Analysis of the Current Situation and Problems of China's National

Infectious Disease Network Direct Reporting System Under the

COVID-19

Chang Liu

, Yuanshan Liang

and Mengqi Zhu

Macao Polytechnic University, Faculty of Humanities and Social Science, Macao SAR, 999078, China

Guangdong University of Foreign Studies, Academy of International and Regional Studies, Guangzhou, 510000, China

Xuchang Central Hospital, Department of Geriatrics, Xuchang, 461000, China

Keywords: Infectious Disease Epidemiology, Surveillance systems, National Infectious Disease Reporting System.

Abstract: Considering the highly transmissible feature of infectious diseases, each country establishes its surveillance

system for infectious diseases to restrain the spread of infectious diseases quickly. This is the first step of

humanity’s “war against epidemics”. This paper briefly reviews the development of China's national

infectious disease network direct reporting model. From the early days of handwriting and mail delivery to

the world’s largest direct reporting system for infectious diseases, China’s digital government has brought a

huge breakthrough in preventing infectious diseases. However, the direct reporting system for infectious

diseases, which was claimed to be able to reach the National Centre for Disease Control and Prevention in

China within 2 hours, did not work as expected during the early outbreak of “COVID-19” in early 2020.

Therefore, this paper explores the basic reasons for the “non-functioning” of the network direct reporting

system and, hence, discusses the problems of digital government in infectious disease surveillance and the

important role of advanced technology in infectious disease surveillance systems. Finally, suggestions are

made for the direct reporting system of infectious disease networks in China.

1 INTRODUCTION

The Chinese Ministry of Health officially launched

Decree No. 37 on January 1, 2004, on the

implementation of the Measures for the

Administration of Information Reporting on

Surveillance of Public Health Emergencies and

Infectious Diseases, followed by the opening of a

direct network reporting system based on case

reporting of infectious diseases throughout the

country, which means that the information network is

extended to townships (towns) and urban

communities through national, provincial, municipal

and county disease prevention and control agencies,

thus forming a vertical and horizontal information

reporting network (Li & Zhang, 2011). The

innovative management model of reporting

epidemics directly from the most grassroots medical

and health institutions to the National Centre for

Disease Prevention and Control (NCDC) has become

a breakthrough in the information management

model in China's public health sector, improving the

early detection of abnormal information through real-

time monitoring of epidemics, especially plays an

important role in the prevention, control, and disposal

of infectious disease epidemics, the safeguarding of

major rally events and the prevention of epidemics

during natural disaster relief.

2 REVIEW OF THE EPIDEMIC

OUTBREAK REPORTING

METHODS IN CHINA

China’s statutory epidemic reporting and feedback

system was established in the 1950s when the

Chinese State Council approved a bill to establish

Health Protection Stations (HEPS) nationwide. Since

1952, the Ministry of Health issued a series of health

statistics forms, including the Basic Health

Information Form, the Infectious Disease Form, the

Hospital Work Form, the Hospital Inpatient Disease

Classification Form, and the Population Injury and

648

Liu, C., Liang, Y. and Zhu, M.

Analysis of the Current Situation and Problems of China’s National Infectious Disease Network Direct Reporting System Under the COVID-19.

DOI: 10.5220/0012041400003620

In Proceedings of the 4th International Conference on Economic Management and Model Engineering (ICEMME 2022), pages 648-653

ISBN: 978-989-758-636-1

 2023 by SCITEPRESS – Science and Technology Publications, Lda. Under CC license (CC BY-NC-ND 4.0)

Death Statistics Form. Subsequently, the Chinese

Academy of Medical Sciences (CAMS) was

established in 1956 and the Chinese Academy of

Preventive Medicine (CAPM) in 1986, both of which

are responsible for the collection, management,

analysis, and feedback of infectious disease

surveillance data throughout China(Wang, 1996).

Before 1985, infectious disease surveillance in China

was conducted in the most primitive way, that is,

clinicians filled out “infectious disease report cards”

manually, and then reported and summarized

statistics by mail through health prevention stations

in villages, towns, counties, cities, provincial, and

national levels (from county health bureau to city

health bureau, to provincial health bureau, and finally

to CAPM)(Xu & Chen, 2020). In other words, it often

takes more than a month, or even longer, for

information about the infectious disease to reach

decision-makers. In the 1970s, China set up a single

disease surveillance system for influenza, AIDS, and

malaria, followed by a comprehensive disease

surveillance system in the 1980s, with 145 disease

surveillance sites nationwide, monitoring four areas:

birth, death, and infectious disease incidence, and

planned immunization (Ma et al., 2006).

By the year 1986, there has been an initial

electronic reporting system of infectious diseases in

China, with more than 200 network nodes nationwide

implementing monthly electronic reporting of

national statutory infectious diseases, and some

provinces even began using e-mail as a more efficient

reporting method. In 2002, the Chinese Academy of

Preventive Medicine (CAPM) was officially

renamed the National Centre for Disease Control and

Prevention (NCDC). According to the Law of the

People’s Republic of China on the Prevention and

Control of Infectious Diseases (2004), CDCs at all

levels are responsible for the surveillance, prediction,

epidemiological investigation, and notification of

epidemics and other prevention and control work of

infectious diseases. Based on the official data from

the NCDC, the epidemic dynamic results of 35

statutory infectious diseases analyzed by the national

disease surveillance sites in 2000 is shown in figure

Figure 1: The epidemic situation of 35 statutory infectious diseases in national disease surveillance sites in 2000.

It can be seen that the lowest reporting rate of 35

statutory infectious diseases at the national disease

surveillance sites from 2000 to 2002 was 77.08% in

April 2000, and the highest reporting rate was

95.14% in June and July 2000. There were no months

with a 100% reporting rate during this period. In

2003, after the SARS crisis, the NCDC established

the National Network Direct Reporting System

(NDRS) for infectious diseases and public health

emergencies with the database of infectious diseases

and public health emergencies as the core, according

to the construction principle of “horizontal to the

edge and vertical to the bottom” through the

reorganization and transformation of the epidemic

reporting procedure (Huang et al., 2008). “Vertical to

the end” means that all health institutions above the

township level are included in the system and entitled

to log in and fill in the information reported;

“horizontal to the edge” means that all health

institutions in the country are covered, including

medical, supervision, disease prevention, and control

institutions. According to the official data from the

NCDC, the system has been used by all health

institutions in China. According to the official data of

the NCDC, the dynamic analysis of the epidemic

situation of 37 statutory infectious diseases at the

national disease surveillance sites in 2006 is shown

in figure 2.

122

134 134

111

128

137 137

131 131

133 133

129

100

150

data analysis of 35 statutory infectious diseases in national disease surveillance sites in

2000

The actual number of copies of reports received (144 copies should be received)

Analysis of the Current Situation and Problems of China’s National Infectious Disease Network Direct Reporting System Under the

COVID-19

649

Figure 2: Epidemiological trends of 37 statutory infectious diseases in national disease surveillance sites in 2006.

Since the digital government model was initiated,

the number of report cards has increased abruptly,

with the lowest number of monthly report cards in

2006 being over 300,000 and the highest number of

report cards close to 600,000. The increase in the

number of infectious disease report cards means that

China’s ability to monitor infectious diseases has

improved, and reflects the positive effect that the

digital government has brought to infectious disease

surveillance. On September 29, 2017, the

“Development of China’s Public Health as an

Essential Element of Human Rights (2017)” stated

that China has built the world’s largest online direct

reporting system for notifiable epidemic diseases and

public health emergencies. The epidemic disease

reporting system covers 71,000 medical institutions,

with 160,000 users and nine million annual

individual reports. Development of health and

progress of human rights in China describes that the

country has set up a laboratory network comprised of

disease control and prevention institutions at the

national, provincial, city, and county levels.

Influenza, poliomyelitis, measles, and meningitis B

labs of the NCDC have become WHO reference labs.

According to the above tables, we can briefly

draw the network direct reporting process stipulated

in the “Administrative Measures for Monitoring

Information Reporting of Public Health Emergencies

and Infectious Disease Epidemic Situations”, as

shown in the following.

Figure 3: Direct network reporting process as stipulated in the Measures for the Management of Information Reporting on

Surveillance of Public Health Emergencies and Infectious Diseases (image source: the author’s self-made).

It is clear that before 2020, the major reporters for

China’s direct infectious disease network reporting

system were either the hospitals to which the primary

clinicians belonged or the local CDCs at the county

level or above. However, the COVID-19 outbreak in

early 2020 was not initially reported through the

direct infectious disease network reporting system,

and this issue will be addressed and analyzed in the

following sections.

3 CASE STUDY

At the end of 2019, Hubei Provincial Hospital of

Integrated Traditional Chinese and Western

Medicine found several family-like cases of

pneumonia of unknown cause. On December 27, the

hospital reported to the Wuhan Jianghan District

CDC. On December 29, the hospital conducted the

first joint expert consultation, and then the hospital

reported the situation to the provincial and municipal

health commission yet did not report it through the

network direct reporting system(2020). On

December 30, the Wuhan Municipal Health

Commission issued the internal departmental

guidance documents “Emergency Notice on

Reporting the Treatment of Unexplained

Pneumonia” and “Emergency Notice on Doing a

Good Job in the Treatment of Unexplained

Pneumonia”. A comprehensive and retrospective

investigation of seafood market-related pneumonia

cases was launched. On the same day, Li Wenliang,

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data analysis of 37 statutory infectious diseases in national disease surveillance sites in

2006

The actual number of copies of reports received (144 copies should be received)

If there is no network direct

reporting system account

If there is a network direct

reporting system accoun

Organizing expert

consultation

Primary Clinician

Departments/

Hospitals

Direct network

ortin

Local CDC does direct network reporting

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an ophthalmologist at the Central Hospital of Wuhan,

forwarded text messages that 7 cases of SARS were

diagnosed in the South China Fruit and Seafood

Market in the WeChat group, with a photo of clinical

pathogen screening results and a video of lung

examination as a reminder for relatives and friends to

take precautions. As news of the epidemic spread,

Wuhan's work arrangements for the prevention and

control of unexplained pneumonia, by-laws and

regulations on the prevention and control of

infectious diseases, public security management, and

other laws and regulations, as well as the notification

of the Municipal Health Commission, the public

security administration of Wuhan started to

investigate the information on infectious diseases on

the Internet. Investigate the situation. On January 3,

2020, the Zhongnan Road Police Station of the

Wuchang Branch of the Wuhan Public Security

Bureau contacted Doctor Li Wenliang, and then he

and his colleagues came to the police station for a

conversation, and finally, Doctor Li Wenliang was

given a letter of admonition(2020).

After learning about the pneumonia of unknown

cause in Wuhan through other channels, National

Health Commission sent an expert team to Wuhan to

discuss the “pneumonia of unknown cause” with the

staff of the Wuhan Municipal Health Commission on

December 31, 2019. On the same day, Wuhan

Municipal Health Commission released news that 27

cases of pneumonia of unknown cause were found in

Wuhan through its official media platform, and that

“so far no obvious human-to-human transmission has

been found in the investigation, and no medical staff

infection has been found(About the Current Situation

of the City’s COVID-19 Outbreak, 2019)”. Among

the 138 consecutive patients admitted to Zhongnan

Hospital of Wuhan University from January 1st to 28,

the proportion of medical staff was as high as

29%(Wang B X et al., 2020). The Wuhan Municipal

Health and Family Planning Commission issued the

“Manual for Medical Treatment of Unexplained

Viral Pneumonia” on January 4, which stipulates that

for suspected cases, the hospital should organize

expert consultation within 12 hours, and the results of

the diagnosis should be immediately reported online

when there is suspected pneumonia of unknown

cause. Two more adjustments were subsequently

made, as shown in Table 1.

Table 1: Changes in the reporting process of the online direct reporting system.

Time File name

The reporting process of the network direct reporting

system

2006

Administrative Measures for Monitoring

Information Reporting of Public Health

Emergencies and Infectious Disease

Epidemic Situations

The responsible reporting unit or person-make a direct

online report immediately (within 2 hours).

2020.0

1.04

Wuhan Municipal Health Commission

“Work Manual for Medical Treatment of

Unexplaine

Viral Pneumonia”

Primary doctors discover suspected cases-relevant

departments organize expert consultation-hospitals/medical

institutions-report directly online (within 12 hours).

2020.0

1.05

Wuhan Municipal Health Commission

“Work Manual for Medical Treatment of

Unexplained Viral Pneumonia”

Primary doctors discover suspected cases-relevant

departments organize expert consultation-hospitals/medical

institutions-district health commissions organize expert

consultation-report directly online.

2020.0

1.10

Wuhan hospitals received oral notices from

relevant staff of municipal and provincial

health commissions

Primary doctors discover suspected cases-relevant

departments organize expert consultations-

hospitals/medical institutions-district health Commission

organizes expert consultation-Municipal Health

Commission organizes expert consultation-Provincial

Health Committee organizes expert consultation-report

directly online.

In the 2006 revised version of the “Administrative

Measures for Monitoring Information Reporting of

Public Health Emergencies and Infectious Disease

Epidemic Situations”, “direct reporting on the

Internet” does not require other levels of review and

consultation, although it also requires the

consultation of county, municipal and provincial

levels. However, the purpose of the consultation is to

“exclude the possibility of SARS”. The consultation

is not a prerequisite for “direct online reporting”, but

to facilitate the revision of the results of previous

online direct reporting and issue early warnings and

Analysis of the Current Situation and Problems of China’s National Infectious Disease Network Direct Reporting System Under the

COVID-19

651

take appropriate preventive and control measures on

time. By contrast, it can be seen that in just a few days

from January 4 to January 10, 2020, the original

reporting method that the cases can be reported

directly online once it is confirmed by the primary

clinician has changed to the way by which direct

online reporting is only possible after expert

consultations organized by the district, city, and

provincial health commissions at all levels, as well as

the approval of the provincial health commission.

Until January 24, when the unknown virus was

officially named “new-coronavirus” (COVID-19)

and the emergency system was debugged, the

“dynamic monitoring function of pneumonia caused

by new coronavirus infection” of the infectious

disease network direct reporting system was finally

launched.

4 CONCLUSION

Undoubtedly it is particularly important to have easy

access to online reporting for infectious diseases, but

at the beginning of the outbreak, due to the

refrainment of reporting authority, the Hubei

Provincial Health Commission kept claiming “no

increase” until January 15, 2020, but the fact is that

the spread of the virus never stopped during this time.

In addition, even the top level of the NCDC has no

executive power or decision-making authority, which

means it is unable to make policy measures to prevent

and control the outbreak. Therefore, although the

NCDC reported the outbreak to the central

government as soon as possible, before the central

leadership approved the decision, members of the

high-level expert group of the NCDC could do

nothing but remind and urge people to reduce

unnecessary outings and gatherings at the press

conference, which also hindered the prevention work

in the early stage of the epidemic.

First of all, the NCDC in China is a technical

institution that provides technical services, and is

responsible for reporting to higher administrative

departments but is not entitled to release information

to the public. Meanwhile, local CDCs are under the

jurisdiction of the local health commissions and the

local governments. The NCDC, which is supposed to

be the “whistle-blower” for major public health

events, is caught in a dilemma between local

hospitals facing cases or suspected cases and the

National Health Commission (NHC), owing to

administrative decision-making authority. The

reporting of infectious diseases through the direct

network reporting system is still an administrative

act, which means that timely reporting is not the key,

but approval by higher authorities is the key, while at

the same time, the Health and Welfare Commission,

which is not directly involved in technical guidance,

holds the power to release information about the

epidemic. Instead of institutionalization and

professionalization, the legal obligation of direct

reporting on the Internet has become administrative.

On the other hand, January 24, 2020, is the

Chinese Lunar New Year. The “two sessions” and the

“Spring Festival” drew the public attention, and the

original professional direct reporting has become a

political issue related to local economic development

and social stability, and the direct online reporting

system has turned into a political tool instead of

technical service. When reporting cases of infectious

diseases, the Health Commission or local

governments had to take into consideration the

factors such as the possible social instability caused

by outbreaks and even the possible negative impact

on personal promotions. Policymakers attempted to

weaken and conceal the severity of the epidemic,

resulting in opaque reporting of early cases of the

epidemic, which did not attract sufficient attention

from higher levels of government and thus failed to

effectively control the outbreak as early as possible.

Besides, a complex and accurate report of infectious

diseases can be finished by a single physician under

a normal situation. However, at the beginning of the

outbreak, all the hospitals in Wuhan received at least

200 to 300 outpatients every day, and the number of

patients with pneumonia of unknown cause increased

rapidly. It was hard for doctors to report online,

which exposed the loopholes of the current online

reporting system.

All in all, the case study of the failure of China’s

infectious disease network direct reporting system

implies that scientific and technological means such

as digital government cannot replace the

government’s scientific management, power

distribution, and balance. Infectious disease

prevention and control work is a complex system

arrangement instead of technical work only. At the

same time, it is quite important to properly broaden

the audience of the monitoring system, facilitate the

operation and open the data. Therefore, it is

recommended to explore the automatic reporting

model of the hospital, which can reduce costs and the

possibility of false reporting and concealment. At the

national level, it is recommended that the NCDC be

directly led by the State Council, or managed by the

National Health Commission on behalf. If it extends

downwards, it is possible to merge the local NCDC

and the disease control department of the Health

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Commission. At present, the two sectors overlap in

some work at the grassroots level, which is not

helpful for prevention and control in a state of crisis.

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