by the National Institute of Parasitic Diseases, China CDC, since its foundation in 1950s. Those researches, e.g., the temporal-spatial patterns of disease transmission and the identification of risk factors, have contributed significantly to the national parasitic disease control and elimination programmes in China. With the development and application of epidemiological data analysis in the last decade, all research results improve our understanding of parasitic diseases epidemiology and related health issues through the application platform of epidemiological big data and analytical tools. In particular, implementation research on analytical predictions on disease outbreak or epidemic risks have provided references to the scientific guidance on effective preventions and interventions in the parasitic disease elimination in China, such as fliariasis, malaria and schistosomiasis. This review has reflected the function of data accumulation and application of temporospatial tools in parasitic diseases control, and the ways of the NIPD's sustained contributions to the disease control programmes in China.

The "1-3-7" Approach to Malaria Surveillance and Response - Henan Province, China, 2012-2018

What is already known about this topic? The "1-3-7" approach to malaria surveillance and response was a key measure for malaria elimination in China and was first introduced into the World Health Organization (WHO) as an international guideline for malaria surveillance and response in 2018. What is added by this report? The "1-3-7" approach was well implemented in Henan Province from 2012-2018. Over this study period, a total of 1,294 malaria cases were detected and reported, and all cases were diagnosed and reported within 1 day with 99.23% (1,284/1,294) of cases were investigated within 3 days. In addition, 93.7% (1,212/1,294) of foci were investigated and vector control was implemented within 7 days at all residual non-active foci to prevent further spread. What are the implications for public health practice? The "1-3-7" controlling pattern would be an effective and approachable method for implementation especially in malaria-eliminating countries and regions, but the interval from symptom onset to diagnosis cannot be ignored. Thus, the roles and responsibilities that all actors involved in the health sector must be specified too.

Malaria elimination using the 1-3-7 approach: lessons from Sampov Loun, Cambodia

Background

Cambodia has targeted malaria elimination within its territory by 2025 and is developing a model elimination package of strategies and interventions designed to achieve this goal.

Methods

Cambodia adopted a simplified 1-3-7 surveillance model in the Sampov Loun operational health district in western Cambodia beginning in July 2015. The 1-3-7 approach targets reporting of confirmed cases within one day, investigation of specific cases within three days, and targeted control measures to prevent further transmission within seven days. In Sampov Loun, response measures included reactive case detection (testing of co-travelers, household contacts and family members, and surrounding households with suspected malaria cases), and provision of health education, and insecticide-treated nets. Day 28 follow up microscopy was conducted for all confirmed P. falciparum and P. falciparum-mixed-species malaria cases to assess treatment efficacy.

Results

The number of confirmed malaria cases in the district fell from 519 in 2015 to 181 in 2017, and the annual parasite incidence (API) in the district fell from 3.21 per 1000 population to 1.06 per 1000 population. The last locally transmitted case of malaria in Sampov Loun was identified in March 2016. In response to the 408 index cases identified, 1377 contacts were screened, resulting in the identification of 14 positive cases. All positive cases occurred among index case co-travelers.

Conclusion

The experience of the 1-3-7 approach in Sampov Loun indicates that the basic essential malaria elimination package can be feasibly implemented at the operational district level to achieve the goal of malaria elimination in Cambodia and has provided essential information that has led to the refinement of this package.

Malaria Elimination in China: Improving County-Level Malaria Personnel Knowledge of the 1-3-7 Strategy through Tabletop Exercises

As China moves to the prevention of reestablishment of malaria, maintaining skills for malaria in county personnel on the "1-3-7" surveillance and response strategy is critical. China's "1-3-7" strategy defines targets used to guide and monitor malaria case reporting, investigation, and response, respectively: reporting of malaria cases within 1 day, their confirmation and investigation within 3 days, and the appropriate public health response to prevent further transmission within 7 days. Assessing the knowledge of local CDC malaria personnel on the "1-3-7" surveillance and response strategy is urgently needed. In June 2016, two different training modules (classroom-style teaching and tabletop exercises) were conducted for 125 CDC staff in Jiangsu Province, China, to determine the effectiveness of the two training modules on CDC staff knowledge and learning of the "1-3-7" strategy. The classroom-style training module just imparted the malaria knowledge to participants through teaching. Tabletop exercises were carried out through discussion-based scenarios using questions and answers on the "1-3-7" strategy. Questionnaires assessing knowledge improvement were designed and administered to personnel responsible for malaria surveillance and response activities, including at baseline and end line. Overall, knowledge of the "1-3-7" strategy for malaria elimination was 63.2% correct at baseline, 70.6% after implementing a classroom-style teaching module (χ2 = 11.20, P = 0.001), and 84.6% after the tabletop exercise module (χ2 = 48.82, P < 0.001). The knowledge of each component of the "1-3-7" strategy improved significantly after the tabletop exercise module. The total proportion of respondents with a high score (greater than or equal to 75%) was 82.7% in the classroom-style module and 95.2% in the tabletop exercise module. The proportion of respondents with a high score significantly increased after tabletop exercises in the stratified demographic groups of men who work at the county CDC level, have a bachelor's degree, hold a professional title as professor or assistant, are aged 31-50 years, and have attained 11-20 years of service with the CDC compared with the classroom-style module. Acceptability of the classroom-style module (78.2%) compared with tabletop exercises (94.4%) by the CDC malaria personnel increased significantly (χ2 = 11.96, P = 0.004). Feedback from participants on the modules suggest the tabletop exercises were an effective training method, which could maintain and improve the knowledge and capacity for malaria surveillance and response in basic CDC level personnel in China.

Tracking progress towards malaria elimination in China: Individual-level estimates of transmission and its spatiotemporal variation using a diffusion network approach

In order to monitor progress towards malaria elimination, it is crucial to be able to measure changes in spatio-temporal transmission. However, common metrics of malaria transmission such as parasite prevalence are under powered in elimination contexts. China has achieved major reductions in malaria incidence and is on track to eliminate, having reporting zero locally-acquired malaria cases in 2017 and 2018. Understanding the spatio-temporal pattern underlying this decline, especially the relationship between locally-acquired and imported cases, can inform efforts to maintain elimination and prevent re-emergence. This is particularly pertinent in Yunnan province, where the potential for local transmission is highest. Using a geo-located individual-level dataset of cases recorded in Yunnan province between 2011 and 2016, we introduce a novel Bayesian framework to model a latent diffusion process and estimate the joint likelihood of transmission between cases and the number of cases with unobserved sources of infection. This is used to estimate the case reproduction number, Rc. We use these estimates within spatio-temporal geostatistical models to map how transmission varied over time and space, estimate the timeline to elimination and the risk of resurgence. We estimate the mean Rc between 2011 and 2016 to be 0.171 (95% CI = 0.165, 0.178) for P. vivax cases and 0.089 (95% CI = 0.076, 0.103) for P. falciparum cases. From 2014 onwards, no cases were estimated to have a Rc value above one. An unobserved source of infection was estimated to be moderately likely (p>0.5) for 19/ 611 cases and high (p>0.8) for 2 cases, suggesting very high levels of case ascertainment. Our estimates suggest that, maintaining current intervention efforts, Yunnan is unlikely to experience sustained local transmission up to 2020. However, even with a mean of 0.005 projected up to 2020, locally-acquired cases are possible due to high levels of importation.

Challenges in early phase of implementing the 1-3-7 surveillance and response approach in malaria elimination setting: A field study from Myanmar

Background

The National Plan for Malaria Elimination (NPME) in Myanmar (2016–2030) aims to eliminate indigenous Plasmodium falciparum malaria in six states/regions of low endemicity by 2020 and countrywide by 2030. To achieve this goal, in 2016 the National Malaria Control Program (NMCP) implemented the “1-3-7” surveillance and response strategy. This study aims to identify the barriers to successful implementation of the NPME which emerged during the early phase of the “1-3-7” approach deployment.

Methods

A mixed-methods study was conducted with basic health staff (BHS) and Vector Born Disease Control Program (VBDC) staff between 2017 and 2018 in six townships of six states/regions targeted for sub-national elimination by 2020. A self-administered questionnaire, designed to assess the knowledge required to implement the “1-3-7” approach, was completed by 544 respondents. Bivariate analysis was performed for quantitative findings and thematic analysis was conducted for qualitative findings using Atals.ti software.

Results

Although 83% of participants reported performing the key activities in the “1-3-7” surveillance and response approach, less than half could report performing those activities within 3 days and 7 days (40 and 43%, respectively). Low proportion of BHS correctly identified six categories of malaria cases and three types of foci (22 and 26%, respectively). In contrast, nearly 80% of respondents correctly named three types of case detection methods. Most cited challenges included ‘low community knowledge on health’ (43%), ‘inadequate supplies’ (22%), and ‘transportation difficulty’ (21%). Qualitative data identified poor knowledge of key surveillance activities, delays in reporting, and differences in reporting systems as the primary challenges. The dominant perceived barrier to success was inability to control the influx of migrant workers into target jurisdictions especially in hard-to-reach areas. Interviews with township medical officers and the NMCP team leaders further highlighted the necessity of refresher training for every step in the “1-3-7” surveillance and response approach.

Conclusions

The performance of the “1-3-7” surveillance and response approach in Myanmar delivers promising results. However, numerous challenges are likely to slow down malaria elimination progress in accordance with the NPME. Multi-stakeholder engagement and health system readiness is critical for malaria elimination at the sub-national level.

Indigenously developed digital handheld Android-based Geographic Information System (GIS)-tagged tablets (TABs) in malaria elimination programme in Mangaluru city, Karnataka, India

BACKGROUND

Under-reporting, delayed diagnosis, incomplete treatment and inadequate vector management are few among many factors responsible for uninterrupted transmission of malaria in India. Information technology (IT) and mobile apps can be utilized effectively to overcome these hurdles. Indigenously developed digital handheld geographic information system (GIS)-tagged Android-based tablets (TABs) has been designed especially for implementation of digitization protocol. This has changed the effectiveness of malaria surveillance and intervention strategies in a malaria endemic area of Mangaluru city, Karnataka, India.

METHODS

A software was developed and implemented for control measures to create a digital database of each malaria case. Secondary data analyses were carried out to determine and compare differences in malariometric indices between pre- and post-digitization years. With the introduction of this software active surveillance, information education and communication (IEC), and anti-vector measures were made 'incidence-centric'. This means that the entire control measures were carried out in the houses where the malaria cases (index cases) were reported and also in surrounding houses.

RESULTS

Annual blood examination rate (ABER) increased from 13.82 to 32.8%. Prompt reporting of new cases had improved (36% within 24 h and 80% within 72 h). Complete treatment and parasite clearance time were documented in 98% of cases. In the second post-digitization year untraceable cases reduced from 11.3 to 2.7%; contact blood smears collection also increased significantly (p < 0.001); Slide Positivity Rate (SPR) decreased from 15.5 to 10.48%; malaria cases reduced by 30%.

CONCLUSIONS

IT is very useful in translation of digitized surveillance to core interventions thereby effectively reduce incidence of malaria. This technology can be used effectively to translate smart surveillance to core interventions following the '1-3-7-14' strategy.

Management of imported malaria cases and healthcare institutions in central China, 2012-2017: application of decision tree analysis

Background

Imported malaria has been an important challenge for China. Fatality rates from malaria increased in China, particularly in Henan Province, primarily due to malpractice and misdiagnoses in healthcare institutions, and the level of imported malaria. This study aims to investigate the relationship between the state of diagnosis and subsequent complications among imported malaria cases at healthcare institutions, based on malaria surveillance data in Henan Province from 2012 to 2017.

Methods

A retrospective descriptive analysis was performed using data from the Centre for Disease Control and Prevention, Zhengzhou City, the capital of Henan Province. A decision tree method was exploited to provide valuable insight into the correlation between imported malaria cases and healthcare institutions.

Results

From 2012 to 2017, there were 371 imported malaria cases, mostly in males aged between 20 and 50 years, including 319 Plasmodium falciparum cases. First visits of 32.3%, 19.9% and 15.9% malaria cases for treatment were to provincial, municipal and county healthcare institutions, respectively. The time interval between onset and initial diagnosis of 284 cases (76.5%) and the time interval between initial diagnosis and final diagnosis of 197 cases (53.1%) was no more than 72 h. An apparent trend was found that there were notably fewer patients misdiagnosed at first visit to healthcare institutions of a higher administrative level; 12.5% of cases were misdiagnosed in provincial healthcare institutions compared to 98.2% in private clinics, leading to fewer complications at healthcare institutions of higher administrative level due to correct initial diagnosis. In the tree model, the rank of healthcare facilities for initial diagnosis, and number of days between onset and initial diagnosis, made a major contribution to the classification of initial diagnosis, which subsequently became the most significant factor influencing complications developed in the second tree model. The classification accuracy were 82.2 and 74.1%, respectively for the tree models of initial diagnosis and complications developed.

Conclusion

Inadequate seeking medical care by imported malaria patients, and insufficient capacity to diagnose malaria by healthcare institutions of lower administrative level were identified as major factors influencing complications of imported malaria cases in Henan Province. The lack of connection between uncommon imported malaria cases and superior medical resources was found to be the crucial challenge. A web-based system combined with WeChat to target imported malaria cases was proposed to cope with the challenge.

Modelling reactive case detection strategies for interrupting transmission of Plasmodium falciparum malaria

BACKGROUND

As areas move closer to malaria elimination, a combination of limited resources and increasing heterogeneity in case distribution and transmission favour a shift to targeted reactive interventions. Reactive case detection (RCD), the following up of additional individuals surrounding an index case, has the potential to target transmission pockets and identify asymptomatic cases in them. Current RCD implementation strategies vary, and it is unclear which are most effective in achieving elimination.

METHODS

OpenMalaria, an established individual-based stochastic model, was used to simulate RCD in a Zambia-like setting. The capacity to follow up index cases, the search radius, the initial transmission and the case management coverage were varied. Suitable settings were identified and probabilities of elimination and time to elimination estimated. The value of routinely collected prevalence and incidence data for predicting the success of RCD was assessed.

RESULTS

The results indicate that RCD with the aim of transmission interruption is only appropriate in settings where initial transmission is very low (annual entomological inoculation rate (EIR) 1-2 or prevalence approx. < 7-19% depending on case management levels). Every index case needs to be followed up, up to a maximum case-incidence threshold which defines the suitability threshold of settings for elimination using RCD. Increasing the search radius around index cases is always beneficial.

CONCLUSIONS

RCD is highly resource intensive, requiring testing and treating of 400-500 people every week for 5-10 years for a reasonable chance of elimination in a Zambia-like setting.

Technical and operational underpinnings of malaria elimination from Sri Lanka

Malaria was eliminated from Sri Lanka in 2012, and the country received WHO-certification in 2016. The objective of this paper is to describe the epidemiology of malaria elimination in Sri Lanka, and the key technical and operational features of the elimination effort, which may have been central to achieving the goal, even prior to schedule, and despite an ongoing war in parts of the country. Analysis of information and data from the Anti Malaria Campaign (AMC) of Sri Lanka during and before the elimination phase, and the experiences of the author(s) who directed and/or implemented the elimination programme or supported it form the basis of this paper. The key epidemiological features of malaria on the path to elimination included a steady reduction of case incidence from 1999 onwards, and the simultaneous elimination of both Plasmodium falciparum and Plasmodium vivax. Against the backdrop of a good health infrastructure the AMC, a specialized programme within the Ministry of Health operated through a decentralized provincial health system to implement accepted strategies for the elimination of malaria. Careful planning combined with expertise on malaria control at the Central level with dedicated staff at all levels at the Centre and on the ground in all districts, for several years, was the foundation of this success. The stringent implementation of anti-relapse treatment for P. vivax through a strong collaboration with the military in whose cadres most of the malaria cases were clustered in the last few years of transmission would have supported the relatively rapid elimination of P. vivax. A robust case and entomological surveillance and investigation system described here enabled a highly focused approach to delivering interventions leading to the interruption of transmission.

Monitoring and evaluation of intervals from onset of fever to diagnosis before "1-3-7" approach in malaria elimination: a retrospective study in Shanxi Province, China from 2013 to 2018

BACKGROUND

China's 1-3-7 approach was extensively implemented to monitor the timeframe of case reporting, case investigation and foci response in the malaria elimination. However, activities before diagnosis and reporting (before '1') would counteract the efficiency of 1-3-7 approach but few data have evaluated this issue. This study aims to evaluate the timelines between onset of fever and diagnosis at healthcare facilities in Shanxi Province.

METHODS

Routine data were extracted from IDIRMS and NMISM database from 2013 to 2018. Time intervals between onset of fever and healthcare-seeking and between healthcare-seeking and diagnosis were calculated. Each of the documented malaria cases was geo-coded and paired to the county-level layers of polygon.

RESULTS

A total of 90 cases were reported in 2013-2018 in Shanxi Province, and 73% of cases reported at provincial health facilities. All malaria cases were imported from Africa (90%) and Southeast Asia (10%) especially around the Chinese Spring Festival (n = 46, 51%). The median days between fever and healthcare-seeking and between healthcare-seeking and diagnosis of malaria were 3 and 2, respectively.

CONCLUSIONS

The current "1-3-7" approach is well executed in Shanxi Province, but delays intervals observed in case finding before 1-3-7 approach occurred in all levels of facilities in Shanxi Province, which imply that more efforts are highlighted for timely case finding. Health education should be provided for improving awareness of healthcare-seeking, and various technical training aiming at the physicians should be carried out to improve diagnosis of malaria.

Imported malaria cases in former endemic and non-malaria endemic areas in China: are there differences in case profile and time to response?

BACKGROUND

China has achieved zero indigenous malaria case report in 2017. However, along with the increasing of international cooperation development, there is an increasing number of imported malaria cases from Chinese nationals returning from malaria-affected countries. Previous studies have focused on malaria endemic areas in China. There is thus limited information on non-endemic areas in China, especially on the performance of malaria surveillance and response in health facilities.

METHODS

A comparative retrospective study was carried out based on routine malaria surveillance data collected from 2013 to 2017. All imported malaria cases reported within the mainland of China were included. Variables used in the comparative analysis between cases in former endemic and former non-endemic areas, included age, gender and occupation, destination of overseas travel, Plasmodium species and patient health outcome. Monthly aggregated data was used to compare seasonal and spatial characteristics. Geographical distribution and spatial-temporal aggregation analyses were conducted. Time to diagnosis and report, method of diagnosis, and level of reporting/diagnosing health facilities were used to assess performance of health facilities.

RESULTS

A total of 16 733 malaria cases, out of which 90 were fatal, were recorded in 31 provinces. The majority of cases (96.2%) were reported from former malaria endemic areas while 3.8% were reported from former non-malaria endemic areas. Patients in the age class from 19 to 59 years and males made the highest proportion of cases in both areas. There were significant differences between occupational categories in the two areas (P <  0.001). In former endemic areas, the largest proportion of cases was among outdoor workers (80%). Two peaks (June, January) and three peaks (June, September and January) were found in former endemic and former non-endemic areas, respectively. Time between the onset of symptoms and diagnosis at clinics was significantly different between the two areas at different level of health facilities (P <  0.05).

CONCLUSIONS

All the former non-endemic areas are now reporting imported malaria cases. However, the largest proportion of imported cases is still reported from former endemic areas. Health facilities in former endemic areas outperformed those in former non-endemic areas. Information, treatment, and surveillance must be provided for expatriates while capacity building and continuous training must be implemented at health facilities in China.

Monitoring of malaria vectors at the China-Myanmar border while approaching malaria elimination

BACKGROUND

Tengchong County was one of the counties located at the China-Myanmar border with high malaria incidence in the previous decades. As the pilot county for malaria elimination at the border area, Tengchong County is aiming to be the first county to achieve malaria elimination goal. A cross-sectional entomological survey was carried out to evaluate the feasibility of elimination approach and assess the receptivity of malaria reintroduction.

METHODS

Light traps associated with live baits were used to investigate the abundance of adult mosquitoes in nine villages in Tengchong County. Light traps were set to collect adult mosquitoes in both human houses and cowsheds from dusk till dawn in each site.

RESULTS

A total of 4948 adult Anopheles mosquitoes were collected from May to December in two villages. Of the mosquitoes were captured, 24.2% were in human houses and 75.8% in cowsheds. The peak of abundance occurred in July for An. sinensis and in September-October for An. minimus (s.l.) Ten Anopheles species were collected, the most prevalent being An. sinensis (50.3%), An. peditaeniatus (31.6%) and An. minimus (s.l.) (15.8%), contributing to 97.6% of the sample. Potential breeding sites were also investigated and a total of 407 larvae were collected, with An. sinensis (50.1%) and An. minimus (s.l.) (46.2%) as predominant species. Ponds and rice fields were the two preferred breeding sites for Anopheles mosquitoes; however, the difference between the number of adults and larvae captured suggest other breeding sites might exist. Both An. sinensis and An. minimus (s.l.) were found zoophilic with human blood index as 0.21 and 0.26, respectively. No Plasmodium positive Anopheles specimens were found by PCR among 4,000 trapped mosquitoes.

CONCLUSIONS

Although no indigenous malaria cases have been reported in Tengchong County since 2013, there is still a risk from the presence of vectors in the context of human population movements from neighboring malaria endemic areas. The presence of An. sinensis, associated to rice fields, is particularly worrying. Sustained entomological surveillance is strongly suggested even after malaria elimination certification.

Ready for malaria elimination: zero indigenous case reported in the People's Republic of China

BACKGROUND

Malaria was once one of the most serious public health problems in China. However, the disease burden has sharply declined and epidemic areas have shrunk after the implementation of an integrated malaria control and elimination strategy, especially since 2000. In this review, the lessons were distilled from the Chinese national malaria elimination programme and further efforts to mitigate the challenges of malaria resurgence are being discussed.

METHODS

A retrospective evaluation was performed to assess the changes in malaria epidemic patterns from 1950 to 2017 at national level. The malaria data before 2004 were collected from paper-based annual reports. After 2004, each of the different cases from the Infectious Diseases Information Reporting Management System (IDIRMS) was closely examined and scrutinized. An additional documenting system, the National Information Management System for Malaria, established in 2012 to document the interventions of three parasitic diseases, was also examined to complete the missing data from IDIRMS.

RESULTS

From 1950 to 2017, the occurrence of indigenous malaria has been steeply reduced, and malaria-epidemic regions have substantially shrunk, especially after the launch of the national malaria elimination programme. There were approximately 30 million malaria cases annually before 1949 with a mortality rate of 1%. A total of 5999 indigenous cases were documented from 2010 to 2016, with a drastic reduction of 99% over the 6 years (2010, n = 4262; 2016, n = 3). There were indigenous cases reported in 303 counties from 18 provinces in 2010, but only 3 indigenous cases were reported in 2 provinces nationwide in 2016. While in 2017, for the first time, zero indigenous case was reported in China, and only 7 of imported cases were in individuals who died of Plasmodium falciparum infection.

CONCLUSION

Malaria elimination in China is a country-led and country-owned endeavour. The country-own efforts were a clear national elimination strategy, supported by two systems, namely a case-based surveillance and response system and reference laboratory system. The country-led efforts were regional and inter-sectoral collaboration as well as sustained monitoring and evaluation. However, there are still some challenges, such as the maintenance of non-transmission status, the implementation of a qualified verification and assessment system, and the management of imported cases in border areas, through regional cooperation. The findings from this review can probably help improving malaria surveillance systems in China, but also in other elimination countries.

From diagnosis to case investigation for malaria elimination in Swaziland: is reporting and response timely?

Background: Swaziland is one of the southern African countries that aim to eliminate malaria by 2020. In 2010, the country introduced an Immediate Disease Notification System (IDNS) for immediate reporting of notifiable diseases, including malaria. Health facilities are to report malaria cases within 24 h through a toll-free telephone number (977), triggering an alert for case investigation at the patient's household within 48 h. We assessed the completeness of reporting in the IDNS, the subsequent case investigation, and whether it was done within the stipulated timelines. Methods: A cross-sectional study using routine country-wide data. Results: Of 1991 malaria cases notified between July 2011 and June 2015, 76% were reported in the IDNS, of which 68% were investigated-a shortfall of 24% in reporting and 32% in case investigations. Of the 76% of cases reported through the IDNS, 62% were reported within 24 h and 20% were investigated within 48 h. These shortcomings were most pronounced in hospitals and private facilities. Investigated cases (n = 1346) were classified as follows: 60% imported, 35% local and 5% undetermined. Conclusion: The utilisation of the IDNS for case reporting to trigger investigation is crucial for active surveillance. There is a need to address the reporting and investigation gaps identified to ensure that malaria cases receive appropriate interventions.

"Alert-Audit-Act": assessment of surveillance and response strategy for malaria elimination in three low-endemic settings of Myanmar in 2016

Background

Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and response strategy similar to “1-3-7” Chinese strategy to achieve sub-national elimination in six low-endemic region/states of the country. Among these, Yangon, Bago-East, and Mon region/states have implemented this malaria surveillance and response strategy with modification in 2016. The current study was conducted to assess the case notification, investigation, classification, and response strategy (NICR) in these three states.

Methods

This was a retrospective cohort study using routine program data of all patients with malaria diagnosed and reported under the National Malaria Control Programme in 2016 from the above three states. As per the program, all malaria cases need to be notified within 1 day and investigated within 3 days of diagnosis and response to control (active case detection and control) should be taken for all indigenous malaria cases within 7 days of diagnosis.

Results

A total of 959 malaria cases were diagnosed from the study area in 2016. Of these, the case NICR details were available only for 312 (32.5%) malaria cases. Of 312 cases, the case notification, investigation, and classification were carried out within 3 days of malaria diagnosis in 95.5% cases (298/312). Of 208 indigenous malaria cases (66.7%, 208/312), response to control was taken in 96.6% (201/208) within 7 days of diagnosis.

Conclusion

The timeline at each stage of the strategy namely case notification, investigation, classification, and response to control was followed, and response action was taken in nearly all indigenous malaria cases for the available case information. Strengthening of health information and monitoring system is needed to avoid missing information. Future research on feasibility of mobile/tablet-based surveillance system and providing response to all cases including imported malaria can be further studied.

Driving towards malaria elimination in Botswana by 2018: progress on case-based surveillance, 2013-2014

Background: Reliable information reporting systems ensure that all malaria cases are tested, treated and tracked to avoid further transmission. Botswana aimed to eliminate malaria by 2018, and surveillance is key. This study focused on assessing the uptake of the new malaria case-based surveillance (CBS) system introduced in 2012, which captures information on malaria cases reported in the Integrated Disease Surveillance and Response (IDSR) system. Methods: This was a retrospective descriptive study based on routine data focusing on Ngami, Chobe and Okavango, three high-risk districts in Botswana. Aggregated data variables were extracted from the IDSR and compared with data from the CBS. Results: The IDSR reported 456 malaria cases in 2013 and 1346 in 2014, of which respectively only 305 and 884 were reported by the CBS. The CBS reported 34% fewer cases than the IDSR system, indicating substantial differences between the two systems. The key malaria indicators with the greatest variability among the districts included in the study were case identification number and date of diagnosis. Conclusion: The IDSR and CBS systems are essential for malaria elimination, as shown by the significant gaps in reporting between the two systems. These findings highlight the need for further investigation into these discrepancies. Strengthening the CBS system will help to reach the objective of malaria elimination in Botswana.

A review of progress towards sub-national malaria elimination in Matabeleland South Province, Zimbabwe (2011-2015): a qualitative study

Background

Malaria remains a public health problem in Zimbabwe. However, malaria elimination has become a foreseeable prospect with Matabeleland South Province making significant gains towards halting local malaria transmission. This study reviews malaria elimination progress and challenges to date utilizing the World Health Organization’s Malaria Programme Review framework.

Results

Between 2011 and 2015, malaria incidence was less than one case per 1000 population at risk in all districts save for Beitbridge and Gwanda. The majority of cases were from Beitbridge with local transmission in the same. Incidence declined in Bulilima (p = 0.01), Gwanda (p = 0.72) and Umzingwane (p = 0.44), increasing in Beitbridge (p = 0.35), Insiza (p = 0.79) and Mangwe (p = 0.60). Overall provincial incidence declined although this was not statistically significant. Malaria transmission was bimodal, with a major peak in April and a minor peak in October. A case based malaria surveillance system existed but was not real-time. Foci response guidelines were not domesticated. Artemisinin formed the backbone of case management regimens with primaquine for gametocyte clearance. Indoor residual spraying coverages were below the national target of 95% for rooms targeted for spraying.

Conclusion

Matabeleland South province has set precedence for targeting sub-national malaria elimination in Zimbabwe. This experience may prove useful for national scale up. There is need to improve surveillance, foci response and intensification of activities to halt residual malaria transmission in Beitbridge District.

Projecting environmental suitable areas for malaria transmission in China under climate change scenarios

INTRODUCTION

The proportion of imported malaria cases in China has increased over recent years, and has presented challenges for the malaria elimination program in China. However, little is known about the geographic distribution and environmental suitability for malaria transmission under projected climate change scenarios.

METHODS

Using the MaxEnt model based on malaria presence-only records, we produced environmental suitability maps and examined the relative contribution of topographic, demographic, and environmental risk factors for P. vivax and P. falciparum malaria in China.

RESULTS

The MaxEnt model estimated that environmental suitability areas (ESAs) for malaria cover the central, south, southwest, east and northern regions, with a slightly wider range of ESAs extending to the northeast region for P. falciparum. There was spatial agreement between the location of imported cases and area environmentally suitable for malaria transmission. The ESAs of P. vivax and P. falciparum are projected to increase in some parts of southwest, south, central, north and northeast regions in the 2030s, 2050s, and 2080s, by a greater amount for P. falciparum under the RCP8.5 scenario. Temperature and NDVI values were the most influential in defining the ESAs for P. vivax, and temperature and precipitation the most influential for P. falciparum malaria.

CONCLUSION

This study estimated that the ESA for malaria transmission in China will increase with climate change and highlights the potential establishment of further local transmission. This model should be used to support malaria control by targeting areas where interventions on malaria transmission need to be enhanced.

Mapping transmission foci to eliminate malaria in the People's Republic of China, 2010-2015: a retrospective analysis

BACKGROUND

China has initiated the National Malaria Elimination Action Plan, which aims to eliminate malaria by 2020. However, the transmission of malaria occurs sporadically or in distinct foci, which greatly hampers progress toward elimination in China and other countries. The object of this study was to foci categorization and evaluates whether the response met the requirements issued by the nation or WHO.

METHODS

Residual transmissions were investigated and located with fine spatial resolution mapping from parasitological confirmed malaria cases by use of routine national surveillance data. The "1-3-7" timeframes were monitored for each focus between 2012 and 2015. Each focus was identified, and the application of appropriate measures was evaluated.

RESULTS

A total of 5996 indigenous cases were recorded between 2010 and 2015; during this period, the number of cases declined by 99.1% (2010, n = 4262; 2015, n = 39). Most indigenous cases (92.5%) were reported in Anhui (n = 2326), Yunnan (n = 1373), Henan (n = 930), Hubei (n = 459), and Guizhou (n = 458). The temporal distribution showed that the indigenous malaria cases were clustered during the period of May to August. A total of 320 foci were carefully investigated and analyzed: 24 were active foci; 72, residual non-active foci; and 224 cleared-up foci. For the foci response evaluation, all the active foci were investigated within 7 days, while 80.2% of the residual non-active foci were responded within 7 days. In addition, reactive case detection (RACD) was carried out with 92.9% of the active foci and vector investigation carried out with 75%. For residual non-active foci, RACD was carried out with 83.2% and vector investigation with 78.2% of the foci.

CONCLUSIONS

This study used nationwide data to categorize foci in China and evaluate the response of these areas during the control and elimination phases. Our approach stratifies future control responses by identifying those locations where the elimination of endemic transmission is needed, such as in the counties at the China-Myanmar border and in Tibet. In addition, this study will help local CDC staff to reassess their needs and responses against different types of foci during the elimination and post-elimination phases.

ASGDB: a specialised genomic resource for interpreting Anopheles sinensis insecticide resistance

BACKGROUND

Anopheles sinensis is an important malaria vector in Southeast Asia. The widespread emergence of insecticide resistance in this mosquito species poses a serious threat to the efficacy of malaria control measures, particularly in China. Recently, the whole-genome sequencing and de novo assembly of An. sinensis (China strain) has been finished. A series of insecticide-resistant studies in An. sinensis have also been reported. There is a growing need to integrate these valuable data to provide a comprehensive database for further studies on insecticide-resistant management of An. sinensis.

RESULTS

A bioinformatics database named An. sinensis genome database (ASGDB) was built. In addition to being a searchable database of published An. sinensis genome sequences and annotation, ASGDB provides in-depth analytical platforms for further understanding of the genomic and genetic data, including visualization of genomic data, orthologous relationship analysis, GO analysis, pathway analysis, expression analysis and resistance-related gene analysis. Moreover, ASGDB provides a panoramic view of insecticide resistance studies in An. sinensis in China. In total, 551 insecticide-resistant phenotypic and genotypic reports on An. sinensis distributed in Chinese malaria-endemic areas since the mid-1980s have been collected, manually edited in the same format and integrated into OpenLayers map-based interface, which allows the international community to assess and exploit the high volume of scattered data much easier. The database has been given the URL: http://www.asgdb.org /.

CONCLUSIONS

ASGDB was built to help users mine data from the genome sequence of An. sinensis easily and effectively, especially with its advantages in insecticide resistance surveillance and control.

Receptivity to malaria in the China-Myanmar border in Yingjiang County, Yunnan Province, China

Background

The re-establishment of malaria has become an important public health issue in and out of China, and receptivity to this disease is key to its re-emergence. Yingjiang is one of the few counties with locally acquired malaria cases in the China–Myanmar border in China. This study aimed to understand receptivity to malaria in Yingjiang County, China, from June to October 2016.

Methods

Light-traps were employed to capture the mosquitoes in 17 villages in eight towns which were categorized into four elevation levels: level 1, 0–599 m; level 2, 600–1199 m; level 3, 1200–1799 m; and level 4, > 1800 m. Species richness, diversity, dominance and evenness were used to picture the community structure. Similarity in species composition was compared between different elevation levels. Data of seasonal abundance of mosquitoes, human biting rate, density of light-trap-captured adult mosquitoes and larvae, parous rate, and height distribution (density) of Anopheles minimus and Anopheles sinensis were collected in two towns (Na Bang and Ping Yuan) each month from June to October, 2016.

Results

Over the study period, 10,053 Anopheles mosquitoes were collected from the eight towns, and 15 Anopheles species were identified, the most-common of which were An. sinensis (75.4%), Anopheles kunmingensis (15.6%), and An. minimus (3.5%). Anopheles minimus was the major malaria vector in low-elevation areas (< 600 m, i.e., Na Bang town), and An. sinensis in medium-elevation areas (600–1200 m, i.e., Ping Yuan town). In Na Bang, the peak human-biting rate of An. minimus at the inner and outer sites of the village occurred in June and August 2016, with 5/bait/night and 15/bait/night, respectively. In Ping Yuan, the peak human-biting rate of An. sinensis was in August, with 9/bait/night at the inner site and 21/bait/night at the outer site. The two towns exhibited seasonal abundance with high density of the two adult vectors: The peak density of An. minimus was in June and that of An. sinensis was in August. Meanwhile, the peak larval density of An. minimus was in July, but that of An. sinensis decreased during the investigation season; the slightly acidic water suited the growth of these vectors. The parous rates of An. sinensis and An. minimus were 90.46 and 93.33%, respectively.

Conclusions

The Anopheles community was spread across different elevation levels. Its structure was complex and stable during the entire epidemic season in low-elevation areas at the border. The high human-biting rates, adult and larval densities, and parous rates of the two Anopheles vectors reveal an exceedingly high receptivity to malaria in the China–Myanmar border in Yingjiang County.

malERA: An updated research agenda for combination interventions and modelling in malaria elimination and eradication

This paper summarises key advances and priorities since the 2011 presentation of the Malaria Eradication Research Agenda (malERA), with a focus on the combinations of intervention tools and strategies for elimination and their evaluation using modelling approaches. With an increasing number of countries embarking on malaria elimination programmes, national and local decisions to select combinations of tools and deployment strategies directed at malaria elimination must address rapidly changing transmission patterns across diverse geographic areas. However, not all of these approaches can be systematically evaluated in the field. Thus, there is potential for modelling to investigate appropriate 'packages' of combined interventions that include various forms of vector control, case management, surveillance, and population-based approaches for different settings, particularly at lower transmission levels. Modelling can help prioritise which intervention packages should be tested in field studies, suggest which intervention package should be used at a particular level or stratum of transmission intensity, estimate the risk of resurgence when scaling down specific interventions after local transmission is interrupted, and evaluate the risk and impact of parasite drug resistance and vector insecticide resistance. However, modelling intervention package deployment against a heterogeneous transmission background is a challenge. Further validation of malaria models should be pursued through an iterative process, whereby field data collected with the deployment of intervention packages is used to refine models and make them progressively more relevant for assessing and predicting elimination outcomes.

Malaria in the Guangxi Zhuang Autonomous Region in China: A Twelve-Year Surveillance Data Study

The incidence of an indigenous malaria, defined as malaria acquired by a local mosquito transmission, declined from 2004 to 2015 in the Guangxi Zhuang Autonomous Region. However, imported malaria, defined as malaria acquired from other endemic regions outside of China, has been increasing in the region, as in the rest of the country, particularly the disease caused by Plasmodium falciparum. A retrospective study was conducted to explore malaria-endemic characteristics in Guangxi during the 2004-2015 timeframe; a total of 2,726 confirmed malaria cases were reported, and the majority (90.3%) were due to P. falciparum (N = 1,697 [62.2%]) and Plasmodium vivax (N = 765 [28.1%]). Thirty-four indigenous cases (1.2%) were observed, with no cases of transmission recorded since 2012. Imported P. vivax and Plasmodium ovale infections increased since 2013. The interval between returning to China and the onset of illness was longer for P. vivax and P. ovale infections than for P. falciparum and Plasmodium malariae infections. The difference interval among the species is likely because of the relapse of P. vivax and P. ovale caused by the activation of the latent hypnozoites. Therefore, health clinics should raise awareness and carry out epidemiological studies and follow-up surveys on migrant workers to avoid misdiagnosis and mistreatment. The evaluation of radical treatment should be carried out using a genotyping technology based on glucose-6-phosphate dehydrogenase deficiency levels, and some new drugs active against the hypnozoites should be developed to mitigate malaria in the region.

Spatiotemporal Analysis of the Malaria Epidemic in Mainland China, 2004-2014

The purpose of this study is to characterize spatiotemporal heterogeneities in malaria distribution at a provincial level and investigate the association between malaria incidence and climate factors from 2004 to 2014 in China to inform current malaria control efforts. National malaria incidence peaked (4.6/100,000) in 2006 and decreased to a very low level (0.21/100,000) in 2014, and the proportion of imported cases increased from 16.2% in 2004 to 98.2% in 2014. Statistical analyses of global and local spatial autocorrelations and purely spatial scan statistics revealed that malaria was localized in Hainan, Anhui, and Yunnan during 2004-2009 and then gradually shifted and clustered in Yunnan after 2010. Purely temporal clusters shortened to less than 5 months during 2012-2014. The two most likely clusters detected using spatiotemporal analysis occurred in Anhui between July 2005 and November 2007 and Yunnan between January 2010 and June 2012. Correlation coefficients for the association between malaria incidence and climate factors sharply decreased after 2010, and there were zero-month lag effects for climate factors during 2010-2014. Overall, the spatiotemporal distribution of malaria in China changed from relatively scattered (2004-2009) to relatively clustered (2010-2014). As the proportion of imported cases increased, the effect of climate factors on malaria incidence has gradually become weaker since 2011. Therefore, new warning systems should be applied to monitor resurgence and outbreaks of malaria in mainland China, and quarantine at borders should be reinforced to control the increasingly trend of imported malaria cases.

Piloting a programme tool to evaluate malaria case investigation and reactive case detection activities: results from 3 settings in the Asia Pacific

BACKGROUND

Case investigation and reactive case detection (RACD) activities are widely-used in low transmission settings to determine the suspected origin of infection and identify and treat malaria infections nearby to the index patient household. Case investigation and RACD activities are time and resource intensive, include methodologies that vary across eliminating settings, and have no standardized metrics or tools available to monitor and evaluate them.

METHODS

In response to this gap, a simple programme tool was developed for monitoring and evaluating (M&E) RACD activities and piloted by national malaria programmes. During the development phase, four modules of the RACD M&E tool were created to assess and evaluate key case investigation and RACD activities and costs. A pilot phase was then carried out by programme implementers between 2013 and 2015, during which malaria surveillance teams in three different settings (China, Indonesia, Thailand) piloted the tool over a period of 3 months each. This study describes summary results of the pilots and feasibility and impact of the tool on programmes.

RESULTS

All three study areas implemented the RACD M&E tool modules, and pilot users reported the tool and evaluation process were helpful to identify gaps in RACD programme activities. In the 45 health facilities evaluated, 71.8% (97/135; min 35.3-max 100.0%) of the proper notification and reporting forms and 20.0% (27/135; min 0.0-max 100.0%) of standard operating procedures (SOPs) were available to support malaria elimination activities. The tool highlighted gaps in reporting key data indicators on the completeness for malaria case reporting (98.8%; min 93.3-max 100.0%), case investigations (65.6%; min 61.8-max 78.4%) and RACD activities (70.0%; min 64.7-max 100.0%). Evaluation of the SOPs showed that knowledge and practices of malaria personnel varied within and between study areas. Average monthly costs for conducting case investigation and RACD activities showed variation between study areas (min USD $844.80-max USD $2038.00) for the malaria personnel, commodities, services and other costs required to carry out the activities.

CONCLUSION

The RACD M&E tool was implemented in the three pilot areas, identifying key gaps that led to impacts on programme decision making. Study findings support the need for routine M&E of malaria case reporting, case investigation and RACD activities. Scale-up of the RACD M&E tool in malaria-eliminating settings will contribute to improved programme performance to the high level that is required to reach elimination.

Estimation of malaria parasite reservoir coverage using reactive case detection and active community fever screening from census data with rapid diagnostic tests in southern Zambia: a re-sampling approach

Background and methods

In areas where malaria transmission has been suppressed by vector control interventions many malaria control and elimination programmes are actively seeking new interventions to further reduce malaria prevalence, incidence and transmission. Malaria infection prevalence and incidence has been shown to cluster geographically, especially at lower transmission levels, and as such a reactive strategy is frequently used, by which index cases presenting to a passive surveillance system are used to target small areas for testing and treatment, reactive case detection (RCD), or focal drug administration (fDA). This study utilizes geo-located data from a census with parasitological testing with rapid diagnostic tests (RDTs) and treatment-seeking data collection conducted in southern Zambia to estimate the coverage of RCD or fDA in terms of the population and parasite reservoir as well as the operational requirements of such strategies, using a re-sampling algorithm developed exclusively for this purpose. This re-sampling algorithm allows for the specification of several parameters, such that different operational variants of these reactive strategies can be examined, including varying the search radius, screening for fever, or presumptive treatment (fDA).

Results

Results indicate that RCD, fDA and active fever screening followed by RCD, even with search radii over several hundered meters will only yield limited coverage of the RDT positive parasite reservoir during a short period. Long-term use of these strategies may increase this proportion. Reactive strategies detect a higher proportion of the reservoir of infections than random searches, but this effect appears to be greater in areas of low, but not moderate malaria prevalence in southern Zambia.

Discussion

Increases in the sensitivity of RDTs could also affect these results. The number of individuals and households that need to be searched increase rapidly, but approximately linearly with search radius.

Conclusions

Reactive strategies in southern Zambia yield improved identification of the parasite reservoir when targeted to areas with prevalence less than 10%. The operational requirements of delivering reactive strategies routinely are likely to prevent their uptake until prevalence falls far below this level.

Beyond pilotitis: taking digital health interventions to the national level in China and Uganda

BACKGROUND

Innovation theory has focused on the adoption of new products or services by individuals and their market-driven diffusion to the population at large. However, major health sector innovations typically emerge from negotiations between diverse stakeholders who compete to impose or at least prioritise their preferred version of that innovation. Thus, while many digital health interventions have succeeded in terms of adoption by a substantial number of providers and patients, they have generally failed to gain the level of acceptance required for their integration into national health systems that would promote sustainability and population-wide application. The area of innovation considered here relates to a growing number of success stories that have created considerable enthusiasm among donors, international agencies, and governments for the potential role of ICTs in transforming weak national health information systems in middle and low income countries. This article uses a case study approach to consider the assumptions, institutional as well as technical, underlying this enthusiasm and explores possible ways in which outcomes might be improved.

METHODS

Literature review and case study analysis.

RESULTS

The two systems considered have had considerable success in terms of gaining and maintaining government support and addressing the concerns of providers without compromising their core elements. In Uganda, the system has flourished in spite of severe resource constraints, using a participatory approach that has encouraged a high level of community engagement. In China, concern with past failures generated the political will to build a high quality surveillance system, using the latest technology and drawing on a highly skilled human resource base.

CONCLUSIONS

Both example stress the importance of recognising the political, social and historical context within which information systems have to function. Implementers need to focus as much on the perceptions, attitudes and needs of stakeholders as on the technology. Implementers should distinguish between factors which may influence engagement at an institutional level and those aimed at supporting and supervising individuals within those institutions. Finally, we would suggest that designing interoperability into systems at the outset, rather than assuming that this can be achieved at some point in the future, may prove far easier in the longer term.