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Control of "Neglected" Zoonoses: One Health approaches for securing health and livelihoods in developing countries

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GRF One Health Summit 2012, Davos: Presentation by Susan Welburn, University of Edinburgh, United Kingdom

GRF One Health Summit 2012, Davos: Presentation by Susan Welburn, University of Edinburgh, United Kingdom

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Control of "Neglected" Zoonoses: One Health approaches for securing health and livelihoods in developing countries Control of "Neglected" Zoonoses: One Health approaches for securing health and livelihoods in developing countries Presentation Transcript

  • Control of "Neglected" Zoonoses:One Health approaches for securing health and livelihoods in developing countries Anna Louise OKELLO & Susan WELBURN GRF Davos One Health Summit 19-22nd Feb 2012 Session WE 3.2: Public Health and Livelihoods
  • One Health in a Changing World• Offers the opportunity to link people, animals and environment (physical, human and social) across Public and Private sectors• The 21st century of “health uncertainties” will require a “new culture of collaboration” that recognises the essential link between human, domestic animal and wildlife health and the threat disease poses to people, their food supplies and economies, and accepts that biodiversity is essential to maintaining health.• Ecosystem health demands effective integration of ecology including disease ecology with the social and health sciences.• ‘One Health’ seeks to shift the paradigm from an "individual," or "disease centered," approach to a "system," or "community based," “whole of society” approach.
  • The Challenge• One Health presents a challenge for low resource countries that require improved human, livestock and ecosystem health that will link improvements in livestock production to better human and community health.• The condition of many of our ecosystems is changing dramatically altering the way human populations function rapidly in the developing world.Unknown knowns• What are the effects of landscape configurations on the spread of certain diseases, particularly those associated with animal vectors?• What landscape and human settlement patterns mitigate disease spread?• What strategies can keep systems from becoming pathological?
  • World Hungerhttp://www.un.org/Pubs/chronicle/2001/issue3/0103p15.html
  • Major neglected zoonotic diseases - Hot Spots? Open-ended List of "NZDs" EUR EMR Brucellosis Echinococcosis Anthrax Multilocular Brucellosis Bovine tuberculosis AMR Echinococcosis Rabies SEAR/WPR Brucellosis Rabies Z.Leishmaniasis Rabies Rabies Echinococcosis Cysticercosis/taeniosis AFR Echinococcosis Cysticercosis Rabies Trematodoses Echinococcosis/Hydatidosis Leptospirosis Echinococcosis Cysticercosis Brucellosis Zoonotic trypanosomiasis Cysticercosis, Leptospirosis B.tuberculosis Zoonotic Brucellosis leishmaniasis B.Tuberculosis Rabies Z. TrypanosomiasisSpotlight on Neglected Tropical DiseasesThe Royal Society of Medicine, Saturday 28 November 2009, London, UK
  • The Forgotten Zoonoses are endemic Disease of PovertyUnintended consequence system of prioritization (DALYs)Funding, while logical neither fair or sensibleEvidence base is poorDifficulties in defining the burden of these diseasesGross under-reportingDivision of responsibility between medical and veterinary sectors is a barrier tosustainable controlPrivatisation of veterinary services e.g. in Uganda - too much too soon and animaldisease control slipped awayZoonotic disease control fell between cracks medical and veterinary servicesExpose failings in Community Public Health
  • Case StudySleeping Sickness - The great epidemic 1896 - devastating epidemic of Sleeping sickness in Uganda killed an estimated 300,000 people
  • Wish you were here?By 1908 1/3 population Busoga dead (300,000 people)
  • In 1909 Governor Bell ordered evacuation from Lake Shore
  • Case Study Sleeping Sickness Scene set for Control 100 years AgoIdentified agentSuspected that there were 2 forms of disease - sleeping sicknessIdentified the vectorAcknowledged infection could pass to animalsTreatment proposed – Robert Koch using Atoxyl Uganda 1906But no tools were available to control the disease
  • Case Study Sleeping Sickness Management and FinanceAfter a series of epidemics (1950 and 1980) a One Health body was establishedby the Government of Uganda. COCTU – Co-ordinating office for Control ofTrypanosmiasis UgandaTextbook case of One Health = representation from MoH, MoAFF, Ministry ofFinance, Vector ControlMedical, veterinary, social scientist, economists, vector biologists, wildlifespecialists, geosciences epidemiology. What was missing?
  • Sleeping sickness casesin affected villages,1987Tororo, Butaleja andBusia districts
  • 1988Tororo, Butaleja andBusia districts
  • 1989Tororo, Butaleja andBusia districts
  • 1990Tororo, Butaleja andBusia districts
  • 1991Tororo, Butaleja andBusia districts
  • 1992Tororo, Butaleja andBusia districts
  • 1993Tororo, Butaleja andBusia districts
  • 1994Tororo, Butaleja andBusia districts
  • 1999 – Emerging Public Heath Crisis in UgandaT. b. rhodesiense spreading towards T. b. gambiense
  • HAT moving around shores of Lake Kyoga 100 km8 districts in 8 years - 18 districts now affected
  • cattle market focus to new areasFevre et al., Lancet 2001  70 cases in 18 months  Cases near ‘Brookes Corner’  Cattle restocking was moving Kyoga from cattle market traffic  Area never before at risk for HAT  Disease was moving around Lake infected animals from established  1st human case reported Dec 1998 N u m Number of cases b e r o f c a s e s 0 5 10 15 20 25 30 D e c - 9 8 J a n - 9 9 F e b - 9 9 M a r - 9 9 A p r - 9 9 M a y - 9 9 J u n - 9 9 - J u l 9 9 A u g - 9 9 S e p - 9 9 O c t - 9 9 N o v - 9 9 D e c - 9 9 J a n - 0 0 F e b - 0 0 M a r - 0 0 Soroti Outbreak - 2000 A p r - 0 0 Month M a y - 0 0 Month J u n - 0 0 - J u l 0 0 A u g - 0 0 S e p - 0 0 O c t - 0 0 N o v - 0 0 D e c - 0 0 J a n - 0 1 F e b - 0 1 M a r - 0 1 A p r - 0 1 M a y - 0 1 J u n - 0 1 - J u l 0 1 A u g - 0 1
  • a Tira 68 a Mela 32 a Papol 371 a Tira 17 b BWP 1 c AKOC43 a Mawero 80 Parasites in cows human infective a Mawero 85 a Bumanda 25 a Magola 18 a Iyolwa 116 In 2001 SRA (serum resistance associated a Mela 3 a Buteba 135 a Iyolwa 147 a Katerima 311 gene) identified and adapted to field tool a Iyolwa 125 a Mawero 32 a Mela Pig1 a Mela Pig2 c AKO C8 a Fly 97 a Tira 27 a Bumanda 146 a Mawero 65 c AKOC 15 c AKOC20 c LIRI 31 c LIRI 26 c LIRI 30 c LIRI 37 c LIRI 24 c LIRI 39 c LIRI 16 c LIRI 25 a Mela 27 a UGE a Mawero 31 a UGI a Mela 2 a UGJ a UGH a Mawero 66 a Katerima 116 a Mawero 42 a Eoketch a UGC a UGG 88 a UG 89/1 SRA a UGM c AKOC16 c LIRI 14 a Fly 73 a Papol 278 a UG 89/8 a Mapollo a Fly 48 a UGL b Kinuhw b kinuc21 b bugh1 a Pmasaba a Maaja a Htaka a Fnamuiza a UGK a UGC 88 a UGB 88 a UGA 88 a UGA a UG 89/9 a UG 89/5 a UG 89/3 a UG 89/2 a Mela 71 a UG 89/10% similarity 70% 80% 90% 100% Welburn et al., Lancet 2001, 2005
  • In Practice - Cattle in Sitengo village carrying human infective parasites T. b. rhodesiene (SRA PCR).
  • Stamp Out Sleeping Sickness – PPP Model Beautiful Danger by Christ’l Van Puijenbroeck
  • Stamp Out Sleeping Sickness – PPP Model Beautiful Danger by Christ’l Van Puijenbroeck
  • Stamp out Sleeping Sickness – Phase ICost – effective intervention for Zoonotic sleeping sickness1. Treat the 250,000 in cattle high risk zone with trypanocide2. Prevent re-infection by follow on application of RAP method ‘pour-on’ insecticides N4. Stop market introductions by reinforcement of Government policy for point of sale treatment4. Community One Health Messaging SOS Phase 1 SOS Phase 2PPP PartnersIndustri Kapital/ IKARE, CEVA Sante Animale, DFID RIU, WHO, COCTUUniversity of Makerere/ University of Edinburgh.
  • SOS Phase 1 - Emergency intervention 2006/2007 1.Remove reservoir of SOS human parasite in cattle 2.Provide follow-up treatmentsPhysical Challenge I – 250,000 treatments across 5 districtsCEVA Sante animale provides drugs for the exercise.IK/IKARE provided the finance for animal treatments.Makerere Vet School – final year cohort to provide assistance to DVO systemat community level as part of training at a cost of $1US per animal treated.DFID – Monitoring and Evaluation
  • Challenge II – TechnologicalHow to Sustainably Prevent re-infection
  • Restricted application - innovation  Tsetse mostly feed on legs and belly of cattle  Half of all feeds are on cow  Insecticide (dip formula) applied to tsetse predilection sites  Cattle act as live baits  Monthly application maintained prevalence <1% all trypanosomes  No re-infection with T. brucei over 6 month trialAffordable (10 cents), quick, effective and convenient addedbonus - kills ticks Torr and Vale, University of Greenwich
  • SOS Phase I - Achievements  Approximately 250,000 cattle treated in 5 districts  75% reduction of all trypanosomes in cattle (human and cattle pathogens)  Far fewer sleeping sickness cases after rains – cases clustered near markets  Northwards spread of sleeping sickness contained – no epidemic  First time undergraduate vets exposed to in-field experience/community service PROOF OF CONCEPT ESTABLISHED
  • SOS Phase I - Challenges  Challenge of spreading SOS message underestimated  Some community level resistance due to lack of communication  Farmers sometimes confused as also other activities occurring  Difficulties in ensuring continuous product supply, also into remote areas  Cross talk between medical and veterinary and vector control does not translate into action  Treatment at point of sale not undertaken – continued re-infection
  • Evolution of SOS – building sustainability Emergency intervention + follow- 2006/2007 SOS up treatments Establishment of InTracs Building sustainability 3V Vet Initiative Creating awareness 2008 Provision of vet serviceSolution3V Vet Initiative – sustainable veterinary entrepreneurship
  • SOS - 3 V Vet initiative 5 graduate vets recruited Each vet allocated an district/area (territory) Job descriptions and clear work agenda put in place Map activities and actors in area – establish contacts – build trust Ability to move about and reach all corners of territory Establish a spray person network to increase outreach of spraying activity
  • SOS initiative – outputs Emergency 2006/2007 SOS intervention + follow- up treatments 250,000 cattle treated InTracs Building sustainability 2008 3V Vets Creating awareness 1.7 million peopleSpray peopleApprox. 80 Job creation: 3V Vets Improved health & wealth Private vets & 20% of cattle in now 2009/2010 regularly treated – shops Farmer pays for CPH
  • Parallel ‘unexpected’ developments Incorporation of in-field activity and community service into Vet Med Curriculum – Institutional change AFRESA - MINTRACS Incorporation of SOS activities into Governments 5 year plan “Prosperity for All” 3V Vets identified un-tapped markets Closer One Health working relationship with MOH, MAIFF Development of Tripartite plan for the NZDs elimination of zoonotic ss within 10 year time frame (Uganda case example).
  • Phase II Roll-out of SOS activities under Mintracs to neighbouring Soroti District- Additional 175,000 cattle have targeted in first round Roll-out of 3 V Vet initiative in parallel- 5 new Vets recruited Adopt more integrated and holistic approach – veterinary students, medicine students, agriculture students working with communities BUT Treatment of animals at point of sale needs to be reinforced POLICY REINFORCEMENT AND ADVOCACY
  • 3 V Vet Entrepreneurship – AH distribution network KAABONG YU E MB MOYO K G IT UM KOBOKO ADJUMANI KOTIDO OLUFFE GULU PADER NWOYA GULU PADER ABIM MOROTO NWOYA MOROTO 450000 540000 630000 NEBBI OYAM x x { { LIRA x { AMU IA R x { APAC x { DOKO O LL BU IS LI A MASINDI x x { { x { x { KATAKWI x { K KABERAMAIDO ABERAMAIDO N APIRIPI RI AK AMOLATAR x { SOROTI N PADER HOIMA x { KUMI N AS AK ONGO A L KAPCHO WA R BUKWA GULU PALLISA S O IR NKHO KAMULI KALIRO ABIM N AS E AK EK KAYUNGA PALLISA Animal Drug K O IB GA KALIRO BUNDIBUGYO KAMULI M ALE B W E K ALE IB BUSIKI LUWERO IGANGA T0 O O R R distribution network KYENJOJO MUBENDE BUGIRI KABAROLE M TYAN I A JINJA S MAYUGE BUSIA MUKONO KAMPALA KAMWENGE K ES AS E SEMBABULE M G PI I WAKISO NWOYA IBANDA K U RA IR HU MOROTO 450000 450000 OYAM MASAKA BUSHENYI RU NGIRI KU KALANGALA { x LIRA RAKAI { xK UNG AN U IS N O I GIR NTUNGAMO KABALE { x AMURIA { x APAC { x DOKOLLO MASINDI { x { x { x { x KATAKWI { x KABERAMAIDO { x AMOLATAR SOROTI Legend 360000 360000 { x KUMI { x Drug Distribution point Water bodies NAKASONGOLA Protected areas District boundaries PALLISA KAMULI SIRONKHO NAKASEKE KAYUNGA PALLISA 20 0 20 Kms 450000 KALIRO 540000 630000
  • Private Sector - Why SOS?  Initially seen as a CSR effort… Assessed as ”Investment case” Sense of Urgency – due diligence ”soft” – active engagement Strong and Alignment of – plan, budget and execute active partners interest – assign responsibilities and deliverables – leverage knowledge and networks – monitor, monitor, monitor – solve problems as they occur and adjust
  • Platform for scaling-up “ 3 V Vet “ activity has created awareness, pull for products and spray demand 80 spray team businesses set up with micro-financing attached 150,000 cattle currently commercially sprayed on regular basis 3 V Vets established their own businesses and distribution networks Possible to address both improving health and creating jobs/improving wealth in one go Closer working relationship medics and vets and underpinning of COCTU Zoonotic SS flagged for elimination in Uganda in 10 years by WHO Looking to Social Investment Bonds for long term investment  SOS TOOL KIT IN PLACE
  • Combined societal / economic viewpoint Patient and Livestock patient’s keepers and household animal owners Government Private health veterinary & Governmenth care providers extension ealth service services Private veterinary care providers Acknowledgement, Alex Shaw
  • Combined societal / economic viewpoint Patient and Livestock patient’s keepers and household animal owners Government Private health veterinary & Governmenth care providers extension ealth service services Private veterinary care providersis the basis on which government, donors, NGOs should allocate resources
  • SOS - Persuasive Rates of return on investmentAssumptions about the rate at which an unchecked epidemic wouldexpand are based on previous experience and expert opinionIn 2009, without the SOS intervention, it is likely that we would haveexperienced some 4000 new cases (majority under-reported)WHO suggest these would treble annually, in this projection weconservatively assume they may doubleThe figures of between 0.4 and 1.6 million DALYs averted (or extra lifeyears gained) are realisticIn addition between $15 and $60 million dollars of health careexpenditure for patients and the health services have been savedWhen a money value is given to the DALYs, similar to the value ofGNP, these figures increase to a staggering $100 - $400 millionShaw & WelburnDFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’
  • Health Implications for a 20-year scenarioThe implications in terms of human life and money, can be saved by SOSapproaches, here for 4 scenarios regarded as likely by WHO’s experts Maximum $ million Economic* annual Million health total: number of Year What happens DALYs costs $ million new cases reached thereafter averted saved saved Reduce by 1/4 each 30,000 2012 year 1.55 $57.63 $367.25 Reduce by 1/4 each 20,000 2012 year 1.14 $42.52 $275.47 Reduce by 1/2 each 20,000 2012 year 0.75 $28.17 $194.88 Reduce by 1/2 each 10,000 2011 year 0.39 $14.50 $103.25 *Discounted at 5% per annum and valuing 1 Disability adjusted life year (DALY) at $340DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’
  • SOS - Persuasive Rates of return on investmentAssumptions about the rate at which an unchecked epidemic wouldexpand are based on previous experience and expert opinionIn 2009, without the SOS intervention, it is likely that we would haveexperienced some 4000 new cases (majority under-reported)WHO suggest these would treble annually, in this projection weconservatively assume they may doubleThe figures of between 0.4 and 1.6 million DALYs averted (or extra lifeyears gained) are realisticIn addition between $15 and $60 million dollars of health careexpenditure for patients and the health services have been savedWhen a money value is given to the DALYs, similar to the value ofGNP, these figures increase to a staggering $100 - $400 millionShaw & WelburnDFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’
  • SOS – Animal Health rates of returnRestricted application RAP @ 12x applications/ annum results in average gain20$ per bovine/year (maximum 30-40$ fertile female or working bull).Approximately 9 - 10,000$ gained per square km ‘productive land’15% RAP coverage is sufficient to drive Ro < 1 - 20% head of population needs treatmentresulting in a gain for 150,000 head @ 3.75M$/yr but since protection afforded incommunity at herd level this translates to = 22.500M$ per year.Shaw & Welburn - DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’
  • Combined societal / economic viewpoint Patient and Livestock patient’s keepers and household animal owners GovernmentPrivate health veterinary & Governmenth ONE HEALTH?care providers extension services ealth service Private veterinary care providers Acknowledgement, Alex Shaw
  • POLICY AND ADVOCACY Treatment of animals at point of sale needs to be reinforced
  • Added ValueLong term capacity buildingIntervening to control the forgotten zoonoses may be the catalyst to link thedrivers for change and lessons that have evolvedEmerging to EndemicMove from ‘crisis response’ to a long term strengthening of public health systemsAd hoc inter-ministerial task forces formed during zoonotic disease outbreaks e.g.anthrax and rift valley fever, should be formalised into long-standing platforms forrisk analysis and prevention for a range of endemic disease support this evolutionIntegrated Control of Neglected Zoonoses can pull together Animal Health +Development + Human Health public actors but to achieve the necessaryimpact for change need to work with Private Sector
  • The role of Private sector - Lessons from NTDs Novartis Merck & Co Inc Continuing commitment to MDT for Mectizan for as long as needed for leprosy;triclabendazole for fascioliasisonchocerciasis and filariasis in Africa Johnson & Johnson Mebendazole for intestinal worms GlaxoSmithKlineAlbendazole for lymphatic filariasis at least to 2020 Medpharm (generic manufacturer) Praziquantel via Canadian voluntary funds (0.20 US$/treatment) Pfizer Azithromycin for trachoma 120 Sanofi Aventis million doses Support for drugs for sleeping sickness treatment
  • Ceva Sante Animale
  • Improving human healthand animal productionthrough scientificinnovation and publicengagement1.Build Evidence base2.Underreporting - value3.Intervention solutions4.Cost effectiveness5.One Health Solutions6.Case study FrameworksWHO BENEFITS AND WHO PAYS?
  • ICONZ: transforming weaknesses into strengthsGeographically Cheaper to clustered control Benefits ofCurrently greatly control higherUnder-reported than thought Can offer more optionsNeed to control for controlIn people and animals Dual costs bring dual benefits
  • ICONZ Case Studies Uganda, Mozambique, Nigeria, Mali, Morocco, Tanzania Zambia Anthrax, Rabies, Leishmaniasis, Echinococossis, Zoonotic trypanosomiasis, Brucellosis, Cysticercosis and Bovine TB. Teams comprising medics, vets, biomedical scientists In country partnerships with human animal health service providers Partnerships with other groups (research and control) International Agencies, NGOs, NFP, Civil society) Sound epidemiological, social and economic frameworks Models for case studies that can be extended and applied to other systems Public Engagement in disease control
  • ICONZ in 2015 Able to calculate cost-effectiveness of a number of control strategies from the point of view of human health in $ / DALY averted Developed a case study framework that can be rolled out to other setting to establish community burdens of zoonoses Better knowledge of costs to animal health so that could look at benefit-cost to livestock sector of control strategies Have explored practical ways of combining these measures to look at the total societal cost and examine overall cost- effectiveness Have recommendations on how veterinary and medical sectors could most effectively share costs
  • Can we quantify the total societal cost? ESTIMATING INCIDENCE: surveys, better reporting estimates of under-reporting QUANTIFYING DISEASE IDENTIFYING GROUPS BURDEN: AT RISK: DALYS for people Individual factors for economic impact for people & animals, livestock geography, povertyHow high can the benefits of control be? Acknowledgement, Alex Shaw
  • OUTPUTS EVIDENCE Papers into policy*Partnerships build evidence One Policy to planning and Practice informs evidence Health practitioners gaps/ needs Training into programmes Practice to people
  • Positive Indications for OH• National/ regional platforms established as a result of HPAI investments may lead to long term intersectoral collaboration for other zoonotic diseases e.g. sleeping sickness and rabies.• After 5 years of cooperation on emerging diseases, One Health is evolving towards the federation of vet and health services.• Added value of Community Public Health is starting to be factored into interventions.• Accelerating science and knowledge base• Emerging funding models (Global Fund, Gates Foundation)• Political commitment• Increasing engagement with Private sector – PP ownership of problem
  • ICONZ Concept‘Endemic diseases’ of ‘poor countries’ are ‘forgotten’ diseases’Collection of evidence needed for effective MGT1. NZDs selectively affect poor families in poor and marginalised communities2. Because of under-reporting their apparently low incidence is an illusion in many cases3. Diseases cluster in certain communities and amongst identifiable groups at risk4. In these communities they impose a dual burden on human and animal (mainly livestock) health5. Relatively simple and often low-cost tools exist to control most NZ (although there are deficiencies)6. Much can be achieved with health education and control of the animal reservoir
  • ICONZ – Interventions Mozambique – Cysticercosis Nigeria - Brucellosis and Bovine TB– BACTERIAL Intervention vaccine Brucellosis Mali – Rabies and Leishmaniasis Morocco - Rabies, Leishmaniasis, Echinococossis– DOG Intervention – dog vaccine trial for Echinococossis Tanzania - Brucellosis and Bovine TB.– BACTERIAL Intervention vaccine Brucellosis Zambia - Cysticercosis and soil transmitted helminths– PIG Intervention – Community Led Total Sanitation + OXF Uganda – Zoonotic Trypanosomiasis– VECTOR Intervention – Restricted application