AMR-Intervene: a social-ecological framework to capture the diversity of actions to tackle antimicrobial resistance from a One Health perspective.

The global threat of antimicrobial resistance (AMR) requires coordinated actions by and across different sectors. Increasing attention at the global and national levels has led to different strategies to tackle the challenge. The diversity of possible actions to address AMR is currently not well understood from a One Health perspective. AMR-Intervene, an interdisciplinary social-ecological framework, describes interventions to tackle AMR in terms of six components: (i) core information about the publication; (ii) social system; (iii) bio-ecological system; (iv) triggers and goals; (v) implementation and governance; and (vi) assessment. AMR-Intervene provides a broadly applicable framework, which can inform the design, implementation, assessment and reporting of interventions to tackle AMR and, in turn, enable faster uptake of successful interventions to build societal resilience to AMR.

Characterizing social-ecological context and success factors of antimicrobial resistance interventions across the One Health spectrum: analysis of 42 interventions targeting E. coli.

BACKGROUND: Antimicrobial resistance (AMR) is among the most pressing One Health issues. While interventions and policies with various targets and goals have been implemented, evidence about factors underpinning success and failure of interventions in different sectors is lacking. The objective of this study is to identify characteristics of AMR interventions that increase their capacity to impact AMR. This study focuses on AMR interventions targeting E. coli. METHODS: We used the AMR-Intervene framework to extract descriptions of the social and ecological systems of interventions to determine factors contributing to their success. RESULTS: We identified 52 scientific publications referring to 42 unique E. coli AMR interventions. We mainly identified interventions implemented in high-income countries (36/42), at the national level (16/42), targeting primarily one sector of society (37/42) that was mainly the human sector (25/42). Interventions were primarily funded by governments (38/42). Most intervention targeted a low leverage point in the AMR system, (36/42), and aimed to change the epidemiology of AMR (14/42). Among all included publications, 55% (29/52) described at least one success factor or obstacle (29/52) and 19% (10/52) identified at least one success factor and one obstacle. Most reported success factors related to communication between the actors and stakeholders and the role of media, and stressed the importance of collaboration between disciplines and external partners. Described obstacles covered data quality, access to data and statistical analyses, and the validity of the results. CONCLUSIONS: Overall, we identified a lack of diversity regarding interventions. In addition, most published E. coli interventions were poorly described with limited evidence of the factors that contributed to the intervention success or failure. Design and reporting guidelines would help to improve reporting quality and provide a valuable tool for improving the science of AMR interventions.

Is scientific evidence enough? Using expert opinion to fill gaps in data in antimicrobial resistance research.

BACKGROUND: Antimicrobial Resistance (AMR) is a global problem with large health and economic consequences. Current gaps in quantitative data are a major limitation for creating models intended to simulate the drivers of AMR. As an intermediate step, expert knowledge and opinion could be utilized to fill gaps in knowledge for areas of the system where quantitative data does not yet exist or are hard to quantify. Therefore, the objective of this study was to identify quantifiable data about the current state of the factors that drive AMR and the strengths and directions of relationships between the factors from statements made by a group of experts from the One Health system that drives AMR development and transmission in a European context. METHODS: This study builds upon previous work that developed a causal loop diagram of AMR using input from two workshops conducted in 2019 in Sweden with experts within the European food system context. A secondary analysis of the workshop transcripts was conducted to identify semi-quantitative data to parameterize drivers in a model of AMR. MAIN FINDINGS: Participants spoke about AMR by combining their personal experiences with professional expertise within their fields. The analysis of participants' statements provided semi-quantitative data that can help inform a future of AMR emergence and transmission based on a causal loop diagram of AMR in a Swedish One Health system context. CONCLUSION: Using transcripts of a workshop including participants with diverse expertise across the system that drives AMR, we gained invaluable insight into the past, current, and potential future states of the major drivers of AMR, particularly where quantitative data are lacking.

Scope and applicability of social-ecological resilience to antimicrobial resistance.

Social-ecological systems conceptualise how social human systems and ecological natural systems are intertwined. In this Personal View, we define the scope and applicability of social-ecological resilience to antimicrobial resistance. Resilience to antimicrobial resistance corresponds to the capacity to maintain the societal benefits of antimicrobial use and One Health systems' performance in the face of the evolutionary behaviour of microorganisms in response to antimicrobial use. Social-ecological resilience provides an appropriate framework to make sense of the disruptive impacts resulting from the emergence and spread of antimicrobial resistance; capture the diversity of strategies needed to tackle antimicrobial resistance and to live with it; understand the conditions that underpin the success or failure of interventions; and appreciate the need for adaptive and coevolutionary governance. Overall, resilience thinking is essential to improve understanding of how human societies dynamically can cope with, adapt, and transform to the growing global challenge of antimicrobial resistance.

Exploring the factors that contribute to the successful implementation of antimicrobial resistance interventions: a comparison of high-income and low-middle-income countries.

Introduction: Antimicrobial resistance (AMR) is a challenge to modern medicine. Interventions have been applied worldwide to tackle AMR, but these actions are often not reported to peers or published, leading to important knowledge gaps about what actions are being taken. Understanding factors that influence the implementation of AMR interventions and what factors are relevant in low-middle-income countries (LMICs) and high-income countries (HICs) were the key objectives of this exploratory study, with the aim to identifying which priorities these contexts need. Methods: A questionnaire was used to explore context, characteristics, and success factors or obstacles to intervention success based on participant input. The context was analyzed using the AMR-Intervene framework, and success factors and obstacles to intervention success were identified using thematic analysis. Results: Of the 77 interventions, 57 were implemented in HICs and 17 in LMICs. Interventions took place in the animal sector, followed by the human sector. Public organizations were mainly responsible for implementation and funding. Nine themes and 32 sub-themes emerged as important for intervention success. The themes most frequently reported were 'behavior', 'capacity and resources', 'planning', and 'information'. Five sub-themes were key in all contexts ('collaboration and coordination', 'implementation', 'assessment', 'governance', and 'awareness'), two were key in LMICs ('funding and finances' and 'surveillance, antimicrobial susceptibility testing and preventive screening'), and five were key in HICs ('mandatory', 'multiple profiles', 'personnel', 'management', and 'design'). Conclusion: LMIC sub-themes showed that funding and surveillance were still key issues for interventions, while important HIC sub-themes were more specific and detailed, including mandatory enforcement, multiple profiles, and personnel needed for good management and good design. While behavior is often underrated when implementing AMR interventions, capacity and resources are usually considered, and LMICs can benefit from sub-themes captured in HICs if tailored to their contexts. The factors identified can improve the design, planning, implementation, and evaluation of interventions.

Studying Factors Affecting Success of Antimicrobial Resistance Interventions through the Lens of Experience: A Thematic Analysis.

Antimicrobial resistance (AMR) affects the environment, and animal and human health. Institutions worldwide have applied various measures, some of which have reduced antimicrobial use and AMR. However, little is known about factors influencing the success of AMR interventions. To address this gap, we engaged health professionals, designers, and implementers of AMR interventions in an exploratory study to learn about their experience and factors that challenged or facilitated interventions and the context in which interventions were implemented. Based on participant input, our thematic analysis identified behaviour; institutional governance and management; and sharing and enhancing information as key factors influencing success. Important sub-themes included: correct behaviour reinforcement, financial resources, training, assessment, and awareness of AMR. Overall, interventions were located in high-income countries, the human sector, and were publicly funded and implemented. In these contexts, behaviour patterns strongly influenced success, yet are often underrated or overlooked when designing AMR interventions. Improving our understanding of what contributes to successful interventions would allow for better designs of policies that are tailored to specific contexts. Exploratory approaches can provide encouraging results in complex challenges, as made evident in our study. Remaining challenges include more engagement in this type of study by professionals and characterisation of themes that influence intervention outcomes by context.

Factors influencing antimicrobial resistance in the European food system and potential leverage points for intervention: A participatory, One Health study.

INTRODUCTION: Antimicrobial resistance (AMR) is a global crisis that evolves from a complex system of factors. Understanding what factors interact is key to finding solutions. Our objective was to identify the factors influencing AMR in the European food system and places to intervene. MATERIALS AND METHODS: We conducted two workshops involving participants with diverse perspectives to identify the factors influencing AMR and leverage points (places) to target interventions. Transcripts were open coded for factors and connections, then transcribed into Vensim 8.0.4 to develop a causal loop diagram (CLD) and compute the number of feedback loops. Thematic analysis followed to describe AMR dynamics in Europe's food system and places for intervention. The CLD and themes were confirmed via participant feedback. RESULTS: Seventeen participants representing human, animal and agricultural sectors identified 91 CLD factors and 331 connections. Seven themes (e.g., social and economic conditions) describing AMR dynamics in Europe's food system, five 'overarching factors' that impact the entire CLD system (e.g., leadership) and fourteen places for intervention (e.g., consumer demand) emerged from workshop discussions. Most leverage points fell on highly networked feedback loops suggesting that intervening at these places may create unpredictable consequences. CONCLUSIONS: Our study produced a CLD of factors influencing AMR in Europe's food system that implicates sectors across the One Health spectrum. The high connectivity between the CLD factors described by participants and our finding that factors are connected with many feedback mechanisms underscores the complexity of the AMR problem and the challenge with finding long-term solutions. Identifying factors and feedbacks helped identify relevant leverage points in the system. Some actions, such as government's setting AMU standards may be easier to implement. These actions in turn can support multi-pronged actions that can help redefine the vision, values and goals of the system to sustainably tackle AMR.

Factors impacting antimicrobial resistance in the South East Asian food system and potential places to intervene: A participatory, one health study.

Background: With AMU projected to increase, South East Asia (SEA) is at high risk of experiencing disproportionate health, social, and economic burdens due to antimicrobial resistance (AMR). Our objective was to identify factors influencing AMR in SEA's food system and places for intervention by integrating the perspectives of experts from the region to inform policy and management decisions. Materials and methods: We conducted two 6.5 h workshops and two 90-min interviews involving 18 AMR and other disciplinary experts from human, animal, and environment sectors who brainstormed the factors influencing AMR and identified leverage points (places) for intervention. Transcripts and workshop materials were coded for factors and their connections and transcribed into a causal loop diagram (CLD). Thematic analysis described AMR dynamics in SEA's food system and leverage points for intervention. The CLD and themes were confirmed via participant feedback. Results: Participants constructed a CLD of AMR in the SEA food system that contained 98 factors interlinked by 362 connections. CLD factors reflected eight sub-areas of the SEA food system (e.g., government). Seven themes [e.g., antimicrobial and pesticide use and AMR spread (n = 40 quotes)], six "overarching factors" that impact the entire AMR system [e.g., the drive to survive (n = 12 quotes)], and 10 places for intervention that target CLD factors (n = 5) and overarching factors (n = 2) emerged from workshop discussions. Conclusion: The participant derived CLD of factors influencing AMR in the SEA food system demonstrates that AMR is a product of numerous interlinked actions taken across the One Health spectrum and that finding solutions is no simple task. Developing the model enabled the identification of potentially promising leverage points across human, animal, and environment sectors that, if comprehensively targeted using multi-pronged interventions, could evoke system wide changes that mitigate AMR. Even targeting some leverage points for intervention, such as increasing investments in research and capacity building, and setting and enforcing regulations to control antimicrobial supply, demand, and use could, in turn, shift mindsets that lead to changes in more difficult to alter leverage points, such as redefining the profit-driven intent that drives system behavior in ways that transform AMU and sustainably mitigate AMR.

Governing Antimicrobial Resistance (AMR) in a Changing Climate: A Participatory Scenario Planning Approach Applied to Sweden in 2050.

Background: Antimicrobial resistance (AMR) is a growing global crisis with long-term and unpredictable health, social and economic impacts, with which climate change is likely to interact. Understanding how to govern AMR amidst evolving climatic changes is critical. Scenario planning offers a suitable approach. By envisioning alternative futures, stakeholders more effectively can identify consequences, anticipate problems, and better determine how to intervene. This study explored future worlds and actions that may successfully address AMR in a changing climate in a high-income country, using Sweden as the case. Methods: We conducted online scenario-building workshops and interviews with eight experts who explored: (1) how promising interventions (taxation of antimicrobials at point of sale, and infection prevention measures) could each combat AMR in 2050 in Sweden given our changing climate; and (2) actions to take starting in 2030 to ensure success in 2050. Transcripts were thematically analyzed to produce a narrative of participant validated alternative futures. Results: Recognizing AMR to be a global problem requiring global solutions, participants looked beyond Sweden to construct three alternative futures: (1) "Tax Burn Out" revealed taxation of antimicrobials as a low-impact intervention that creates inequities and thus would fail to address AMR without other interventions, such as infection prevention measures. (2) "Addressing the Basics" identified infection prevention measures as highly impactful at containing AMR in 2050 because they would contribute to achieving the Sustainable Development Goals (SDGs), which would be essential to tackling inequities underpinning AMR and climate change, and help to stabilize climate-induced mass migration and conflicts; and (3) "Siloed Nations" described a movement toward nationalism and protectionism that would derail the "Addressing the Basics" scenario, threatening health and wellbeing of all. Several urgent actions were identified to combat AMR long-term regardless which future un-folds, such as global collaboration, and a holistic approach where AMR and climate change are addressed as interlinked issues. Conclusion: Our participatory scenario planning approach enabled participants from different sectors to create shared future visions and identify urgent actions to take that hinge on global collaboration, addressing AMR and climate change together, and achieving the SDGs to combat AMR under a changing climate.

Discomfort period of fattening pigs and sows stunned with CO2: Duration and potential influencing factors in a commercial setting.

Despite raising animal welfare concerns, stunning of pigs with CO2 prior to slaughter remains the most widely applied method in commercial settings. The aim of this study was to assess the discomfort period and its influencing factors in fattening pigs and sows in a commercial slaughterhouse. The discomfort period was defined as the first reaction to the gas or the environment from the point the animal enters the gondola, until complete relaxation of its head. Results showed that the discomfort period lasted 11 s longer in sows than in pigs, and that certain behaviors occurred distinctly later in sows as compared to pigs. Furthermore, higher humidity and temperature in the pit could prolong the duration of the discomfort period. Further research is needed to better understand the underlying physiological processes for both the differences seen between sows and fattening pigs as well as the influence of ambient parameters.

Income compensation options and partial budget analysis following a reduction of antimicrobial sales at the veterinary practice level.

Over the years, the excessive consumption of antimicrobials (AM) by animals and humans has become a major concern at the global level, and several studies have highlighted the link between antimicrobial use (AMU) and antimicrobial resistance. Previous studies showed that, in Switzerland, every calf in the fattening process received in average seven days of AM treatment, and mainly oral group treatments. Therefore, policies to reduce the consumption of AM among veal calves should be implemented and promoted to decrease AM pressure on the microbiome. This study aimed to assess how a potential loss of income due to a reduction of AM prescriptions and sales in the Swiss veal calves sector could potentially be compensated. Partial budget models at the veterinary practice level were built to evaluate the effect on the net profit of veterinary practices, following four different national policy interventions that aim to reduce AM prescriptions for veal calves. The best-case scenarios resulted in a positive net profit. The scenarios assuming complete loss of profit from AM sales resulted in very low or negative net profit. Therefore, without financial support (e.g. through the government or other entities), veterinarians are likely to find it difficult to fully compensate the economic losses. At the practice level, income compensation mechanisms require a fundamental change of the business model. New model should be largely independent of pharmaceutical sales and should promote paid counselling on herd health management.

Building Social-Ecological System Resilience to Tackle Antimicrobial Resistance Across the One Health Spectrum: Protocol for a Mixed Methods Study.

BACKGROUND: Antimicrobial resistance (AMR) is an escalating global crisis with serious health, social, and economic consequences. Building social-ecological system resilience to reduce AMR and mitigate its impacts is critical. OBJECTIVE: The aim of this study is to compare and assess interventions that address AMR across the One Health spectrum and determine what actions will help to build social and ecological capacity and readiness to sustainably tackle AMR. METHODS: We will apply social-ecological resilience theory to AMR in an explicit One Health context using mixed methods and identify interventions that address AMR and its key pressure antimicrobial use (AMU) identified in the scientific literature and in the gray literature using a web-based survey. Intervention impacts and the factors that challenge or contribute to the success of interventions will be determined, triangulated against expert opinions in participatory workshops and complemented using quantitative time series analyses. We will then identify indicators using regression modeling, which can predict national and regional AMU or AMR dynamics across animal and human health. Together, these analyses will help to quantify the causal loop diagrams (CLDs) of AMR in the European and Southeast Asian food system contexts that are developed by diverse stakeholders in participatory workshops. Then, using these CLDs, the long-term impacts of selected interventions on AMR will be explored under alternate future scenarios via simulation modeling and participatory workshops. A publicly available learning platform housing information about interventions on AMR from a One Health perspective will be developed to help decision makers identify promising interventions for application in their jurisdictions. RESULTS: To date, 669 interventions have been identified in the scientific literature, 891 participants received a survey invitation, and 4 expert feedback and 4 model-building workshops have been conducted. Time series analysis, regression modeling of national and regional indicators of AMR dynamics, and scenario modeling activities are anticipated to be completed by spring 2022. Ethical approval has been obtained from the University of Waterloo's Office of Research Ethics (ethics numbers 40519 and 41781). CONCLUSIONS: This paper provides an example of how to study complex problems such as AMR, which require the integration of knowledge across sectors and disciplines to find sustainable solutions. We anticipate that our study will contribute to a better understanding of what actions to take and in what contexts to ensure long-term success in mitigating AMR and its impact and provide useful tools (eg, CLDs, simulation models, and public databases of compiled interventions) to guide management and policy decisions. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/24378.

Building a multisystemic understanding of societal resilience to the COVID-19 pandemic.

The current global systemic crisis reveals how globalised societies are unprepared to face a pandemic. Beyond the dramatic loss of human life, the COVID-19 pandemic has triggered widespread disturbances in health, social, economic, environmental and governance systems in many countries across the world. Resilience describes the capacities of natural and human systems to prevent, react to and recover from shocks. Societal resilience to the current COVID-19 pandemic relates to the ability of societies in maintaining their core functions while minimising the impact of the pandemic and other societal effects. Drawing on the emerging evidence about resilience in health, social, economic, environmental and governance systems, this paper delineates a multisystemic understanding of societal resilience to COVID-19. Such an understanding provides the foundation for an integrated approach to build societal resilience to current and future pandemics.

Evidence for action: a One Health learning platform on interventions to tackle antimicrobial resistance.

Improving evidence for action is crucial to tackle antimicrobial resistance. The number of interventions for antimicrobial resistance is increasing but current research has major limitations in terms of efforts, methods, scope, quality, and reporting. Moving the agenda forwards requires an improved understanding of the diversity of interventions, their feasibility and cost-benefit, the implementation factors that shape and underpin their effectiveness, and the ways in which individual interventions might interact synergistically or antagonistically to influence actions against antimicrobial resistance in different contexts. Within the efforts to strengthen the global governance of antimicrobial resistance, we advocate for the creation of an international One Health platform for online learning. The platform will synthesise the evidence for actions on antimicrobial resistance into a fully accessible database; generate new scientific insights into the design, implementation, evaluation, and reporting of the broad range of interventions relevant to addressing antimicrobial resistance; and ultimately contribute to the goal of building societal resilience to this central challenge of the 21st century.

Comparison of international legislation and standards on veterinary drug residues in food of animal origin.

Current legislation governing monitoring of drug residues in foodstuff of animal origin is being revised at the European level. This study provides a qualitative comparison of the legislation, public and private standards in the European Union, the United States of America (USA) and the Eurasian Customs Union/Russia. We made a quantitative comparison of Maximum Residue Levels (MRLs) applied in each region for pork kidneys for tetracycline (with a focus on doxycycline), penicillin and chloramphenicol. The Customs Union generally applied lower levels than the other regions, with MRLs for tetracyclines in pig kidneys being 1200 times lower than those applied in the USA. Growing consumer interest and concern about chemicals in their food could be leveraged to support and enhance the implementation of new initiatives to improve veterinary public health. Farmers and veterinarians could help reduce findings of drug residues in meat through the judicious use of preventive actions when using veterinary medicine.

Assessing the Adoption of Recommended Standards, Novel Approaches, and Best Practices for Animal Health Surveillance by Decision Makers in Europe.

Animal health surveillance is an important tool for disease mitigation and helps to promote animal health and welfare, protect human health, support efficient animal production, and enable trade. This study aimed to assess adoption of recommended standards and best practice for surveillance (including risk-based approaches) in Europe. It included scoping interviews with surveillance experts in Denmark, the Netherlands, Norway, and Switzerland to gather information on knowledge acquisition, decisions and implementation of surveillance, and perceptions. This was followed by an online survey among animal health and food safety surveillance users in EU, EEA, and Schengen countries. A total of 166 responses were collected from 27 countries; 111 were eligible for analysis. A strong preference for legislation and established standards was observed, with peer-reviewed publications, conferences, symposia, and workshops to be major sources of information. The majority of respondents indicated a need for international evaluation for surveillance and implied that considerations of cost-effectiveness were essential when making a decision to adopt new surveillance standards. However, most of the respondents did not use a formal evaluation to inform the adoption of new standards or only conducted a descriptive assessment before their implementation or adaptation. Only a few respondents reported a quantitative economic evaluation despite economic efficiency being considered as a highly relevant criterion for surveillance implementation. Constraints mentioned in the adoption of new surveillance standards included insufficient time, financial and human resources, and lack of competency. Researchers aiming to achieve impact by their surveillance work are advised to consider ways of influencing binding standards and to disseminate their work pro-actively using varied channels of engagement tailored to relevant target audiences and their needs. Generally, a more formal linkage between surveillance information and disease mitigation decisions-for example, by using systematic evaluation-could help increase the economic value of surveillance efforts. Finally, a collaborative, international platform for exchange and learning on surveillance as well as co-design and dissemination of surveillance standards is recommended.

A One Health Evaluation of the University of Copenhagen Research Centre for Control of Antibiotic Resistance.

We applied the evaluation framework developed by the EU COST Action "Network of Evaluation of One Health" (NEOH) to assess the operations, supporting infrastructures and outcomes of a research consortium "University of Copenhagen Research Centre for Control of Antibiotic Resistance" (UC-CARE). This 4-year research project was a One Health (OH) initiative with participants from 14 departments over four faculties as well as stakeholders from industry and health authorities aiming to produce new knowledge to reduce the development of antimicrobial resistance (AMR). This was a case study focusing on assessing beneficial and counter-productive characteristics that could affect the OH outcomes. The study was also used to provide feedback to NEOH about the evaluation framework. The framework and evaluation tools are described in the introduction paper of this special journal issue. Data for the evaluation were extracted from the funding research proposal, the mid-term UC-CARE project evaluation report and supplemented with opinions elicited from project participants and stakeholders. Here, we describe the underlying system, theory of change behind the initiative and adapted questions from the NEOH tools that we used for semi-open interviews with consortium members throughout the evaluation process. An online survey was used to obtain information from stakeholders. The NEOH evaluation tools were then used for the qualitative and quantitative evaluation of the OH characteristics of UC-CARE. Senior UC-CARE researchers were interested and willing to be interviewed. Young scientists were more difficult to engage in interviews, and only 25% of stakeholders answered the online survey. Interviewees mentioned that the main benefit of UC-CARE was an increased awareness and general understanding of AMR issues. All interviewees stated that the adopted OH approach was relevant given the complexity of AMR. However, some questioned the applicability, and identified potentially counter-productive issues mainly related to the information sharing, collaboration and working methods across the consortium. A more integrated project organization, more stakeholder involvement and time for the project, flexibility in planning and a dedicated OH coordinator were suggested to allow for more knowledge exchange, potentially leading to a higher societal impact.

Assessment of biosecurity and control measures to prevent incursion and to limit spread of emerging transboundary animal diseases in Europe: An expert survey.

Decision-makers and risk managers are often called upon to prioritise on and recommend suitable measures to prevent the risk of introduction and spread of pathogens. The main objective of this study was to assess the perceptions of experts in Italy, Switzerland and the United Kingdom concerning the importance, effectiveness, feasibility, costs and acceptability of selected biosecurity measures to prevent the introduction and limit the spread of rabies, blue tongue (BT) and classical swine fever (CSF). After identifying the most relevant measures by the project team, an expert knowledge elicitation was implemented through a questionnaire. After preliminary descriptive analyses, a number of statistical calculations were performed such as weighted medians, Spearman rank correlation tests, Wilcoxon comparison tests and ranking of measures. Three experts from each country completed the questionnaires, one expert for each disease. The mean answer rates for CSF, BT and rabies were 73%, 100% and 99% respectively. "Tracing system for live animal trade" was highlighted as very relevant in all diseases. The implementation of a "restriction zone after a suspicion or confirmation" was also rated as a relevant measure, especially for CSF. We identified generally a small correlation between costs and the other criteria. Among the rabies experts, measures related to "zoonotic risk" were rated highly, supporting the idea of a One Health approach. Disagreement among experts concerned 43 measures for the three pathogens: the debated measures were "control of the wildlife CSF status", "arthropod-vector control" and "rabies vaccination for domestic animals". Facing budget restriction, decision-makers need to prioritise their actions and make efficient prevention choices. With this study, we aimed to provide elements for reflection and to inform priority setting. The results can be applied through the implementation of similar surveys or directly from the knowledge already gathered in this study.

Implementation of a Regional Training Program on African Swine Fever As Part of the Cooperative Biological Engagement Program across the Caucasus Region.

A training and outreach program to increase public awareness of African swine fever (ASF) was implemented by Defense Threat Reduction Agency and the Ministries of Agriculture in Armenia, Georgia, Kazakhstan, and Ukraine. The implementing agency was the company SAFOSO (Switzerland). Integration of this regional effort was administered by subject matter experts for each country. The main teaching effort of this project was to develop a comprehensive regional public outreach campaign through a network of expertise and knowledge for the control and prevention of ASF in four neighboring countries that experience similar issues with this disease. Gaps in disease knowledge, legislation, and outbreak preparedness in each country were all addressed. Because ASF is a pathogen with bioterrorism potential and of great veterinary health importance that is responsible for major economic instability, the project team developed public outreach programs to train veterinarians in the partner countries to accurately and rapidly identify ASF activity and report it to international veterinary health agencies. The project implementers facilitated four regional meetings to develop this outreach program, which was later disseminated in each partner country. Partner country participants were trained as trainers to implement the outreach program in their respective countries. In this paper, we describe the development, execution, and evaluation of the ASF training and outreach program that reached more than 13,000 veterinarians, farmers, and hunters in the partner countries. Additionally, more than 120,000 booklets, flyers, leaflets, guidelines, and posters were distributed during the outreach campaign. Pre- and post-ASF knowledge exams were developed. The overall success of the project was demonstrated in that the principles of developing and conducting a public outreach program were established, and these foundational teachings can be applied within a single country or expanded regionally to disseminate disease information across borders; overall, this method can be modified to raise awareness about many other diseases.