An exploratory study on the perceptions of rabies and ill-health causations and health seeking behaviours of school children and local communities in southern Bhutan.

BACKGROUND: The perception of illness and health-seeking behaviours, including rabies differ from one culture to another. Depending on the cultural setting of the society in which people live, the definition of the causal factors of illness may range from natural biological causes to supernational causes which greatly influence subsequent health-seeking behaviour. To ensure best health practices and plan effective health interventions for the control of dog-mediated-human rabies, we explored how school children and adult communities perceive and respond to illnesses, including rabies in southern Bhutan. METHODS: We collected quantitative data related to the causes of illness and health-seeking practices of school children using a questionnaire survey (QS). Qualitative data were collected through focus group discussions (FGDs) and in-depth interviews (IDIs) with older members of communities (≥ 18 years) that work closely with school children. Descriptive analysis was performed for the quantitative data and thematic analysis was performed for the qualitative data. RESULTS: The participants during the FDGsand IDIshave linked the illnesses to past actions, spirits, energy channels, planetary movement, sorcery, black magic, food, physical or environmental factors, individual habits and social factors. The survey of the school children reported microorganisms (75%), past actions (16.8%), spirits (9.6%) and black magic (9.1%) as causal factors for illnesses. Health seeking behaviours reported by the participants included visiting hospitals, performing spiritual or religious rituals and local treatments. Similarly, school children also mentioned that illnesses can be treated by visiting hospitals (98%), performing rituals (59.1%), and seeking traditional treatments practices (18.8%). Both school children and adult members of the communities that we interviewed were well aware on the causes of rabies and need for allopathic treatments rather than seeking spiritual or local treatments. CONCLUSION: There is a need for the consideration of the socio-cultural context in the planning and implementation of health-related policies, including the rabies prevention programs in Bhutan, by involving traditional healers and religious entities with "One Health" public health sectors.

Setting-up an Ebola vaccine trial in a remote area of the Democratic Republic of the Congo: Challenges, mitigations, and lessons learned.

Since the largest Ebola outbreak in West Africa (2013-2016) highlighted the potential threat of the Ebola virus to the world, several vaccines have been under development by different pharmaceutical companies. To obtain vaccine licensure, vaccine trials assessing the safety, immunogenicity and efficacy of new vaccines among different populations (e.g. different in age, gender, race, and ethnicity) play a crucial role. However, while this deadly disease mainly affects Central and West Africa, clinical trial regulations are becoming increasingly complex and consequently more expensive, influencing the affected low- and middle-income countries (LMICs) in performing high quality clinical trials. Consequently, the completion of such trials in LMICs takes more time and vaccines and drugs take longer to be licensed. To overcome some of the obstacles faced, the EBOVAC3 consortium, funded by the European Union's Innovative Medicines Initiative and the Coalition for Epidemic Preparedness Innovations, enabled high quality vaccine trials in Central and West Africa through extensive North-South collaborations. In this article, the encountered challenges, mitigations, recommendations and lessons learned from setting-up an Ebola vaccine trial in a remote area of the Democratic Republic of Congo are presented. These challenges are grouped into eight categories: (1) Regulatory, political and ethical, (2) Trial documents, (3) International collaborations, (4) Local trial staff, (5) Community engagement and sensitization, (6) Logistics, (7) Remoteness and climate conditions, (8) Financial. By sharing the encountered challenges, implemented mitigations and lessons learned for each of these categories, we hope to prepare and inform other researchers aspiring a well-functioning clinical trial unit in similar remote settings in LMICs. ClinicalTrials.gov identifier: NCT04186000.

Algorithm for the support of non-related (serious) adverse events in an Ebola vaccine trial in the Democratic Republic of the Congo.

Implementing an Ebola vaccine trial in a remote area in the Democratic Republic of the Congo (DRC), and being confronted with a dysfunctional health care system and acute unmet health needs of participants, ethical considerations were made regarding the ancillary care obligations of the sponsor and researchers. Spurred by the occurrence of non-related (serious) adverse events (NR-SAEs), the Universities of Antwerp and Kinshasa jointly developed an algorithm, accompanied by an algorithm policy. The algorithm consists of a set of consecutive questions with binary response options, leading to structured, non-arbitrary and consistent support and management for each NR-SAE. It is the result of dialogue and collaboration between the sponsor (University of Antwerp) and the principal investigator (University of Kinshasa), consultation of literature, and input of research ethics and social sciences experts. The characteristics of the project and its budgetary framework were taken into account, as well as the local socioeconomic and healthcare situation. The algorithm and related policy have been approved by the relevant ethics committee (EC), so field implementation will begin when the study activities resume in November 2021. Lessons learnt will be shared with the relevant stakeholders within and outside DRC.If NR-SAEs are not covered by a functioning social welfare system, sponsors and researchers should develop a feasible, standardised and transparent approach to the provision of ancillary care. National legislation and contextualised requirements are therefore needed, particularly in low/middle-income countries, to guide researchers and sponsors in this process. Protocols, particularly of clinical trials conducted in areas with 'access to care' constraints, should include adequate ancillary care arrangements. Furthermore, it is essential that local ECs systematically require ancillary care provisions to enhance the well-being and protection of the rights of research participants. This project was funded by the European Union's Horizon 2020 research and innovation programme, European Federation of Pharmaceutical Industries and Associations, and the Coalition for Epidemic Preparedness Innovations.

Feasibility and acceptability of a new integrated approach to control cystic echinococcosis in Morocco: Vaccination of sheep and anthelmintic treatment of dogs.

Cystic echinococcosis (CE) or hydatidosis is a common parasitic disease worldwide, especially in poor and developing countries. In Morocco, CE is a major zoonosis, despite the implementation of a national control program since 2007. Therefore, in 2016, a field trial that associates the EG95 vaccine (lambs) and anthelmintic treatment (dogs) was started in the Mid Atlas, the most endemic region in Morocco, with preliminary positive results. Here, a qualitative approach was used to analyze the feasibility and social acceptability of this strategy. Fifteen focus group discussions were separately conducted with breeders and with their wives, and forty-two individual interviews were performed with private-sector veterinarians and officers from structures responsible for the CE control program. Recordings were transcribed and analyzed with the R software, using the RQDA package. This qualitative research was validated using the credibility, transferability, dependability and confirmability criteria. This study showed that the professionals' views on sheep vaccination and anthelmintic treatment were divided between acceptability and concerns. Conversely, breeders and their wives highlighted the issue of the costs of procedures the utility of which was not immediately clear to them. All participants proposed solutions to improve this strategy, and also stressed the lack of education on CE. By bringing together the views of the communities and the professionals, this study traced the main lines (targeting the different aspects of CE and taking into account the local socio-cultural beliefs) that must be taken into account to ensure the short- and long-term CE control in Morocco.

Research priorities for control of zoonoses in South Africa.

BACKGROUND: Zoonoses pose major threats to the health of humans, domestic animals and wildlife, as seen in the COVID-19 pandemic. Zoonoses are the commonest source of emerging human infections and inter-species transmission is facilitated by anthropogenic factors such as encroachment and destruction of wilderness areas, wildlife trafficking and climate change. South Africa was selected for a 'One Health' study to identify research priorities for control of zoonoses due to its complex disease burden and an overstretched health system. METHODS: A multidisciplinary group of 18 experts identified priority zoonotic diseases, knowledge gaps and proposed research priorities for the next 5 y. Each priority was scored using predefined criteria by another group of five experts and then weighted by a reference group (n=28) and the 18 experts. RESULTS: Seventeen diseases were mentioned with the top five being rabies (14/18), TB (13/18), brucellosis (11/18), Rift Valley fever (9/11) and cysticercosis (6/18). In total, 97 specific research priorities were listed, with the majority on basic epidemiological research (n=57), such as measuring the burden of various zoonoses (n=24), followed by 20 on development of new interventions. The highest research priority score was for improving existing interventions (0.77/1.0), followed by health policy and systems research (0.72/1.0). CONCLUSION: Future zoonotic research should improve understanding of zoonotic burden and risk factors and new interventions in public health. People with limited rural services, immunocompromised, in informal settlements and high-risk occupations, should be the highest research priority.

Using qualitative approaches to explore the challenges of integrated programmes for zoonosis control in developing countries: Example of hydatidosis control in Morocco.

Cystic echinococcosis, rabies and bovine tuberculosis are major neglected zoonoses in many developing countries, including Morocco. A common step in their control strategies is the management of slaughterhouses and/or the control of dog populations. This study used a qualitative approach to identify the barriers to the implementation of the cystic echinococcosis control programme in Morocco that focused on slaughterhouses and dog control. This approach could be used to understand the causes leading to the defective management of other zoonoses, and to go beyond the often-invoked 'lack of means' reason to explain failure in disease control in the Global South. Specifically, slaughterhouse observation and in-depth individual interviews with stakeholders involved in the cystic echinococcosis control programme were carried out in five Moroccan regions (Rabat-Sale-Kenitra, Mellal-Khenifra, Sous-Masaa, Laayoune-Sakia El Hamra and Guelmim-Oued Noun) for 3 years (from 2014 to 2016). Interviews (n = 81) were with agents responsible of the services managing slaughterhouses and dog population control, and also with slaughterers. Recordings were fully transcribed and narratives were analysed with the RQDA package and the R software. Triangulations and the criteria proposed by Guba and Lincon were used to assess the approach validity. This analysis revealed that in addition to 'lack of means', zoonosis control programmes can be hindered by overlapping authority/functions among the involved authorities, conflicts of interest, lack of proper training and professional practices. Zoonosis control requires the commitment of all structures, the establishment of a national and inter-regional strategy, and the updating of the legislative arsenal.

Stakeholder analysis to improve the national control program of cystic echinococcosis in Morocco.

Cystic echinococcosis (CE) is a major zoonosis in Morocco. Despite a national hydatidosis control programme (NHCP) established in 2005, CE burden is still high nationwide. The aim of this study was to carry out an NHCP stakeholders' analysis to identify weak points and propose improvement strategies. In total, 164 semi-structured interviews were carried out with national and local stakeholder representatives, and one stakeholders' workshop was organized. Classical categories of stakeholder analysis (i.e. involvement, interest, importance, influence, priority, and power) were semi-quantified. Based on these categories, an analytical framework was proposed, by selecting elements from the stakeholder analysis, to structure the assessment around three criteria: measure appropriation, political agency, and socio-technical agency. Besides specific weak points of the NHCP, the analysis highlighted the complexity of implementing a zoonotic disease control programme due to the involvement of many different stakeholders. Finally, this study provides a simplified stakeholder analysis method that could be used to assess other health programmes targeting zoonotic diseases, in Morocco and in similar countries.

The socio-economic burden of cystic echinococcosis in Morocco: A combination of estimation method.

Cystic echinococcosis (CE) is a major zoonosis in Morocco despite the launch of a national control programme in 2005. As its economic consequences have not been studied yet in Morocco, this study estimated CE impact in terms of monetary losses, disability-adjusted life years (DALY), and DALY for zoonotic diseases (zDALY) in the entire country and in specific regions for the 2011 to 2014 period. The direct monetary losses were related to organ seizure from infected animal in slaughterhouses, and to healthcare expenses as well as lost wages for infected humans. Animal production losses concerned milk yield, fertility, carcass weight, and wool production. Losses due to human infection were also composed of disability and productivity losses at work. Monte Carlo simulations were used to estimate monetary losses and zDALY values. Nationwide, the estimated DALY was 0.5 years per 100,000 persons per year, and the zDALY was 55 years per 100,000 persons per year. Total yearly losses were estimated at 73 million USD (54-92 million USD). However, losses differed significantly among regions. Most of the economic losses consisted of unperceived consequences, i.e. decreased animal production and reduced productivity of asymptomatic individuals. Future studies should determine the socioeconomic and epidemiological factors underlying the differences in economic losses among regions to develop better adapted control programmes.

Risk practices for bovine tuberculosis transmission to cattle and livestock farming communities living at wildlife-livestock-human interface in northern KwaZulu Natal, South Africa.

Bovine tuberculosis (bTB) is a disease of cattle that is transmitted through direct contact with an infected animal or ingestion of contaminated food or water. This study seeks to explore the local knowledge on bTB, obtain information on social and cultural practices regarding risk of bTB transmission to cattle and humans (zoonotic TB) in a traditional livestock farming community with a history of bTB diagnosis in cattle and wildlife. Information was collected using a qualitative approach of Focus Group Discussions (FGDs) targeting household members of livestock farmers that owned bTB tested herds. We conducted fourteen FGDs (150 individuals) across four dip tanks that included the following categories of participants from cattle owning households: head of households, herdsmen, dip tank committee members and women. The qualitative data was managed using NVivo Version 12 Pro software. Social and cultural practices were identified as major risky practices for bTB transmission to people, such as the consumption of undercooked meat, consumption of soured /raw milk and lack of protective measures during slaughtering of cattle. The acceptance of animals into a herd without bTB pre-movement testing following traditional practices (e.g. lobola, 'bride price', the temporary introduction of a bull for 'breeding'), the sharing of grazing and watering points amongst the herds and with wildlife were identified as risky practices for M. bovis infection transmission to cattle. Overall, knowledge of bTB in cattle and modes of transmission to people and livestock was found to be high. However, the community was still involved in risky practices that expose people and cattle to bovine TB. An inter-disciplinary 'One Health' approach that engages the community is recommended, to provide locally relevant interventions that allows the community to keep their traditional practices and socio-economic systems whilst avoiding disease transmission to cattle and people.

Perceptions and acceptability of piloted Taenia solium control and elimination interventions in two endemic communities in eastern Zambia.

Infections with Taenia solium cause significant public health and economic losses worldwide. Despite effective control tools, long-term sustained control/elimination of the parasite has not been demonstrated to date. Success of intervention programs is dependent on their acceptability to local communities. Focus group discussions (FGDs) and questionnaires (QS) were conducted in two study communities in eastern Zambia to assess local perceptions and acceptance of two piloted intervention strategies: one targeting pigs only ('control' study arm), and one integrated human- and pig-based ('elimination') strategy. QS (n = 227) captured data regarding participation in project activities, knowledge and perceptions of T. solium and of the interventional drugs used in the study. FGDs (n = 18) discussed perceived advantages and disadvantages of the interventions and of the project's delivery and value. QS data revealed 67% of respondents participated in at least one educational activity, and 80% correctly identified at least one disease targeted by the education. All elimination study arm respondents (n = 113) had taken the human treatment, and 98% intended to do so next time. Most (70%) indicated willingness to pay for future treatments (median 0.20 USD per dose). Of pig-owning respondents, 11/12 (92%) had allowed their pigs to be treated/vaccinated and all intended to do so again next time. Four pig owners indicated willingness to pay 0.10-0.50 USD per dose of treatment or vaccine. FGD feedback revealed positive perceptions of interventions; people reported improved health in themselves and their pigs, and fewer cysticerci in pork. Latrine use, hand washing, meat inspection and proper cooking of pork had reportedly increased since the program's inception. Preliminary assessment indicates that the piloted intervention methods are generally acceptable to the communities. The reported willingness of many respondents to pay for the medications would contribute to the feasibility of long-term, government-led T. solium intervention programs in future.

Community perception and knowledge of cystic echinococcosis in the High Atlas Mountains, Morocco.

BACKGROUND: Cystic echinococcosis (CE), a neglected zoonosis caused by the larval stage of the tapeworm Echinococcus granulosus, remains a public health issue in many developing countries that practice extensive sheep breeding. Control of CE is difficult and requires a community-based integrated approach. We assessed the communities' knowledge and perception of CE, its animal hosts, and its control in a CE endemic area of the High Atlas Mountains, Morocco. METHODS: We conducted twenty focus group discussions (FGDs) stratified by gender with villagers, butchers and students in ten Berber villages that were purposefully selected for their CE prevalence. RESULTS: This community considers CE to be a severe and relatively common disease in humans and animals but has a poor understanding of the parasite's life cycle. Risk behaviour and disabling factors for disease control are mainly related to cultural practices in sheep breeding and home slaughtering, dog keeping, and offal disposal at home, as well as in slaughterhouses. Participants in our focus group discussions were supportive of control measures as management of canine populations, waste disposal, and monitoring of slaughterhouses. CONCLUSIONS: The uncontrolled stray dog population and dogs having access to offal (both at village dumps and slaughterhouses) suggest that authorities should be more closely involved in CE control. This study also highlights the need for improved knowledge about the transmission cycle of the parasite among communities and health professionals. Inter-sectoral collaboration between health staff, veterinarians, and social scientists appears to be crucial for sustainable control of this parasitic zoonosis.

The need for European OneHealth/EcoHealth networks.

Elaborating from the European One Health/Ecohealth (OH/EH) workshop that took place in fall 2016 and aimed to bring together different communities and explore collaborative potential, the creation of European networks focusing on the development of important OH/EH perspectives was a direct output from discussions at the end of some sessions, in particular: - A network on transdisciplinary One Health education. - A network integrating inputs from social sciences in One Health/EcoHealth actions and networks. - A network aiming at translating research findings on the Environment-Microbiome-Health axis into policy making, with a view to make healthy ecosystems a cost-effective disease prevention healthcare strategy. It was also suggested that a European Community of Practice could be initiated in order to support these several concrete networking initiatives, and to help to promote the building of other emerging initiatives.

[The origin of Ebola: Biomedical approach versus popular interpretations in Macenta, Guinea]. / Sur l'origine d'Ebola : discours biomédical versus interprétations populaires à Macenta en Guinée.

In December 2013, a two-year-old child died from viral haemorrhagic fever in Méliandou village in the South-East of Guinea, and constituted the likely index case of a major epidemic. When the virus was formally identified as Ebola, epidemiologists started to investigate the chains of transmission, while local people were trying to make sense out of these deaths. The epidemic control measures taken by national and international health agencies were soon faced by strong reluctance and a sometimes aggressive attitude of the affected communities. Preliminary ethnographic observations were carried out by ST in Macenta (Forest region) during an assignment (October-November 2014) for the Global Outbreak and Alert Response Network (GOARN) of the World Health Organization. ST carried out participative observation, informal conversations and in-depth interviews to identify the rumours and their sources, understand the local population's perception and knowledge about the history and origin of the Ebola outbreak in Guinea. Epidemiologists involved in the outbreak response attributed the first Ebola deaths in the Forest region to the transmission of a virus by contact with fluids of patients, but other Guinean citizens believed these deaths were caused by the breach of a taboo. The epidemiological and popular explanations, mainly evolving in parallel, but sometimes overlapping, are driven by different explanatory models, a biomedical model and a traditional-religious model. The outbreak response must be flexible and must systematically document popular discourse(s), rumours, codes, practices, knowledge and opinions related to the outbreak and use this information to shape and adapt its control interventions.

Psychosocial impact of scars due to cutaneous leishmaniasis on high school students in Errachidia province, Morocco.

BACKGROUND: In Morocco, cutaneous leishmaniasis (CL) is usually known to be a slowly healing localized skin disease, but in some cases, it can lead to mutilating scars. The outbreak of CL due to Leishmania major in the Errachidia province in southeastern Morocco between 2008 and 2010 left many adolescents with permanent scar tissue on the face or other exposed body parts. We studied the psychosocial impact of CL on these young people. METHODS: In 2015 we conducted a cross-sectional survey among high-school students living in boarding schools in two CL-endemic areas of Errachidia: Rissani and Tinejdad. A self-administered questionnaire elicited responses about general knowledge of CL and related scars. An open-ended question focused on the possible psychosocial effects associated with these scars. The quantitative data were analyzed with Epi Info™ and the text data with NVivo software. RESULTS: Almost 20% of 448 respondents reported they had experienced a CL lesion and 87% said it could possibly or definitely lead to psychological consequences. The text analysis showed that girls more often than boys expanded on the negative psychological effects of CL. The students considered CL as "dangerous", "serious", and "deathly", and said it sometimes led to extreme suicidal ideations. CONCLUSIONS: The burden of CL in this age group is not negligible. The indelible CL scars lead to self-stigma and social stigma, and the emergence of negative psychological effects in this age group. While some students accepted their CL scars and related suffering as their "destiny", others were eagerly demanding protective measures against CL and treatment for the scars.

Why pigs are free-roaming: Communities' perceptions, knowledge and practices regarding pig management and taeniosis/cysticercosis in a Taenia solium endemic rural area in Eastern Zambia.

Taenia solium cysticercosis is a neglected parasitic zoonosis in many developing countries including Zambia. Studies in Africa have shown that the underuse of sanitary facilities and the widespread occurrence of free-roaming pigs are the major risk factors for porcine cysticercosis. Socio-cultural determinants related to free range pig management and their implications for control of T. solium remain unclear. The study objective was to assess the communities' perceptions, reported practices and knowledge regarding management of pigs and taeniosis/cysticercosis (including neurocysticercosis) in an endemic rural area in Eastern Zambia, and to identify possible barriers to pig related control measures such as pig confinement. A total of 21 focus group discussions on pig husbandry practices were organized separately with men, women and children, in seven villages from Petauke district. The findings reveal that the perception of pigs and their role in society (financial, agricultural and traditional), the distribution of the management tasks among the family members owning pigs (feeding, building kraal, seeking care) and environmental aspects (feed supply, presence of bush, wood use priorities, rainy season) prevailing in the study area affect pig confinement. People have a fragmented knowledge of the pork tapeworm and its transmission. Even if negative aspects/health risks of free-range pigs keeping are perceived, people are ready to take the risk for socio-economic reasons. Finally, gender plays an important role because women, and also children, seem to have a higher perception of the risks but lack power in terms of economic decision-making compared to men. Currently pig confinement is not seen as an acceptable method to control porcine cysticercosis by many farmers in Eastern Zambia, vaccination and treatment seemed to be more appropriate. Embedded in a One Health approach, disease control programs should therefore ensure a complementary appropriate set of control strategies by engaging new sectors such as agronomy, spatial ecology and finally consider the socio-cultural context, which is likely to enhance the development of control methods that could be accepted by the communities.

Why latrines are not used: communities' perceptions and practices regarding latrines in a Taenia solium endemic rural area in Eastern Zambia.

Taenia solium cysticercosis is a neglected parasitic zoonosis occurring in many developing countries. Socio-cultural determinants related to its control remain unclear. Studies in Africa have shown that the underuse of sanitary facilities and the widespread occurrence of free-roaming pigs are the major risk factors for porcine cysticercosis. The study objective was to assess the communities' perceptions, practices and knowledge regarding latrines in a T. solium endemic rural area in Eastern Zambia inhabited by the Nsenga ethno-linguistic group, and to identify possible barriers to their construction and use. A total of 21 focus group discussions on latrine use were organized separately with men, women and children, in seven villages of the Petauke district. The themes covered were related to perceived latrine availability (absence-presence, building obstacles) and perceived latrine use (defecation practices, latrine management, socio-cultural constraints).The findings reveal that latrines were not constructed in every household because of the convenient use of existing latrines in the neighborhood. Latrines were perceived to contribute to good hygiene mainly because they prevent pigs from eating human feces. Men expressed reluctance to abandon the open-air defecation practice mainly because of toilet-associated taboos with in-laws and grown-up children of the opposite gender. When reviewing conceptual frameworks of people's approach to sanitation, we found that seeking privacy and taboos hindering latrine use and construction were mainly explained in our study area by the fact that the Nsenga observe a traditionally matrilineal descent. These findings indicate that in this local context latrine promotion messages should not only focus on health benefits in general. Since only men were responsible for building latrines and mostly men preferred open defecation, sanitation programs should also be directed to men and address related sanitary taboos in order to be effective.

Intersectoral collaboration between the medical and veterinary professions in low-resource societies: The role of research and training institutions.

BACKGROUND: Neglected zoonoses continue to significantly affect human health in low-resource countries. A symposium was organised in Antwerp, Belgium, on 5 November 2010 to evaluate how intersectoral collaboration among educational and research institutions could improve the situation. RESULTS: Brucellosis and echinococcosis were presented as models for intersectoral collaboration. Low-resource societies face evident knowledge gaps on disease distribution, transmission within and across species and impact on human and animal health, precluding the development of integrated control strategies. RECOMMENDATIONS: While veterinarians have been the main driver of the One Health initiative, the medical profession does not seem to be fully aware of how veterinary science can contribute to human public health. It was postulated that transdisciplinarity could help fill knowledge gaps and that encouraging such transdisciplinarity should start with undergraduate students. Furthermore, intersectoral collaboration on zoonoses should not ignore the social sciences (e.g. assessment of indigenous knowledge and perception; participatory surveillance), which can contribute to a better understanding of the transmission of diseases and improve communities' participation in disease control activities.