Uppsala Health Summit: Behaviour change and biosciences necessary to tackle infectious diseases threats

This blog entry has been reblogged from the CGIAR research programme on livestock website featuring the Uppsala Health Summit, themed “Tackling Infectious Disease Threats” that was held as from 10th to 11th October, 2017 of which the team lead of our ZED Group, Prof Eric Fèvre, presented work from our Urban Zoo project on how pathogens from livestock are introduced and spread in urban environments .

Photo credit: Fernanda Dórea

Research shows that six out of 10 emerging human infectious diseases are zoonoses. Thirteen zoonotic diseases sicken over 2 billion people and they kill 2.2 million each year, mostly in developing countries. Poor people are more exposed to zoonoses because of their greater contact with animals, less hygienic environments, lack of knowledge on hazards, and lack of access to healthcare. 80% of the burden of these zoonotic diseases thus falls on people in low and middle income countries.

A workshop at last week’s Uppsala Health Summit zoomed in on zoonotic diseases in livestock and ways to mitigate risk behaviour associated with their emergence and spread. Critical roles and behaviours of people and institutions in preventing, detecting and responding to zoonotic livestock diseases were identified – as well as necessary changes and incentives so we are well-prepared for infections long before they reach people.

These zoonotic infections often originate from livestock which can serve as a bridge for disease transmission between animals and humans. Thus, controlling zoonotic diseases in livestock is an important means to reduce infectious disease threats to humans. Zoonotic diseases are a threat not only to public health, but also to food production, food safety, animal welfare, and rural livelihood.

Within their own sectors, researchers and practitioners from different fields have a considerable understanding of outbreaks of disease and how to handle them. They also know they must bear in mind how local factors, traditions and politics can determine the outcome. But a disease outbreak causing deaths and disruption is always a complex picture. It requires all actors to gather knowledge from beyond their own field of expertise to be fully able to address disease outbreaks efficiently.

The 50 or so workshop participants, comprising vets and medics in a one health context, tackled two objectives. First, they identified who is involved in preventing, detecting and responding to zoonotic livestock diseases and the associated behaviours that need to change. Second, they set out some initial recommendations and incentives to mitigate risky behaviours.

Biosciences and behaviour

Co-organizer Ulf Magnusson from the Swedish University of Agricultural Sciences explained in his opening remarks that the challenge for the group lies at the intersection between biosciences and behaviour. We know a lot about the biosciences; but for the biosciences to be effective, we need to change and strengthen the behaviours of different actors involved in infectious diseases.  He particularly emphasized the ‘one health’ element, that we need to look beyond animals to develop productive collaboration across the veterinary and medical professions.

Three people were charged to set the scene: Barbara Wieland from the International Livestock Research Institute (ILRI) introduced mainly Ethiopian experiences from rural settings; Eric Fèvre from the University of Liverpool and ILRI gave some urban perspectives from Kenya; and Elisabeth Lindahl-Rajala from the Swedish University of Agricultural Sciences shared a case on controlling Brucella in Tajikistan.

Wieland argued that effective prevention, detection and response requires good understanding of the specific ‘local’ situations in which livestock are kept and especially the roles of different people in this. Her research pointed to major gender differences with women closer to the animals, their care and feeding, and the farmstead and men more involved in marketing, slaughter and dealing with externals like vets. She also pointed to local cultural practices and their effect on handling and consumption of some animal-source products like milk or cheese. Taking account of these role differences and cultural aspects is very critical when designing interventions to tackle zoonotic infectious diseases. Focusing on the farmer actor, she identified especially the need for smaller more manageable changes, the transformative opportunities offered by information and communication technologies and the potential of one health to help overcome capacity and infrastructure problems in remote rural areas.

Fèvre reported on research in Nairobi to understand how pathogens from livestock are introduced and spread in urban environments. He introduced the notion of ‘interfaces’ – physical and social – as useful to help understand disease transmission between livestock and food systems, arguing that the behaviours of people, institutions and policies in and across these interfaces are critical in zoonotic disease spread. Looking at the food systems in a city like Nairobi, value chains connect the many different actors, moving animals and products, moving payments, moving animal health information, and ultimately also accelerating or hindering the spread of diseases. While Wieland focused on rural farmers as a primary actor, the urban systems and chains that Fèvre isolated comprise many different public and private actors, each with specialized roles and sets of desirable behaviours. Mapping and measuring these from a zoonotic perspective will allow current and future disease risks to be understood, leading to improved prevention, detection, and response.

Photo credit: Tanja Strand

Lindahl-Rajala reported on research on the prevalence of Brucella, the cause of brucellosis, in the city of Dushanbe in Tajikistan. Globally, some 500,000 cases of brucellosis occur each year, making it one of the most common bacterial infection spread from animals to humans worldwide. In Tajikistan, increasing urbanization of people is leading to increasing urbanization of animals and increased threats from brucellosis though consumption of raw dairy products or direct contact with infected animals. Research showed Brucella to be widespread in the city’s animals. It also showed low levels of awareness of the diseases among producer and consumers as well as several risky behaviours.  Lindahl-Rajala identified three priority actor groups who need to be targeted to tackle the spread of this disease:  farmers who need to adopt safer behaviours, consumers who need to avoid raw milk from street vendors and policy makers who need to give greater attention and devise a long-lasting control program.

Mapping actors and behaviours

Starting from the three presentations and using their own expertise, the initial task of participants was to take each of the three priorities – prevent, detect and respond – and map the main actors and the desirable behaviours/roles necessary to tackle the spread of zoonotic infectious diseases.

Actors identified across the different priorities included livestock owners and keepers, household members, vets, researchers and academics, diagnostic labs, local government, ministries, traders, transporters, medics and physicians, the media, private companies and consumers. One group, tackling ‘responding’ identified the animals themselves as key actors, in this case to ‘stay put’ and avoid people.

After this broad mapping of the actors, participants were asked to dive deeper, to prioritize the most important actors and behaviour changes for different rural and urban scenarios and likely incentives to achieve these changes. This led to more focus on specific actors and behaviours and to a wide range of useful materials and lessons to build out recommendations in this area (see photos below).

Emerging messages

Sofia Boqvist from the Swedish University of Agricultural Sciences reported some key insights to the summit plenary (see picture top of this post).

Under ‘prevention’, the three key messages identified were: effective biosecurity measures, good communication all round, and long term investment. She emphasized a point from within the group that detecting, and treating, a zoonotic infection in a sick person is an indicator of failure. Investing in up-front prevention of disease in animals will keep people healthy.

Under ‘detection’, the three key messages identified were: good infrastructure in rural areas – to overcome geography, distance and poor connectivity, joint medical/veterinary surveillance so all the key actors look out for all the risks, and proper compensation to protect livelihoods when animals need to be culled to protect lives.

Under ‘response’, the three key messages identified were: the importance of strong and effective institutions that do their assigned tasks and roles well, effective communications and especially media engagement to provide proper information and avoid scares, and sufficient resources and expertise to actually tackle the situations. In an informal unscientific poll of participant perceptions in the workshop, this was the area highlighted as the weakest link among the prevent, detect and respond priorities.

Participants discuss zoonotic disease mitigation priorities. Photo credit: Erik Bongcam-Rudloff

More information

The workshop was organized by Sofia Boqvist and Ulf Magnusson from the Swedish University of Agricultural Sciences. Magnusson leads the Livestock Health Flagship of the CGIAR Research Program on Livestock.

A summary report from the workshop will be produced as part of the overall summit report.

See the presentation by Barbara Wieland; more on this work

See the presentation by Eric Fèvre; more on this work

See more on Elisabeth Lindahl-Rajala’s work in Tajikistan

WHO promotes water, sanitation to battle neglected tropical diseases

Water, sanitation and hygiene are part of a new World Health Organisation strategy to fight neglected tropical diseases which afflict more than 1.5 billion people, the WHO said on Thursday.

 

Those suffering from the 17 diseases, such as intestinal worms, river blindness, leprosy and sleeping sickness include many of the poorest people in the world.

 

“If we put in place universal access to safe water and sanitation and hygiene then the neglected tropical diseases in most cases will completely disappear or be put under control,” Maria Neira, head of public health at WHO, told the Thomson Reuters Foundation.

 

Including water and sanitation in local and national programmes would reduce infections, improve treatment, and reduce the discrimination and stigma that people disfigured by diseases often face, the WHO said.

 

“Those terrible diseases require hygiene and sanitation and we hope that this contribution will add to our argument that access to safe water and sanitation is one of the most important determinants of our health,” Neira said at the launch of the initiative at a global water conference in Stockholm.

 

Neglected tropical diseases thrive where people live in extreme poverty with poor sanitation and little access to healthcare – usually in remote rural areas, urban slums or conflict zones.

 

“Water and sanitation require resources that exceed what WHO can generate for neglected tropical diseases, so we want to make sure that interventions both in public health and water and sanitation reach the poorest as a matter of priority,” Dirk Engels, director of the Department of Neglected Tropical Diseases at the WHO, told the Thomson Reuters Foundation.

 

The new strategy was announced just weeks before a new set of development objectives – known as the Sustainable Development Goals – is due to be adopted at a U.N. summit in September.

 

The new goals include eradicating extreme poverty by 2030 and providing universal access to water and sanitation.

 

More than 660 million people around the world live without access to clean water, and 2.4 billion do not have access to proper sanitation, according to UNICEF and the WHO.

 

WaterAid, an international charity which has been working with communities affected by neglected tropical diseases, gave the example of leprosy, saying that nearly 5,000 new cases are reported each year in Ethiopia.

 

“Once you have the severe form of a disease like leprosy, you pretty much have it for life and the people affected often suffer from exclusion,” Yael Velleman, WaterAid senior policy analyst on sanitation and health, told the Thomson Reuters Foundation.

 

The stigma associated with those diseases mean that people who have them may not be allowed to use the same washrooms as family members and may be unable to access water, because if they have a disability it is harder for them to carry water, Velleman said.

 

“It’s not just about controlling a disease, it’s making sure that the poorest of the poor and the most marginalised have access to these basic services,” she said.

 

The new strategy was launched as a partnership between the WHO, WaterAid and other charities.

This article can also be found on the ILRI Livetock matters online paper and credited to Thomson Reuters Foundation, the charitable arm of Thomson Reuters, that covers humanitarian news, women’s rights, corruption and climate change.

Sustainable Development Goals Must Tackle Neglected Tropical Diseases

With the Millennium Development Goals (MDGs) about to expire, the global health community is looking back on major accomplishments in reducing poverty and improving health over the last 15 years. Perhaps one of the greatest surprises has been the success of international efforts to tackle neglected tropical diseases (NTDs).

The World Health Organization estimates that nearly 1.8 billion people, including more than 800 million children, require annual treatment for NTDs. These parasitic and bacterial infections affect people for years or decades, mostly striking the world’s poorest, most marginalized communities.

Adults and children living with chronic NTDs in Africa, Asia, and the Americas endure horrific disfigurement, blindness, and often extreme and debilitating pain. Children with NTDs often do not attend school, or have great difficulties learning in school, while adults cannot work. As a result, NTDs are leading causes of poverty in less developed nations. Yet, despite the scale of the NTD problem, just over 40 percent of those at risk receive the treatment they need.

Neglected tropical diseases fail to generate MDG interest

When the MDGs were created, NTDs were placed in a category of “other diseases.” To nobody’s surprise, this vague label did not generate much interest, compared to specifically named diseases like HIV/AIDS and malaria. In fact, AIDS and malaria stimulated multibillion-dollar initiatives for mass treatment and prevention, including the President’s Emergency Plan for AIDS Relief, the President’s Malaria Initiative and the Global Fund.

In response to the lack of interest, a group of committed investigators who have devoted their lives to research, treatment, and prevention of NTDs worked with the World Health Organization to target these diseases through mass drug administrations, using a package of pills that could be delivered annually for only 50 cents per person.

By 2006, USAID initiated an NTD Program that produced achievements as impressive as those of other bilateral and multilateral organizations. According to USAID’s statistics, this program has delivered more than one billion NTD treatments in 25 low- and middle-income countries over the last decade. This support is complemented by the UK Department for International Development’s (DFID) efforts, demonstrating a good case of donor harmonization.

By 2012, the average cost of treatment was reduced to 22 cents per person per year, by delivering treatment for many diseases at the same time. This freed more resources for distribution of the expanded drug donations that were pledged in the London Declaration on NTDs by 13 pharmaceutical companies.

Impressive gains in control and elimination

Following its Global Burden of Disease Study (GBD) in 2013, the Institute for Health Metrics and Evaluation at the University of Washington released data for 301 diseases and conditions, and some of the numbers reflect impressive gains in NTD control and elimination. This progress is due in large part to USAID- and DFID-sponsored interventions. It includes a 39 percent decrease in the prevalence of trachoma and a 32 percent drop in lymphatic filariasis (LF). Impressive reductions in the prevalence of Ascaris roundworm (45 percent) and onchocerciasis, or river blindness (51 percent), have been achieved through other mass drug administrations.

But this is a modest reflection of the true impact of NTD programs. When researchers looked at age groups that tend to have the most infections, the decrease in trachoma and LF prevalence was even greater: 65 percent for trachoma and 53 percent for LF. The world is on track to achieve USAID’s objective of eliminating these diseases by 2020.

Thankfully, NTDs have been included in a number of critical inputs into the post-2015 development agenda process, including the High Level Panel report released in May 2013 and the Open Working Group (OWG) proposal for Sustainable Development Goals (SDGs) released in July 2014. The OWG reportincluded a specific target for NTDs, alongside AIDS, tuberculosis, and malaria.

Choose the right indicator for SDGs

The next critical step for NTDs in the post-2015 process is to ensure that the right indicator is used to measure progress over the next 15 years. The NTD community strongly recommends the following indicator, as a global measurement tool: A 90 percent reduction in the number of people requiring interventions against NTDs by 2030.

In addition, we also need to consider the overlap between NTDs and other factors: nutrition; water, sanitation, and hygiene; maternal and child health; and education. Development goals cannot be achieved in isolation. In fact, NTDs are so inextricably linked to these development issues that their prevalence is seen as an effective proxy for broader socioeconomic and human development. The recently-published “worm index” demonstrates a high correlation between the prevalence of intestinal worms and development.

Finally, the SDGs need to incorporate a research and development agenda for NTDs, particularly for diseases not currently benefiting from major gains in mass treatment. This would include developing vaccines for hookworm infection, whose prevalence has decreased only five percent, and schistosomiasis, which has not decreased at all.

Hookworm vaccines are under development by our Sabin Vaccine Institute Product Development Partnership (Sabin PDP) in collaboration with the European HOOKVAC consortium, as is a vaccine for river blindness through The Onchocerciasis Vaccine for Africa Initiative. Most likely, vaccines would be combined with mass drug administrations.

In addition, NTDs such as Chagas disease and leishmaniasis urgently require new interventions, including new drugs being developed by the Drugs for Neglected Disease Initiative, and the Sabin PDP’s therapeutic Chagas vaccine. Despite the lack of traditional market incentives to develop drugs for poor communities, the pharmaceutical industry has engaged in product development partnerships, and many have opened their compound libraries to academic and NGO partners.

Out of the spotlight, the NTD community has made significant strides. With explicit inclusion of these diseases in the SDGs, we can do even more. We have the opportunity to eliminate LF and trachoma before 2030, and reach key milestones in combating all NTDs through mass treatment efforts and the creation of new tools through research and development.

View this item also on the ILRI Livestock Matters online paper

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