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The First Forum on Surveillance Response System Leading to Tropical Diseases Elimination

The Report
June16-18, 2012    Shanghai, China

© National Institute of Parasitic Diseases, 2012

This document is not a formal publication of the National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention (NIPD), and all rights are reserved by the Institute. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale or for use in conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

 

1. Introduction
1.1 Background
1.2 General Objective
1.3 Specific Objectives
1.4 Expected outcome
2. Opening Address
2.1 Welcome speech by Dr. Wang Yu, Director General, China CDC, P.R. China
2.2 Opening Remarks by Dr. Michael O'Leary, WHO China Representative
2.3 Introduction speech by Prof. Marcel Tanner, Director, Swiss TPH, Switzerland
2.4 Welcome remark by Dr. Wang Panshi, Deputy Director, the Bureau of Public Health of Shanghai Municipality
2.5 Remark by Dr. Lei Zhenglong, Deputy Director General, Department of Disease Control, Ministry of Health, P.R. China
3. Keynote Speeches–current elimination program
3.1 an integrated Strategy to Control Schistosomiasis japonica in P. R. China, by Dr. Wang Longde, Chairman of Chinese Association of Preventive Medicine, P.R. China
3.2 Sustaining the drive to overcome the global impact of neglected tropical diseases, by Dr. Lester Chitsulo (for Dr. Lorenzo Savioli), Director, Department of Neglected Tropical Diseases, WHO.
3.3 China Malaria Elimination Action Plan (2010-2020), by Dr. Yang Weizhong, Deputy Director General, China CDC.
3.4 Global malaria elimination and research needs, by Prof. Marcel Tanner, Director, Swiss TPH.
4.Parallel Session.
4.1 Malaria.
4.1.1 Dr. Zhou Shuisen: The strategy of malaria elimination surveillance in P.R. China 
4.1.2 Dr. Yang Yaming: Curbing border malaria prevention and control in Yunnan border areas 
4.1.3 Dr. Ernest Tambo: Comparison of health system in malaria elimination between China and Africa
4.1.4 Dr. Hu Ximin: Elimination of falciparum malaria in Hainan province
4.1.5 Dr. Zhang Hongwei (for Xu Bianli): Response to Imported Malaria in Henan Province
4.1.6 Dr. Shen Bo: New strategies for discovering and characterizing pyrethroid-resistance associated genes in mosquitoes
4.2 Schistosomiasis
4.2.1 Dr. Lester Chitsulo (for Dr. Dirk Engels): Schistosomiasis Strategic Plan 2012–2020
4.2.2 Dr. Zhu Rong: The assessment of risk transmission of schistosomiasis in endemic village, China
4.2.3 Dr. Don McManus: Research Challenges and Needs for Control of Zoonotic Schistosomiasis
4.2.4 Dr. Hu Wei: Development of omics-based new diagnostic tools for schistosomiasis
4.2.5 Dr. Wang Tianping: Agriculture practice involved in elimination of schistosomiasis in Anhui province
4.2.6 Dr. Yuan Liping: Surveillance on imported case of schistosomiasis from the Chinese migrant labourers in Africa
4.2.7 Dr. Lu Shaohong: New surveillance-response tool: risk mapping of infected Oncomelania snails detected by Loop-mediated isothermal amplification (LAMP) with pooling samples
4.3 Other communicable diseases
4.3.1 Prof. Sian Griffiths: Challenges in elimination of infectious diseases of poverty
4.3.2 Dr. Cai Li for (Dr. Pan Qichao): Elimination of parasitic diseases in Shanghai municipality 
4.3.3 Prof. Maria Dolores Bargues Castello: Molecular Tools For The Assessment Of Transmission And Epidemiology Patterns In Vector-Borne Parasitic Diseases
4.3.4 Dr. Liu Qin: Vector survey on tick-borne diseases in China
4.3.5 Dr. Lv Shan: Invasive emerging disease: Responses to outbreaks of snail-borned diseases in China 
4.3.6 Dr. Somphou Sayasone: Challenges in schistosomiasis control in Laos: past and current situation
4.3.7 Dr. Zhang Ting: Echinococcosis in Western China
4.4 Diagnostics role in certification of disease elimination
4.4.1 Dr. Robert Bergquist: Needs in diagnostic development for the elimination stage of some tropical diseases
4.4.2 Dr. Xu Jing: Tools to support policy decisions related to treatment strategies and surveillance of schistosomiasis japonica towards elimination
4.4.3 Prof. Banchob Sripa: Diagnostics development in human liver flukes
4.4.4 Prof. Pan Weiqing: Tools to detect residual cases of malaria and schistosomiasis in low endemicity areas
4.5 Innovation Surveillance Tools and data management
4.5.1 Dr. Charles Delacollette: innovation tools in monitoring drug resistance of falciparum malaria in GMR region
4.5.2 Dr. Franziska Bieri: Video-Based health education prevents soil-transmitted helminth infections in Chinese schoolchildren
4.5.3 Dr. Gao Qi: A novel method to visualize LAMP results via microcrystalline wax-dye capsule
4.5.4 Dr. Chen Junhu: High throughput screening platform for discovery malaria molecular used to monitor the antibody variation in elimination stage
4.6 Surveillance and Response System
4.6.1 Dr. Colin Butler: Disease Emergence and Global Change: Thinking Systemically in a Shrinking World
4.6.2 Dr. Yang Guojing: A Google Earth-based surveillance system for schistosomiasis japonica implemented in the lower reaches of the Yangtze River, China
4.6.3 Dr. Edmund Seto: Application of GIS tools in surveillance system of schistosomiasis leading to elimination
4.6.4 Prof. Ji-Ming Liu: Predicting the Prevalence and Diffusion Patterns of Tropical Diseases from Surveillance Data: Needs and Implications
5. Plenary Session: New strategies and tools for elimination
5.1 Surveillance and response: The challenge for new tools and approaches - the case of malaria, by Dr. Laurence Slutsker MD, MPH, Associate Director for Science, Center for Global Health, USA
5.2 Regional strategies and research framework on control and elimination of infectious diseases of poverty. By Dr. Jun Nakagawa, WHO-WPRO, Philippines
5.3 Lessons in the elimination of filariasis in China, by Dr. Wu Weiping, Chief of Department of Filariasis, Leishmaniasis and Echinococcosis, NIPD, China CDC
5.4 Global Challenges and New Tools for the Control of Human Fascioliasis by Prof. Mas-Coma, President, Europe Association of Parasitology, Spain
6. Roundtable Discussion on Elimination Strategy
6.1 Discussion on prospective of China involvement on global efforts. Leading presentation: Needs in global elimination-Africa case study. By Dr. Moussa Sacko, Head of Laboratory of Parasitology, and Coordinator of NTDS Research Program, National Institute for Research in Public Health (INRSP), Mali
6.2 Plan of action for China's possible involvement on any on-going elimination effort to the Region. Leading presentation: China’s experience with control of tropical disease and their potential for other regions by Dr. Zhou Xiaonong, Director, NIPD, China CDC
6.3 Funding Ways and Priorities of National International S&T Cooperation on Infectious Disease by Dr. Li Ruiguo, Executive Deputy Head, International Cooperation Division, National Center of Biotechnology Development (CNCBD), MOST
7. Summary report: by Dr. Zhou Xiaonong, and Marcel Tanner
8. Closing remarks by:
Annex 1
Agenda
Annex 2
Organization Committee
Scientific Committee

 

1. Introduction

1.1 Background

Effective and timely public health responses reflect the ability of a health system to provide reliable and timely information for public health action. The tropical diseases are a group of infectious diseases which primarily affect the poorest sectors of a society in tropical and subtropical areas, especially the rural population and the most disadvantaged urban populations in the developing countries. In addition, more than one billion people in the world suffer from Neglected Tropical Diseases (NTDs), that are also characterized by little attention from policy-makers, lack of priority within health strategies, inadequate research, limited resource allocation and few interventions. The global smallpox and polio eradication programs provide examples of the critical role that surveillance plays in linking surveillance data to targeted, effective public health responses. Thus, the establishment of surveillance-response-system (SRS) is critical for tropical diseases elimination. This forum, in collaboration with the Swiss Tropical and Public Health Institute (Swiss TPH) and the World Health Organization (WHO)  brings together scientists in research, public health and health policy to explore and discuss the surveillance response systems for the elimination of tropical diseases with focus but not limited to malaria, schistosomiasis, filariasis and other NTDs.

1.2 General Objective

The purpose of this forum is to share the knowledge and experience on diseases control and prevention, and to discuss novel approaches towards the establishment of integrated surveillance-response systems that will assist in disease elimination efforts.

1.3 Specific Objectives

  1. Overview the current endemicity of tropical diseases, the current national and international strategies towards elimination, including current status, challenges, feasibility, sustainability, needs (tools) and lessons learnt.
  2. Comparatively assess prevailing strategies and novel approaches required to achieve elimination.
  3. Discuss on how more effective and novel surveillance- response-systems can be established in tailored to the various disease endemic areas.

1.4 Expected outcome

  1. A critically assessment on the potential for disease elimination focusing on P.R. China and its diseases priorities. Discuss on the role of China as a partner in regional and global elimination efforts.
  2. Establish a research and validation agenda for novel tools for diseases elimination focusing on surveillance-response systems/approaches. And develop a work-plan of action targeting low picking fruits intervention in the Region.

2. Opening Address

 2.1 Welcome speech by Dr. Wang Yu, Director General, China CDC, P.R. China

 2.2 Opening Remarks by Dr. Michael O'Leary, WHO China Representative

 2.3 Introduction speech by Prof. Marcel Tanner, Director, Swiss TPH, Switzerland

 2.4 Welcome remark by Dr. Wang Panshi, Deputy Director, the Bureau of Public Health of Shanghai Municipality

2.5 Remark by Dr. Lei Zhenglong, Deputy Director General, Department of Disease Control, Ministry of Health, P.R. China

 

3. Keynote Speeches–current elimination program

3.1 an integrated Strategy to Control Schistosomiasis japonica in P. R. China, by Dr. Wang Longde, Chairman of Chinese Association of Preventive Medicine, P.R. China.

Schistosomaisis has been prevalent in China for more than 2000 years, which evidenced by discovery the eggs of Schistosoma japonicum from a female corpse of Western Han dynasty in 1971 in Changsha. Before 1955, just after the founding of P.R. China, this disease was still highly epidemic in the southern China. Some verses of the poem describe the devastating impact of schistosomiasis: “Hundreds of villages overgrown with weeds and sick people shitting , thousands of desolate house-ghosts singing”. Achievements: in schistosomiasis control. History of Schistosomiasis Control Programme. Lessons:In general, an integrated control strategy was applied in the past time, with the developement of socioeconomic, science and technology in China.

With different focuses: From 1956 to 1984, more focus on snail control; from 1985 to 2002, more focus on morbidity control based on chemotherap with praziquentel. The essential for the adjustment of control strategy in new century. Re-emergence -New features in transmission.Because of flooding, and ecosystem changes: Snail is not able to be eliminated although mollusciciding; Snail spreads widely and its area enlarged. Because of more mobile population, and animal trading: More water contact; More infection and re-infection; Re-emergence of schistosomiasis in transmission controlled counties and transmission interrupted counties (2003)

Objectives and Goal:To understand the epidemiological characteristics of schistosomiasis transmission in the lake region. Put forward to a new control strategy adapting to the new phases of social econocmic develement, with more effectiveness in control programme. Epidemiological features and patterns of schistosomiasis-Ecology study on infected snails. Infection and re-infection in human, Re-infection in buffalo, Epidemic Characteristics.

1. Main contents of new strategy: 1)undertaking health education to deliver the right information to local people; 2) Rebuild lavatory or build biogas pool,to make all toilets in endemic areas reach the requirements of  fecal harmless; 3) Replace bovines with machines, don’t use farm cattle during the course of farm cultivation; 4) Isolate marshland and prohibit grazing or rear domestic animals,all stools from domestic animals are put into Marsh gas pool or disposed with High temperature composting; 5) Stools from fishermen during water work, should be collected with container and make centralized disinfection  and insecticidal treatment , should not be discharged into water; 6) Supported as a subsidy by the government

2.  Formulation of operational manuals and technical guidelines = Replace bovines with machines = Rebuild lavatory  = Isolate marshland and prohibit grazing = the administration of fishermen  faeces

3. Field Assessment-Anhui, Maps of Pilot Study-Jiangxi. Evaluation working plan. Assessment effectiveness of new strategy (2005.5-2008.11,Jinxian)

Innovation of the study: 1)Transmission patterns:High infection and re-infection rate both in human and buffalo ( The re-infection rate reach 68% in buffalo during 10 months), it is the main reason for us to control schistosomiasis difficultly; 2)Transmission featurs:Environmental contamination by eggs from animal faeces is the source for the infection of human and animal, the total number of eggs from buffalo account for  89.8% of eggs from all of animals. Contribution of buffalo for the transmission of schistosomias account for 90%; 3)Formulation of control strategy:It is the first time to put forward the key measures to interrupt the environmental contamination by eggs, as well as the new integrated strategy with emphasis on infectious sources; 4)Assessment of the strategy:Assessment of the strategy was carried out in 26 villages, 6 townships of 4 counties among 4 province, results indicated that the human infection rate reduced to 0-1% after 3 transmission seasons post-intervention.  Both snail infection rate and infection rate in sentinel mouse reduced to 0 after 4 transmission seasons post-intervention. The effectiveness of the strategy is quite stable.

Achievements: 1) The new strategy has been taken action as the national strategy for schistosomiasis control  in the lake region currently; 2) The new strategy was adapted in the “National Medium- and Long-Term Program for Schistosomiasis Control” issued by the State Council; 3) The new strategy was written in the “National Regulation of Schistosomiasis Control” issued by the State Council; 4) The indicators and surveillance methods provided the information for the "National Criteria for Schistosomiasis Control and Elimination (GB 15976-2006)"; 5) The new strategy has been implemented in 90 counties with high endemicity in the lake region.

Publications: Articles: 40 articles were published (A total of 14 articles were published in SCI journals, including some published in New Eengl J Med, Lancet, etc.  The total of impact factors was 111.5,cited by 148 publications;A total of 26 articles were published in national journals, cited by 104 publications)

 

3.2 Sustaining the drive to overcome the global impact of neglected tropical diseases, by Dr. Lester Chitsulo (for Dr. Lorenzo Savioli), Director, Department of Neglected Tropical Diseases, WHO.

What are neglected tropical diseases? 17 diseases these are prevalent in tropical and subtropical areas in Africa, Asia and South America. Mainly affect populations who are living in poverty, in areas where sanitation is lacking and who have close contact with infectious vectors. Diseases for which research and development for treatment lags behind because those affected cannot afford new medicines. Perpetuate poverty because they retard growth, cause chronic morbidity and disability, and generate social stigma. Protozoan infections, Leishmaniasis (visceral, cutaneous and mucocutuneous), Human African trypanosomiasis (sleeping sickness), Chagas disease.

First WHO report focuses on 17 diseases and disease groups Of 149 endemic countries and territories:at least 100 are endemic for 2 or more diseases;30 are endemic for 6 or more diseases.

WHO recommends five public-health strategies for prevention and controls: expansion of preventive chemotherapy; intensified case-detection and case management; improved vector control; appropriate veterinary public-health measures; provision of safe water, sanitation and hygiene. 5 additional countries certified dracunculiasis-free in 2011; 192 countries and territories currently certified free of the disease.143 cases as of April 2012, of which 142 cases from South Sudan (62% decrease compared to 2011).New funding up to 2015.

A roadmap for implementation, January 2012.The NTD roadmap was presented at a meeting on "Uniting to combat neglected tropical diseases - Ending the Neglect and Reaching 2020 Goals" featuring Dr Margaret Chan, Mr Bill Gates and 9 pharmaceutical company CEOs. 

3.3 China Malaria Elimination Action Plan (2010-2020), by Dr. Yang Weizhong, Deputy Director General, China CDC.

Recent Process: Malaria incidence decrease sharply because of the implementation of malaria elimination program and the support of Global Fund.According to the increase of international interaction, malaria imported cases increased fast. Broad involvement and collaboration of multi-department has been strengthened to fight against malaria and achieve malaria elimination goals. Malaria status of China in 2011. Trends of Imported falciparum malaria during 2002—2011.Death caused by malaria. Map of Malaria case death situation.

ObjectivesOverall Goal:By 2015, no locally transmitted malaria cases around China except some border regions of Yunnan province; By2020, to nationally eliminate malaria.

Period objectives:To eliminate malaria in all Type 3 counties by 2015.No locally transmitted malaria case in all counties of Type 2 and Type 1 (except for some border regions of Yunnan province); to achieve elimination of malaria by 2018.Incidence rate drop to 1/10,000 in Type 1 counties of Yunnan border regions by 2015; no locally transmitted malaria case by 2017; to nationally eliminate malaria by 2020.

Strategies and Measures. Strategies: The type 1 counties should strengthen infectious source and vector control measures to reduce the incidence of malaria. The type 2 countries should eliminate the infectious source of malaria to interrupt local malaria transmission. The type 3 counties should enhance the monitoring and disposition of the imported cases to prevent the secondary transmission. The type 4 counties should deal with the imported cases well. The strategies can be adjusted according to the control process and the change of the epidemic. Strengthen the control and management of the infectious source. Strengthen vector control. Strengthen the health education. Strengthen malaria control in the mobile population. Perfect malaria surveillance and testing network. Control strategy against imported malaria Cooperation and collaboration between multi-sectors. Strengthen surveillance at enter and leave the port. Capability building of medical staff -training of treatment ability for clinicians. Health education to populations at high risk.

3.4 Global malaria elimination and research needs, by Prof. Marcel Tanner, Director, Swiss TPH.

Short note on definitions: 1) Eradication: Permanent reduction to zero of the worldwide incidence of infection, as a result of time-bound, deliberate efforts.  Intervention measures are no longer needed once eradication has been achieved; 2)Elimination: Reduction to zero of the incidence of infection in a defined geographical area as a result of deliberate efforts.  Continued measures to prevent re-establishment of transmission are required; 3)Control:Reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts.

Determinants of elimination – GMEP: 1) Political stability and firm political and financial commitment to the elimination; 2) No or only minor dependence on external funding; 3) Good organizational and technical infrastructure together with high quality and competence of personnel, incl. commitment to training; 4) Fully developed and functional general health care services; 5) Enlightened public, understanding and supporting the programme ; 6) Absence of internal and external conflicts; 7) Absence of major uncontrolled population movements; 8) Malaria originally unstable or of low grade intermediate stability;  9) P.vivax addressed and tackled.

Moving from reduction of morbidity and mortality to interruption of transmission; There are two basic ways of reducing transmission; Reduce the reservoir of infection – time a person is infectious; Reduce rate at which infections are spread: Ro  (Less than one new case per existing case); Expansion of the research portfolio to include the other human malarias, P. vivax with the highest priority.

Strengthened focus on P.vivax: In vitro culture and study of hypnozoites; Drugs to be used for mass drug administration to clear infections and provide prophylaxis to prevent new infections; Vaccines that interrupt transmission; New vector control approaches for (i) outdoor biting / resting mosquitoes and (ii) achieving permanent reductions of vectorial capacity in areas where transmission is predominantly due to A. gambiae; New approaches for fast and accurate assessment of transmission at community level and strengthened diagnostic, monitoring, and surveillance tools/approaches that are linked and embedded in the health and social health systems; Tool kits to scientifically assess and determine health system readiness for moving from control to elimination efforts; New approaches in mathematical modelling to inform Target Product Profiles of tools, and predict expected outcomes of intervention strategies; particularly intervention mixes. Classical definition of surveillance: Ongoing systematic collection, analysis, and interpretation of data, usually incidence of cases of disease; WHO GMEP definition: “....surveillance is: aimed at discovery, investigation, and elimination of continuing transmission, the prevention and cure of infection and final substantiation of claimed eradication”; Surveillance – resonse or “surveillance as an intervention” to reduce transmission

Some consequences: 1) As countries approach malaria elimination, monitoring, evaluation (M&E), and surveillance activities will need to shift  from measuring morbidity and mortality to detecting infections and measuring transmission; 2)Higher need for diagnostic tools and strategies; particularly feasible, field-ready tools for the detection of asymptomatic infection and possibly DNA-based and/or serological biomarkers for malaria infection and transmission), 3) New/more effective approaches tracking population dynamics ; 4) Effective field based mapping linked to data bases; 5) Improved measurements of transmission; 6) Improve the feasibility, efficiency, and cost-effectiveness of new health information systems.

Approaches for surveillance: 1) Passive – „collecting for action“ : High(er) endemicity ; Sentinel sites from parasitology to vectors and resistance monitoring; From MaxPD to MinED – particularly link M&E of GFATM; Evaluate ® synthesize ® act/responses ; 2)Active – „searching for action“:Cases detected/reported ® responses; Community surveillance ® responses; 3)Mix and switch: Case studies; Modeling to accompany surveillance, monitoring, & evaluation to make course corrections from endemicity through elimination; From control to elimination; Pacific: Surveillance – Response. Transmission measurement; Surveillance as an intervention: Surveillance-response; Surveillance-response approaches; SMS for life – a surveillance-response system; Even in our HDSS districts - Ifakara, Tanzania; But some HDSS districts do better - Rufiji, Tanzania.

Some consequences for national and global level : Systematically review lessons learned from surveillance-response approaches to determine how it can be tailored to various programmatic settings as part of health systems: Systems-based surveillance response; Update M&E Framework to include transmission reduction, and develop and validate key minimal essential data elements (systematic review / modeling); Develop and use improved diagnostic tools for use in M&E and surveillance, focusing on practical field-ready tools for detection of asymptomatic infection; Assessment of biomarkers to capture transmission; Develop shareable databases for parasite strain information to better track transmission; Develop “RAPopDyn” for accessing and tracking population movements and their dynamics; Develop “RAPMap”: Maps to show probability of a threshold of transmission being exceeded and map with wider range of metrics such as serological and entomological data; Develop health management information systems to monitor malaria infections, facilitate timely local program decisions and responses to reduce transmission.

How effective coverage is lost in health systems: Example of ACTs in Rufiji District, Tanzania in 2006: Malaria Endemic areas – Africa 80s; Success through integrated approaches; Malaria mortality under-5s – Tanzania; Malaria parasite prevalence among children under age five – 2010; Malaria reported case rates (all ages) by district 2011.      “The history of special antimalarial campaigns is chiefly a record of exaggerated expectations followed sooner of later by disappointment and abandonment of the work. This record of failure and disappointed hopes makes it clear that the  only prospect of real progress lies in renewed activity in the continuous study of the disease in all its aspects”. Malaria Commission (1927) Principles and Methods of Antimalarial Measures in Europe. 2nd General Report of the Malaria Commission of the League of nations, Geneva.

4.Parallel Session

4.1 Malaria

4.1.1 Dr. Zhou Shuisen: The strategy of malaria elimination surveillance in P.R. China

China malaria elimination program was launched in 2010, and the corresponding action plan 2010-2020 was issued by Ministry of Health and other 12 ministries and commissions with an overall goal of eliminating malaria in China by 2020.

Therefore, the national malaria surveillance strategy was changed as well from controloriented into elimination-oriented.

The adjustment of National malaria surveillance strategy is to know well timely the transmission and the relative influence factors particularly the distribution of vectors, to estimate the potential risk of transmission, to evaluate the effect, and ultimately to provide more guidance and evidence for the elimination.

The malaria elimination surveillance strategies include two parts, one is national routine surveillance, and the other is sentinel site surveillance. The routine surveillance should be carried out nationwide and includes reports of epidemic situation, investigation and verification of cases, and foci survey. The sentinel surveillance is conducted in 40 sentinel sites.

In the 28 sentinel sites with higher local morbidity, the detection, report and management of cases are mainly conducted, including malaria infection monitoring (blood test and serological test), malaria under reporting evaluation, and malaria vector monitoring.

In the other 12 sites with high imported morbidity, the communication mechanism will be built between CDC and relating departments and the screening test among the population come from malaria endemic areas will be conducted by the sentinel hospital and CDC.

4.1.2 Dr. Yang Yaming: Curbing border malaria prevention and control in Yunnan border areas

I. Review to curb border malaria prevention and control in Yunnan Border areas

Malaria, dengue fever and other tropical diseases are the major infectious diseases in Greater Mekong Subregion region (GMS). These diseases have not become major public health problem in China, Laos, Myanmar, Vietnam, but also focus on prevention and control of diseases in border areas of Yunnan, China.

Mobile population frequent cross-border flows

Yunnan is directly adjacent to the northwest of Laos, Myanmar’s northeastern and northern Vietnam respectively, with 4061km in long border. Countries and the provincial commercial port is 18, and the communication channel is about 643, the average annual number of cross-border population trips is about 14.52 million people, cross-boundary vehicles is about 1.42 million. For example, foreign residents transnational marriage were about 16 000, primary and secondary school students were 3765, workers were about 300 000 in 2011. In addition, the large-scale hydropower construction projects in 2011 and planting projects were more than 30 projects, its border trade was more than 2.9 billion U.S. dollars.

The border of Yunnan and its corresponding outside the malaria epidemic is more serious. A total of malaria cases were reported 22,458 in the period of 2005-2011 in the border areas of Yunnan, however, malaria prevention and control work was conducted only the adjacent offshore border with Yunnan. The investigation of malaria indirect fluorescent antibody (IFAT) was carried out in 2007 in 18 ports of 25 Border counties, and found that IFAT-positive rate in 17,944 cases of immigrants was 4.99%, which Chinese nationals positive rate was 3.2%, foreign was 10.7%. More than 200 cases of malaria infection/ year were reported in workers of Chinese nationality populations in five provinces of northern Laos.

Cross-border control of infectious diseases in border regions as early as the 1990s, Yunnan proceeded to organize the implementation of the program, and has issued “A management program of movement population for malaria control in border areas of Yunnan Province. These laid the foundation for the establishment of a border disease protection barrier. From 2007 to 2011, the sixth round of the Global Fund malaria program for cross-border prevention implemented in 12 counties in the China-Burma border region, the 68 malaria advisory service stations also were established; 50 overseas service stations was established the Myanmar border region outside. The malaria prevention and control was effectively carried out in the border line of 20-30Km ranges. From 2005 to 2011, the Roll Back Malaria / Dengue / AIDS cross-border joint prevention and control pilot project has implemented in 10 border counties in Yunnan. Only 12 malaria / dengue fever overseas sentinel surveillance sites set up, and an monitoring timely found a large number of malaria and dengue fever cases outside, and more than 100 foreign health workers were trained to prevent and control malaria and dengue fever. The above activities, one to the forefront of the province of malaria prevention and control, goes on a 20-30Km to the Burmese border, another to the 68 malaria consulting service stations strengthens the input of the barrier of the protective disease in our province. A significant reduction in the outside incidence of malaria has showed up, and fulfilled in reducing the threat of imported malaria on our side.

Sixth round and the tenth round of the Global Fund Malaria cross-border projects currently implemented in the border area. The former is about to end in June 2012, the tenth round of the China-Burma border global fund malaria control project was discontinued in 2013. Both the prevention and control of regional control activities or protective barrier function will be seriously affected because the cost can not meet needs on the important infectious diseases of the border region cross environmental prevention and control. In the border areas of Yunnan Province, the rapid development of the three countries border trade and its tourism industry is urgent to curb border infectious diseases prevention and control work in a timely manner to contain the source of infection at the source, and reduce the input pressure to the territory so as to the border people of health protection.

II. Proposal to curb border malaria prevention and control in border areas of Yunnan

The overall goal:To establish long-term cooperation mechanism on important infectious diseases cross-borderjoint prevention and control, target the elimination of malaria, control its foreign input, and provide protection for the health of the people of border areas.Specific objectives establish a long-term bilateral mechanism of health cooperation, to strengthen an important disease surveillance and prevention,to share bilateral disease outbreak information, toreduce the incidence of diseases in border region.Perfect the early frontier platform function of malaria control, consolidate and expand the achievement of prevention and control, ensure national plan for the elimination of malaria .Establish emergency disposal mechanism of the important disease in border area, preventthe spread of disease or epidemic. Stability of personnel resources, improve the ability of emergency for outbreaks of disease.

III. Main contents: 1. The establishment of the bilateral leadership, health officials and technical personnel of the project coordination and information system 2.The establishment of bilateral health cooperation mechanism for important disease in border area. 3. The consolidation of the existing malaria advisory service station and perfect service functions of advisory service station. 4. The establishment of the rapid response mechanism of emergency for the important infectious disease of Yunnan. 5.Strengthen ability of disease prevention and control in border areas.

4.1.3 Dr. Ernest Tambo: Comparison of health system in malaria elimination between China and Africa

Although, considerable efforts have been achieved in implementing the millennium development and Roll Back malaria initiatives, malaria still remains an importance public health burden in most endemic tropical and sub tropical countries, especially in Sub Saharan Africa, where mostly children under the age of five years old, pregnant women and non immune travelers are the most vulnerable.

The retrospective study aimed at assessing the health system in China and Africa from 1960-2011, and at determining the major challenges and approaches in healthcare system dynamics towards achieving the Global health vision by 2020. Findings from published literature searched with predetermined inclusion criteria showed that Africa health system faces enormous challenges.

Challenges that have been successful tackled by China healthcare system as result of the fundamental transformation of the rural and urban healthcare system provided by China Economic Reforms in 1987, and consolidated health system reforms in 2005. Analysis showed that population centered healthcare increases the average life expectancy in china from 42 to 74.68 (68-90) years old [1960- 2010], with 97% health covered at local levels compared 41 to 51 years old (54-68) with hardly 51%coverage in Africa.

However, it was observed in Africa the indicators are worsened due to lack of integrated intersectorial strategies and translation of national health policy into strategic actions plans/programs which hindered the progress in most infectious diseases elimination and health system development in Africa. Meanwhile, the findings showed that direct comparison of health system and statistics in both continents and across the provinces are complex.

In conclusion, recent political commitment and synergism of Africa leaders towards Pan-African Health Program with the mutual support from international institutions might improve the health system in Sub Sahara Africa, yet unevenly distributed across nations. Importantly, initiatives of implementation of China health system reforms as well as its malaria eradication program as model could certainly bring valuable contributions to Africa health system policy transformation towards achieving the Global malaria eradication campaign.

4.1.4 Dr. Hu Ximin: Elimination of falciparum malaria in Hainan province

Introduction to Hainan province: The population of Hainan province is 8.6 million, the Han nationality accounts for 82.8% of whole population and the national minority accounts for 17.2%. There are 18 cities or counties. Hainan Province located in southern China, 18º10´ to 20º10´N latitude and 108º37´to 111º03´E longitude, is a tropical zone where the climate is warm and the mosquito vectors are active all year round which is quite suitable for the transmission of malaria . Hainan Province was the most severe epidemic area of malaria in China.

Malaria control measures:

1) Blood examination for patients who have a fever
2) Prompt effective anti-malarial treatment for malaria cases
3) High risk group taking medicine prophylactically
4) The control of malaria vector
5) Timely detection and treatment of malaria focus
6) To establish ten pilot sides for malaria control. Establishing malaria prevention depot in the town where the incidence rate was high and traffic was inconvenient in 10 high incidence rates of malaria cities. Reinforcing management to decrease the incidence of malaria and accumulate experience for malaria control.
7) Health education:Strengthen community-based multi-sector cooperation for malaria control

4.1.5 Dr. Zhang Hongwei (for Xu Bianli): Response to Imported Malaria in Henan Province

There has been serious malaria-endemic situation in Henan province, 13 million malaria cases were reported and malaria incidence was 16.94% in 1970. Malaria incidence was significantly decreased after decades of hard work, 314 malaria cases were found and malaria incidence was 0.33 per hundred thousand in 2011. A new aim of malaria elimination in Year 2020 was made.

With the development of economic and increasing of foreign exchange activities, the numbers of imported malaria cases increased quickly, especially in imported falciparum malaria cases from Africa, Southeast Asia, the Indian subcontinent, South America, the Pacific island countries. It becomes serious threats to people’s health and life, and great challenges to eliminate malaria in Henan province.

1. Situation of imported malaria

1.1 Characteristics of imported malaria: a) Continuing escalating trend: The number of imported malaria cases has significant increased since 2008, and the number of falciparum malaria cases accounted for more than 80 percent of all the imported malaria cases. 24 imported malaria cases were reported in 2008, and were 167 % of that in 2007(9 cases). There were 32, 88 and 146 imported malaria cases were found in 2009-2011 respectively. b) All four plasmodium were found: Total of 146 imported malaria cases were found in 2011. 111 cases were imported falciparum malaria. 30 cases were imported vivax malaria. Each of 3 cases was malariae malaria and ovale malaria. c) Critical patients’ increase: Severe falciparum malaria is increasing, accounted for about 10-20% of total falciparum malaria. 111 cases were imported falciparum malaria, 2 of which died.

1.2 Feature of patients: a) Main patients come back from malaria-endemic area, especially from Africa, Southeast Asia: Among 146 imported malaria cases in 2011, 113 (79.58%) were from Africa, 28 (19.72%) were from Southeast Asia. 84.62% (55/65) patients returned from Africa in 2012. 15.38%(10/65) were from Southeast Asia. b) Main patients engaged in construction, road construction, mining and other field operations: 29 (43.28%) were farmers and 12(17.91%) were workers in 2012. c) Mostly young men: 25 cases (37.31%) were found in group of 10-34 years old; 40 cases (59.70%) were in group of 35-59 years old. The ratio of male and female was 63: 2.

1.3 Characteristics of diagnosis: a) First diagnosis in local medical care, confirmed at provincial and city level: All 65 patients were confirmed by blood smear examination. 3(4.6%)were confirmed at township and below level, 14(21.54%) at county level, 20(30.77%) at city level and 28(43.08%) at provincial level. 61(93.85%) were confirmed in Henan province. 4(6.15%) were confirmed in other provinces where they lived there. b) 83% patients conformed by Center for Disease Control and Imported Malaria Treatment Center: 32(49.23%) were confirmed by Centers for Disease Control and Prevention at different level, 22(33.85%) were confirmed by Imported Malaria Treatment Center of Henan province. c) Half of the patients were conformed more than 3 days: The longest time from upset to confirm is 50 days, average 7 days from Jan to May in 2012. 28(43.08%) were confirmed within 3 days, and 24(36.92%) were confirmed in 4-7days. One dead patient was confirmed after 16 days.

2. Response to imported malaria

2.1 Improve doctors’ awareness of imported malaria: a) Documents were published by Health Bureau of Henan Province: Issue the medical staff paying more attention to imported malaria, scanning fever patients who come back from malaria endemic areas, especially from Africa, Southeast Asia, the Indian subcontinent, South America, the Pacific island countries. b) A Letter to Doctors Activity: Print and send a letter to doctors, wish them pay more attention to imported malaria. c) A Letter of Commitment Activity: village/private doctors promise that they must pay more attention to residents who come from malaria endemic areas, and transmit patient who is suspected as imported malaria to township hospitals.

2.2 Strengthening the professional and technical training: a) Training on diagnosis and treatment of imported falciparum malaria: Training was held by Health Bureau of Henan Province in September 2011, staffs from medical institute and Centers for Diseases Control and Prevention at city and provincial level were trained to improve diagnosis and treatment of imported falciparum malaria. b) Training on blood smear examination: microscopic technicians from 18 cities, 158 counties were trained to improve blood smear examination for plasmodium. c) Evaluation on ability of blood smear examination: 177 microscopic technicians accepted the test to evaluate the ability of blood smear examination in April 2012. d) Malaria Diagnostic Reference Laboratory: Malaria Diagnostic Reference Laboratory in Henan province was certificated by national level. e) Certification of malaria microscopist( level 1/ expert): Qiuye Yan was certificated expert of malaria microscopist by WHO on March 15, 2010.

2.3 Imported Falciparum Malaria Treatment Center of Henan Province : Imported Falciparum Malaria Treatment Center was set up by Health Bureau of Henan Province on July 8, 2010. Until May 2012, 72 imported falciparum malaria were treated, of which 23(31.9%) were severe malaria, 49 (68.1%) were uncomplicated malaria.

2.4 Health education and promotion to targeted population: a) Malaria Day Activity: All kinds of promotion measures such as propaganda trucks, SMS, banners, propaganda panels, television, network, and so on are carried to give residents knowledge of malaria control and prevention. b) Drama with local features: Two dramas of ‘Come From Africa’( I and II) were written, directed, played by stuffs themselves in Henan Center for Disease Control and Prevention in 2010 and 2011. It told the stories of malaria diagnosis and treatment to peoples who went and came from Africa, issue the residents about the knowledge of malaria control. c) A Letter to Whom Go to Africa, Southeast Asia and Other Malaria Endemic Areas Activity: It gives the message of malaria control to people who will go to malaria endemic areas.

2.5 Exchanges, cooperation and scientific research: a) Workshop of clinical treatment of severe malaria: It was sponsored by the Ministry of Health, hosted by Henan Centers for Disease Control and Prevention (CDC) on May 22, 2012. The key issues of treatment of severe malaria were discussed. During the meeting, experts visited Imported Falciparum Malaria Treatment Center of Henan Province. b) Global Fund for malaria project: Global Fund for malaria project not only gives financial support but also trains the teams for malaria management, diagnosis and treatment, and prevention and control in Henan province. The implementation of the Global Fund for malaria project promotes entering the process of malaria elimination in Henan province. c) Carry out scientific research: Studies on genetic identification, and resistance to antimalaria medicine of plasmodium; Studies on surveillance of vector density, monitoring for insecticide resistance of Anopheles; observation on indicators for severe malaria are carrying.

4.1.6 Dr. Shen Bo: New strategies for discovering and characterizing pyrethroid-resistance associated genes in mosquitoes

Mosquito-borne diseases cause serious mortality and morbidity in humans, and pose significant threats to public health.

Vector control has long been a vital part of the ongoing global strategy for the control of mosquito-associated diseases and insecticide application is the most important component of the control effort. Because of high efficacy, rapid rate of knockdown, and low mammalian toxicity, pyrethroid insecticide is currently being promoted worldwide for indoor spray and bednet impregnation, the main tool for preventing malaria in Africa. The wide use of pyrethroids has resulted in the emergence and spread of resistance in mosquito populations, and lead to recent resurgent of malaria in Africa.

The mechanisms conferring pyrethroid resistance in mosquitoes can conveniently be divided into two major groups: target site insensitivity and metabolic detoxification. Our researches are designed to elucidate the genetic and molecular mechanisms of pyrethroid resistance in mosquitoes, and to develop more accurate and cost-effective resistance detection methods that are applicable to field samples.

Target-site resistance to pyrethroids was also known as knockdown resistance(kdr), resulting from the reduced sensitivity of the sodium channels. Mutations in the sodium channel gene were associate with a kdr phenotype in the mosquitoes. In present study, we selected 6 locations from Jiangsu, Anhui and Shangdu proviences and examined the nucleotide diversity of kdr gene in field mosquito populations. We detected the mutation from leucine to phenylanaline and mutation from leucine to serine at the 1014 site in the Culex mosquito, which indicated that L1014F mutations in the kdr gene may be used as a molecular marker for detecting and monitoring deltamethrin resistance. So, we developed Taqman method using floruscent probes with higher sensitivity and higher specificity to detect the kdr alleles.

Furthermore, deltamethrin resistant strains of Culex were established in insectary to study the metabolic resistance. Culex were selected with synthetic pyrethroid- deltamethrin for 9 generations. The LC50 was increased from 0.040 mg/l to 21.27 mg/l and the resistance index Department of Pathogen Biology, Nanjing medical University. We found that increased deltamethrin resistance was associated with reduced fitness in Culex, which was indicated by decreased fecundity, percentage of pupation and adult emergence rate.

Suppressive subtractive hybridization (SSH) libraries were constructed using deltamethrinsusceptible and resistant strains of Culex. The clones that differentially expressed between two strains were spotted to microarrays. After hybridization with susceptible and resistant RNAs, differently expressed genes (over 3 fold) were identified as resistance associated genes. We identified 15 new genes, 13 of which showed significant sequence homology to known genes, and the others were still unknown. Further functional studies are being conducted to characterize these genes.

In addition, to discover more resistance associated genes, quantitative trait loci (QTL) mapping technique was used to identify the genome regions conferring resistance to pyrethroids. Pyrethroid resistance in Culex is a polygenic trait. F2 segregating populations were established from deltamethrin-sensitive and resistant populations and tested for susceptibility. Parental, F1 and F2 individuals were genotyped using amplified fragment length polymorphism (AFLP). Among 136 applied AFLP primer combinations, 29 primer combinations produced polymorphic fragments linked to resistance phenotype were used for linkage mapping and QTL analysis. These QTL analyses will identify the chromosomal regions conferring resistance to deltamethrin, and determine the contributions of these quantitative trait loci (QTL) to insecticide resistance.

An oligonucleotide microarray was spotted with reported 8 P450 genes and 2 GSTs probes, along with 15 new gene probes identified in our lab. 11 genes were found to be upregulated in resistant strain. After qRT-PCR validation and bivariate analysis, two genes, designated CYP6Z10 and PSMB6,were particularly overexpressed in resistant populations. Consequently, we verified these two candidates in field-collected mosquitoes from six different regions in Shandong province. These results indicated that combination of CYP6Z10 and PSMB6 may be used as molecular marker for field mosquito resistance detection.

4.2 Schistosomiasis

4.2.1 Dr. Lester Chitsulo (for Dr. Dirk Engels): Schistosomiasis Strategic Plan 2012–2020

Lessons learned over the past 30 years: 1) High praziquantel treatment coverage has a massive impact on morbidity and transmission. 2) After a number of years of high coverage with preventive chemotherapy, control interventions can be more focal allowing for continued progress while using less praziquantel. 3) Treatment needs to be complemented with “infection source control” measures (such as sanitation, water supply, hygiene education, and modified agricultural practices) to proceed towards the interruption of transmission

Revising the strategy for schistosomiasis control: 1) Success with morbidity control should be followed by transition phases towards the interruption of transmission. 2) Each country and endemic setting has the option to determine whether to maintain achieved goals or to gradually proceed towards the interruption of transmission; 3) This will need adoption of other components for “infection source control”, including (environmental and chemical) snail control, sanitation, provision of potable water, hygiene education, changes in water resource utilization and agricultural practices, (e.g. PRC, Egypt). 4) These transitions will take variable periods depending on endemic situation and commitment/investment by governments and partners.

Operational components for control: 1) Morbidity control: Large scale chemotherapy, Provision of water and adequate sanitation, Hygiene education. 2) Elimination as a public health problem: Provision of water and adequate sanitation, Hygiene education, Chemotherapy in hot-spots of transmission, Modification of the environment to limit intermediate hosts, Snail control, Modification of agricultural and water use practices; 3) Interruption of transmission: Strengthened surveillance, Schistosomiasis should be a notifiable disease, with follow up to avoid resurgence of transmission

Tools for assessing progress in control Available or requiring further development into field applicable formats (Morbidity control – prevalence of heavy infections): 1) Kato-Katz technique, Antigen detection tests; 2) Elimination as a public health problem: Kato-Katz technique, Hatching test, Antigen and parasite DNA detection tests; 3) Interruption of transmission: Antibody detection tests for humans and reservoir hosts, Tests to detect parasite DNA in snail intermediate hosts.

Schistosomiasis elimination is feasible provided that: 1) All endemic countries scale control interventions, and proceed in a step-wise fashion; 2) Sufficient resources, particularly praziquantel become available; 3) Beyond morbidity control, other operational components become more prominent, and in conjunction with enhanced socio-economic development; 4) Monitoring and surveillance will need to be strengthened to detect all residual foci of transmission.

4.2.2 Dr. Zhu Rong: The assessment of risk transmission of schistosomiasis in endemic village, China

Objective: To conduct in-depth analysis of the epidemic situation, clear the difficulties and response measures of elimination of

schistosomiasis in China, decompose the task of elimination of schistosomiasis to the every township for the rational plans of elimination of schistosomiasis. Materials and Methods: Data collection: (1) to collect the prevenlence of schistosomiasis that was investigated in 80 surveillance sites of whole country in 2005-2010; (2) to collect the report data of endemic situation of three level including the county level, township level and village level in 2008-2010. Analysis: using the prevenlence of schistosomiasis of 80 surveillance sites of whole country in 2005- 2010 to establish the correction calibration standard of serological positive rate, and to get the classification (0,1,2,3) for each village; to calculate the indicators of transmission risk assessment for every village, the comprehensive risk score (R) = risk score of human infection (r1) + risk score of acute schistosomiasis (r2)+ risk score of livestock infection (r3)+ risk score of snail infection (r4). Using hierarchical cluster analysis (HCA) to determine classification standards of the transmission risk of schistosomiasis; according to the classification standards of the transmission risk of schistosomiasis to make the assessment and judgment of th each villages, and put forward the response strategie for the endemic village with different transmission risk. Conclusion: 1. Schistosomiasis control focus on the endemic village with the moderat risk and on the identification of hot spot with infectious snails for improving the snail-killing effect. At the same time, the chemotherapy coverage of the high-risk human groups and the local residents should be strengthen; 2.The issue of the schistosomiasis elimination in China is that livestock infection rate was not significantly reduced and entered a platform; 3. Little gap between the actual human infection rate and the request of calibration standard of elimination will result that the difficulty of achievement of the indicators refer to human infection rate is relatively low in the schistosomiasis elimination process of the next four years.

4.2.3 Dr. Don McManus: Research Challenges and Needs for Control of Zoonotic Schistosomiasis

Zoonotic (Asiatic) schistosomiasis is caused by infection with Schistosoma japonicum and S. mekongi. S. japonicum occurs in the People’s Republic of China, the Philippines, and small pockets in Indonesia, whereas S. mekongi is found along the Mekong River in Cambodia and Lao People’s Democratic Republic (Laos). Despite substantial and largely successful control measures, particularly in China, the disease still persists. The challenge for researchers who aim to improve the diagnosis, management and control of zoonotic schistosomiasis will be to find a way to respond to environmental changes and to the threat of praziquantel resistance. New diagnostic procedures that are simple, rapid, and able to diagnose light infections in humans and animals (such as improved microscopic procedures, simple dipstick tests for antibody/antigen detection and PCR-based assays) need further development, as do new drugs that act effectively on both adult and larval schistosomes, and vaccines that target either the human host or the animal reservoir hosts. Some recent research developments in China and the Philippines along these lines will be discussed. An integrated approach to the management of zoonotic schistosomiasis that offers treatment alongside measures to reduce transmission by snail control (focal mollusciciding and environmental modification), health education and promotion, improved sanitation, and use of viable vaccines, when available, is the key to sustainable long term control of the disease.

4.2.4 Dr. Hu Wei: Development of omics-based new diagnostic tools for schistosomiasis

Schistosomiasis japonica remains one of the public health problems in China. Sensitive diagnosis is crucial for the control and prevention of the disease. The traditional parasitological method stands as the gold standard for diagnosis of the disease; however, it is difficult to be applied in large scale in the field survey because of its labor-intensive, time-consuming and low-sensitive drawbacks. Immunological diagnostic approaches, which are highly sensitive, specific and feasible, are widely used for screening serological positives in epidemiological survey and surveillance.

Nucleic acid detection is able to directly determine whether the examinee carrying the parasite. Therefore, to identify the antigenic antigens and the released nucleic acids is the key to develop rapid, sensitive and specific diagnostic techniques.

The omics technology provides an advanced way to find the diagnostic antigen and nucleic acid markers. Firstly, the genome and transcriptome information provide a large number of expressed genes and species-specific, high copy genomic sequences. Through the bioinformatics analysis on the genome and transcription data, secreted proteins, highly expressed proteins and membrane proteins with the potential for diagnostic purpose could be searched, as well as the species specific and high copy number of DNA fragments.

Secondly, the genome and transcriptome provides a large number of protein-coding genes, which made it possible to identify new diagnostic antigens by the proteomic methods. The secreted proteins, tegument proteins and the worm intestinal proteins revealed from theproteomics study may provide a new source of diagnostic antigens. In addition, the immune proteomics technology can directly access the antigens recognized by patient sera. On the other hand, the omics techniques create new opportunities for identification of circulatingantigens. The circulating antigen molecules can be isolated by immunoprecipitation with patient sera, and identified by mass spectrometry and bioinformatics analysis.

Through the omics studies, we have found some promising target antigens, among them one recombinant protein was use to develop a colloidal-gold immuno-chromatography assay (GICA) strip to detect the specific antibody induced by schistosome infection. The GICA showed similar sensitivity and higher specificity when compared with the other diagnostic systems reported using the crude antigens of worm source. The use of recombinant antigen for the diagnostic approach has the advantages in quality control and product standardization, and in reducing the cost, of which the worm source antigens has been soaring in recent years. Therefore, the recombinant reagent may be popularized in the field use instead of worm source reagents. Meantime, the new nucleic acid markers found from genome sequences showed potential value in early diagnosis and evaluation of chemotherapy.

It is believed that the omics studies may provide new and efficient ways to develop new diagnostic tools.

4.2.5 Dr. Wang Tianping: Agriculture practice involved in elimination of schistosomiasis in Anhui province

1. Livestock infection source control  measures:livestock chemotherapy; replacing bovine with machine; raising livestock in pens; forbidden depasturing livestock on the marshland with snails

2. Agricultural engineering measures to control snails: turning paddy fields into dry land; digging ponds to breed fish in snail areas; hardening irrigation ditches with snails
3. Agricultural measures combined with  the construction of new socialist countryside: supplying safety water: digging wells, building  water plants, etc; improving sanitary toilets in rural areas; building household biogas pools  in countryside
   For the reasons mentioned above, replacing bovine with machine to plough is a very effective measure for schistosomiasis control, and at the same time, it can improve the efficiency of agricultural production.
Table 3  General situation of schistosomiasis in Anhui
By the end of 2010, among 50 endemic counties: 17 had reached the status of transmission interruption; 7 had reached the status of transmission control; 26 had reached the status of epidemic control
Talbe 8  The implementation of replacing bovine with machine in Anhui from 2009 to 2011

Comparison between 2008 and 2011
number of cases  decreased from 36812 to 30571, reduced by 16.95%
number of acute cases decreased from 19 to 2, reduced by 89.47%
infection rate of human decreased from 0.54% to 0.44%, reduced by 18.52%
density of infected snail decreased from 0.0006/0.1m2 to 0.0003/0.1m2 , reduced by 50.00%

4.2.6 Dr. Yuan Liping: Surveillance on imported case of schistosomiasis from the Chinese migrant labourers in Africa

S. haematobium and S. mansoni are not present in China but S. japonicum is highly endemic. However, since 2007, Hunan Institute of Parasitic Diseases admitted 184 subjects for the treatment of S. haematobium. The medical records of these 184 cases were analyzed and the results showed that all subjects used to be migrant labourers in different African countries where there are known S. haematobium and S. mansoni transmission. In 2011, a follow-up study was undertaken in one state-owned enterprise based in Xi’an, Shanxi Province, which is not endemic for schistosomiasis. The findings show that 340 people had signs and symptoms, and 121 persons (7.22%) out of 1,709 surveyed employees are suspected to be infected with S. haematobium or S. mansoni. Questionnaire survey shows they had never heard about schistosomiasis before the finding of the first cases in 2005, and had no knowledge about its mode of transmission. They frequently contacted local fresh water during both occupational and leisure activities. Common early symptoms of S. haematobium infection, including dysuria, pollakisuria and hematuria, are similar to the signs and symptoms of sexually transmitted diseases (STD). Interview of some labourers indicated that these symptoms occurred in some subjects who thought they had contracted a STD and were treated for STD.

Currently, it is estimated that over one million Chinese migrant labourers work in African countries where there is high prevalence of schistosomiasis. We hypothesize, that a large number of cases have not been identified or have been misdiagnosed. The existence of schistosomiasis in African countries and its public health significance are ignored by overseas construction companies. There is an urgent need to assess and quantify the schistosome prevalence and the demographic, environmental and transmission modes on health outcomes associated with the workplaces of the large migrant population involved in extensive construction programs in African countries, and to develop standard methods in China for the definitive diagnosis and treatment of S. haematobium and S. mansoni.

4.2.7 Dr. Lu Shaohong: New surveillance-response tool: risk mapping of infected Oncomelania snails detected by Loop-mediated isothermal amplification (LAMP) with pooling samples

Background: In spite of schistosomiasis remains a serious health problem worldwide, great achievements on schisotsomiasis control has been gained in P.R.China that the disease has been eliminated in 5 out of 12 endemic provinces. The remained endemic areas are at low endemicity towards elimination. It is necessary to develop a rapid and sensitive method for monitoring the distribution of infected Oncomelania hupensis, the intermediate snail host of S. japincum.

Methods: We developed a loop-mediated isothermal amplification (LAMP) assay targeting 28S rDNA which is a rapid and effective method to detect S. japonicum DNA in O. hupensis. For application in the field, the individual and pool sample detections of field-collected snails were conducted using the established LAMP assay. For pooling sample detection snails were collected from 28 endemic areas, 50 snails from each area were pooled based on the maximum pool size estimation, then crushed together (50 snails) and DNA was extracted from pooled samples for LAMP detection, meanwhile a nested-PCR assay was used to assess the performance of the LAMP assay. The risk map was made using ArcMap based on the infection rate of O. hupensis with S. japonicum detected by LAMP assay.

Results: The detection limit of the LAMP method with these primers was 100 fg of S. japonicum genomic DNA. These primers do not amplify DNA from Paragonimus westermani, Clonorchis sinensis, Toxoplasma gondii and Angiostrongylus cantonensis. The results of individual LAMP detection were consistent with those of microscopic examination of S. japonicum cercariae. Based on the formula of pooling sample detection, the infection rate of O. hupensis of Xima village reached 1.33% while the infection rate of Heini, Hongjia, Yangjiang and Huangshan was 0.67% and both Tuanzhou and Suliao were 0.33%. The rest 21 monitoring field sites of 5 provinces showed negative results. By using the result of pooling infection rates, the risk map for the transmission of schistosomiasis was created which guiding the surveillance-response in the high risk areas.

Conclusions: The LAMP was a rapid, specific, and convenient assay to detect S. japonicum DNA, and easily be adapted as an innovative tool in the surveillance-response system towards schistosomiasis elimination.

4.3 Other communicable diseases

4.3.1 Prof. Sian Griffiths: Challenges in elimination of infectious diseases of poverty

Global Report for Research on Infectious Diseases of Poverty

Infectious diseases of poverty
Why research infectious diseases of poverty? Ten compelling reasons:
Reason #1: Break the vicious cycle of poverty and infectious disease
Examples of roles of research (I)
Examples of roles of research (II)
Reason #2: Forge and escape for the poor and vulnerable(Three Gorges Dam)
Reason #3: Tackle multiple problems
Reason #4: Commute the life sentence
Reason #5: Be prepared – forewarned is forearmed
Reason #6: Reach the hardest to reach
Reason #7: Prevent loss in translation
Reason #8: Identify small changes that can make a big difference
Reason #9: Stay focused on the light at the end of the tunnel
Reason #10: Act quickly on what we know
Ten compelling reasons for research

4.3.2 Dr. Cai Li for (Dr. Pan Qichao): Elimination of parasitic diseases in Shanghai municipality

Agricultural measures for schistosomiasis control: The role of domestic animals in schistosomiasis transmission; Replacing bovine with machine for schistosomiasis control; The epidemic status of schistosomiasis in Anhui; The implementation and effect of replacing bovine with machine in Anhui; The role of domestic animals in schistosomiasis transmission; Replacing bovine with machine for schistosomiasis control;  The epidemic status of schistosomiasis in Anhui; The implementation and effect of replacing bovine with machine in Anhui

1. Livestock infection source control measures: livestock chemotherapy; replacing bovine with machine; raising livestock in pens; forbidden depasturing livestock on the marshland with snails
2. Agricultural engineering measures to control snails: turning paddy fields into dry land; digging ponds to breed fish in snail areas; hardening irrigation ditches with snails
3. Agricultural measures combined with the construction of new socialist countryside: supplying safety water: digging wells, building water plants, etc; improving sanitary toilets in rural areas; building household biogas pools in countryside

There are more than 40 species of mammals have been reported to be reservoirs of S.japonicum, which play an important role in the disease transmission. Cattle and buffalo are the most important reservoir hosts for human schistosomiasis.

 Although goats and sheep are very susceptible, they are usually few in number and cannot contribute much to overall transmission. Horses, donkeys, and mules are also susceptible, but the opportunity for young schistosome to develop into adult worm in these animals are lower than that in cattle and goats.

4.3.3 Prof. Maria Dolores Bargues Castello: Molecular Tools For The Assessment Of Transmission And Epidemiology Patterns In Vector-Borne Parasitic Diseases

Zoonotic and vector-borne are characteristics of transmission and epidemiology shared by most of the parasitic diseases showing emergence or re-emergence nowadays. Such emergence phenomena have partly been related to climate change, given the high dependence of both poiquiloterm invertebrate vectors and parasite larval stages on climatic and environmental characteristics, as well as to anthropogenic modifications of the environment linked to the so-called global change. These zoonotic and vector-borne parasitic diseases are characterized by their complicate transmission ways, involving different domestic and sylvatic animal reservoirs plus different vector species as a consequence of the relatively low specificity of the causal agents of these diseases. American trypanosomiasis or Chagas disease and fascioliasis are good examples of this complexity among insect-borne protozooses and snail-borne helminthiases, respectively. Molecular markers are among the first line tools to appropriately assess the complexity of these diseases, in the way to not only understand transmission and epidemiology in each endemic area, but also for the designing of control strategies and subsequent monitoring and evaluation of campaign results and long term surveillance. Among the very wide spectrum of molecular tools, neutral ribosomal and mitochondrial DNA markers (rDNA, mtDNA) should be highlighted because of offering markers of different assessment characteristics and capacities, and enabling appropriate comparison analyses. Additionally, single nucleotide polymorphism (SNP) haplotyping allows for very deep and detailed studies. These genotyping tools are, moreover, showing their usefulness in the non-stop increasing detection of problems posed by crossbreeding, introgression and hybridisation of both vectors and parasites in overlap areas. Nuclear rDNA appears to correlate with parasite phenotypic characteristics and parasite/vector specificity, whereas mtDNA does not. However, organisms sometimes appear so intermediate that they cannot be ascribed to either one or another species from the phenotypic-systematic point of view and vector specificity may be opposite to the one deduced from the parasite morphotype.

Funded by Project No. SAF2010-20805 of the Ministry of Economy, Madrid, and by Red de Investigación Cooperativa en Enfermedades Tropicales – RICET (Project No. RD06/0021/0017 of RETICS/FEDER), FIS, Ministry of Health, Madrid, Spain

4.3.4 Dr. Liu Qin: Vector survey on tick-borne diseases in China

The ticks are ectoparasites which parasites on the bodies of vertebrates. Ticks are distributed in the world distribution.

According to historical records, there are 203 species of ticks in the world. Far as we know, there are 117 species ticks (2 families and 6 subfamilies 10 genera) in China. Ticks are the vector or storage host for many pathogens. According to statistics, 10% of the ticks may carry pathogens. Tick-borne diseases are the diseases which are transmitted to humans and animals most commonly by tick bites. In certain circumstances, it may cause endemic zoonotic disease after tick bites. Many tick-borne diseases have been confirmed in Chian. For example, the deep forest encephalitis, Lyme disease, human granulocytic anaplasmosis and Babesiosis, etc. Recently, some new tick-borne diseases were reported, such as Leishmania infantum, Colpodella spp.-like Parasite and so on.

Piroplasmosis is the disease which caused by the blood protozoon parasites in the blood cell of the host and which is transmitted by Ixodes ticks. It is the eneral term of Babesia and Theileria family. Piroplasma is often parasites in red blood cells of the host, and some can also be parasitic in the reticuloendothelial cells, which caused the piroplasmosis of human and livestock. piroplasmosis has occurred in many countries and regions in the world. In recent years, human cases of Piroplasmosis reported also increased. Therefore, in the present study, we designed genus-specific primers V4 hypervariable region according to the 18S rRNA genen of piroplasma, and nested PCR detection method was developed subsequently. 745 ticks (6 genera and 13 species) samples were collected from 12 provinces of China (Jiangxi, Guangxi, Jiangsu, Shanghai, Hainan, Fujian, etc) were tested. The results showed that there are seven species were found, including Theileria sp, T.buffeli, T.sergenti, T.Oriental, Babesia vogeli, B.bigemina, Babesia sp. The positive rates are as following, 3.4% (25), 5.1% (38), 0.8% (6), 0.9% (7), 4.2% (31), 0.5% (4) and 0.5% (4). 364 ticks were collected from the bodies of the police dogs from 11 province which are mainly Rhipicephalus sanguineus and the infected parasites are B.vogeli (8.1%). 364 ticks collected from the bodies of cattles are mainly Boophilus microplus and B.annulatus and the infected parasites are Theileria sp (10.4%) and T.buffeli (6.9%). Multiple sequence alignment and Phylogenetic analysis showed that there may be new species of Theileria and Babesia.

4.3.5 Dr. Lv Shan: Invasive emerging disease: Responses to outbreaks of snail-borned diseases in China

Helminthes are characterized by complex life history and thus affected by a series of biological and ecological factors. Many diseases due to helminth infection are emerging in the face of environmental and climate change. Human angiostrongyliasis and fascioliasis are typical cases of emerging parasitic diseases in China. The former is normally endemic in wild rats but recently switch to human due to the abundance of edible invasive snail species. The latter impose huge impact on veterinary health and can be transmitted to humans via consuming raw aquatic vegetables. The emergence of human fascioliasis in mountainous areas probably thanks to abnormal climatic events.

This presentation shows the outbreaks of human angiostrongyliasis and fascioliasis in China and the priorities in research and control of such emerging diseases. I recommend a surveillance system for snail-borne parasitic diseases for response to the potential outbreaks in the areas with high risk.

4.3.6 Dr. Somphou Sayasone: Challenges in schistosomiasis control in Laos: past and current situation

Schistosoma mekongi  was: first described in human in 1957; confirmed an endemic foci in Laos (1967) and Cambodia (1970); recognized as public health problem of community along  the lower Mekong River basin in 1980s: High number of severe cases hospitalized in local health facilities; High number of deaths associated with severe infection. In 1990s, a community-based chemotherapy control was implemented (Laos and Cambodia) with aims: to reduce the morbidity-related infection intensity  and dynamic transmission. Currently, S. mekongi is highly endemic in the low Mekong River Basin (Lao-Cambidian crossed border)

Conclusion: Chemotherapy-based morbidity control for schistosomiasis was successfully implemented in 1990s in Laos; Today, it is re-emerging in the endemic community along the Mekong River. This rapidly re-emerging is due to: interruption of chemotherapy; inadequate sanitation ; lack of access to clean water; continued human water contacts; A large scale of chemotherapy must be reviewed.

4.3.7 Dr. Zhang Ting: Echinococcosis in Western China

Echinococcosis, a parasitic zoonosis, is one of the major infectious diseases worldwide imposing severe threat on the health of humans and animals, and affecting the socioeconomic development.

Cystic echinococcosis (CE) and alveolar echinococcosis (AE), caused by Echinococcus granulosus and E. multilocularis  respectively, are highly prevalent in west China, where CE and AE co-exist in some areas and the disease burden appears to be the highest in the world. In China, there are 344 counties in 23 provinces (or Autonomous Regions) that have reported cases of echinococcosis, including Xinjiang Uygur Autonomous Region, Qinghai province, Sichuan province, Inner Mongolia Autonomous Region, Gansu province, Ningxia Hui Autonomous Region and Tibet Autonomous Region, etc. The prevalence rate is 1.1% in the endemic area, with 66 million people at risk and about 50 million livestock suffering from the disease each year, the economic losses of livestock caused by the disease are more than 30 billion yuan. It is estimated that each year, 18,235 (95% confidence interval 11,900-28,200) new cases of AE occur globally and that most of these cases are concentrated in China (n=16,629; 91%), in addition, China is responsible for 40% of the world’s burden due to CE alone.

In 2007, the central government listed echinococcosis as one of six serious infectious diseases that must receive free treatment. Until now, there still have not obtained the fundamental changes on diagnosis, prevention and treatment of echinococcosis. The current pressing needs for control and prevention of AE and CE are: 1) research and development of novel rapid and sensitive diagnostic tests for humans and animals; 2) development of new drugs for CE and AE; 3) deployment of a transmission-blocking vaccine for canids.

4.4 Diagnostics role in certification of disease elimination

4.4.1 Dr. Robert Bergquist: Needs in diagnostic development for the elimination stage of some tropical diseases

Information regarding the distribution, incidence, prevalence and intensity of various diseases rely on the performance and operational characteristics of the diagnostic techniques applied.  This is particularly apparent for those helminth infections that have been subjected to large-scale control for a long time, and where considerable progress has been achieved. Further progress made towards control and ultimate elimination demands increased sensitivity and specificity, and the lesson learnt from the fields of filariasis and schistosomiasis is that the diagnostic approach must change to satisfy and better reflect the current dominance of lighter burdens of disease in many areas. The evaluation of efficacy and community effectiveness of interventions, verification of local disease elimination and early detection of resurgence depend strongly on the quality of the diagnostic tools used. When moving from morbidity control towards transmission control, which above all calls for highly sensitive assays (for the definitive host), the diminished positive predictive value of the test obstructs further progress and ultimately, the elimination of the infection in question.

Intensity of infection is a key determinant of morbidity, but the relation between egg excretion in stool (or urine or sputum) and severity of disease is complex and research is warranted to put forth new or refined infection intensity classes for the helminthiases. Stool examination for schistosomiasis provides an acceptable measure of the stage of infection in highly endemic areas and it has recently been shown by the Secretariat of the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) in a 5-country field investigation that a urine-based cassette assay targeting the Circulating Cathodic Antigen (CCA) of S. mansoni is fully adequate for the mapping of intestinal schistosomiasis. However, although it was originally hoped that antigen detection would be applicable for the other end of the control spectrum (i.e. in areas of very low endemicity), validation in areas of low endemicity has not lived up to its alleged potential. On the other hand, molecular approaches such as for example the polymerase chain reaction (PCR) or the Loop-Mediated Isothermal Amplification (LAMP), have shown promise both in definitive and intermediate hosts.

Serology and microscopy are complementary, but the integration of serological methods into national control programmes requires the development of accurate, methodologically standardized and easily applicable assays for the detection of both specific antibodies and antigens. This presentation highlights the diagnostic needs with the view to relate them to the stage of control achieved.

4.4.2 Dr. Xu Jing: Tools to support policy decisions related to treatment strategies and surveillance of schistosomiasis japonica towards elimination

Background: Appropriate diagnostics to monitor disease trends and assess the effectiveness and impact of interventions are essential for guiding treatment strategies at different thresholds of schistosomiasis transmission and for certifying elimination. Field validation of these assays is urgently needed before they can be adopted to support policy decisions of the national programme for control and elimination of schistosomiasis in P.R. China. We compared the efficacy and utility of different immunoassays in guiding control strategies and monitoring the endemic status of S. japonicum infections towards elimination.

Methodology/Principal Findings: A cross-sectional survey was conducted in seven villages with different transmission intensities settings to assess the performance and utility of three immunoassays, e.g., an indirect hemagglutination assay (IHA_JX), an enzyme linked immunosorbent assay (ELISA_SZ), and a dot immunogold filtration assay (DIGFA_SH). 6248 individuals aged 6-65 years old who gave consent and supplied their stool and blood samples were included for data analysis. Results showed that ELISA_SZ performed significantly higher sensitivity (95.45%, 95%CI: 92.94-97.97%) than IHA_JX (87.59%, 95%CI: 83.51-91.49%) and DIGFA_SH (79.55%, 95%CI: 74.68-84.41%), especially in subgroups with very low infection intensity. The specificity of ELISA_SZ, IHA_JX, DIGFA_SH in 6-9 years old with occasionally exposure was nearly 90%. DIGFA_SH performed the highest screening efficacy for patients among three assays with overall positive predicative value of 13.07% (95%CI: 11.42-14.72%). We found a positive correlation of antibody positive rate of IHA_JX with results of stool examination in age strata (r=0.70, P<0.001). Seropositivity of IHA_JX in children aged 6-9 years old showed an excellent correlation with prevalence of schistosome infection in the seven communities (r=0.77, P<0.05).

Conclusions/Significance: Studies suggest that ELISA_SZ could be used to guide selective chemotherapy in moderate or low endemic regions. IHA_JX could be used to as a surveillance tool and for certifying elimination of schistosomiasis through monitoring children as a sentinel population.

4.4.3 Prof. Banchob Sripa: Diagnostics development in human liver flukes

Human liver flukes including Clonorchis sinensis, Opisthorchis viverrini and Opisthorchis felineus are important foodborne trematodes in many parts of Eastern/Southeastern Asia and Eastern Europe with over 30 million are infected and 600 million are at risk worldwide.  The infections are associated with several hepatobiliary diseases, i.e. cholangitis, cholelithiasis, hepatomegaly, hepatolithiasis, and the most fatal bile duct cancer, cholangiocarcinoma (CCA). Southeastern and Eastern Asia have been reported the top 10 highest incidence of CCA in the world. Indeed, O. viverrini and C. sinensis have been designated as Group 1 carcinogens by WHO International Agency for Research on Cancer. 

Diagnosis of the liver fluke infection is conventionally made by fecal egg morphology using Kato-Katz thick smears. Particular problems arise in the parasitological diagnosis of trematodes in endemic areas of South-East Asia due to the very similar appearances of the liver fluke eggs and other less common minute intestinal flukes.  In addition, parasitological methods are insensitive in light infection particularly in those areas with parasite control programmes are being implemented. Serodiagnostic tests have been developed for Clonorchis and Opisthorchis infections but most of them are relatively non-specific. Antibody tests using recombinant antigens may be more specific. 

However, all serological tests do not enable differentiation between past and current infection. Coproantigen diagnostic testing by ELISA with monoclonal antibodies raised against secretory antigens of liver flukes have been developed with high specificity.  A monoclonal antibody-based copro-ELISA was found to be more sensitive than conventional faecal examination, particularly in light infections. 

Although data from coproantigen detection is promising, a more simple diagnostic kit is needed for point-of-care application. PCR-based diagnosis using mitochondrial DNA or internal transcribed spacers (ITS1 and ITS2) has frequently been used as a molecular marker for differentiating closely-related food-borne trematode species. However, results undertaken with clinical stool samples have not always been in concordance with results of tests undertaken by standard egg detection.  In addition, LAMP technique has been applied successfully for the detection of these food-borne trematodes, however, false positive tests can occur due to contamination. 

A potential drawback of all PCR-based diagnostic tests is the presence of PCR inhibitors that can reduce sensitivity of the test.  In conclusion, no perfect tests are currently ready for clinical and epidemiologic purposes.  A simple coproantigen detection test using a more sensitive and specific antibody for liver fluke is more potential than the others.

4.4.4 Prof. Pan Weiqing: Tools to detect residual cases of malaria and schistosomiasis in low endemicity areas

The diagnosis of schistosomiasis in low endemicity areas is challenging. In this study, we developed a GST-based high throughput screening methods to screen for molecular markers for serological diagnosis of schistosomiasis in low transmission areas. We constructed and expressed over 200 GST-Sj fusion proteins. These fusion proteins were bound to the immobilized glutathione in the 96-well plate by the interaction of GST and glutathione. A panel of immune sera from schistosomiasis patients infected with S. Japonicum were used for selection of the proteins that gave high immune interaction with the sera. Total 23 proteins were identified, of them a selected secretary protein (named E38) showed the highest sensitivity and interacted with all immune sera detected. Moreover, a E38-based immunodiagonostic ELISA kit was developed for diagnosis of schistosomiasis. A field study was conducted to evaluate its sensitivity and specificity, showing the 95.9% sensitivity comparing to that by the kato-katz stool examination whereas only 2 showed false positive in 174 healthy human serum samples. Moreover, of 1,371 individuals living in the high-endemic area, 394 with negative kato-katz examination showed serological positive interaction. We detected the SjR2 retrotransposons of S. japonicum and  92.4% samples gave the positive results in the 394 individuals with egg negative but sera positive, indicating they were most likely infected with the parasite. This tool has a potential implication in detection of residual cases of schistosomiasis in low endemicity areas.

4.5 Innovation Surveillance Tools and data management

4.5.1 Dr. Charles Delacollette: innovation tools in monitoring drug resistance of falciparum malaria in GMR region

Since decades, WHO has pooled expertise to standardize field methodologies in order to accurately monitor the global and regional situation of malaria parasite resistance to antimalarial medicines and propose remedial measures such as revision of drug policy in a timely basis. In vivo therapeutic efficacy protocols which have technically evolved over time to match specific technical and field concerns and improve quality of data and results have been proposed to national malaria programmes as a routine programmatic tool to be consistently used over space and time. As a result, based on information generated by Member States, WHO has been able to manage and publish an accurate global and regional data base on drug resistance with national experts and researchers willing to perform the same protocol, share their data for quality improvement and ultimately share their results for policy action. In vivo therapeutic efficacy studies remain so far the gold standard tool to generate data and inform decision-makers about potential drug policy change.

In parallel to in vivo tests, various research institutions all over the world have pursued the validation and use of alternative tools to in vivo techniques like in vitro and molecular marker techniques in order to partially or fully address limitations of in vivo procedures (linked to e.g. unknown patients’ immunity level, lack of adherence to treatment, substandard drugs tested, individual absorption differences, 28-day patient follow up, etc.).

In vitro assays for monitoring drug resistant P. falciparum malaria has undergone major innovations and technical improvements in the last 40 years, from the classic morphological assays (WHO microtest system) using microscopy, to radioisotope method using 3H-labelled hypoxanthine, and more recently the enzyme-linked immunosorbent assay (ELISA) with monoclonal antibodies directed against either plasmodium lactate dehydrogenase (LDH) enzyme or histidine-rich protein II (HRP2), and the fluorometric assay with DNA-binding fluorescent dyes (Syber Green®). While each method has its own advantages over the others from a laboratory viewpoint, the major limitation though is the persistent lack of a single, universally accepted standardized protocol to perform in vitro tests e.g. to allow comparison over time and across locations / countries. In addition, whatever the method used, there is no clear correlation between in vitro response (EC50 thresholds) and clinical and parasitological outcomes so confusing the decision to keep or not the drug tested into the national policy.

However, if the same in vitro method with same operating procedures has been used during a sufficient period of time in same locations, results might contribute to assess in vitro response (EC50) trends for each drug tested and when combined with in vivo results and genetic markers can contribute to consolidate the evidence for policy-makers to take action.

Genetic markers linked to fully or partially sensitive or resistant phenotype malaria parasites identified by in vivo or in vitro method are the best tools to identify resistant parasites to specific anti-malaria medicines. Such markers are in existence in particular chromosome locations for some drugs like chloroquine (Pf chloroquine resistant transporter [Pfcrt]), sulfadoxine (dihydropteroate synthase [dhps]], pyrimethamine (dihydrofolate reductase [dhfr]), atovaquone-proguanil (cytochrome b), or even mefloquine (Pfmdr copy numbers). Screening such markers with known primers in a given population will inform the programme about the true prevalence of resistant parasites to specific drugs independently of usual confounding factors such as the host immunity, quality of drug tested, drug adherence and drug absorption, etc. Unfortunately, such markers are not in existence yet for all antimalarial medicines in particular to detect and assess the importance of falciparum resistance to artemisinin derivatives in particular locations in Asia and all over the word. Boosted by the national and international recognition of the increasing problem of parasite tolerance and resistance to artemisinin on the Cambodia-Thailand border, intensive basic research activities have been conducted in the region backed up by internationally recognized research institutions e.g. under the ARC3 project. The malaria genome was fully sequenced in 2002 allowing substantial progress to correlate sensitive, moderate and resistant parasite phenotypes (based on documented parasite clearance time in hours) with several promising genetic modifications but not yet fully understood on chromosome 13. The scientific work is extremely complex in a context where there is still lack of understanding how artemisinin derivatives work. The documented assumption is that ring young forms rather than old forms are the first developing resistant mechanisms to artemisinins which could be partially correct.

WHO recommends the use of artemisinin-based combinations (ACTs) rather than artemisinin monotherapies and other monotherapies with the overall guiding principle that the 2 drugs in combination are fully effective and acting in synergy (different targets on the parasite). So this is important as well to assess the therapeutic efficacy of the partner drug when ACTs are possibly failing (Adequate clinical and parasitological response less than 90%). It is very useful for example to test piperaquine efficacy in case of DHAPIP failure or mefloquine efficacy in case of potential artesunate+mefloquine therapeutic failure.

Last but not least, the engagement of national programmes to carefully monitor the therapeutic efficacy of their first line anti malaria medicines through agreed upon standardized protocols allowing comparison within and outside countries remains a must.

4.5.2 Dr. Franziska Bieri: Video-Based health education prevents soil-transmitted helminth infections in Chinese schoolchildren

Introduction: Over a third of the world’s population is infected with soil-transmitted helminths (STH), mainly in developing Asian, African and Latin American countries. STH are intestinal parasitic nematode worms and comprise the most common of the 13 major neglected tropical diseases (NTDs) causing disabling chronic infections globally.

We examined the effect of a video-based health education package in rural schools in Hunan province, China where soil-transmitted helminth (STH) infections are prevalent and are strongly associated with poor hygiene and inadequate sanitation. The intervention aimed to increase knowledge of STH, induce improved hygiene practice and reduce infection.

Materials and Methods: We undertook a single-blind unmatched cluster randomized intervention trial in 38 schools (N=1718, aged 9-10 years). Schools were randomly assigned to either a health education intervention package that included an educational cartoon video (19 schools) or to a control package (19 schools) where a traditional health education poster only was installed. Infection rates, knowledge and hand washing behavior were assessed at the beginning and at the end of the school year. Albendazole treatment was given to all the participants at baseline and all positive cases at follow-up.

Results: The intervention had a significant impact on all three outcome measures. There was a 50% decrease in incidence of STH (P<0.0001) and a 90% increase in knowledge scores between the intervention and control groups (P<0.0001). The proportion of students washing hands after using the toilet increased by a factor of two in the intervention group (P<0.02). To our knowledge, a 50% reduction in incidence is unprecedented for school-based health educational interventions targeting STH.

The research objectives, study design, and main results will be discussed; and we will show the 12-min animated narrative cartoon video that has been professionally developed within this project.

Conclusion: New control strategies to tackle STH are urgently needed, since current control efforts in form of mass drug administration (MDA) have shown to be unsustainable due to rapid re-infection. The video-based health education package not only proved highly effective in increasing primary school student knowledge but also led to significant behavior change and reduced STH incidence within one school-year. As a result, we advocate incorporating the health education package into the school curriculum in areas endemic for STH in China and beyond.

This work was supported by UBS Optimus Foundation, Zurich, Switzerland

Presenting author:

4.5.3 Dr. Gao Qi: A novel method to visualize LAMP results via microcrystalline wax-dye capsule

In this study, we chose microcrystalline wax and SYBR Green I as the basic materials in order to develop a wax-dye capsule for the establishment of a novel visualized LAMP detection assay, which could avoid the inhibition of LAMP reaction by pre-load SYBR Green I, and minimize the risk of potential aerosol contamination.

Standard thin wall PCR tubes were used, and 25 μl LAMP reaction solution was placed in the bottom section. The fluid level constantly remained below the interface of the tapered bottom section and the straight column body section. This enabled space for insertion of the column-like SYBR Green I contained wax-dye capsule without contacting the reaction solution (Fig. 1A). Following LAMP amplification at 65°C for 60 min, all wax capsules in the tubes still remained intact during the reaction process. All tubes were then heated at 95°C for 5 min, therefore SYBR Green I was released into reaction solution form melting wax capsules. Subsequently, tubes were allowed to cool to room temperature, and a thick white solid layer was observed to have formed above the reaction solution (Fig. 1B). This barrier seals the amplification solution into the bottom of tube. The contamination risk was therefore reduced during and after testing.

Then LAMP results were observed and determined under this blue light. Positive tubes displayed a visible green colour, whereas the negative tubes maintained the orange colour of unbound SYBR Green I. When visible blue light or UV light was used to excite the SYBR Green I, positive tubes showed a higher degree of green fluorescence, and the negative tubes remained orange. However, without using the capsule, when same amount of SYBR Green I was added to the LAMP tube before the reaction, the amplification was completely inhibited (Fig. 1C). And a simple model tool was developed for blue light excitation of SYBR Green I. One 475 nm (visible blue light) LED element was used to replace the bulb of a household flashlight (Fig. 1D). This thumb size portable tool is reusable and the total cost is below US$ 0.5.

This visualized closed-tube LAMP method was established utilising microcrystalline wax-dye capsules, which can deliver highly sensitive DNA fluorescence dye to the reaction mixture following amplification by melting the wax shell through heating to 95°C. This modified visualized LAMP method retains high sensitivity and specificity even using the rapid boiling DNA extraction from dried blood spot (DBS). Furthermore, in order to assess its suitability for use in the field, a total of 200 field samples were tested by this method. Compared to microscopy, considered as the ‘gold’ standard of malaria diagnosis, very high sensitivity and specificity of this modified visualized LAMP method were found, and were in good agreement with a classical P. vivax nested PCR method (Fig. 2). This novel, cheap and quick visualized LAMP method holds promise for malaria diagnosis in resource-limited settings. The procedure offers great potential and merits further and comprehensive field validation before it can become part of routine surveillance-response approaches in China or elsewhere.

Figure 1 Using microcrystalline wax-dye capsule in LAMP detection. (A) Dye contained within a microcrystalline wax capsule; there is no contact between the wax and the LAMP mixture before amplification. (B) After isothermal amplification the capsule remains intact, and the dye was released by melting at 95°C; positive tube shows bright green, negative is orange, while cooling wax turns into solid barrier. (C) The LAMP reaction was monitored by a real-time turbidimeter, amplification and judgment curves of tubes with capsule added are similar to those without capsules, and the addition of SYBR Green I directly to the reaction prior to amplification completely inhibited the reaction. (D) A modified household flashlight with one 475 nm LED, and the result of blue light excitation.

Figure 2 Detection limit of Plasmodium vivax mtDNA LAMP and nested PCR. (A) Agarose gel electrophoresis of LAMP product before (1) and after (2) digestion by Dde I (Fermentas). M: DNA ladder (1 kb Plus, Fermentas). (B) pGEM-PvMito plasmid was 10-fold serially diluted and tested by LAMP, M: DNA ladder, 1: 1.0 × 106, 2: 1.0 × 105, 3: 1.0 × 104, 4: 1.0 × 103, 5: 1.0 × 102, 6: 1.0 × 101, 7: DDW, results were observed by both electrophoresis and under blue light. (C) A P. vivax DBS sample with parasitaemia at 11,000 parasites/μl blood was serially diluted with DDW and tested by LAMP and nested PCR: M: DNA ladder, 1, undiluted, 2: 1:10, 3, 1:100, 4, 1:1,000, 5, 1:10,000; 6, DDW. (D) The same P. vivax DBS sample of (C) was diluted using mixed negative DBS sample and was tested as (C).

4.5.4 Dr. Chen Junhu: High throughput screening platform for discovery malaria molecular used to monitor the antibody variation in elimination stage

To estimate the burden of malarial disease, and evaluate the likely effects of control strategies, requires reliable predictions of malaria transmission intensity. It has long been suggested that antimalarial antibody prevalence could provide a more accurate estimate of transmission intensity than traditional measures such as parasite prevalence or entomological inoculation rates. Completed genome sequences and stage-specific transcriptomes of the intraerythrocytic developmental cycle of Plasmodium vivax offers the opportunity to profile immune responses against P. vivax infection using innovative screening approaches. To detect the immune responses to blood stage-specific proteins, we applied a protein array technology to screen the sera of vivax malaria patients. Herein, a set of genes from the P. vivax blood stage was cloned using the In-Fusion cloning method and expressed by a wheat germ cell-free system. A total of 94 open reading frames (ORFs) were cloned and 89 (95%, 89/94) proteins were expressed, which were screened with sera from P. vivax-infected patients and healthy individuals using protein arrays. A total of 18 (19.1%, 18/94) highly immunoreactive proteins were identified, including 7 well-characterized vivax antigens. In this first report, high-throughput screening assays have been applied to investigate blood stage-specific immunoproteomes from vivax malaria. These methods may be used to discovery malaria molecular with high sensitivity and specificity to monitor the antibody variation in elimination stage.

4.6 Surveillance and Response System

4.6.1 Dr. Colin Butler: Disease Emergence and Global Change: Thinking Systemically in a Shrinking World

Emerging infectious diseases (EIDs) include old diseases with new drug resistance, and formerly included old diseases with new vectorial insecticide resistance. These categories legitimately engender concern, however, most anxiety about EIDs is of genuinely novel conditions, such as HIV/AIDS and SARS. Yet, with the single exception of HIV/AIDS, the burden of morbidity and mortality of novel infections is very low, even trivial, compared to old maladies such as TB, malaria, diarrhoea, lower respiratory tract infections in children and other diseases associated with poverty and undernutrition. The burden of disease of neglected tropical diseases such as hookworm and schistosomiasis is also far higher than novel EIDS (other than HIV/AIDS). Nonetheless, the economic cost to prepare and cope with some novel EIDs despite their apparent low disease burden, most notably SARS and H5N1, is very high, mainly because they are perceived as placing wealthy populations at unaccustomed risk.

More rigour and nuance is needed in the conceptualisation of EIDs. Instead of viewing them as a single category, can criteria be developed to guide the global public health community to distinguish major from minor EID threats? Relatedly, the milieu in which diseases evolve and emerge may be more important than the pathogen. Understanding and modifying the milieu may therefore cost-effectively reduce pandemic risk. Excessive attention to pathogens has contributed to a high opportunity cost, as has excessive attention to many EIDs with a low potential public health burden.

For example, insufficient systemic thinking, including appreciation of evolutionary drivers, has led to excessive focus on 'magic bullets', with adverse consequences for pharmaceuticals, insecticides and agriculture. These include high rates of drug and insecticide resistance and poly-pharmacy. Excessive faith in plants genetically modified to resist insecticides has also stimulated the evolution of insecticide resistant weeds and insects. As a result there has been little transition to upstream, preventative thinking from the curative, acute model (where the bulk of funding remains concentrated)

However, while scepticism about novel EIDs may be warranted, adverse global environmental change (GEC) may indeed predispose humanity to very severe future global public health problems, particularly from “old” diseases. Scarcely recognised as yet, adverse GEC such as climate change, energy scarcity, biofuels and diminishing phosphate reserves are already driving food prices higher, thus undermining nutrition and immunity. The determinants of an adequate public health response are also being eroded, as is now evident in many parts of sub-Saharan Africa.

Improved understanding of the relationships between human-induced changes to the environment, especially agricultural, climatic and energy-related, is fundamental to reduce these interconnected challenges. Upstream, integrated-systems thinking is complex, socioeconomically and politically risky, and difficult to measure, but is where the greatest gains stand to be made, concerning both EIDs and GEC.

 

4.6.2 Dr. Yang Guojing: A Google Earth-based surveillance system for schistosomiasis japonica implemented in the lower reaches of the Yangtze River, China

Due to the success of the national schistosomiasis control programme in China, transmission has been sufficiently reduced in many areas to severely limit identification of areas at risk by conventional snail surveys only. In this study, we imported Google Earth technology and a Global Positioning System (GPS) into the monitoring system for schistosomiasis surveillance of the banks of the Yangtze River in Jiangsu Province, China. A total of 45 sites were selected and the risk was assessed monthly by water exposure of sentinel mice at these sites from May to September in 2009 - 2011.

The results were assembled and broadcast via the Google Earth platform. The intensity of schistosomiasis transmission showed peaks of risk in June and September of 2009, while there was only one small peak in both 2010 and 2011 as the number of detected positive transmission sites dropped dramatically that year thanks to improved mollusciciding. River ports were found to be areas of particular risk, but ferry terminals and other centres of river-related activities were also problematic. The results confirm that the surveillance system can be rapidly updated and easily maintained, which proves the Google Earth approach to be a user-friendly, inexpensive warning system for schistosomiasis risk.

4.6.3 Dr. Edmund Seto: Application of GIS tools in surveillance system of schistosomiasis leading to elimination

The transition from schistosomiasis control to elimination is a current challenge in Sichuan Province, China, where great strides in reducing infection has been made in recent years. 

 The challenge has taught us important lessons on the limitations of existing public health tools that are used for disease control, and their inadequacy for preventing disease reemergence. 

There are urgent needs for (1) better and new forms of diagnostics that are sensitive to low intensityinfection situations, (2) better accounting for parasite reservoirs in the environment and the pathways that exist for parasites to reinfect previously controlled communities, and (3) modern data-driven Geographic Information Systems (GIS) that can assess the risk of reemergence. 

Using data from Sichuan as an example, mathematical modeling resultsillustrate the ability for disease to persist given existing diagnostic tools, and reveal how reservoir hosts make it incredibly difficult to eliminate transmission when environmental factors continue to support infection.  Finally, we suggest a GIS approach using modern data collection protocols and data analytics that may help with the ongoing surveillance and continued control necessary to bring about elimination.

4.6.4 Prof. Ji-Ming Liu: Predicting the Prevalence and Diffusion Patterns of Tropical Diseases from Surveillance Data: Needs and Implications

In the real world, the spread of tropical diseases can be caused and affected by multiple or even hidden factors, making it difficult to timely and accurately predict the impact of disease elimination programs that have been undertaken and the potential disease resurgence and spread that may continue to emerge.

One approach at the moment is to develop and deploy effective surveillance systems (whether traditional or electronic) in an attempt to determine them as timely as possible and thus to enable policy makers to modify and implement strategies for further preventing their transmission. Most of the accumulated surveillance data will be of temporal and spatial nature. That is, we will face a large amount of historical surveillance data in the form of time series, collected and stored by various regional/local medical organizations, which contains temporal, spatial, clinic, and even demographic information.

From an interdisciplinary point of view, we are interested in answering the following important as well as challenging question: Based on the available surveillance data in terms of temporal and spatial forms, how can we help build a more effective surveillance mechanism for monitoring and early detecting the relative prevalence and diffusion patterns of tropical diseases?  What we can note from the existing clustering-based surveillance software systems is that they do not infer the underlying diffusion networks of diseases.

However, such networks can be quite informative and insightful as they characterize how diseases diffuse from one place to another, which would in turn allow public health policy makers and researchers to uncover the hidden key factors such as environment, genetics and ecology and to discover/predict tropical disease transmission patterns/trends.  In this presentation, currently on-going efforts in developing new models and techniques for inferring disease prevalence and diffusion patterns based on surveillance data were reported.

5. Plenary Session: New strategies and tools for elimination

5.1 Surveillance and response: The challenge for new tools and approaches - the case of malaria, by Dr. Laurence Slutsker MD, MPH, Associate Director for Science, Center for Global Health, USA

Surveillance in the context of malaria elimination will needs to shift from measuring reductions in morbidity and mortality to detecting infections (with or without symptoms). The malaria elimination surveillance research and development agenda needs to develop tools and strategies for active and prompt detection of infection. The capacity to assess trends and respond without delay will need to be developed, so that surveillance itself becomes an intervention. Research is needed to develop sensitive field tests that can detect low levels of parasitaemia and/or evidence of recent infection. Examples of recent work on surveillance and response issues in several African countries will be discussed to illustrate approaches in active case detection and case investigations, cell phone reporting and response, and strategies to access mobile populations.

5.2 Regional strategies and research framework on control and elimination of infectious diseases of poverty. By Dr. Jun Nakagawa, WHO-WPRO, Philippines

There still exist substantial programmatic gaps in control and prevention of infectious diseases of poverty.  Neglected tropical diseases (NTDs) continue to cause significant morbidity and mortality.  Most of this burden is felt in developing countries and in the most vulnerable population groups. While many programmes to control and eliminate these diseases have met with considerable success, there is a vital need to consolidate these successes and further reduce the burden of disease, and research questions exist which prevent them functioning in the most effective and efficient way.

Efforts are needed to further expand coverage of interventions, specifically preventive chemotherapy, case management, and transmission control, for NTDs in the Region. Sustained support is critical to further assess the burden of infection and disease and adapt newly developed tools and guidelines to suit the various epidemiological situations and populations at risk. Another important regional focus is ensuring countries and areas can complete interventions to eliminate LF, blinding trachoma, leprosy, schistosomiasis, and yaws and have appropriate surveillance in place to monitor for recrudescence. Finally, increased emphasis on collaboration and partnerships at all levels using an inter-programmatic and inter-sectoral approach is necessary if required outcomes are to be achieved and sustained.

Key challenges facing operational research in infectious diseases of poverty include: capacity building; governance and quality control of research; identifying knowledge gaps including estimation of burden of diseases, development of socioeconomic indicators; resource mobilization; need of development of inter-programmatic, inter-sectoral prevention and control strategies; and linking research, program and policy for evidence-based decision making.  To tackle these challenges, it requires the adoption of a regional approach through sustained collaboration between countries, research institutions, and internal organizations in order to implement evidence-based interventions and use the identified best practices. 

In the Western Pacific Region, WPRO has been developing a series of disease-specific as well as comprehensive regional strategies and frameworks to accelerate the effort of disease control and elimination of infectious diseases of poverty.  Regional Acton Plans on Dengue and Malaria have been endorsed by countries, and Regional Plan for Neglected Tropical Diseases (NTDs) in the Western Pacific (2012-2016) is planned to be endorsed this year.  In addition, WPRO is developing a Regional Research Framework to Strengthen Communicable Diseases Control and Elimination in the Western Pacific.

Among those strategies and frameworks, the WHO Regional Action Plan for NTDs in the Western Pacific (2012-2106) will be the Region's NTD roadmap for the next five years. The purpose of the Regional Action Plan is to link the global NTD roadmap with national plans of action, to monitor national NTD programmes, and to mobilize internal and external resources. The regional goal is to reduce the health and socio-economic impact due to NTDs, especially among vulnerable groups, and eliminate specific NTDs where feasible. 

The purpose of the Regional Research Framework is to support research aimed at strengthening key communicable disease programmes. Given the limited resources available for communicable disease research, the framework aims to improve effective use of these resources through detailing WHO's support Member States and areas through liaising with stakeholders, use of its convening role in harmonizing intersectoral partners, and setting and fulfilling priority research goals.

5.3 Lessons in the elimination of filariasis in China, by Dr. Wu Weiping, Chief of Department of Filariasis, Leishmaniasis and Echinococcosis, NIPD, China CDC

China was one of the most seriously endemic countries of lymphatic filariasis (LF) in the world. LF was endemic in 864 counties/cities in 16 provinces, autonomous regions and municipalities in the mainland China,there were total 30.994 million LF cases in the country before LF control. After foundation of the People’s Republic of China, the Chinese government paid great attention to the control of LF, and gave higher priority to LF control, and systematically organized the implementation of LF investigation, control throughout the country. After 50 years of profound and sustained effort, the goal of eliminating LF was achieved in 2006.The National Report on Elimination of Lymphatic Filariasis in China has been submitted to WHO by Ministry of Health in March 2006.

However in 2007, 1 microfilaremiae case was reported from Changtang administrative village in Guangxi autonomous region, after mass survey in the village, a total of 14 cases and another 3 cases in migrant people work outside was found. The historical record showed that there were 33 cases found in the village. The possible reasons were that the village missed control, surveillance and evaluation procedure.

5.4 Global Challenges and New Tools for the Control of Human Fascioliasis by Prof. Mas-Coma, President, Europe Association of Parasitology, Spain

Fascioliasis is a disease which affects humans and livestock species almost everywhere. This highly pathogenic liver parasitosis is emerging in many countries of Latin America, Europe, Africa and Asia in the last two decades. Throughout its large geographical distribution, fascioliasis is a well-known veterinary problem. Moreover, studies carried out in recent years have shown it to be an important public health problem as well. Human cases have been increasing in the five continents. Recent articles estimate human infection up to several million people, or even higher depending from the hitherto unknown situations in many countries, mainly of Asia and Africa. From 51 countries with human infection counted in 1990, the present situation already includes 81 countries in which human infection has been described. A global analysis of the geographical distribution of human cases shows that the expected correlation between animal and human fascioliasis only appears at a basic level. High prevalences in humans are not related to areas where fascioliasis is a great veterinary problem. Major health problems are known in Andean countries (Bolivia, Peru, Chile, Ecuador), the Caribbean area (Cuba), northern Africa (Egypt), the Near East (Iran and neighbouring countries), western Europe (Portugal, France and Spain), and recently also in South East Asia (Vietnam, Laos). When comparing different human endemic areas, a large diversity of situations and environments appear, including different human endemic/epidemic situations, different human demographies, races, diets, habits, traditions and religions, different domestic and wild mammal reservoir species, different lymnaeid transmitting species, zones in both the Northern and Southern hemispheres, altitudes from –27 m (as besides the Caspian Sea) up to 4,200 m (as in Andean countries), hot and cold weathers, seasonal and yearly constant temperatures, scarce to pronounced annual rainfall, low and high mean annual potential evapotranspiration, and from lack of dry period to lack of wet period through different dryness/humidity rates. Moreover, from the landscape point of view, these areas include from altiplanos to valleys, from islands to mainlands, from natural to artificial irrigations, from lakes to lagoons, from large rivers to small streams, and from permanent to temporal water bodies. When translating all this to disease terms, fascioliasis in human hypo- to hyperendemic areas appears to present, in the different continents, a very wide spectrum of transmission and epidemiological patterns related to the very wide diversity of environments. This transmision and epidemiological heterogeneity constitutes different challenges in the different human endemic and present epidemic areas. Efforts are being made to evaluate how better deal with the control in these areas of different disease characteristics. Strategies include the evaluation of new tools from quick diagnostic up to usefulness for monitoring and evaluation, as well as for long term surveillance, to complement the different control campaign strategies designed specifically for each kind of human fascioliasis pattern.

6. Roundtable Discussion on Elimination Strategy

6.1 Discussion on prospective of China involvement on global efforts. Leading presentation: Needs in global elimination-Africa case study. By Dr. Moussa Sacko, Head of Laboratory of Parasitology, and Coordinator of NTDS Research Program, National Institute for Research in Public Health (INRSP), Mali

In Africa, Neglected Tropical Diseases (NTDs) are major health and socio economic problem. Among the group of NTDs diseases, schistosomiasis both urinary and intestinal is one of the most important parasitic disease and poverty-related health problem in many countries with an estimate of more than 600 million people living in schistosomiasis endemic and more than 200 million being infected  The disease is particularly widespread among the poor populations in less developed countries, who live under conditions that favour transmission and without access to proper health care or effective prevention measures. Eighty five percent of infected people are currently living on the African continent.

During the last 10 year, WHO and its partners have intensively initiated several  activities leading to the control of NTDs. It has been proved that several of the NTDs including schistosomiasis and STH can be controlled through the implementation of Preventive chemotherapy. This strategy has been shown to be effective.  However, the successful of the control towards elimination of schistosomiasis and other neglected tropical diseases  will required an integrated approach including proper scaling up of preventive chemotherapy, monitoring and evaluation, transmission control, strengthening health system, behavior changes, health education, intersectorial collaboration, water and sanitation, capacity building and the experience of other countries (i.e. China) in achieving control of neglected tropical diseases

A number of issues among other were discussed. These include: i) what are the key barriers to scaling up NTDs programmes in Africa, ii) what are the key challenges and obstacles for conducting  integrated sustainable approaches (monitoring and evaluation, transmission, intersectorial collaboration), iii) what are the needs for appropriate capacity building and development of partnership?

6.2 Plan of action for China's possible involvement on any on-going elimination effort to the Region. Leading presentation: China’s experience with control of tropical disease and their potential for other regions by Dr. Zhou Xiaonong, Director, NIPD, China CDC

Tropical disease was one of important infectious diseases affecting the people’s health seriously, with more than 100 pathogens were recorded. Due to great efforts through government leadership, professional guidance and community involvement, its higher burden of disease has been declined significantly with the economic development in China. With the progress on elimination of tropical diseases, for example, lymphatic filariasis has been eliminated in China by 2007 and both malaria and schistosomiasis will be eliminated soon in China, Chinese lessons on the elimination will help other developing countries to achieve the objective of national elimination programme on tropical diseases. 

Taking example of schistosomiasis japonica, which has been prevalent in China over than 2000 years, due to its public-health and socioeconomic importance, schistosomiasis was recognized as one of important infectious diseases and the national schistosomiasis control programme was initiated since 1950s. Great achievements have been gained, 5 out of 12 endemic provinces has reached the criteria of elimination, and 3 provinces has reached the criteria of transmission controlled, and the remained 4 provinces will reach the criteria of transmission controlled by 2015. The lessons of political will, sustained financial and technical support, and an integrated approach readily adapted to different eco-epidemiological settings and fine-tuned over time have been learnt which have substantially reduced the burden of schistosomiasis.

In addition to the integrated control strategy of schistosomiasis developed recently in China which transfers the morbidity control into transmission control, more technical developments in tropical diseases have accelerated the progress of the national control programme significantly, such as novel chemical molluscicides, rapid diagnostics, new development of drugs, as well as new tools to monitor the transmission of tropical diseases. All those control strategy and novel tools/products are ready to be used in the transition phase from control programme into elimination programme in other regions although the various species of pathogens are different in terms of biology and morbidity caused. It is promising for Chinese scientists to work together with local professionals in other region to tailor the Chinese control strategy or experience into local settings, to achieve the goal of transmission control leading to elimination of tropical diseases.

6.3 Funding Ways and Priorities of National International S&T Cooperation on Infectious Disease by Dr. Li Ruiguo, Executive Deputy Head, International Cooperation Division, National Center of Biotechnology Development (CNCBD), MOST

Formulate Principles: Emphasize national orientation; Based on independent innovation; Integrate advantage resource; Breakthrough major S&T problem; Develop key technologies.

Identify Priorities: Basic research: mechanism of infection Product; diagnostic, vaccine and drug; Technology platform

Funding Ways: National Major Scientific and Technological Project on Infectious Disease; National High-tech R&D Program (863 Program); Key Technologies R&D Program; National Key Basic Research Program of China (973 Program); National Natural Science Foundation of China; ISTCP

General Aims: Completely improve the level of infectious disease prevention, diagnostic, treatment and control, perfect the technological support system including comprehensive prevention and control, emergency disposal, and scientific research.

Basic Research: Epidemic characteristics; Pathogenesis; Diagnosis and treatment; Vaccine and drug developmentNew strategy on infectious disease surveillance, early warning, prevention, diagnosis and treatment

Key technologies Research: AIDS, viral hepatitis, tuberculosis and other major infectious diseases; Construction of key technology platform Including: Infectious disease emergency detection platform; diagnosis; monitoring; clinical treatment; early warning; Lab biosafety; Animal model; Vaccine; Key edging technology; Product evaluation.

New emergent infectious disease: Tropical diseases/Parasitic disease; Foot and mouth disease; Other major infectious diseases research.

Product Research and Development: New diagnostic agent and tool; New type of vaccine; Drug: chemical drug; biotechnology drug; TCM

Funding Ways: National Major Project; 863,973,Key technologies Program; ISTCP; International organization (ICGEB; Global Foundation( MOST and Bill Gates ); Others (NNSFC,CAS)

Proposal Review Mechanism: Release of grant call for proposal (MOST or CISTC Website); Submission of Proposals (by organizing unit); Committee meeting for Strategic Expert consultation; Committee meeting for technological Expert  consultation; Submission to the DIC for discussion; Final decision 

Human Health (Basic and applied research in infectious diseases & structural biology); Agriculture ( Biotic and abiotic stress,  plant transformation , insect resistance, biopestcides etc); Technology development and transfer

7. Summary report: by Dr. Zhou Xiaonong, and Marcel Tanner

Participants: More than 100 participants from10 countries/regions: Switzerland, Sweden, USA, Mali, Australia, Thailand, Philippines, Spanish, P.R.Laos, Hong Kong, Taiwan, P.R.China

Overall Objective: Share the knowledge and experience on tropical diseases control and prevention on their way to elimination; Discuss novel approaches towards the establishment of integrated surveillance-response systems that will enable disease elimination efforts. Specific objectives: Review the current endemicity of tropical diseases, (focus on NTDs) the current national and international strategies towards elimination; Comparatively assess prevailing strategies and novel approaches required to achieve elimination; Discuss on how more effective and novel surveillance response approaches / systems can be established in tailored to the various disease endemic areas.

Format - forum with four parts: 1)Keynote addresses; 2)Plenary sessions; 3)Six special group sessions; 4)  Roundtable discussion

1) Keynote addresses: Topic: current elimination program especially on schistosomiasis and malaria. An integrated strategy to control schistosomiasis japonica in P.R.China- Dr. Wang Longde; Sustaining the drive to overcome the global impact of neglected tropical diseases- Dr. Lester Chitsulo; China malaria elimination action plan(2010-2020)-Dr. Yang Weizhong; Global malaria elimination/eradication and research needs-Dr. Marcel Tanner

2) Plenary session: Topic: new strategies and tools for elimination; Surveillance and response: the challenge for new tools and approaches-the case of malaria - Dr. Laurence Slutsker; Regional strategies and research framework on control and elimination of infectious diseases of poverty- Dr. Jun Nakagawa; Lessons in the elimination of filariasis in China- Dr. Wu Weiping; Global challenges and new tools for the control of human Fascioliasis- Prof. Mas-Coma

3) Group sessions (6 sessions): The first day divided by diseases: Group1: Malaria; Group2: Schistosomiasis; Group3: Other communicable diseases. The second day divided by academic fields; Group 4: Diagnostics role in certification of disease elimination; Group 5: Innovation surveillance tools and data management; Group 6: Surveillance and response system

4) Roundtable Discussion: Funding channels in China; Needs from Africa; Chinese engagement in global health

Academic fields covered: 1) Diagnosis: Serological assay, LAMP, proteinomics; 2) Surveillance-response:  Risk mapping, GIS, drug resistance, antibody monitoring, outbreak; 3) Management:  Health system, case management; 4) Strategies:  Integrated strategy, health education

From control to elimination: China: Great achievements on schistosomiasis and malaria control and now read to develop and implement action plans towards elimination; Elimination also considered for other NTDs; trematodes, VL; WHO:  has established roadmap for NTD control and elimination; Consequence:  Move towards surveillance (remaining transmisson, reintroductions) and development of effective surveillance-response systems/approaches tailored to respective setting/situations; Data Collected But Not Used; Data rich but information poor

Responses: System effectiveness decay from efficacy of tools to effectiveness Example of ACTs in Rufiji District, Tanzania in 2006. Great challenges existed to eliminate infectious diseases. Sensitive tools based on molecular method need to be developed and can be used to as surveillance tools for xeno-monitoring or certificate the elimination of tropical diseases.

Classical definition of surveillance: Ongoing systematic collection, analysis, and interpretation of data, usually incidence of cases of disease; WHO GMEP definition: “....surveillance is .. aimed at discovery, investigation, and elimination of continuing transmission, the prevention and cure of infection and final substantiation of claimed eradication”; Surveillance – resonse or “surveillance as an intervention” to reduce transmission; Surveillance-response approaches: Cases studies: Zambia, Zanzibar, Nigeria, Pacific…; Approaches for surveillance – response: Passive – „collecting for action“ ; High(er) endemicity; Sentinel sites from parasitology to vectors and resistance monitoring; From MaxPD to MinED – particularly link M&E of GFATM; Evaluate  synthesize  act/responses; Active – „searching for action“; Cases detected/reported responses; Community surveillance responses; Survey and action: Diagnosis & Treatment combined with e.g. IRS and LLINs; Mix and switch

8. Closing remarks by

Dr. Santiago Mas-Coma, EU Association of Parasitology.

Dr. Michael O'Leary, WHO China Representative.

Dr. Marcel Tanner, Swiss TPH.

Dr. Yang Weizhong, China CDC

Annex 1

Agenda
The First Forum on Surveillance Response System Leading to Tropical Diseases Elimination (Shanghai)
Hope Hotel, Shanghai, P.R. China, 16-17 June, 2012

16 June

Activities

09:00-09:45

Opening Ceremony

Venue: Cheng Gu Hall

Welcome speech by Dr. Wang Yu, Director General, China CDC, PR China.

Opening Remarks by Dr. Michael O'Leary, WHO China Representative.

Introduction speech by Prof. Marcel Tanner, Director, Swiss TPH, Switzerland.

Welcome remark by Dr. Wang Panshi, Deputy Director, the Bureau of Public Health of Shanghai Municipality.

Speech by Dr. Lorenzo Savioli, Director, Department of Neglected Tropical Diseases, WHO.

Remark by Dr. Lei Zheng Long, Deputy Director General, Department of Disease Control, Ministry of Health, P.R. China.

Chaired by Dr. Zhou Xiaonong, Director, National Institute of Parasitic Diseases, China CDC

9:45-10:30

Coffee Break & Group Photo

 

 

 

 

10:30-10:55

 

 

10:55-11:20

 

11:20-11:45

 

11:45-12:15

Keynote speaker  – current elimination program (20min presentation plus 5 min discussion for each)

  • An intergrated Strategy to Control Schistosomiasis japonica in P. R. China, by Dr. Wang Longde, Chairman of Chinese Association of Preventive Medicine, P.R. China.
  • Sustaining the drive to overcome the global impact of neglected tropical diseases, by Dr. Lorenzo Savioli, Director, Department of Neglected Tropical Diseases, WHO.
  •  China Malaria Elimination Action Plan (2010-2020), by Dr. Yang Wei-Zhong, Deputy Director General, China CDC.
  •  Global malaria elimination and research needs, by Prof. Marcel Tanner, Director, Swiss TPH.

Chaired by Dr. Yang Weizhong and Dr. Michael O'Leary

12:15-14:00

Lunch

14:00-17:30

Parallel Session: Capacity of Chinese Institutions with emphasis on elimination of communicable diseases (10 min presentation followed by 5 min discussion)

G1- Malaria:

Venue: Zong Luo Hall

Dr. Zhou Shuisen: The strategy of malaria elimination surveillance in P.R. China.
Dr. Yang Yaming: Curbing border malaria prevention and control in Yunnan border areas.
Dr. Ernest Tambo: Comparison of health system in malaria elimination between China and Africa.
Dr. Hu Ximin: Elimination of falciparum malaria in Hainan province.
Dr. Xu Bianli: Response to Imported Malaria in Henan Province.
Dr. Shen Bo: New strategies for discovering and characterizing pyrethroid-resistance associated genes in mosquitoes.

Chaired by Prof. Gao Qi and Dr. Laurence Slutsker
Panelists: Prof. Marcel Tanner, Prof. Pan Wei-Qing, Dr. Gao Qi, Dr. Laurence Slutsker, Dr. Zhou Shuisen, Dr. Ernest Tambo (Identification of research priorities in surveillance and response systems leading to elimination of malaria )

 

G2- Schistosomiasis:

Venue: Ming Long Hall

Dr. Dirk Engels: Schistosomiasis Strategic Plan 2012–2020.
Dr. Zhu Rong: The assessment of risk transmission of schistosomiasis in endemic village, China.
Dr. Don McManus: Research Challenges and Needs for Control of Zoonotic Schistosomiasis.
Dr. Hu Wei: Development of omics-based new diagnostic tools for schistosomiasis.
Dr. Wang Tianping: Agriculture practice involved in elimination of schistosomiasis in Anhui province.
Dr. Yuan Liping: Surveillance on imported case of schistosomiasis from the Chinese migrant labourers in Africa.
Dr. Lu Shaohong: New surveillance-response tool: risk mapping of infected Oncomelania snails detected by Loop-mediated isothermal amplification (LAMP) with pooling samples.

Chaired by Dr. Chia-Kwung Fan and Dr. Lester Chitsulo
Panelists: Dr. Chia-Kwung Fan, Dr. Lester Chitsulo, Dr. Xu Jing, Dr. Don McManus, Dr. Robert Bergquist, Dr. Wang Tian Ping, Dr. Hu Wei(Identification of research priorities in surveillance and response systems leading to elimination of tropical diseases )

 

G3- Other communicable diseases:
Venue: Chang Gong Hall
Prof. Sian Griffiths: Challenges in elimination of infectious diseases of poverty.
Dr. Pan Qichao: Elimination of parasitic diseases in Shanghai municipality.
Prof. Maria Dolores Bargues Castello: Molecular Tools For The Assessment Of Transmission And Epidemiology Patterns In Vector-Borne Parasitic Diseases.
Dr. Liu Qin: Vector survey on tick-born diseases in China.
Dr. Lv Shan: Invasive emerging disease: Responses to outbreaks of snail-borned diseases in China.
Dr. Somphou Sayasone: Challenges in schistosomiasis control in Laos: past and current situation.
Dr. Zhang Ting: Echinococcosis in Western China.

Chaired by Prof. Jyh-wei Shin and Prof. Sian Griffiths
Panelists: Prof. Jyh-wei Shin, Prof. Sian Griffiths, Dr. Cao Jian-Ping, Dr. Dirk Engels, Dr. Somphou Sayasone, Prof. Maria Castello, Prof. Mas-Comas, Dr. Lv Shan, Dr. Jun Nakagawa (Identification of research priorities in surveillance and response systems leading to elimination of NTDs )

 

18:30-19:30

Welcome Dinner

17 June

Activities

08:30-10:20

Plenary Session: New strategies and tools for elimination (20min presentation followed by 5 min discussion for each)
Venue: Cheng Gu Hall

  • Surveillance and response: The challenge for new tools and approaches - the case of malaria, by Dr. Laurence Slutsker MD, MPH, Associate Director for Science, Center for Global Health, USA.
  • Regional strategies and research framework on control and elimination of infectious diseases of poverty. By Dr. Jun Nakagawa, WHO-WPRO, Philippines
  •  Lessons in the elimination of filariasis in China, by Dr. Wu Weiping, Chief of Department of Filariasis, Leishmaniasis and Echinococcosis, NIPD, China CDC.
  • Global Challenges And New Tools For The Control Of Human Fascioliasis by Prof. Mas-Comas, President, Europe Association of Parasitology, Spain.

Chaired by Prof. Pan Weiqing and Dr. Don McManus

10:20-10:45

Coffee break

10:45-12:15

Parallel Session: Overview of research priorities, 4-5 scientists each group focusing on innovative mechanism with emphasis on tool development targeting verification of elimination followed by discussion and recommendation (10 min presentation followed by 5 min discussion).

G4- Diagnostics role in certification of disease elimination

Venue: Ming Long Hall

Dr. Robert Bergquist: Needs in diagnostic development for the elimination stage of some tropical diseases.
Dr. Xu Jing: Tools to support policy decisions related to treatment strategies and surveillance of schistosomiasis japonica towards elimination.
Prof. Banchob Sripa: Diagnostics development in human liver flukes.
Prof. Pan Weiqing: Tools to detect residual cases of malaria and schistosomiasis in low endemicity areas.
Chaired by Prof. Hu Wei, and Prof. Mas-Coma

G5- Innovation Surveillance Tools and data management
Venue: Zong-Luo Hall

Dr. Charles Delacollette: innovation tools in monitoring drug resistance of falciparum malaria in GMR region.
Dr. Franziska Bieri: Video-Based health education prevents soil-transmitted helminth infections in Chinese schoolchildren.
Dr. Gao Qi: A novel method to visualize LAMP results via microcrystalline wax-dye capsule.
Dr. Chen Junhu: High throughput screening platform for discovery malaria molecular used to monitor the antibody variation in elimination stage.
Chaired by Prof. Su Chuan and Dr. Charles Delacollette

G6- Surveillance and Response System
Venue: Chang Gong Hall
Dr. Colin Butler: Disease Emergence and Global Change: Thinking Systemically in a Shrinking World.
Dr. Yang Guojing: A Google Earth-based surveillance system for schistosomiasis japonica implemented in the lower reaches of the Yangtze River, China.
Dr. Edmund Seto: Application of GIS tools in surveillance system of schistosomiasis leading to elimination.
Prof. Ji-Ming Liu: Predicting the Prevalence and Diffusion Patterns of Tropical Diseases from Surveillance Data: Needs and Implications.

Chaired by Dr. Yang Guojing and Dr. Robert Bergquist

12:15-13:30

Lunch

14:15-15:30

Roundtable Discussion on Elimination Strategy (10 min leading presentation followed by roundtable discussion)

Venue: Cheng Gu Hall

  • Discussion on prospective of China involvement on global efforts. Leading presentation: Needs in global elimination-Africa case study. By Dr. Moussa Sacko, Head of Laboratory of Parasitology, and Coordinator of NTDS Research Program, National Institute for Research in Public Health (INRSP), Mali.
  • Plan of action for China's possible involvement on any on-going elimination effort to the Region. Leading presentation: China’s experience with comprehensive schistosomiasis control strategies and their potential for other regions by Dr. Zhou Xiaonong, Director, NIPD, China CDC.
  • Funding Ways and Priorities of National International S&T Cooperation on Infectious Disease by Dr. Li Ruiguo, Executive Deputy Head, International Cooperation Division, National Center of Biotechnology Development (CNCBD), MOST
    Chaired by Dr. Yu Senhai and Dr. Marcel Tanner

15:30-16:00

Coffee Break

16:00-17:30

Closing ceremony:
Venue: Cheng Gu Hall
Presentations by each chair of G1-6 (10 mins for each)
Summary report: By Dr. Zhou Xiaonong, and Marcel Tanner.
Closing remarks by:
Dr. Santiago Mas-Coma, EU Association of Parasitology.
Dr. Michael O'Leary, WHO China Representative.
Dr. Marcel Tanner, Swiss TPH.
Dr. Yang Weizhong, China CDC.

18:30-19:30

Dinner

 

 

 

Annex 2

Organization Committee

Chairman:
Dr. Wang Yu, Director General, China CDC, Beijing, P.R. China

Vice Chairmen:
Dr. Lei Zheng-Long, Deputy Director General, Department of Disease Control, MOH, Beijing, P.R. China
Dr. Yang Wei-Zhong, Deputy Director General, China CDC, Beijing, P.R. ChinaDr. Marcel Tanner, Director and Professor, Swiss Tropical Public Health Institute, Basel, Switzerland
Dr. Zhou Xiao-Nong, Director and Professor, National Institute of Parasitic Diseases, China CDC, Shanghai, P.R China

Members :

Dr. Michael O'leary, WHO Representative in China, Beijing, P.R. China
Dr. Wang Pan-Shi, Deputy Director General, Shanghai Health Bureau, Shanghai, P.R. China
Dr. Lorenzo Savioli, Director, Department of Neglected Tropical Diseases (NTD), WHO, Geneva, Switzerland
Dr. Shiva Murugasampillay, Global Malaria Program (GMP), WHO, Geneva, Switzerland
Dr. John Ehrenberg, Regional Advisor, Malaria, other Vectorborne and Parasitic Diseases Unit. (MVP), WPRO, WHO, Manila, Philippines
Dr. Sian Griffiths, Dean and Professor, Director of School of Public Health, The Chinese University of Hong Kong, Hong Kong, P.R. China
Dr. Cao Jian-Ping, Deputy Director and Professor, National Institute of Parasitic Diseases, China CDC, Shanghai, P.R. China

Scientific Committee

Co-Chairs
Yang Wei-Zhong, Deputy Director General, China CDC, Beijing, P.R. China
Marcel Tanner, Director and Professor, Swiss Tropical Public Health Institute, Basel, Switzerland
Zhou Xiao-Nong, Director and Professor, National Institute of Parasitic Diseases, China CDC, Shanghai, P.R. China 

Members:
Robert Bergquist, Editor-in-Chief, Geospatial Health, Sweden
Colin D. Butler, Associate Professor, National Centre for Epidemiology and Population Health, Australian National University, canberra, Australia
Cao Jian-Ping, Deputy Director and Professor, National Institute of Parasitic Diseases, China CDC, Shanghai, P.R. China
 Dirk Engels, Department of Neglected Tropical Diseases (NTD), WHO, Geneva, Switzerland
Hu Wei, Professor, Faculty of Life Science, Fudan University, Shanghai, P.R. China
Jiang Qing-Wu, Dean, School of Public Health, Fudan University, Shanghai, P.R. China
Santiago Mas-Coma, Professor, Department of Parasitology, University of Valencia, Valencia, Spain
Don McManus, Professor, Molecular Parasitology Laboratory, Queensland Institute of Medical Research, Melbourne, Australia
Xiao Ning, Deputy Director and Professor, National Institute of Parasitic Diseases, China CDC, Shanghai, P.R. China
Pan Wei-Qing, Director and Professor,, Department of Pathogen Biology, The Second Military Medical University, Shanghai, P.R. China
Rosanna Peeling, London School of Tropical Medicine and Hygiene, London, U.K.
Laurence Slutsker, Associate Director for Science, Center for Global Health, CDC, U.S.A.
Banchob Sripa, Khon Kaen University, Khon Kaen, Thailand
Rick Steketee, Project Advisor, MVI-PATH, U.S.A.
Shin Jyh-wei, Director and Professor, Taiwan Society of Parasitology, Cheng Kung University, Tainan, Taiwan, P.R. China
Tang Lin-Hua, Professor, National Institute of Parasitic Diseases, China CDC, Shanghai,P.R.China
Juerg Utzinger, Professor, Head Ecosystem Health Unit, Swiss Tropical Public Health Institute, Basel, Switzerland
Sirenda Vong, Chief of MVP, WHO Beijing Office, Beijing, P.R. China
Wu Fan, Director, Shanghai Municipality CDC, Shanghai, P.R. ChinaYang Guo-Jing, Assistant Professor, School of Public Health and Primary Care, The Chinese University of Hong Kong, Hong Kong, P.R. China