Breaking institutional barriers to enhance women's participation in and benefit from the Peste des Petits Ruminants and Newcastle Disease vaccine value chains for Sembabule district of Uganda.

This paper describes the institutional context that shapes the visibility and positioning of women along the Peste des Petits Ruminants (PPR) and Newcastle Disease (ND) vaccine value chains for Sembabule district of Uganda. It examines the institutional barriers and opportunities that affect women's empowerment derived from inclusion of women in the decision-making processes along the livestock vaccine value chain (LVVC) and that can support viable women-centered and owned enterprises, at the vaccine development, delivery, distribution and use level. Qualitative data analysis tools such as focus group discussions, focus meals, jar voices and key informant interviews were used. Using outcome mapping, a stakeholder analysis of the critical partners in the PPR and ND value chain was done involving the regulators, vaccine manufacturers, importers, distributors, agrovets, public and private veterinary service deliverers, local leaders, women groups, and farmers. The study concluded that training related to gender equality and livestock vaccines, infrastructural and technical support to the poultry and goat women and men farmers and other chain actors are inadequate in themselves to increase vaccine adoption and improve livestock productivity in Sembabule district. Strategies that promote gender-transformative collaborative efforts among the LVVC actors and build viable gender-transformed women groups and networks are critical to increase women's participation in and benefit from the livestock vaccine value chain.

Using Outcome Mapping to Mobilize Critical Stakeholders for a Gender Responsive Rift Valley Fever and Newcastle Disease Vaccine Value Chain in Rwanda.

Approximately 752 million of the world's poor keep livestock to produce food, generate income, and build assets. Women represent two-thirds (~400 million people) of low-income livestock keepers. Infectious diseases are a major issue in preventing livestock keepers from optimizing production earnings and improving food security. In Rwanda, highly contagious yet preventable diseases that affect animals that women manage, such as Rift Valley fever in goats and Newcastle disease in chickens have a high-mortality rate and can devastate their herds. Women are disproportionately affected because they bear primary responsibility for goats and chickens. These diseases are preventable through vaccination, but smallholder women farmers rarely benefit from livestock vaccines. Social norms and entrenched cultural stereotypes limit women's confidence and decision-making and restrict their access to resources and information. Women smallholder farmers find that there is little support for the small livestock they manage, because of the official preference given to cattle. They are also challenged by limited availability of livestock vaccines due to lack of a cold chain, inadequate extension, and veterinary services, especially for goats and chickens, and unreliable structures for vaccine delivery. To identify opportunities for women's engagement in the livestock vaccine value chain (LVVC) and reduce their barriers to accessing and using livestock vaccines, we used Outcome Mapping, a stakeholder engagement tool, and the Gender Equality Continuum Tool to classify and engage critical partners in the LVVC. We analyzed each critical partner's capacities, incentives, and drivers for engagement with women, challenges and barriers that hinder their support for women farmers, opportunities at systemic and programmatic levels for women's participation and benefit in the LVVC, and the gender capacities and perceptions of different stakeholders. Enhanced positioning and visibility of women in the LVVC can occur through a systemic engagement of all stakeholders, and recognition of the roles that women play. Women smallholder farmer involvement when determining and shaping the potential entry-points is critical to ensure support for their existing responsibilities in family food security, and future opportunities for generating income. Strengthening gender capacities of LVVC stakeholders, addressing identified barriers, and building on existing opportunities can increase women's participation in the LVVC.

Operationalizing the One Health Approach in Uganda: Challenges and Opportunities.

Uganda is considered as a 'hot spot' for emerging and re-emerging infectious disease epidemics. The country has experienced several epidemics including; Ebola, Marburg, plague, Rift Valley fever, yellow fever and Crimean Congo haemorrhagic fever. Epidemics overwhelm health systems, devastate economies and cause global health insecurity. These public health challenges arising from the interaction of humans-animals-environment link require a holistic approach referred to as One Health (OH). OH is the collaborative effort of multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals, and the environment. Given its situation, Uganda has embraced the OH approach in order to be able to predict, prepare and respond to these public health challenges effectively, though still in infancy stages. In this paper, we present major achievements and challenges of OH implementation, and make recommendations for systematic and sustainable OH implementation. Achievements include: formation of the National One Health (NOH) platform with a Memorandum of Understanding between sectors; a national priority list of zoonotic diseases, the NOH Strategic Plan and a One Health communication strategy to strengthen engagement across sectors and stakeholders. There have also been efforts to integrate OH in academia. The challenges are related to inadequate; coordination across sectors, government commitment, advocacy and awareness creation and research. For systematic and sustainable OH engagements, urgent efforts should be made through government support to address current and related future challenges.

Podoconiosis in Rwanda: Knowledge, attitudes and practices among health professionals and environmental officers.

BACKGROUND: Podoconiosis is a neglected tropical disease commonly found in volcanic regions, where soil is rich in silica. It usually manifests as bilateral lower limb edema. The majority of people affected by podoconiosis are farmers who do not wear shoes. The condition was recently documented in all 30 districts in Rwanda but knowledge, attitudes and practices (KAP) of Rwandan health professionals and environmental officers towards podoconiosis are unknown. METHODOLOGY/FINDINGS: The objective of this study was to assess the knowledge, attitudes and practices (KAP) of Rwandan health providers and environmental officers towards podoconiosis in order to improve patient healthcare experiences and health outcomes, and to reduce stigma against affected individuals. To achieve this goal, we administered a KAP assessment to physicians (N = 13), nurses/midwives (N = 59), community health workers (N = 226), and environmental officers (N = 38) in the third highest podoconiosis prevalence district in Rwanda (Musanze). All 336 respondents had heard of podoconiosis, but 147 (44%) respondents correctly identified soil as the only direct cause of podoconiosis. The awareness of signs and symptoms and risk groups was lower than any other category (31.5% and 47.5%, respectively). The overall attitude toward podoconiosis was positive (86.1%), with CHWs least likely to harbor negative beliefs against podoconiosis patients. One particular area where most respondents (76%) expressed negative attitude was that they saw people with podoconiosis as a threat to their own health and their family's health. Prescription of antibiotics and use of ointments/soap to manage wounds was low (5% and 32.2%, respectively), in part due to supply shortages at health facilities. CONCLUSIONS: This study identified clear gaps in health provider knowledge and practices that affect patient care for those with podoconiosis. Improved access to essential medicines at health facilities and podoconiosis-focused training sessions for practicing health providers are necessary to minimize the burden and stigma of affected individuals.

Equity for health delivery: Opportunity costs and benefits among Community Health Workers in Rwanda.

Community Health Workers (CHWs) play a vital role delivering health services to vulnerable populations in low resource settings. In Rwanda, CHWs provide village-level care focused on maternal/child health, control of infectious diseases, and health education, but do not receive salaries for these services. CHWs make up the largest single group involved in health delivery in the country; however, limited information is available regarding the socio-economic circumstances and satisfaction levels of this workforce. Such information can support governments aiming to control infectious diseases and alleviate poverty through enhanced healthcare delivery. The objectives of this study were to (1) evaluate CHW opportunity costs, (2) identify drivers for CHW motivation, job satisfaction and care provision, and (3) report CHW ideas for improving retention and service delivery. In this mixed-methods study, our team conducted in-depth interviews with 145 CHWs from three districts (Kirehe, Kayonza, Burera) to collect information on household economics and experiences in delivering healthcare. Across the three districts, CHWs contributed approximately four hours of volunteer work per day (range: 0-12 hrs/day), which translated to 127 684 RWF per year (range: 2 359-2 247 807 RWF/yr) in lost personal income. CHW out-of-pocket expenditures (e.g. patient transportation) were estimated at 36 228 RWF per year (range: 3 600-364 800 RWF/yr). Participants identified many benefits to being CHWs, including free healthcare training, improved social status, and the satisfaction of helping others. They also identified challenges, such as aging equipment, discrepancies in financial reimbursements, poverty, and lack of formal workspaces or working hours. Lastly, CHWs provided perspectives on reasonable and feasible improvements to village-level health programming that could improve conditions and equity for those providing and using the CHW system.

Pesticide Application Practices and Knowledge among Small-Scale Local Rice Growers and Communities in Rwanda: A Cross-Sectional Study.

BACKGROUND: Agriculture contributes a third of Rwanda's GDP and is the main source of income for rural households, with 80% of the total population involved in crop and/or livestock production. The Government of Rwanda established the Muvumba rice project in 2011 amidst a policy shift towards rice as a national staple crop. However, the indiscriminate use of pesticides by local, low-income rice growers has raised concerns about potential human, animal and ecosystem health impacts as pesticide distribution and application are not strictly regulated. Although pesticide use can directly influence farmer health and ecosystems, little is known about small-scale farmers' pesticide application practices and knowledge. We aimed to assess local application practices and understanding of pesticides to identify gaps in farmers' knowledge on safe pesticide use and deviations from established standards and recommended practices. METHODS: We conducted a cross-sectional study consisting of observations of pesticide practices and interviews with 206 small-scale rice growers in Nyagatare District, Rwanda, in March 2017. Descriptive statistical analyses (sample means, standard deviation and range) were performed, and we evaluated the association between farmers' personal protective equipment (PPE) use and their education level and literacy status. RESULTS: Over 95% of observed farmers did not comply with minimum standards for safe pesticide use, and 80% of respondents reported that they stored pesticides in their homes without personal protection measures. Education and literacy level were not significantly associated with PPE use. Additionally, 90% of respondents had experienced adverse health effects after using pesticides including intense headache, dizziness, stomach cramps, skin pain and itching, and respiratory distress. All respondents also reported animals in and around the rice scheme (cattle, birds, and fish) behaving abnormally or with signs consistent with pesticide exposure in the six months preceding the study, which may be linked to pesticide-contaminated water. CONCLUSIONS: Our study demonstrates potential for high exposure to pesticides for farmers, their families, and animals sharing rice-growing or downstream environments and points to the need for training on safe and effective pesticide use.

Building a framework for the design and implementation of One Health curricula in East and Central Africa: OHCEAs One Health Training Modules Development Process.

•Identification of One Health Core Competencies for Africa•Development of One Health training modules for a multidisciplinary workforce•Integration of One Health competencies into courses and curricula•A framework for the design and implementation of One Health curricula for professionals who impact disease detection prevention and response.

Producing Interdisciplinary Competent Professionals: Integrating One Health Core Competencies into the Veterinary Curriculum at the University of Rwanda.

Infectious diseases of grave concern to human health are emerging from wildlife and livestock populations in multiple regions of the world. Responding effectively to these emerging pandemics requires engagement of multidisciplinary groups of professionals. Using a One Health approach, One Health Central and Eastern Africa (OHCEA), a network of seven schools of public health and seven veterinary schools, with the support of the United States Agency for International Development (USAID), has engaged in curriculum review with the aim of building the skills of multidisciplinary groups of professionals to improve their capacity to respond to emerging infectious diseases. Through stakeholder analysis and curriculum development workshops, the University of Rwanda's School of Veterinary Medicine, in association with Tufts University, revised its curriculum to incorporate One Health competencies to be better prepared to respond to any infectious disease outbreak in Africa. The revised curriculum aimed to build cross-sectoral skills and knowledge; transform students' ways of thinking about infectious disease outbreak response; link human, veterinary, and wildlife health training opportunities; and strengthen community frontline responder training. Eight different disciplines engaged in the curriculum review process: Veterinary Medicine, Livestock Production, Wildlife and Aquatic Resources, Environmental Health and Epidemiology, Communication Technology, Engineering, Agriculture, and Public Health. One Health competencies such as communication, collaboration, leadership, and advocacy were added to the new curriculum, helping ensure that each professional be appropriately equipped with skills to recognize and respond effectively to any emerging infections.

A One Health, participatory epidemiology assessment of anthrax (Bacillus anthracis) management in Western Uganda.

Sporadic anthrax outbreaks have occurred in and around Uganda's Queen Elizabeth National Park (QENP) for years, affecting wildlife, domestic animals, and humans. Reported outbreaks (2004-2005 and 2010) in QENP collectively killed over 500 wild animals and over 400 domestic animals. A 2011 outbreak in Sheema district temporarily froze local markets while killing two humans and seven bovines. One Health is multidisciplinary at its core, yet studies sometimes focus on the effects of animals on human health to the detriment of investigating the surrounding ecological and cultural contexts. Participatory methods connect problems - such as disease - to their context. A multidisciplinary team used participatory epidemiology and conventional structured questionnaires to investigate the impacts of anthrax on human livelihoods and the related perceptions of conservation, public health, and veterinary health efforts in the QENP area. Proximities to previous anthrax outbreaks and to QENP were treated as risk factors in the collection and evaluation of data. Participants' feedback indicates that anthrax prevalence may be greater than officially reported. Community member perceptions about anthrax and other diseases appear to be more closely related to their proximity to QENP than their proximity to anthrax outbreaks. Neither risk factor had a strong effect on knowledge of disease, nor any effect on behaviors associated with disease response or control. Instead, participants reported that social pressures, the economics of poverty, and the lack of health and veterinary infrastructure highly influenced responses to disease. The complex connections between the social needs and the economic context of these communities seem to be undermining current anthrax control and education measures. This livelihood-based decision-making may be unlikely to respond to educational intervention alone. This study provides a strong base for further research and for improvements in effective disease control.

Bacillus subtilis: a temperature resistant and needle free delivery system of immunogens.

Most pathogens enter the body through mucosal surfaces. Mucosal immunization, a non-invasive needle-free route, often stimulates a mucosal immune response that is both effective against mucosal and systemic pathogens. The development of mucosally administered heat-stable vaccines with long shelf life would therefore significantly enhance immunization programs in developing countries by avoiding the need for a cold chain or systemic injections. Currently, recombinant vaccine carriers are being used for antigen delivery. Engineering Bacillus subtilis for use as a non-invasive and heat stable antigen delivery system has proven successful. Bacterial spores protected by multiple layers of protein are known to be robust and resistant to desiccation. Stable constructs have been created by integration into the bacterial chromosome of immunogens. The spore coat has been used as a vehicle for heterologous antigen presentation and protective immunization. Sublingual (SL) and intranasal (IN) routes have recently received attention as delivery routes for therapeutic drugs and vaccines and recent attempts by several investigators, including our group, to develop vaccines that can be delivered intranasally and sublingually have met with a lot of success. As discussed in this review, the use of Bacillus subtilis to express antigens that can be administered either intranasally or sublingually is providing new insights in the area of mucosal vaccines. In our work, we evaluated the efficacy of SL and IN immunizations with B. subtilis engineered to express tetanus toxin fragment C (TTFC) in mice and piglets. These bacteria engineered to express heterologous antigen either on the spore surface or within the vegetative cell have been used for oral, IN and SL delivery of antigens. A Bacillus subtilis spore coat protein, CotC was used as a fusion partner to express the tetanus fragment C. B. subtilis spores known to be highly stable and safe are also easy to purify making this spore-based display system a potentially powerful approach for surface expression of antigens. These advances will help to accelerate the development and testing of new mucosal vaccines against many human and animal diseases.

Sublingual immunization with an engineered Bacillus subtilis strain expressing tetanus toxin fragment C induces systemic and mucosal immune responses in piglets.

UNLABELLED: Sublingual (SL) and intranasal (IN) administration of a Bacillus subtilis-based tetanus vaccine was tested in piglets, which more closely mimic the human immune system than mice. Piglets were immunized by the SL, IN or oral routes with vaccine expressing tetanus toxin fragment C, or commercial tetanus vaccine given by intramuscular injection as a control. Tetanus toxoid specific ELISA and passive neutralization tests were used to measure IgG and IgA levels in serum and mucosal secretions, and assess protective serum antibodies, respectively. The nature of the immune response was explored by MHC Class II, TGF-ß1 expression, and ELISA assays for multiple cytokines. SL or IN immunization of piglets induced neutralizing tetanus toxoid specific serum antibody and local salivary and vaginal IgA responses. Standard tetanus vaccine resulted in systemic antibodies, whereas oral administration of the Bacillus-based vaccine was ineffective. Further analyses indicated a balanced Th1/Th2 response to SL or IN immunization. CONCLUSION: This study demonstrates for the first time that SL or IN administration is effective for inducing both systemic and mucosal responses in a piglet model, indicating that SL or IN delivery of a B. subtilis-based tetanus vaccine can be a simple, non-invasive, low cost strategy to induce immunity to tetanus.