• Loading metrics

Advancing Sino-Indian Cooperation to Combat Tropical Diseases

  • Peter Hotez , (PH);, (XNZ)

    Affiliations Department of Pediatrics and Molecular Virology and Microbiology, National School of Tropical Medicine, Baylor College of Medicine, Houston, Texas, United States of America, Sabin Vaccine Institute and Texas Children's Hospital Center for Vaccine Development, Houston, Texas, United States of America, James A. Baker III Institute for Public Policy, Rice University, Houston, Texas, United States of America

  • Sunit K. Singh,

    Affiliation Laboratory of Neurovirology and Inflammation Biology, Centre for Cellular and Molecular Biology (CCMB), Council of Scientific and Industrial Research (CSIR), Hyderabad, India

  • Xiao-Nong Zhou (PH);, (XNZ)

    Affiliation National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China

Advancing Sino-Indian Cooperation to Combat Tropical Diseases

  • Peter Hotez, 
  • Sunit K. Singh, 
  • Xiao-Nong Zhou

In 2005 India, Nepal, and Bangladesh signed a landmark agreement to eliminate visceral leishmaniasis in South Asia. There is an exciting opportunity for India and China to also engage in international science diplomacy for controlling or eliminating the major neglected tropical diseases in their two countries, and thereby reducing the global NTD burden by up to 40% or more.

Why are we in India so embarrassed to recognise our own strengths, our achievements? We are such a great nation. We have so many amazing success stories but we refuse to acknowledge them. —Abdul Kalam (former President of India) [1]

It is a trite saying that one half the world knows not how the other lives. Who can say what sores might be healed, what hurt solved, were the doings of each half of the world's inhabitants understood and appreciated by the other. —Mahatma Gandhi [2]

China and India each have a population of more than one billion people, and today the two nations combined account for more than one-third of the world's population (Table 1) [3]. China and India are also important emerging economies with a combined gross domestic product (GDP) of more than $7 trillion, a dollar amount exceeded only by the economic output of the United States [4]. However, at the same time almost 600 million Chinese and Indians live below the World Bank poverty figure of $1.25 per day, and together these two nations account for almost one-half of the world's “bottom billion”, i.e., the 1.29 billion people who live on essentially no money [5], [6].

There is an intimate link between poverty and disease, especially for the neglected tropical diseases (NTDs) that disproportionately strike the bottom billion [7]. With so many people living in extreme poverty it should be no surprise that both China and India are middle-income countries plagued with widespread infectious and neglected tropical diseases [8][12].

Shown in Table 2 is a summary of the major NTDs affecting both countries [8][34]. By our current estimates, China and India account for roughly one-fifth of the world's soil-transmitted helminth infections (e.g., ascariasis, trichuriasis, and hookworm) [9], [10], [12][14], while India accounts for more than 40% of the world's population requiring mass drug administration for lymphatic filariasis [15]. China also suffers from the greatest number of cases of liver fluke infection (caused by Clonorchis sinensis) and lung fluke infection (caused by Paragonimus spp.), and accounts for most of the world's disease burden from these two infections [9], [10], [16] as well as for more than 90% of the disease burden from alveolar echinococcosis [17]. Alveolar echinococcosis also occurs across the border in Kashmir, India [17]. Both cystic echinococcosis and schistosomiasis remain endemic in China [18], [19]. Among the serious protozoan infections, China and India (but mostly India) account for 70% of the world's cases of visceral leishmaniasis (kala-azar) [20] and, according to newer estimates, almost one in five deaths from malaria occurs in India [21][23].

Among the neglected bacterial infections, 35% of all deaths from tuberculosis occur in China and India [24], [25], and these two nations account for more than 40% of the world's leprosy cases [10], [12], [26]. Trachoma is still endemic in China and India [27]. Among the neglected viral infections, 40% of the global rabies deaths, mostly from canine rabies, occur in China and India [12], [28], [29]. Two flavivirus infections also stand out: China and India account for more than 50% of the global cases of Japanese encephalitis [12], [28], [31], and together these two nations account for more than 40% of the global burden of dengue with possibly more than 150 million cases annually [34]. Southern China (especially Guangdong Province) saw an increasing tendency for imported cases of dengue during the last decade [32], [33].

Under the leadership of the National Institute of Parasitic Diseases of the Chinese Centers for Disease Control and Prevention [35] and the Indian Council of Medical Research, enormous strides have been made in NTD control in China and India, respectively. For instance, in China lymphatic filariasis has been eliminated and the prevalence of schistosomiasis dramatically reduced over the last half of the 20th century [8], [36], [37]. China has also been an important innovator for new anthelminthic drugs and diagnostics and for the development of OMICs technologies [38][41]. Similarly, India has made enormous strides in the eradication of guinea worm [42], and the control and elimination of leprosy and lymphatic filariasis [43][45]. Likewise, India has been an important innovator for new NTD therapeutics.

Despite these important gains, China and India are still faced with a devastating burden of disease resulting from parasitic, bacterial, and viral NTDs; and despite their rapidly growing economies these two nations still account for approximately 20–70% of the global burden from the major NTDs. In addition to their health impact, there is growing evidence that the NTDs trap people in poverty and thwart economic growth [7], so that the NTDs may represent a reason why China and India have not progressed further as emerging market economies.

Given the ability of scientists working in China and India to pursue advanced technologies and the financial and other resources made available to achieve these goals, there is every reason to believe that both China and India also possess the “scientific horsepower” and the resources to tackle their indigenous NTDs [46]. Solving the NTD problem in China and India has enormous potential dividends both in terms of reducing the global disease burden by up to 40% or more and simultaneously promoting economic growth and public health in Asia.

Controlling and eliminating NTDs in Asia will require a scale-up of mass drug administration, especially for the soil-transmitted helminth infections, lymphatic filariasis, food-borne trematode infections, and trachoma, while simultaneously conducting research and development for new drugs, diagnostics, and vaccines [8]. In parallel with these activities is an important yet underutilized opportunity for international cooperation and science diplomacy.

China and India share an extensive 2,200 mile border and an ancient history [47]. Most of that history has been peaceful, although a border war occurred in 1962 [46], [47]. In 2005, China and India partially resolved some key border differences in an agreement between Indian premier Manmohan Singh and Chinese premier Wen Jiabao, with additional commitments to promote joint economic cooperation and information technology [47]. Subsequently, key trade agreements were announced [48].

Ultimately, the huge disease burden from NTDs now shared between China and India creates an interesting opportunity to enhance scientific cooperation between these nations. For example, India might learn from China's historical successes at eliminating lymphatic filariasis, while China might benefit from India's recent experience in combating dengue and other arboviruses. Both nations could expand mass drug administration in order to reduce the number of cases of soil-transmitted helminth infections and trachoma, as well as to reduce a staggering burden of disease from tuberculosis. There also remains a high burden from malaria in India and in China's southwestern region. The fact that such a heavy burden of tropical diseases now occurs in two of the world's largest economies, each with top-ranked universities—Beijing, Tsinghua, and Fudan Universities in China and the Indian Institute of Technology, Centre for Cellular and Molecular Biology (CCMB), and All India Institute of Medical Sciences—and the recognized ability to produce nuclear technologies, indicates that the talent to achieve science diplomacy goals is already present. On the medical research front there are almost limitless opportunities to collaborate on new drugs, diagnostics, and vaccines for NTDs common to both nations [49].

In 2005 the governments of India, Nepal, and Bangladesh signed an important agreement at the World Health Assembly (Geneva) for mutual cooperation in order to eliminate visceral leishmaniasis from South Asia [50]. This agreement could be considered a landmark achievement in international science and medical diplomacy. We would urge that government leaders support China and India's major public health and research institutions devoted to NTDs and possibly look to that agreement as a starting point for identifying common ground and exploring opportunities for a Sino-Indian partnership on NTDs.


  1. 1., accessed 24 November 2012.
  2. 2. Gandhi M, Fischer L (2002) The Essential Gandhi: An Anthology of His Writings on His Life, Work and Ideas, Vintage, 2nd Edition, 368 p. Quoted in Hotez PJ. 2008. Forgotten Diseases, Forgotten People: The Neglected Tropical Diseases and their Impact on Global Health and Development, ASM Press, 224 p.
  3. 3., accessed 24 November 2012.
  4. 4., accessed 24 November 2012.
  5. 5., accessed 24 November 2012.
  6. 6.,,contentMDK:20040961~menuPK:435040~pagePK:148956~piPK:216618~theSitePK:430367~isCURL:Y,00.html, accessed 24 November 2012.
  7. 7. Hotez PJ, Fenwick A, Savioli L, Molyneux DH (2009) Rescuing the bottom billion through control of neglected tropical diseases. Lancet 373: 1570–5.
  8. 8. Hotez PJ, Ehrenberg JP (2010) Escalating the global fight against neglected tropical diseases through interventions in the Asia Pacific region. Adv Parasitol 72: 31–53.
  9. 9. Li T, He S, Zhao H, Zhao G, Zhu XQ (2010) Major trends in human parasitic diseases in China. Trends Parasitol 26: 264–70.
  10. 10. Hotez PJ (2012) Engaging a rising China through neglected tropical diseases. PLOS Negl Trop Dis 6: e1599
  11. 11. John TJ, Dandona L, Sharma VP, Kakkar M (2011) Continuing challenge of infectious diseases in India. Lancet 377: 252–69.
  12. 12. Lobo DA, Velayudhan R, Chatterjee P, Kohli H, Hotez PJ (2011) The neglected tropical diseases of India and South Asia: review of their prevalence, distribution, and control or elimination. PLOS Negl Trop Dis 5: e1222
  13. 13. De Silva NR, Brooker S, Hotez PJ, Montresor A, Engels D, Savioli L (2003) Soil-transmitted helminth infections: updating the global picture. Trends Parasitol 19: 547–51.
  14. 14. Bethony J, Brooker S, Albonico M, Geiger SM, Loukas A, et al. (2006) Soil-transmitted helminth infections: ascariasis, trichuriasis, and hookworm. Lancet 367: 1521–32.
  15. 15. World Health Organization. Neglected tropical diseases PCT databank. Accessed 30 August 2013.
  16. 16. Furst T, Keiser J, Utzinger J (2012) Global burden of human food-borne tremtodiases: a systematic review and meta-analysis. Lancet Infect Dis 12: 210–21.
  17. 17. Torgerson PR, Keller K, Magnotta M, Ragland N (2010) The Global Burden of Alveolar Echinococcosis. PLoS Negl Trop Dis 4: e722
  18. 18. Yang YR, Williams GM, Craig PS, McManus DP (2010) Impact of increased economic burden due to human echinococcosis in an underdeveloped rural community of the People's Republic of China. PLoS Negl Trop Dis 4: e801
  19. 19. Steinmann P, Keiser J, Bos R, Tanner M, Utzinger J (2006) Schistosomiasis and water resources development: systematic review, meta-analysis, and esitmates of people at risk. Lancet Infect Dis 6: 411–25.
  20. 20. Alvar J, Velez ID, Bern C, Herrero M, Desjeux P, et al. (2012) Leishmaniasis worldwide and global estimates of its incidence. PLoS ONE 7 (5) e35671
  21. 21. Zhou SS, Wang Y, Xia ZG (2011) Malaria situation in the People's Republic of China in 2009. Zhongguo Ji Sheng Chong Xue Yu Ji Sheng Chong Bin Za Zhi 29: 1–3.
  22. 22. Hay SI, Gething PW, Snow RW (2010) India's invisible malaria burden. Lancet 376: 1716–17.
  23. 23. Murray CJ, Rosenfeld LC, Lim SS, Andrews KG, Foreman KJ, et al. (2012) Global malaria mortality between 1980 and 2010: a systematic analysis. Lancet 379: 413–31.
  24. 24., accessed 25 November 2012.
  25. 25., accessed 25 November 2012.
  26. 26. World Health Organization (2012) Global leprosy situation, 2012. Wkly Epidemiol Rec 87: 317–28.
  27. 27. World Health Organization (2012) Global WHO Alliance for the Elimination of Blinding Trachoma by 20120: Progress report on elimination of trachoma, 2010. Wkly Epidemiol Rec 87: 161–8.
  28. 28. Yin CP, Zhou H, Wu H, Shen XX, Wang LH, et al. (2011) Epidemiological analysis of rabies in 2010, China. Zhonghua Shi Yan He Lin Chuang Bing Du Xue Za Zhi 25: 434–6.
  29. 29., accessed 25 November 2012.
  30. 30. Zheng Y, Li M, Wang H, Liang G (2012) Japanese encephalitis and Japanese encephalitis virus in mainland China. Rev Med Virol 22: 301–22.
  31. 31. Erlanger TE, Weiss S, Keiser J, Utzinger J, Wiedenmayer K (2009) Past, present, and future of Japanese encephalitis. Emerg Infect Dis 15: 1–7.
  32. 32. Luo L, Liang HY, Hu YS, Liu WJ, Wang YL, et al. (2012) Epidemiological, virological, and entomological characterisitics of dengue from 1978 to 2009 in Guangzhou, China. J Vector Ecol 37: 230–40.
  33. 33. Li Z, Yin W, Clements A, Williams G, Lai S, et al. (2012) Spatiotemporal analysis of indigenous and imported dengue fever cases in Guangdong province China. BMC Infect Dis 12: 132.
  34. 34. Bhatt S, Gething PW, Brady OJ, Messina JP, Farlow AW, et al. (2013) The global distribution and burden of dengue. Nature 496: 504–7.
  35. 35. Zhou X-N, Chen J-X, Chen M-G, Bergquist R (2005) The National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention: a new administrative structure for schistosomiasis control. Acta Trop 96: 296–302.
  36. 36. Sudomo M, Chayabejara S, Duong S, Hernandez L, Wu WP, Bergquist R (2010) Elimination of lymphatic filariasis in Southeast Asia. Adv Parasitol 72: 205–33.
  37. 37. Utzinger J, Zhou XN, Chen MG, Bergquist R (2005) Conquering schistosomiasis in China: the long march. Acta Trop 96: 69–96.
  38. 38. Xiao SH, Keiser J, Chen MG, Tanner M, Utzinger J (2010) Research and development of antischistosomal drugs in the People's Republic of China a 60-year review. Adv Parasitol 73: 231–95.
  39. 39. Hu Y, Xiao SH, Aroian RV (2009) The new anthelmintic tribendimidine is an L-type (levamisole and pyrantel) nicotinic acetylcholine receptor agonist. PLoS Negl Trop Dis 3: e499
  40. 40. Chen JH, Wang H, Chen JX, Bergquist R, Tanner M, et al. (2012) Frontiers of parasitology research in the People's Republic of China: infection, diagnosis, protection, and surveillance. Parasit Vectors 5: 221.
  41. 41. Chuan J, Feng Z, Brindley PJ, McManus DP, Han Z, et al. (2010) Our wormy world genomics, proteomics and transcriptomics in East and southeast Asia. Adv Parasiol 73: 327–71.
  42. 42. Sharma R (2000) India eradicates guinea worm disease. BMJ 320: 668.
  43. 43. Desikan KV (2012) Elimination of leprosy & possibility of eradication – the Indian scenario. Indian J Med Res 135: 3–5.
  44. 44. Das PK, Ramiah KD, Augustin DJ, Kumar A (2001) Towards elimination of lymphatic filariasis in India. Trends Parasitol 17: 457–60.
  45. 45. Kumari AK, JY, Das LK (2012) Issues in delivering morbidity management for lymphatic filariasis elimination: a study in Pondicherry, South India. Scientific World Journal 2012: 372618.
  46. 46. Hotez PJ (2010) Nuclear weapons and neglected diseases: the “ten-thousand-to-one gap”. PLoS Negl Trop Dis 4: e680
  47. 47. BBC News (2005). China and India sign border deal. Accessed 24 November 2012.
  48. 48. Deccan Herald (2013) India signs 8 pacts, to consider trade agreement. Accessed 30 August 2013.
  49. 49. So AD, Ruiz-Esparza Q (2012) Technology innovation for infectious diseases in the developing world. Infect Dis Poverty 1: 2.
  50. 50. Picado A, Dash AP, Bhattacharya S, Boelaert M (2012) Vector control interventions for visceral leishmaniasis elimination initiative in South Asia, 2005–2010. Indian J Med Res 136: 22–31.