One Health Priorities: Advancing Veterinary Public Health in Latin America and the Caribbean.

One Health (OH) is an integrative approach to human, animal, and environmental health and can be used as a comprehensive indicator for comparative purposes. Although an OH index has been proposed for comparing cities, states, and countries, to date, no practical study has compared countries using this approach. Accordingly, this study aimed to assess OH initiatives using a survey with a veterinary public health focus. The questionnaire contained 104 quantitative questions and was sent to representatives of governmental institutions of 32 countries in the Americas. After exclusion criteria were considered, a total of 35 questionnaires from 17 countries were analyzed, with country names remaining undisclosed during the statistical analyses to protect potentially sensitive information. Principal component analysis (PCA) of health parameters in Latin America and the Caribbean (LAC) as a function of country perception (self-vector) showed that food safety was ranked higher than public policies (p = 0.009), and that both (p = 0.003) were ranked higher than institutional routines related to zoonosis programs. National policies in accordance with international standards, regulations, recommendations, and guidelines was considered the standout topic for public policy, with higher-ranking topics including standard. Meanwhile, challenging topics included tools, preparedness, governance, and research. Food safety showed both strengths and challenges in the coordination of its activities with other sectors. Food safety communication was scored as a strength, while foodborne diseases prevention was ranked as a challenge. Institutional routines for zoonosis maintained both strong and challenging topics in the execution and implementation of attributions and daily routine. Thus, the survey showed that topics such as access to and compliance with international guidelines and intercountry integration were ranked higher than in-country articulation, particularly among food safety, zoonoses, and environmental institutions.

Pre-Exposure Prophylaxis to Prevent Hematophagous Bat-Mediated Rabies Outbreaks in Remote Amazon Communities: Lessons from a Pilot for Public Health Policy.

In 2018, an outbreak of human rabies caused by the hematophagous bat Desmodus rotundus hit the Brazilian Amazon Basin community of Melgaço, Brazil, resulting in the death of 10 people, 9 of them children. The incidence of rabies has been on the rise among populations in conditions of vulnerability in this ecosystem due to human expansion into sylvatic environments and limited access to public health services. To address this issue, in September 2019, a collaborative effort from national, local, and international institutions promoted and executed a pilot for pre-exposure prophylaxis of a population in high-risk areas for hematophagous bat-mediated rabies. This measure is usually only implemented in response to outbreaks. The pilot was conducted in Portel, in a nearby location to the previous outbreak, with the use of fluvial transportation, and 2987 individuals in 411 dwellings were successfully vaccinated. It established a methodology for pre-exposure prophylaxis for populations in conditions of vulnerability, identifying logistics and costs, as well as characterizing the target riverine population regarding risk factors associated with bites by hematophagous bats. This approach offers a proactive measure to prevent future outbreaks and provides valuable insights into how to address the issue of rabies in remote and difficult-to-reach areas.

Livestock and environmental characterization of Colombian municipalities: study of vesicular stomatitis.

Amid the surge in data volume generated across various fields of knowledge, there is an increasing necessity for advanced analytical methodologies to effectively process and utilize this information. Particularly in the field of animal health, this approach is pivotal for enhancing disease understanding, surveillance, and management. The main objective of the study was to conduct a comprehensive livestock and environmental characterization of Colombian municipalities and examine their relationship with the distribution of vesicular stomatitis (VS). Utilizing satellite imagery to delineate climatic and land use profiles, along with data from the Colombian Agricultural Institute (ICA) concerning animal populations and their movements, the research employed Principal Component Analysis (PCA) to explore the correlation between environmental and livestock-related variables. Additionally, municipalities were grouped through a Hierarchical Clustering process. The assessment of risk associated with VS was carried out using a Generalized Linear Model. This process resulted in the formation of four distinct clusters: three primarily characterized by climatic attributes and one predominantly defined by livestock characteristics. Cluster 1, identified as "Andino" due to its climatic and environmental features, exhibited the highest odds ratio for VS occurrence. The adopted methodology not only provides a deeper understanding of the local population and its context, but also offers valuable insights for enhancing disease surveillance and control programs.

Advances in the eradication of foot-and-mouth disease in South America: 2011-2020.

For more than 70 years, the countries of South America have been attempting to eliminate foot-and-mouth disease (FMD), but a regional strategy had not been established by all the affected countries until 1988. The Action Plan 1988-2009 of the Hemispheric Program for the Eradication of Foot-and-Mouth Disease (PHEFA 1988-2009) resulted in an FMD-free status in 88.4% of the bovine population of South America. However, countries of the Andean sub-region maintained an FMD endemic. In addition, sporadic outbreaks in vaccinated cattle populations have been reported in countries of the Southern Cone, endangering the disease-free status in these countries. Within this context, the PHEFA 2011-2020 was approved to eliminate FMD from the subcontinent, and this review describes the most important milestones during its execution. FMD in Ecuador and sporadic outbreaks in the Southern Cone sub-region were effectively eliminated. The outbreaks that occurred in Colombia in 2017 and 2018 were successfully controlled. The type C virus was removed from the vaccines in use in most countries, based on a risk assessment. This review also describes the progress made by the countries advancing toward official recognition as FMD-free in all their territories, with Bolivia, Brazil, and Peru leading the progressive suspension of vaccination to achieve FMD-free status without vaccination. Consequently, at the end of PHEFA 2011-2020, Venezuela was, and still is, the only country in the region whose control program has suffered setbacks, and no evidence has suggested that the transmission and infection of the bovine population have been eliminated. At the end of 2020, a new PHEFA Action Plan 2021-2025 was approved with a five-year horizon, to complete the eradication of the disease in the Americas.

The history of foot-and-mouth disease virus serotype C: the first known extinct serotype?

Foot-and-mouth disease (FMD) is a highly contagious animal disease caused by an RNA virus subdivided into seven serotypes that are unevenly distributed in Asia, Africa, and South America. Despite the challenges of controlling FMD, since 1996 there have been only two outbreaks attributed to serotype C, in Brazil and in Kenya, in 2004. This article describes the historical distribution and origins of serotype C and its disappearance. The serotype was first described in Europe in the 1920s, where it mainly affected pigs and cattle but as a less common cause of outbreaks than serotypes O and A. No serotype C outbreaks have been reported in Europe since vaccination stopped in 1990. FMD virus is presumed to have been introduced into South America from Europe in the nineteenth century, although whether serotype C evolved there or in Europe is not known. As in Europe, this serotype was less widely distributed and caused fewer outbreaks than serotypes O and A. Since 1994, serotype C had not been reported from South America until four small outbreaks were detected in the Amazon region in 2004. Elsewhere, serotype C was introduced to Asia, in the 1950s to the 1970s, persisting and evolving for several decades in the Indian subcontinent and for eighteen years in the Philippines. Serotype C virus also circulated in East Africa between 1957 and 2004. Many serotype C viruses from European and Kenyan outbreaks were closely related to vaccine strains, including the most recently recovered Kenyan isolate from 2004. International surveillance has not confirmed any serotype C cases, worldwide, for over 15 years, despite more than 2,000 clinical submissions per year to reference laboratories. Serology provides limited evidence for absence of this serotype, as unequivocal interpretation is hampered by incomplete intra-serotype specificity of immunoassays and the continued use of this serotype in vaccines. It is recommended to continue strengthening surveillance in regions of FMD endemicity, to stop vaccination against serotype C and to reduce working with the virus in laboratories, since inadvertent escape of virus during such activities is now the biggest risk for its reappearance in the field.

Investigating the temporal and spatial distribution of foot-and-mouth disease virus serotype C in the Region of South America, 1968-2016.

This study investigates the historical temporal trend and geographical distribution of the foot-and-mouth disease virus (FMDv) serotype C in South America; discussing the findings within the context of the actions and strategies carried out for the elimination of foot-and-mouth disease (FMD). This is the first time that such a comprehensive historical compilation has been carried out in the Region; hence, the study is intended as a reference and source of evidence about the presence/absence of FMDv serotype C in South America. Data on the occurrence of FMD were sourced from the Weekly Epidemiological Reports submitted by the countries to Pan American Foot-and-Mouth Disease Center (PANAFTOSA-PAHO/WHO) since 1972, and complemented with other sources of information from the 1968-1971 period. The temporal distribution was examined with local weighted regression (LOESS) to identify two temporal trends, that is, "smoothed" and "over-adjusted", utilising the time-series with the total number of cases per year, at Regional level. Thereafter the outbreaks were aggregated by decades and mapped by the first subnational administrative level. As a result, two major peaks of occurrence were identified, one in the 70s, with up to 1,193 outbreaks, and another in the 80s, with 380. Overall, the investigations show a clear regressive trend in the occurrence of serotype C, with a reduction in the number of outbreaks over-time, and with the subsequent reduction of affected locations. This study illustrates the contrast between the very limited presence over the last 20 years - with only one event in 2004 - and the epidemic situation in the 1970s and 1980s, and suggests that serotype C of FMDv is no longer present in the Region.

Rabies in the Americas: 1998-2014.

Through national efforts and regional cooperation under the umbrella of the Regional Program for the Elimination of Rabies, dog and human rabies have decreased significantly in Latin America and Caribbean (LAC) countries over the last three decades. To achieve this decline, LAC countries had to develop national plans, and consolidate capabilities such as regular mass dog vaccination, opportune post-exposure prophylaxis and sensitive surveillance. This paper presents longitudinal data for 21 LAC countries on dog vaccination, PEP and rabies surveillance collected from the biannual regional meeting for rabies directors from 1998-2014 and from the Regional Epidemiologic Surveillance System for Rabies (SIRVERA). Differences in human and dog rabies incidence rates and dog vaccination rates were shown between low, middle and high-income countries. At the peak, over 50 million dogs were vaccinated annually in national campaigns in the countries represented. The reported number of animal exposures remained fairly stable during the study period with an incidence rate ranging from 123 to 191 reported exposures per 100,000 people. On average, over 2 million doses of human vaccine were applied annually. In the most recent survey, only 37% of countries reported that they had sufficient financial resources to meet the program objectives. The data show a sufficient and sustained effort of the LAC countries in the area of dog vaccination and provide understanding of the baseline effort required to reduce dog-mediated rabies incidence.

Cystic echinococcosis in South America: a call for action.

Cystic echinococcosis (CE) or hydatidosis, a parasitic zoonosis caused by a cestode of the family Taeniidae, species Echinococcus granulosus, is endemic in Argentina, Chile, Peru, Uruguay, and southern Brazil. This report presents CE figures for these five countries in 2009 - 2014 and proposes indicators to measure national control programs. Nearly 5 000 new CE cases were diagnosed annually in the five countries during the study period. The average case fatality rate was 2.9%, which suggests that CE led to approximately 880 deaths in these countries during the 6-year period. CE cases that required secondary or tertiary health care had average hospital stays of 10.6 days, causing a significant burden to health systems. The proportion of new cases (15%) in children less than 15 years of age suggests ongoing transmission. Despite figures showing that CE is not under control in South America, the long-standing implementation of national and local control programs in three of the five countries has achieved reductions in some of the indicators. The Regional Initiative for the Control of CE, which includes the five countries and provides a framework for networking and collaboration, must intensify its efforts.

An inter- laboratory proficiency testing exercise for rabies diagnosis in Latin America and the Caribbean.

The direct fluorescent antibody test (DFA), is performed in all rabies reference laboratories across Latin America and the Caribbean (LAC). Despite DFA being a critical capacity in the control of rabies, there is not a standardized protocol in the region. We describe the results of the first inter-laboratory proficiency exercise of national rabies laboratories in LAC countries as part of the regional efforts towards dog-maintained rabies elimination in the American region. Twenty three laboratories affiliated to the Ministries of Health and Ministries of Agriculture participated in this exercise. In addition, the laboratories completed an online questionnaire to assess laboratory practices. Answers to the online questionnaire indicated large variability in the laboratories throughput, equipment used, protocols availability, quality control standards and biosafety requirements. Our results will inform actions to improve and harmonize laboratory rabies capacities across LAC in support for the regional efforts towards elimination of dog-maintained rabies.

Building the road to a regional zoonoses strategy: A survey of zoonoses programmes in the Americas.

BACKGROUND: In recent years, global public health security has been threatened by zoonotic disease emergence as exemplified by outbreaks of H5N1 and H1N1 influenza, SARS, and most recently Ebola and Zika. Additionally, endemic zoonoses, such as rabies, burden countries year after year, placing demands on limited finances and personnel. To survey the baseline status of the emerging and endemic zoonoses programmes of the Latin American and the Caribbean (LAC) countries, the Pan American Health Organization (PAHO) conducted a survey of priority emerging and endemic zoonoses, countries´ prioritization criteria and methodologies, and suggestions to strengthen countries capacities and regional approaches to zoonoses control. METHODS: A fillable online questionnaire was sent to the zoonoses programme managers of the Ministries of Health (MOH) and Ministries of Agriculture (MAg) of 33 LAC countries from January to April of 2015. The questionnaire comprised 36 single, multiple choice and open-ended questions to inform the objectives of the survey. A descriptive exploratory analysis was completed. RESULTS: Fifty-four ministries (26 MOH, 25 MAg, and 3 combined responses) in 31 LAC countries responded to the survey. Within the ministries, 22 (85%) MOH, 5 (20%) MAg, and 2 (67%) combined entities indicated they had specialized zoonoses units. For endemic zoonoses, 32 of 54 ministries responded that they conduct formal prioritization exercises, most of them annually (69%). The three priority endemic zoonoses for the MOHs were leptospirosis, rabies, and brucellosis while the three priorities for the MAgs were brucellosis, rabies, and tuberculosis. Diagnosis for rabies and leptospirosis were cited as the capacities most in need of development. The most needed cross-cutting capacity was coordination between stakeholders. For emerging zoonoses, 28 ministries performed formal prioritization exercises. The top prioritization criteria were probability of introduction into the country and impact. The three priority emerging zoonoses for the MOHs were Ebola viral disease, avian influenza, and Chikungunya while for the MAgs were avian influenza, bovine spongiform encephalopathy and West Nile virus disease. Surveillance for avian influenza and Ebola, and diagnosis for BSE were quoted as the capacities most needed. For all zoonoses, the majority of respondents (69%) ranked their relationship with the other Ministry as productive or very productive, and 31% minimally productive. Many countries requested a formal regional network, better regional communication and collaboration, and integrated surveillance. CONCLUSIONS: The survey is the first comprehensive effort to date to inform the status of zoonoses programmes in LAC. The information collected here will be used to develop a regional strategy for zoonoses (both endemic and emerging), increase efforts, advocacy, and promote prompt identification and management of EIDs and improvement of endemic programmes.

Tribulations of the Last Mile: Sides from a Regional Program.

In Latin American and Caribbean (LAC) countries, the number of cases of dog-mediated human rabies is at its lowest since the onset of the Regional Program for Rabies Elimination in 1983, a commitment from LAC countries to eliminate dog-mediated rabies coordinated by the Pan American Health Organization. Despite minor setbacks, the decline in the number of human cases has been constant since 1983. While many LAC countries have significantly reduced rabies to a level where it is no longer significant public health concern, elimination has proven elusive and pockets of the disease remain across the region. In the 33-year period since 1983, the region has set and committed to four dates for elimination (1990, 2000, 2012, and 2015). In this paper, we ponder on the multiple causes behind the elusive goal of rabies elimination, such as blanket regional goals oblivious to the large heterogeneity in national rabies capacities. Looking ahead to the elimination of dog-mediated rabies in the region, now established for 2022, we also review the many challenges and questions that the region faces in the last mile of the epidemic. Given the advanced position of the Americas in the race toward elimination, our considerations could provide valuable knowledge to other regions pursuing elimination goals.

Zoonotic tuberculosis in human beings caused by Mycobacterium bovis-a call for action.

Mycobacterium tuberculosis is recognised as the primary cause of human tuberculosis worldwide. However, substantial evidence suggests that the burden of Mycobacterium bovis, the cause of bovine tuberculosis, might be underestimated in human beings as the cause of zoonotic tuberculosis. In 2013, results from a systematic review and meta-analysis of global zoonotic tuberculosis showed that the same challenges and concerns expressed 15 years ago remain valid. These challenges faced by people with zoonotic tuberculosis might not be proportional to the scientific attention and resources allocated in recent years to other diseases. The burden of zoonotic tuberculosis in people needs important reassessment, especially in areas where bovine tuberculosis is endemic and where people live in conditions that favour direct contact with infected animals or animal products. As countries move towards detecting the 3 million tuberculosis cases estimated to be missed annually, and in view of WHO's end TB strategy endorsed by the health authorities of WHO Member States in 2014 to achieve a world free of tuberculosis by 2035, we call on all tuberculosis stakeholders to act to accurately diagnose and treat tuberculosis caused by M bovis in human beings.

Protection induced by a commercial bivalent vaccine against Foot-and-Mouth Disease 2010 field virus from Ecuador.

Foot-and-Mouth Disease serotype O circulated endemically in Ecuador for many years, with an upsurge occurring in 2009. This manuscript describes retrospectively in vitro and in vivo laboratory studies to predict the field effectiveness of a commercial FMD vaccine to protect against the field strain, and explains the key actions and epidemiological strategies followed by the country to control the disease. The results established that the use of a good quality oil vaccine, manufactured with strains that were isolated long ago: O1 Campos Br/58 and A24 Cruzeiro Br/55; combined with the correct epidemiological strategies, are useful to control field strains when used in periodic biannual vaccination campaigns.

Control of Dog Mediated Human Rabies in Haiti: No Time to Spare.

The American region has pledged to eliminate dog-mediated human rabies by 2015. As part of these efforts, we describe the findings of a desk and field mission review of Haiti's rabies situation by the end of 2013. While government officials recognize the importance of dog-mediated rabies control, and the national rabies plan adequately contemplates the basic capacities to that effect, regular and sufficient implementation, for example, of dog vaccination, is hampered by limited funding. Compounding insufficient funding and human resources, official surveillance figures do not accurately reflect the risk to the population, as evidenced by the large number of rabid dogs detected by focalized and enhanced surveillance activities conducted by the Ministry of Agriculture, Natural Resources and Rural Development (MARNDR) and the Health and Population Ministry (MSPP) with the technical assistance of the United States Centers for Disease Control and Prevention. Although international support is common, either in the form of on-the-ground technical support or donations of immunobiologicals, it is not comprehensive. In addition, there is limited coordination with MARNDR/MSPP and with other actors at the strategic or operational level due to human resources limitations. Given these findings, the 2015 elimination goal in the region is compromised by the situation in Haiti where control of the disease is not yet in sight despite the best efforts of the resolute national officials. More importantly, dog-mediated rabies is still a threat to the Haitian population.

Progress towards eliminating canine rabies: policies and perspectives from Latin America and the Caribbean.

Human rabies transmitted by dogs is considered a neglected disease that can be eliminated in Latin America and the Caribbean (LAC) by 2015. The aim of this paper is to discuss canine rabies policies and projections for LAC regarding current strategies for achieving this target and to critically review the political, economic and geographical factors related to the successful elimination of this deadly disease in the context of the difficulties and challenges of the region. The strong political and technical commitment to control rabies in LAC in the 1980s, started with the regional programme coordinated by the Pan American Health Organization. National and subnational programmes involve a range of strategies including mass canine vaccination with more than 51 million doses of canine vaccine produced annually, pre- and post-exposure prophylaxis, improvements in disease diagnosis and intensive surveillance. Rabies incidence in LAC has dramatically declined over the last few decades, with laboratory confirmed dog rabies cases decreasing from approximately 25 000 in 1980 to less than 300 in 2010. Dog-transmitted human rabies cases also decreased from 350 to less than 10 during the same period. Several countries have been declared free of human cases of dog-transmitted rabies, and from the 35 countries in the Americas, there is now only notification of human rabies transmitted by dogs in seven countries (Bolivia, Peru, Honduras, Haiti, Dominican Republic, Guatemala and some states in north and northeast Brazil). Here, we emphasize the importance of the political commitment in the final progression towards disease elimination. The availability of strategies for rabies control, the experience of most countries in the region and the historical ties of solidarity between countries with the support of the scientific community are evidence to affirm that the elimination of dog-transmitted rabies can be achieved in the short term. The final efforts to confront the remaining obstacles, like achieving and sustaining high vaccination coverage in communities that are most impoverished or in remote locations, are faced by countries that struggle to allocate sufficient financial and human resources for rabies control. Continent-wide cooperation is therefore required in the final efforts to secure the free status of remaining countries in the Americas, which is key to the regional elimination of human rabies transmitted by dogs.

Elimination of foot-and-mouth disease in South America: lessons and challenges.

Foot-and-mouth disease (FMD) is a highly transmissible and economically devastating disease of cloven-hoofed livestock. Although vaccines are available and have been instrumental in eliminating the disease from most of the South American animal population, viral circulation still persists in some countries and areas, posing a threat to the advances of the last 60 years by the official veterinary services with considerable support of the livestock sectors. The importance of the disease for the social and economic development of the American continent led to the establishment in 1951 of the Pan American Centre for Foot-and-Mouth Disease (PANAFTOSA), which has been providing technical cooperation to countries for the elimination of the disease. The first FMD national elimination programmes were established in South America around the 1960s and 1970s. To advance the regional elimination efforts in the 1980s, countries agreed on a Plan of Action 1988-2009 of the Hemispheric Program for the Eradication of Foot-and-Mouth Disease. The Plan of Action 1988-2009 did not reach the goal of elimination from the continent; and a new Plan of Action 2011-2020 was developed in 2010 based on the experience acquired by the countries and PANAFTOSA during the past 60 years. This plan is now being implemented; several challenges are still to be overcome to ensure the elimination of FMD from the Americas by 2020, however, the goal is achievable.

Prioritization of capacities for the elimination of dog-mediated human rabies in the Americas: building the framework.

The region of the Americas pledged to eliminate dog-transmitted human rabies by 2015. After 30 years of sustained efforts, regional elimination appears possible as dog-mediated human rabies cases are at an all-time low, and a number of countries and territories have already eliminated the disease. In this setting, there is an opportunity to generate a framework to support countries strategies in the achievement and maintenance of rabies-free status (RFS). To this end, we describe the development of a multi-criteria decision analysis (MCDA) model to help the evaluation of rabies programmes and the identification of the best investment strategy for countries and territories to improve and efficiently maintain their rabies status. The model contemplates human and animal related capacities, six in each area, to comprehensively assess the wide scope of rabies programmes. An initial elicitation of expert opinion of values and weights for the MCDA model was performed via a web-based questionnaire. Even at this pilot stage, the model produces comparable capacity-scores, and overall (combined for public and animal health areas) as well as area-specific investment strategies. The model is being developed by the Pan American Health Organization (PAHO) as part of the regional efforts towards dog-mediated human rabies elimination and will be presented to the countries for review, refinement, contextualization, and testing. The aspiration is that countries use the model to identify the best allocation of resources towards the elimination of dog-mediated human rabies.