An environmental scan of one health preparedness and response: the case of the Covid-19 pandemic in Rwanda

Background Over the past decade, 70% of new and re-emerging infectious disease outbreaks in East Africa have originated from the Congo Basin where Rwanda is located. To respond to these increasing risks of disastrous outbreaks, the government began integrating One Health (OH) into its infectious disease response systems in 2011 to strengthen its preparedness and contain outbreaks. The strong performance of Rwanda in responding to the on-going COVID-19 pandemic makes it an excellent example to understand how the structure and principles of OH were applied during this unprecedented situation. Methods A rapid environmental scan of published and grey literature was conducted between August and December 2020, to assess Rwanda’s OH structure and its response to the COVID-19 pandemic. In total, 132 documents including official government documents, published research, newspaper articles, and policies were analysed using thematic analysis. Results Rwanda’s OH structure consists of multidisciplinary teams from sectors responsible for human, animal, and environmental health. The country has developed OH strategic plans and policies outlining its response to zoonotic infections, integrated OH into university curricula to develop a OH workforce, developed multidisciplinary rapid response teams, and created decentralized laboratories in the animal and human health sectors to strengthen surveillance. To address COVID-19, the country created a preparedness and response plan before its onset, and a multisectoral joint task force was set up to coordinate the response to the pandemic. By leveraging its OH structure, Rwanda was able to rapidly implement a OH-informed response to COVID-19. Conclusion Rwanda’s integration of OH into its response systems to infectious diseases and to COVID-19 demonstrates the importance of applying OH principles into the governance of infectious diseases at all levels. Rwanda exemplifies how preparedness and response to outbreaks and pandemics can be strengthened through multisectoral collaboration mechanisms. We do expect limitations in our findings due to the rapid nature of our environmental scan meant to inform the COVID-19 policy response and would encourage a full situational analysis of OH in Rwanda’s Coronavirus response.

Knowledge, attitude and practices of frontline health workers in relation to detection of brucellosis in rural settings of Tanzania: a cross-sectional study

Background Brucellosis an important zoonotic disease worldwide, which frequently presents as an undifferentiated febrile illness with otherwise varied and non-specific clinical manifestations. Despite its importance, there are few reports on its awareness among frontline health workers. This study aimed at assessing the baseline knowledge, attitude and practice (KAP) related to detection and management of brucellosis among frontline health workers (FHWs) namely; healthcare workers (HWs) and community health workers (CHWs). Methods A cross-sectional study was conducted from December 2019 to January 2020 in Kilosa and Chalinze districts of Tanzania. Data on demographic characteristics, knowledge, attitude and practices regarding brucellosis were collected from the study participants using a structured questionnaire. Interviews were conducted with 32 HWs and 32 CHWs who were systematically selected in study districts. Chi square/fisher Exact was used to assess the association between sociodemographic variables and those related to knowledge, attitude and practices. Results Overall, a total of 30 (93.8%) HWs and nine (28.1%) CHWs from the study districts heard about brucellosis, with (34.4%) of HWs having knowledge about the causative organism. Overall, knowledge showed almost half (46.9%) HWs and (28.1%) CHWs were aware of the symptoms, clinical signs, diagnosis and control regarding brucellosis. Knowledge difference was statistically significant with HWs’ age (p = 0.016). Almost half (46.9%) HWs and less than quarter (12.5%) CHWs had good practices regarding brucellosis control. Almost three quarters (71.9%) of HWs and (21.9%) CHWs had positive attitude regarding brucellosis control; overall attitude was statistically significant with CHWs age (p = 0.028) and education level (p = 0.024). Lack of awareness and unavailability of diagnostic tools were the main challenges faced by FHWs in the two districts. Conclusion The majority of participants were not aware of human brucellosis. Moreover, their overall knowledge was inadequate and the common practices were diagnostic tools, and adequate knowledge to manage brucellosis cases. These findings highlight the need to strengthen frontline health workers knowledge, practices and diagnostic capacities related to brucellosis.

Assessing knowledge, attitude, and practices of veterinarians towards antimicrobial use and stewardship as drivers of inappropriate use in Abuja, Nigeria

Introduction Antimicrobial resistance (AMR) has recently gained worldwide recognition, as the emergence of multi-drug resistant organisms has led to increased mortality and economic burden. This study aimed to assess knowledge, attitudes, and practices of veterinarians towards rational antimicrobial prescribing and identify factors influencing use. Methods We interviewed veterinary doctors in Abuja, Nigeria using a 50-point questionnaire distributed via WhatsApp mobile application. The questionnaire inquired about their experiences, knowledge, attitudes, and practices towards AMR and stewardship. We analyzed the data by calculating frequencies and proportions. Results Of 220 registered veterinarians, 144 (65.5%) participated in the survey. Most (52.8%) were within the age group 30 - 39 years; males (72.2%), with a Master’s degree (42.4%) and worked in public service (44.4%). Three-quarters (75.7%) had good knowledge of antimicrobials; 47.2% had received training on stewardship while 88.9% reported that they believed that overuse of antimicrobials was the major contributory factor towards AMR. Antimicrobial stewardship regulations are important in veterinary practice. Veterinarians were aware of the occurrence of resistant pathogens and agreed that restricting antimicrobial use in animal health care was necessary to reduce AMR. Conclusion Most respondents referred to the veterinary formulary (VF) when in doubt of the appropriate antimicrobial agent to administer. We recommend that the VF be updated following the WHO list of critically-important-antimicrobials (CIA) and veterinarians educated not to use these CIAs in the treatment of food animals.

Dental fluorosis among people and livestock living on Gihaya Island in Lake Kivu, Rwanda

Background Dental fluorosis is caused by prolonged exposure to excessive fluoride during the period of permanent tooth formation and is characterized by tooth discoloration, pitting, and loss of shape. Communities living near Lake Kivu in Western Rwanda exhibit a high prevalence of dental fluorosis; however, data on prevalence and risk factors are scarce. Methods This cross sectional, quantitative study used a One Health approach to investigate dental fluorosis prevalence among people and livestock and to measure fluoride content in the environment. In 2018, oral health examinations were conducted to assess the prevalence of fluorosis in children (aged 9 to 15 years), cattle and goats residing on Gihaya Island (Rwanda, East Africa). All children and cattle/goats meeting basic eligibility criteria (e.g., island residence) were invited to participate. Presence and severity of dental fluorosis was categorized according to the Dean’s Fluorosis Index. Samples of local foods, water, soil and grass were collected from communal sources and individual households and analyzed for fluoride content using standard laboratory techniques. Descriptive and binomial analyses (Fisher Exact Test) were used to assess this dataset. Results Overall, 186 children and 85 livestock owners (providing data of 125 livestock -23 cattle and 102 goats) participated. Dental fluorosis was recorded in 90.7% of children and 76% of livestock. Moderate to severe fluorosis was observed in 77% children while goats and cattle most often exhibited mild or absent/questionable severity, respectively. Water from Lake Kivu (used primarily for human cooking water and livestock drinking water) contained fluoride levels that were consistently higher than the maximum threshold (1.5 mg/L) recommended by the World Health Organization. Other sources (borehole and rainwater) were within safe limits. All food, soil and grass samples contained fluoride. The highest levels were observed in porridge (0.5 mg/g) and small fishes (1.05 mg/g). Conclusions Altogether, dental fluorosis was highly prevalent among children and goats on Gihaya Island with various food and water sources contributing a cumulative exposure to fluoride. An immediate and coordinated response across human, animal and water professionals is needed to reduce fluoride exposure within safe limits for island residents.

A bolder One Health: expanding the moral circle to optimize health for all

One Health is a ground-breaking philosophy for improving health. It imaginatively challenges centuries-old assumptions about wellbeing and is now widely regarded as the ‘best solution’ for mitigating human health problems, including pandemic zoonotic diseases. One Health’s success is imperative because without big changes to the status quo, great suffering and ill-health will follow. However, even in its more ambitious guises, One Health is not radical enough. For example, it has not embraced the emerging philosophical view that historical anthropocentrism is an unfounded ethical prejudice against other animals. This paper argues that One Health should be more imaginative and adventurous in its core philosophy and ultimately in its recommendations and activities. It must expand the circle of moral concern beyond a narrow focus on human interests to include nonhuman beings and the environment. On this bolder agenda, progressive ethical and practical thinking converge for the benefit of the planet and its diverse inhabitants—human and nonhuman.

Prioritizing zoonotic diseases using a multisectoral, One Health approach for The Economic Community of West African States (ECOWAS)

Background Zoonotic diseases pose a significant threat to human, animal, and environmental health. The Economic Community of West African States (ECOWAS) has endured a significant burden of zoonotic disease impacts. To address zoonotic disease threats in ECOWAS, a One Health Zoonotic Disease Prioritization (OHZDP) was conducted over five days in December 2018 to prioritize zoonotic diseases of greatest regional concern and develop next steps for addressing these priority zoonoses through a regional, multisectoral, One Health approach. Methods The OHZDP Process uses a mixed methods prioritization process developed by the United States Centers for Disease Control and Prevention. During the OHZDP workshop, representatives from human, animal, and environmental health ministries from all 15 ECOWAS Member States used a transparent and equal process to prioritize endemic and emerging zoonotic diseases of greatest regional concern that should be jointly addressed by One Health ministries and other partners. After the priority zoonotic diseases were identified, participants discussed recommendations and further regional actions to address the priority zoonoses and advance One Health in the region. Results ECOWAS Member States agreed upon a list of seven priority zoonotic diseases for the region – Anthrax, Rabies, Ebola and other viral hemorrhagic fevers (for example, Marburg fever, Lassa fever, Rift Valley fever, Crimean-Congo Hemorrhagic fever), zoonotic influenzas, zoonotic tuberculosis, Trypanosomiasis, and Yellow fever. Participants developed recommendations and further regional actions that could be taken, using a One Health approach to address the priority zoonotic diseases in thematic areas including One Health collaboration and coordination, surveillance and laboratory, response and preparedness, prevention and control, workforce development, and research. Conclusions ECOWAS was the first region to use the OHZDP Process to prioritize zoonotic disease of greatest concern. With identified priority zoonotic diseases for the region, ECOWAS Member States can collaborate more effectively to address zoonotic diseases threats across the region using a One Health approach. Strengthening national and regional level multisectoral, One Health Coordination Mechanisms will allow ECOWAS Member States to advance One Health and have the biggest impact on improving health outcomes for both people and animals living in a shared environment.

Twenty years of integrated disease surveillance and response in Sub-Saharan Africa: challenges and opportunities for effective management of infectious disease epidemics

Introduction This systematic review aimed to analyse the performance of the Integrated Disease Surveillance and Response (IDSR) strategy in Sub-Saharan Africa (SSA) and how its implementation has embraced advancement in information technology, big data analytics techniques and wealth of data sources. Methods HINARI, PubMed, and advanced Google Scholar databases were searched for eligible articles. The review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. Results A total of 1,809 articles were identified and screened at two stages. Forty-five studies met the inclusion criteria, of which 35 were country-specific, seven covered the SSA region, and three covered 3–4 countries. Twenty-six studies assessed the IDSR core functions, 43 the support functions, while 24 addressed both functions. Most of the studies involved Tanzania (9), Ghana (6) and Uganda (5). The routine Health Management Information System (HMIS), which collects data from health care facilities, has remained the primary source of IDSR data. However, the system is characterised by inadequate data completeness, timeliness, quality, analysis and utilisation, and lack of integration of data from other sources. Under-use of advanced and big data analytical technologies in performing disease surveillance and relating multiple indicators minimises the optimisation of clinical and practice evidence-based decision-making. Conclusions This review indicates that most countries in SSA rely mainly on traditional indicator-based disease surveillance utilising data from healthcare facilities with limited use of data from other sources. It is high time that SSA countries consider and adopt multi-sectoral, multi-disease and multi-indicator platforms that integrate other sources of health information to provide support to effective detection and prompt response to public health threats.

Antimicrobial resistance national level dialogue and action in Ghana: setting and sustaining the agenda and outcomes

Background Antimicrobial resistance (AMR) has gained national and international attention. The design and launch of national policy on antimicrobial use and resistance and action plan marked a milestone in Ghana’s commitment to control AMR. These strategies are some outcomes of getting and sustaining AMR issues prominence on government’s agenda. Understanding the agenda setting processes, policy actors involved and policy change is important as this provides insights on how and why policy actors defined and framed AMR issues to sustain its prominence despite the changing priorities of government agenda. Objective To examine the processes of setting and sustaining AMR issues on government agenda, the policy actors involved and resulting outcomes. Methods A qualitative study was conducted and data collected through interviewing twenty-four respondents and reviewing technical working group meeting reports and health sector documents. Data was analysed drawing on Kingdon’s agenda setting framework. Result Members of a multisectoral technical working group (AMR platform) formed in 2011 constantly built consensus on AMR problem definition, solutions and actively engaged decision makers to mobilise support and interest. The AMR platform members sustained AMR attention and prominence on government’s agenda through the following multisectoral coordination mechanisms: (1) institutionalising AMR platform activities (2) gathering evidence, sharing findings, and supporting research (3) creating awareness and training (4) gaining and maintaining political support. The activities of the AMR platform contributed to three remarkable outcomes and these are (1) maintained network of AMR Champions, (2) design of a national policy on antimicrobial use and resistance in Ghana (1st edition) and national action plan (2017–2021), and (3) Ghana’s hosting of the second Global call to action on AMR. Conclusion The AMR platform members as influencers concentrated their efforts to move and sustain AMR issues on government agenda. The identified multisectoral coordination mechanisms collectively contributed to agenda setting processes and policy change. The AMR platform engagements are ongoing and it is important the momentum is maintained. As multisectoral coordination and activities are vital especially for AMR ‘One Health’ approach, we hope this paper presents lessons for better understanding of how and why multisectoral groups influence national level agenda setting processes.

South-to-south mentoring as a vehicle for implementing sustainable health security in Africa

Background While sustainability has become a universal precept in the development of global health security systems, supporting policies often lack mechanisms to drive policies into regular practice. ‘On-paper’ norms and regulations are to a great extent upheld by frontline workers who often lack the opportunity to communicate their first-hand experiences to decisionmakers; their role is an often overlooked, yet crucial, aspect of a sustainable global health security landscape. Initiatives and programs developing transdisciplinary professional skills support the increased bidirectional dialogue between these frontline workers and key policy- and decisionmakers which may sustainably narrow the gap between global health security policy design and implementation. Methods The International Federation of Biosafety Associations’ (IFBA) Global Mentorship Program recruits biosafety and biosecurity champions across Africa to provide local peer mentorship to developing professionals in their geographic region. Mentors and mentees complete structured one year program cycles, where they are provided with written overviews of monthly discussion topics, and attend optional virtual interactive activities. Feedback from African participants of the 2019–2020 program cycle was collected using a virtual Exit Survey, where aspects of program impact and structure were assessed. Results Following its initial call for applications, the IFBA Global Mentorship Program received considerable interest from professionals across the African continent, particularly in East and North Africa. The pilot program cycle matched a total of 62 individuals from an array of professional disciplines across several regions, 40 of which were located on the African continent. The resulting mentorship pairs shared knowledge, skills, and experiences towards translating policy objectives to action on the front lines. Mentorship pairs embraced multidisciplinary approaches to harmonize health security strategies across the human and animal health sectors. South-to-South mentorship therefore provided mentees with locally relevant support critical to translation of best technical practices to local capacity and work. Conclusion The IFBA’s South-to-South Global Mentorship Program has demonstrated its ability to form crucial links between frontline biosafety professionals, laboratory workers, and policy- and decision-makers across several implicated sectors. By supporting regionally relevant peer mentorship programs, the gap between health security policy development and implementation may be narrowed.

The vital importance of a web of prevention for effective biosafety and biosecurity in the twenty-first century

Biological threats are complex and multifaceted, as evidenced by the ongoing COVID-19 pandemic. Their effective prevention and countering require multiple lines of collaborative action and sustained cross-sectorial coordination. This paper reviews the conclusions of Graham Pearson’s 1997 JAMA article titled ‘The Complementary Role of Environmental and Security Biological Control Regimes in the 21st Century’, taking into account the international policy developments that have occurred over the past two decades. The paper underscores the utility of the concept of a ‘web of prevention’ for elucidating the need for continuous interaction between the international biosafety and international biosecurity regimes, in order to ensure that the life sciences are used only for peaceful purposes. The terms ‘biosafety’ and ‘biosecurity’ are used to denote the primary purpose of the two regimes: the international biosafety regime seeks to prevent the unintentional (accidental) release of pathogens and toxins, including naturally occurring disease, whereas the biosecurity regime seeks to prevent the deliberate release and misuse of pathogens and toxins. The paper concludes by recommending practical steps for strengthening the implementation of all elements of the web of prevention and upholding the norms against the hostile misuse of life sciences.