ENSURE: Enhanced surveillance for control and elimination of malaria in the Philippines

疟疾在世界许多地方仍然是一个问题。即使在感染水平较低的国家，疟疾仍可造成死亡，而且药物和杀虫剂耐药性可能破坏正在进行的任何控制努力，从而使疟疾卷土重来，这一威胁始终存在。在感染罕见的情况下，控制规划的一个主要难题是确定实际发生传播的地点。这是因为目前用于诊断疟疾的方法不够灵敏，无法检测到所有感染，而且遗漏了很大一部分。虽然这些未被发现的感染可能不会引起疾病，但它们仍可能导致蚊子感染，从而维持该地区的疟疾传播。对于许多较贫穷的国家来说，努力并积极发现所有这些病例是一个昂贵的过程，因此需要采用更灵活的方法来确定感染发生的地点，以便有效地针对这些病例。菲律宾是低传播环境的典型例子。该国最近的年度疟疾病例有所减少（从2000年的36 000多例当地病例减少到2014年的不到5 000例），但尽管取得了这一进展，81个省中仍有54个省存在疟疾流行，使1 400万人面临患病风险。需要新的方法和更灵敏的方法来检测是否以及在何处可能发生任何剩余的传播。随着耐药寄生虫在东南亚一些国家传播，通过综合监测系统锁定菲律宾的传播尤为重要，而且可能是解决这一问题的最有效方法。在这个项目中，我们将把现有的监测菲律宾当地诊所患者疟疾的系统与更敏感的诊断方法结合起来，以确定谁感染了疟疾，谁最近曾接触过疟疾。我们将使用来自诊所的数据和平板电脑的尖端测绘技术来确定人们居住的地方，这样我们就可以看到感染发生的地方。我们将把这一信息提供给菲律宾国家疟疾控制规划，以便他们能够针对该地区进行控制。我们将定期在卫生设施开展这些活动，并不断更新地图。这将使我们能够确定新的感染区域，并检查目标区域是否仍然很低。我们将继续与控制规划和卫生机构工作人员密切合作，看看我们正在推广的方法是否可以接受，以及如何加以改进。目标是开发一种方法，使用更现代的方法可以很容易地吸收到现有的卫生系统中，并最终帮助菲律宾消除一种致命且代价高昂的疾病，并有可能帮助其他国家和地区实现同样的目标。该项目还旨在建设菲律宾在血清学和分子监测、数据分析、流行病学、空间研究和卫生系统研究方面的人力能力。国际合作为开发和评估疟疾负担测量工具提供了一个独特的机会，允许在流行病学多样化和复杂的区域制定新的战略，在消除疟疾方面取得的迅速进展需要在研究和创新方面投入大量资金。

Malaria remains a problem in many parts of the world. Even in countries where the level of infection is low, malaria can still cause death and there is the constant threat that drug and insecticide resistance may undermine any ongoing control attempts such that malaria comes back. A major complication for control programmes when infections are rare is identifying where transmission is actually occurring. This is because the current methods used to diagnose malaria are not sensitive enough to detect all infections and miss a substantial proportion. Although these infections that are missed may not cause illness, they can still lead to infections in mosquitoes and therefore maintain malaria transmission in the area. It is an expensive process for many poorer countries to try and actively find all these cases, and so more flexible approaches need to be used to identify where infections are happening so that they can be targeted effectively. The Philippines is a prime example of a low transmission setting. The country has recently experienced a reduction in annual malaria cases (from over 36,000 local cases in 2000 to fewer than 5,000 in 2014), but despite this progress, 54 out of the 81 provinces remain endemic of malaria, putting 14 million people at risk of the disease. Novel approaches and more sensitive methods are needed to detect if and where any remaining transmission might occur. With drug resistant parasites circulating in some countries in South East Asia, targeting transmission in the Philippines through an integrated surveillance system is particularly important and probably the most effective approach to address this issue. In this project, we will combine existing systems that monitor malaria in people who attend local clinics in the Philippines with more sensitive diagnostic methods to see who is infected and who has recently been exposed to malaria. We will use the data from the clinics and cutting edge mapping techniques with tablet computers to identify where people live, so that we can see where infections are occurring. We will give this information to the Philippines National Malaria Control Programme so that they can target the area for control. We will perform these activities regularly at health facilities and continually update the maps. This will allow us to identify new areas of infection and check that targeted areas remain low. We will work closely and continually with the control programme and health facility staff to see if the approach we are promoting is acceptable and how it might be improved. The goal is to develop an approach that can be easily absorbed into the existing health system using more modern approaches, and ultimately to help the Philippines eliminate a deadly and costly disease - and potentially to help other countries and regions achieve the same. The project also aims to build human capacity in the Philippines in serological and molecular surveillance, data analysis, epidemiology, spatial studies and health systems research. The international collaboration provides a unique opportunity to develop and evaluate malaria burden measurement tools, allowing for novel strategies in a region of diverse and complex epidemiology, in which the rapid advances being made on elimination require great input in research and innovation.