Epidemic intelligence in Europe: a user needs perspective to foster innovation in digital health surveillance.

BACKGROUND: European epidemic intelligence (EI) systems receive vast amounts of information and data on disease outbreaks and potential health threats. The quantity and variety of available data sources for EI, as well as the available methods to manage and analyse these data sources, are constantly increasing. Our aim was to identify the difficulties encountered in this context and which innovations, according to EI practitioners, could improve the detection, monitoring and analysis of disease outbreaks and the emergence of new pathogens. METHODS: We conducted a qualitative study to identify the need for innovation expressed by 33 EI practitioners of national public health and animal health agencies in five European countries and at the European Centre for Disease Prevention and Control (ECDC). We adopted a stepwise approach to identify the EI stakeholders, to understand the problems they faced concerning their EI activities, and to validate and further define with practitioners the problems to address and the most adapted solutions to their work conditions. We characterized their EI activities, professional logics, and desired changes in their activities using NvivoⓇ software. RESULTS: Our analysis highlights that EI practitioners wished to collectively review their EI strategy to enhance their preparedness for emerging infectious diseases, adapt their routines to manage an increasing amount of data and have methodological support for cross-sectoral analysis. Practitioners were in demand of timely, validated and standardized data acquisition processes by text mining of various sources; better validated dataflows respecting the data protection rules; and more interoperable data with homogeneous quality levels and standardized covariate sets for epidemiological assessments of national EI. The set of solutions identified to facilitate risk detection and risk assessment included visualization, text mining, and predefined analytical tools combined with methodological guidance. Practitioners also highlighted their preference for partial rather than full automation of analyses to maintain control over the data and inputs and to adapt parameters to versatile objectives and characteristics. CONCLUSIONS: The study showed that the set of solutions needed by practitioners had to be based on holistic and integrated approaches for monitoring zoonosis and antimicrobial resistance and on harmonization between agencies and sectors while maintaining flexibility in the choice of tools and methods. The technical requirements should be defined in detail by iterative exchanges with EI practitioners and decision-makers.

A social-ecological systems approach to tick bite and tick-borne disease risk management: Exploring collective action in the Occitanie region in southern France.

Ticks are amongst the most important zoonotic disease vectors affecting human and animal health worldwide. Tick-borne diseases (TBDs) are rapidly expanding geographically and in incidence, most notably in temperate regions of Europe where ticks are considered the principal zoonotic vector of Public Health relevance, as well as a major health and economic preoccupation in agriculture and equine industries. Tick-borne pathogen (TBP) transmission is contingent on complex, interlinked vector-pathogen-host dynamics, environmental and ecological conditions and human behavior. Tackling TBD therefore requires a better understanding of the interconnected social and ecological variables (i.e., the social-ecological system) that favor disease (re)-emergence. The One Health paradigm recognizes the interdependence of human, animal and environmental health and proposes an integrated approach to manage TBD. However, One Health interventions are limited by significant gaps in our understanding of the complex, systemic nature of TBD risk, in addition to a lack of effective, universally accepted and environmentally conscious tick control measures. Today individual prevention gestures are the most effective strategy to manage TBDs in humans and animals, making local communities important actors in TBD detection, prevention and management. Yet, how they engage and collaborate within a multi-actor TBD network has not yet been explored. Here, we argue that transdisciplinary collaborations that go beyond research, political and medical stakeholders, and extend to local community actors can aid in identifying relevant social-ecological risk indicators key for informing multi-level TBD detection, prevention and management measures. This article proposes a transdisciplinary social-ecological systems framework, based on participatory research approaches, to better understand the necessary conditions for local actor engagement to improve TBD risk. We conclude with perspectives for implementing this methodological framework in a case study in the south of France (Occitanie region), where multi-actor collaborations are mobilized to stimulate multi-actor collective action and identify relevant social-ecological indicators of TBD risk.

Epidemic intelligence activities among national public and animal health agencies: a European cross-sectional study.

Epidemic Intelligence (EI) encompasses all activities related to early identification, verification, analysis, assessment, and investigation of health threats. It integrates an indicator-based (IBS) component using systematically collected surveillance data, and an event-based component (EBS), using non-official, non-verified, non-structured data from multiple sources. We described current EI practices in Europe by conducting a survey of national Public Health (PH) and Animal Health (AH) agencies. We included generic questions on the structure, mandate and scope of the institute, on the existence and coordination of EI activities, followed by a section where respondents provided a description of EI activities for three diseases out of seven disease models. Out of 81 gatekeeper agencies from 41 countries contacted, 34 agencies (42%) from 26 (63%) different countries responded, out of which, 32 conducted EI activities. Less than half (15/32; 47%) had teams dedicated to EI activities and 56% (18/34) had Standard Operating Procedures (SOPs) in place. On a national level, a combination of IBS and EBS was the most common data source. Most respondents monitored the epidemiological situation in bordering countries, the rest of Europe and the world. EI systems were heterogeneous across countries and diseases. National IBS activities strongly relied on mandatory laboratory-based surveillance systems. The collection, analysis and interpretation of IBS information was performed manually for most disease models. Depending on the disease, some respondents did not have any EBS activity. Most respondents conducted signal assessment manually through expert review. Cross-sectoral collaboration was heterogeneous. More than half of the responding institutes collaborated on various levels (data sharing, communication, etc.) with neighbouring countries and/or international structures, across most disease models. Our findings emphasise a notable engagement in EI activities across PH and AH institutes of Europe, but opportunities exist for better integration, standardisation, and automatization of these efforts. A strong reliance on traditional IBS and laboratory-based surveillance systems, emphasises the key role of in-country laboratories networks. EI activities may benefit particularly from investments in cross-border collaboration, the development of methods that can automatise signal assessment in both IBS and EBS data, as well as further investments in the collection of EBS data beyond scientific literature and mainstream media.

Towards an integrated surveillance of zoonotic diseases in Burkina Faso: the case of anthrax.

BACKGROUND: Anthrax is a zoonotic disease that causes frequent outbreaks in livestock and fatal human cases in Burkina Faso. Effective surveillance of this disease calls for the establishment of an integrated surveillance system, in line with the One Health concept. However, despite a strong technical and financial support from international partners, surveillance is still poorly conducted within an integrated approach. Based on stakeholder perspectives, the study has for objective to deepen our understanding of the anthrax surveillance system and to identify the obstacles and levers towards a more integrated approach to anthrax surveillance in Burkina Faso. METHODS: The data was collected from a literature review and interviews with surveillance stakeholders. We first conducted a qualitative descriptive analysis of the data to characterize the surveillance system (programmes, actors, collaboration). In a second step, we conducted a thematic analysis of the informants' discourse in order to identify what represents an obstacle or, conversely, a lever for a more integrated approach to anthrax surveillance. RESULTS: The surveillance system of anthrax in Burkina Faso includes three programmes (in the livestock, wildlife and human sectors), which involves 30 actors. These sectoral programmes operate almost independently from one another, although some collaborations are existing for the governance and implementation of surveillance activities. Analysis of the discourse of key stakeholders led to the identification of four categories of factors that may influence the implementation of an integrated surveillance system in the country: knowledge; technical, organizational and social capacities; motivation; intersectoral governance. CONCLUSIONS: This study highlights the difficulty of translating One Health governance to the national level and the need to better articulate the visions of all categories of stakeholders. This study also reveals the need to develop specific evaluation systems for integrated policies in order to provide credible evidence of their added value for a better management of zoonotic diseases. Finally, our study underlines the need to act upstream the emergence of zoonoses and allocate more resources to the prevention of zoonoses than to their control.

Getting out of crises: Environmental, social-ecological and evolutionary research is needed to avoid future risks of pandemics.

The implementation of One Health/EcoHealth/Planetary Health approaches has been identified as key (i) to address the strong interconnections between risk for pandemics, climate change and biodiversity loss and (ii) to develop and implement solutions to these interlinked crises. As a response to the multiple calls from scientists on that subject, we have here proposed seven long-term research questions regarding COVID-19 and emerging infectious diseases (EIDs) that are based on effective integration of environmental, ecological, evolutionary, and social sciences to better anticipate and mitigate EIDs. Research needs cover the social ecology of infectious disease agents, their evolution, the determinants of susceptibility of humans and animals to infections, and the human and ecological factors accelerating infectious disease emergence. For comprehensive investigation, they include the development of nature-based solutions to interlinked global planetary crises, addressing ethical and philosophical questions regarding the relationship of humans to nature and regarding transformative changes to safeguard the environment and human health. In support of this research, we propose the implementation of innovative multidisciplinary facilities embedded in social ecosystems locally: ecological health observatories and living laboratories. This work was carried out in the frame of the European Community project HERA (www.HERAresearchEU.eu), which aims to set priorities for an environment, climate and health research agenda in the European Union by adopting a systemic approach in the face of global environmental change.

Engaging Stakeholders in the Design of One Health Surveillance Systems: A Participatory Approach.

Many One Health surveillance systems have proven difficult to enforce and sustain, mainly because of the difficulty of implementing and upholding collaborative efforts for surveillance activities across stakeholders with different values, cultures and interests. We hypothesize that only the early engagement of stakeholders in the development of a One Health surveillance system can create an environment conducive to the emergence of collaborative solutions that are acceptable, accepted and therefore implemented in sustainable manner. To this end, we have designed a socio-technical framework to help stakeholders develop a common vision of their desired surveillance system and to forge the innovation pathway toward it. We implemented the framework in two case studies: the surveillance of antimicrobial resistance in Vietnam and that of Salmonella in France. The socio-technical framework is a participatory and iterative process that consists of four distinct steps implemented during a workshop series: (i) definition of the problem to be addressed, (ii) co-construction of a common representation of the current system, (iii) co-construction of the desired surveillance system, (iv) identification of changes and actions required to progress from the current situation to the desired situation. In both case studies, the process allowed surveillance stakeholders with different professional cultures and expectations regarding One Health surveillance to gain mutual understanding and to reconcile their different perspectives to design the pathway toward their common vision of a desired surveillance system. While the proposed framework is structured around four essential steps, its application can be tailored to the context. Workshop facilitation and representativeness of participants are key for the success of the process. While our approach lays the foundation for the further implementation of the desired One Health surveillance system, it provides no guarantee that the proposed actions will actually be implemented and bring about the required changes. The engagement of stakeholders in a participatory process must be sustained in order to ensure the implementation of co-constructed solutions and evaluate their effectiveness and impacts.

Nipah virus circulation at human-bat interfaces, Cambodia.

OBJECTIVE: To better understand the potential risks of Nipah virus emergence in Cambodia by studying different components of the interface between humans and bats. METHODS: From 2012 to 2016, we conducted a study at two sites in Kandal and Battambang provinces where fruit bats (Pteropus lylei) roost. We combined research on: bat ecology (reproductive phenology, population dynamics and diet); human practices and perceptions (ethnographic research and a knowledge, attitude and practice study); and Nipah virus circulation in bat and human populations (virus monitoring in bat urine and anti-Nipah-virus antibody detection in human serum). FINDINGS: Our results confirmed circulation of Nipah virus in fruit bats (28 of 3930 urine samples positive by polymerase chain reaction testing). We identified clear potential routes for virus transmission to humans through local practices, including fruit consumed by bats and harvested by humans when Nipah virus is circulating, and palm juice production. Nevertheless, in the serological survey of 418 potentially exposed people, none of them were seropositive to Nipah virus. Differences in agricultural practices among the regions where Nipah virus has emerged may explain the situation in Cambodia and point to actions to limit the risks of virus transmission to humans. CONCLUSION: Human practices are key to understanding transmission risks associated with emerging infectious diseases. Social science disciplines such as anthropology need to be integrated in health programmes targeting emerging infectious diseases. As bats are hosts of major zoonotic pathogens, such integrated studies would likely also help to reduce the risk of emergence of other bat-borne diseases.

"Health in" and "Health of" Social-Ecological Systems: A Practical Framework for the Management of Healthy and Resilient Agricultural and Natural Ecosystems.

The past two decades have seen an accumulation of theoretical and empirical evidence for the interlinkages between human health and well-being, biodiversity and ecosystem services, and agriculture. The COVID-19 pandemic has highlighted the devastating impacts that an emerging pathogen, of animal origin, can have on human societies and economies. A number of scholars have called for the wider adoption of "One Health integrated approaches" to better prevent, and respond to, the threats of emerging zoonotic diseases. However, there are theoretical and practical challenges that have precluded the full development and practical implementation of this approach. Whilst integrated approaches to health are increasingly adopting a social-ecological system framework (SES), the lack of clarity in framing the key concept of resilience in health contexts remains a major barrier to its implementation by scientists and practitioners. We propose an operational framework, based on a transdisciplinary definition of Socio-Ecological System Health (SESH) that explicitly links health and ecosystem management with the resilience of SES, and the adaptive capacity of the actors and agents within SES, to prevent and cope with emerging health and environmental risks. We focus on agricultural transitions that play a critical role in disease emergence and biodiversity conservation, to illustrate the proposed participatory framework to frame and co-design SESH interventions. Finally, we highlight critical changes that are needed from researchers, policy makers and donors, in order to engage communities and other stakeholders involved in the management of their own health and that of the underpinning ecosystems.

Characteristics of One Health surveillance systems: A systematic literature review.

The concept of One Health (OH) promotes the decompartmentalisation of human, animal, and ecosystem health for the more efficient and sustainable governance of complex health issues. This means that traditional boundaries between disciplines and sectors must be transgressed and that all relevant stakeholders must be involved in the definition and management of health problems. International efforts have been made to strengthen collaboration across sectors and disciplines and OH surveillance is strongly encouraged at global, national and local-level to efficiently manage hazards involving humans, animals and ecosystems. This concept is intuitively appealing and would suggest the enhanced performance and cost-effectiveness of surveillance systems, as compared to more conventional approaches. Nevertheless, confusion and uncertainty regarding the practical application, outcomes and impacts prevail. We believe that this is due to the lack of a conceptual and methodological framework which would (i) define the characteristics of OH surveillance, and (ii) identify the appropriate mechanisms for inter-sectoral and multi-disciplinary collaboration, to ensure that the surveillance system performs well, with regard to the objective, the context and the health hazard under surveillance. The objective of the study is to define the organisational and functional characteristics of OH surveillance systems, the context in which they are implemented, as well as the influential factors which may obstruct or support their implementation and performance. To achieve this, a systematic literature review of existing OH surveillance systems was conducted using the Prisma guidelines. The selected systems were assessed according to 38 predetermined variables. These allowed the characterisation of their objectives, organisation, functioning, performance and benefits. Data extraction was conducted using a spreadsheet and a database was built using an electronic multiple-choice questionnaire. The literature search identified a total of 1635 records. After the screening phase, 31 references were kept and 22 additional references retrieved from bibliographies were added. From these 53 selected documents, we retrieved 41 different surveillance systems in line with the definition proposed in this study. The analysis of this database enabled the identification of different dimensions and areas of collaboration. Barriers and levers for the implementation of OH surveillance systems were also identified and discussed. Based on our results, we propose a framework to characterise the organisation of collaboration for the governance and operation of an effective OH surveillance system.

Assessment of Drivers of Antimicrobial Usage in Poultry Farms in the Mekong Delta of Vietnam: A Combined Participatory Epidemiology and Q-Sorting Approach.

In the Mekong Delta of Vietnam, poultry farmers use high amounts of antimicrobials, but little is known about the drivers that influence this usage. We aimed to identify these drivers using a novel approach that combined participatory epidemiology (PE) and Q-sorting (a methodology that allows the analysis of the subjectivity of individuals facing a common phenomenon). A total of 26 semi-structured collective interviews were conducted with 125 farmers representative of the most common farming systems in the area (chickens, meat ducks, and mobile grazing ducks), as well as with 73 farmers' advisors [veterinarians, veterinary drug shop owners, and government veterinarians/commune animal health workers (CAHWs)] in five districts of Dong Thap province (Mekong Delta). Through these interviews, 46 statements related to the antimicrobials' perceived reliability, costs, and impact on flock health were created. These statements were then investigated on 54 individuals (28 farmers and 26 farmers' advisors) using Q-sorting interviews. Farmers generally indicated a higher propensity for antimicrobial usage (AMU) should their flocks encounter bacterial infections (75.0-78.6%) compared with viral infections (8.3-66.7%). The most trusted sources of advice to farmers were, in decreasing order: government veterinarian/CAHWs, their own knowledge/experience, veterinary drug shop owners, and sales persons from pharmaceutical and feed companies. The highest peak of AMU took place in the early phase of the production cycle. Farmers and their advisors showed considerable heterogeneity of attitudes with regards to AMU, with, respectively, four and three discourses representing their views on AMU. Overall, farmers regarded the cost of AMU cheaper than other disease management practices implemented on their farms. However, they also believed that even though these measures were more expensive, they would also lead to more effective disease prevention. A key recommendation from this finding would be for the veterinary authorities to implement long-term sustainable training programs aiming at reducing farmers' reliance on antimicrobials.

Antibiotic resistance in Vietnam: moving towards a One Health surveillance system.

BACKGROUND: The international community strongly advocates the implementation of multi-sectoral surveillance policies for an effective approach to antibiotic resistance, in line with the One Health concept. To comply with these international recommendations, the Vietnamese government has issued an inter-ministerial surveillance strategy for antibiotic resistance, including an integrated surveillance system. However, one may question the ability and willingness of surveillance stakeholders to implement the collaborations required. To assess the feasibility of operationalising this strategy within the national context, we explored the role of key stakeholders in the strategy, as well as their abilities to comply with it. METHODS: We conducted a qualitative approach based on an iterative stakeholder mapping and analysis, in three distinct steps: (1) a description of the structure of the national surveillance strategy (literature review, key informant interviews); (2) an analysis of the key stakeholders' positions regarding the strategy (semi-structured interviews); (3) the identification of factors influencing the operationalisation of the collaborative surveillance strategy (comparison of data collected at the first and second steps). RESULTS: The mapping of the surveillance system, as well as the characterisation of key stakeholders according to organisational and functional attributes, underlined that inter-sectoral surveillance initiatives do exist, but that the organisation of the national surveillance system remains highly silo-oriented. Based on stakeholder perspectives, we identified seven factors that may influence the implementation of the One Health strategy at national level: governance and operational frameworks, divergence of institutional cultures, level of knowledge, technical capacities, allocation of resources, conflicting commercial interests and influence of international partners. CONCLUSIONS: The study suggests that the operationalisation of the collaborative surveillance strategy requires the full adhesion of stakeholders and the provision of appropriate resources. Based on these findings, we have proposed a guidance framework together with recommendations to move towards a more suitable governance and operational model for One Health surveillance of antibiotic resistance in Vietnam. To lever and promote successful inter-sectoral collaboration, a participatory "learning by doing" process could be applied to guide, frame and mentor stakeholders through the identification of appropriate levels of collaboration, depending on the expected positive impacts on the value of surveillance.

Systems Thinking in Practice: Participatory Modeling as a Foundation for Integrated Approaches to Health.

One Health (OH), EcoHealth (EH), and Planetary Health (PH) share an interest in transdisciplinary efforts that bring together scientists, citizens, government and private sectors to implement contextualized actions that promote adaptive health management across human, animal and ecosystem interfaces. A key operational element underlying these Integrated Approaches to Health (IAH) is use of Systems Thinking as a set of tools for integration. In this paper we discuss the origins and epistemology of systems thinking and argue that participatory modeling, informed by both systems theory and expertise in facilitating engagement and social learning, can help ground IAH theoretically and support its development. Participatory modeling is iterative and adaptive, which is necessary to deal with complexity in practice. Participatory modeling (PM) methods actively involve affected interests and stakeholders to ground the field of inquiry in a specific social-ecological context. Furthermore, PM processes act to reconcile the diverse understandings of the empirical world that stem from divergent discipline and community viewpoints. In this perspective article, we argue that PM can support systems thinking in practice and is essential for IAH implementation. Accordingly we invite PH, OH, and EH practitioners to systematically incorporate specialists in systems science and social engagement and facilitation. This will enable the appropriate contextualization of research practice and interventions, and ensure a balanced representation of the roles and relationships of medical, biological, mathematical, and social disciplines. For completeness, funding schemes supporting IAH need to follow the same iterative, adaptive, and participative processes to accompany IAH projects throughout their implementation.

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.

A Q Method Approach to Evaluating Farmers' Perceptions of Foot-and-Mouth Disease Vaccination in Vietnam.

This study aims to explore the farmers' perceptions of foot-and-mouth disease (FMD) vaccination using a reflexive research method called Q methodology. A structured sample was composed of 46 farmers selected according to gender, farming experience, level of education, and production type. Statements relevant to the farmers' perceptions of and attitudes toward FMD vaccination, related to confidence, logistics, costs, and impacts of vaccination were developed. Results were analyzed by principal component analysis and factor analysis. The influence of demographics and characterized variables on the respondent's contribution to each factor was also tested. Regarding the different beliefs and behavior toward FMD vaccination, the common perceptions held by Vietnamese cattle and pig farmers were divided into three discourses named Confidence (24 subjects), Belief (12 subjects), and Challenge (6 subjects). The identified discourses represented 57.3% of the variances. Consensus points were found, such as the feeling of being more secure after FMD vaccination campaigns; the fact that farmers take vaccination decisions themselves without being influenced by other stakeholders; the opinion that FMD vaccination is cheaper than the costs of treating a sick animal; and that vaccines provided by governmental authorities are of high quality. Part of the studied population did not consider vaccination to be the first choice strategy in prevention. This raises the question of how to improve the active participation of farmers in the FMD vaccine strategy. Taking into consideration farmers' perceptions can help to implement feasible vaccination strategies at the local level.

Biodiversity and health: Lessons and recommendations from an interdisciplinary conference to advise Southeast Asian research, society and policy.

Southeast Asia is an economic, biodiverse, cultural and disease hotspot. Due to rapid socio-economic and environmental changes, the role of biodiversity and ecosystems for human health ought to be examined and communicated to decision-makers and the public. We therefore summarized the lessons and recommendations from an interdisciplinary conference convened in Cambodia in 2014 to advise Southeast Asian societies on current research efforts, future research needs, and to provide suggestions for improved education, training and science-policy interactions. First, we reviewed several examples of the important role of ecosystems as 'sentinels' in the sense that potentially harmful developments for human health become first apparent in ecosystem components. Other ecosystem services which also benefit human well-being are briefly summarized. Second, we summarized the recommendations of the conference's roundtable discussions and added recent developments in the science-policy interface. The recommendations were organized along five themes: Ethical and legal considerations; implementation of the One Health approach; education, training, and capacity building; future research priorities; and potential science-policy interactions. While the role of biodiversity for human health needs further research, especially for zoonoses and emerging diseases, many direct and indirect benefits to human health are already apparent, but have yet to filter down to the science-policy interface in order to influence legislation and enforcement. Therefore, efforts to strengthen the interface in Southeast Asia should become a high priority in order to strengthen the health and resilience of Southeast Asian societies.

Collective resistance to HPAI H5N1 surveillance in the Thai cockfighting community: Insights from a social anthropology study.

Farmers may organize themselves to collectively manage risks such as animal diseases. Our study shows some evidence of such organization among fighting cock owners in Thailand. Fighting cocks were specifically targeted by HPAI (Highly Pathogenic Avian Influenza) H5N1 surveillance and control measures in Thailand because they were thought to pose a high risk of spreading diseases. In this work, we used a social-anthropological approach to gain an inside view of the issues associated with HPAI H5N1 surveillance in the cockfighting community in Thailand. Based on a qualitative analysis of data collected through in-depth interviews and observation of cockfighters' practices, we found that fighting cock owners share a sense of belonging to the same community based on a common culture, values, interests, practices, and internal rules, including rules to manage poultry diseases. During the HPAI H5N1 outbreaks, these rules may have contributed to mitigating the potential risk associated with the intense movements of fighting cocks inside the country. Nevertheless, this community, despite the high awareness and know-how of its members regarding poultry diseases, has shown a strong reluctance to comply with HPAI surveillance programs. We suggest that this reluctance is due to important gaps between the logic and rationales underlying surveillance and those associated with cockfighting activities. Our study highlights the need for multi and trans-disciplinary research involving the social sciences to analyze interactions between stakeholders and the collective actions implemented by communities to face risks.