Communicating and Monitoring Surveillance and Response Activities for Malaria Elimination: China's “1-3-7” Strategy

Taking a malaria control program from the control phases through to elimination is challenging. The reorientation of the malaria control program involves a shift of focus, from reaching high levels of coverage of interventions to prevent morbidity and mortality, to an emphasis on completeness and timeliness of activities in order to seek out infections and interrupt transmission. The need to communicate this change in strategic thinking to large, cumbersome health systems has proven a challenge. Has China found a solution? Surveillance to rapidly identify potential and ongoing areas of disease transmission that initiates a rapid and high-quality targeted response is essential for any disease elimination program. For malaria elimination programs, surveillance and the ensuing response includes refinement in both the spatial aspects of reporting and the timeliness of activities (see Figure 1). Malaria programs in countries that have regions with low endemicity or that are already on a path to malaria elimination operationalize the need to rapidly identify infections and prevent them from spreading through a strategy of surveillance and response. The most widely adopted surveillance and response approach is a strategy called reactive case detection (RACD), whereby household members, neighbors, and other contacts of passively detected cases are screened for infection and treated with antimalarials [1]–[4]. The RACD response is often combined with other essential components of an elimination campaign, namely, vector control and community education and participation. The RACD process is similar to contact tracing in tuberculosis and relies on the fact that at low transmission levels, malaria is highly clustered geographically into micro-foci, or hotspots, or is clustered demographically into high-risk groups, or “hot populations” [2],[5]. Although the effectiveness of RACD in reducing malaria transmission has not been demonstrated, RACD is a widely adopted and implemented malaria elimination strategy. Thirteen out of 14 countries in the Asia Pacific Malaria Elimination Network [6], several countries in Africa (implemented in Swaziland [3] and South Africa [7], and in pilot programs in Zambia [8], Senegal [9], and Namibia), and countries in the elimination phase globally employ some form of RACD activity. RACD programs that have carried out monitoring and evaluation of their systems find that there are challenges with operationalizing RACD, particularly with regards to the timely completion of activities and reaching satisfactory coverage of the target population [3]. At the last stages of malaria elimination, programs must be highly vigilant and seek to find every infection. When identified, action to prevent onward transmission of malaria must be complete and prompt. In health systems that rarely see malaria, as is common in settings close to malaria elimination, communicating to health workers the need to urgently and accurately report cases and carry out RACD, and the need to monitor their actions, is problematic. Here we describe the 1-3-7 system employed by the national malaria elimination program in China to communicate and monitor its key malaria elimination strategy. Figure 1 Shifts in the spatial and temporal scales of reporting and response as countries progress towards malaria elimination. China launched its malaria elimination program in July 2010 with a plan to achieve elimination by 2020 [10]. Malaria cases (local and imported) have been reduced from more than 26,000 in 2008 to 2,716 in 2012, of which only 243 were due to local transmission. Plasmodium falciparum has been almost eliminated (only 16 cases of falciparum malaria in 2012, along the China–Myanmar border) [11]. This success has been driven by a focused program delivering and monitoring targeted interventions to those at risk, including a RACD program that is described by 1-3-7 (see Box 1). Box 1. The 1-3-7 Strategy Designed to Guide and Monitor Malaria Surveillance and Response in China 1: Case reporting within one day. Any confirmed and suspected malaria cases by law must be reported to the web-based health information system within 24 hours of diagnosis by the local health-care provider. 3: Case investigation within three days. All malaria cases should be confirmed and visited by the county-level China CDC, where the case is reported within three days, to determine where the case originated (local or imported). 7: Focus investigation and action within seven days. The focus investigation should be conducted as soon as possible. If local transmission is possible or confirmed, targeted action to seek out other infections and reduce the chance of onward transmission is completed within seven days by the county-level China CDC of the county where the patient resides and/or works.