Untangling the Complexity of Liver Fluke Infection and Cholangiocarcinoma in NE Thailand Through Transdisciplinary Learning

Integrated opisthorchiasis control through the EcoHealth/one health approach: 15 years of success and experiences with the Lawa model

Opisthorchis viverrini infection remains a major health problem in Northeast Thailand and the Mekong region impacting over 12 million and causing bile duct cancer. Using an EcoHealth/One Health approach at Lawa Lake in Thailand, our integrated control program achieved a substantial reduction in liver fluke prevalence from 60 % to <5 % over 15 years. Key interventions included chemotherapy, collaboratively designed health education, ecosystem modification, and community participation. Infections in intermediate hosts, Bithynia snails and Cyprinoid fish, are now undetectable. Improved community knowledge resulted in healthier practices. The "Lawa Model", a recognized model for liver fluke control, is now a training hub being scaled up in Thailand and the Mekong region. This program demonstrates how One Health strategies can address complex health and ecological challenges and aligns with WHO recommendations. The success of the Lawa Model demonstrates the efficacy of integrated One Health interventions against endemic parasitic diseases.

One Health showcase from Asia: the Lawa model-a community-based approach to liver fluke control in Thailand

Liver fluke infection caused by Opisthorchis viverrini is a significant public health challenge in the Lower Mekong Basin, affecting over 10 million people and leading to cholangiocarcinoma, a fatal bile duct cancer. Traditional control efforts often fail due to complex socio-cultural and ecological factors. The Lawa model, implemented in the Lawa Lake region of Khon Kaen, Thailand, adopts a One Health framework to integrate human health interventions, environmental modifications, and animal reservoir management, addressing the transmission cycle comprehensively. This approach respects the cultural context of Isan communities and leverages evidence-based, community-driven strategies. Over 15 years, the model has achieved remarkable success, reducing human infection rates from 60 % to below 5 % and eliminating infections in intermediate hosts. Key lessons include the importance of systems thinking, transdisciplinary collaboration, and community engagement in achieving sustainable health outcomes, despite challenges like cultural dietary practices and environmental disruptions such as flooding.

RAW ATTITUDES: Socio-Cultures, Altered Landscapes, and Changing Perceptions of an Underestimated Disease

Raw attitudes relate to the food cultures, eating habits, and behaviours of people in relation to the consumption of raw, partially cooked, and fermented freshwater fish dishes, which puts people at risk of Ophistochis viverrini and other parasitic infections. The chapter reviews raw attitudes within the countries and across the borders of the greater Mekong region, particularly northeast Thailand, Lao PDR, Vietnam, and Cambodia. Rather than treat each nation-state as an isolated epidemiological box, the chapter explores transborder complexity in relation to multiple anthropogenic transformations to the landscapes of the region and developmental impacts upon ecosystems and life cycles. Economic projects such as multiple hydropower dams, irrigation schemes, water-diversions, roads, and aquaculture ponds have significant impacts on FTZ life-cycle dynamics. In addition, many ecological changes are transboundary ones, and there are added complications relating human mobility, altered agrarian landscapes, and significant numbers of migrant workers. The chapter also examines public health programmes and educational interventions which are altering perceptions of O. viverrini and cholangiocarcinoma over time. A key argument is the need for transdisciplinary scientific and social science strategies alongside multi-pronged health interventions, such as 'the CASCAP model'. There exist many unknowns and gaps relating to widespread anthropogenic modifications upon life cycles, upon lifestyles, livelihoods, and human behaviours, which require research projects that span socio-economic, ecological, geographical, and public health dynamics of disease.

Masculinity and misinformation: Social dynamics of liver fluke infection risk in Thailand

Liver fluke infection through the consumption of raw or undercooked freshwater fish is a major public health problem in the Mekong Region. Despite the extensive efforts of liver fluke health campaigns, Northeast Thailand still reports high human infection prevalence as consumption of raw fish dishes has diminished but not ceased. This study examines the roles of social-cultural factors, particularly the influences of masculinity and misinformation, on liver fluke infection risk. Participant observation, questionnaire surveys and semi-structured interviews were conducted in four villages in Kalasin Province, Thailand, to scrutinize reasons for raw fish consumption, gender differences in raw fish culture, processes of liver fluke information dissemination, and the extent of information mismatch. Our results show that one of the key reasons (76.9%) underlying continued raw fish consumption are deeply embedded cultural practices associated with ways of rural life. About 30% of the participants indicated that they would not avoid eating raw fish, regardless of knowing the health consequences. Gender difference is evident, with 75.6% of males consuming raw fish salad (koi pla), compared to 42.7% of females. Some male participants associate raw meat consumption with virility and strength. Such beliefs underscore the cultural linkage of koi pla consumption with masculinity. Misconceptions of liver fluke life cycle and risk of infection remain, as only 15.3% of the participants correctly selected raw fish as the food source for liver fluke infection while 84.2% misunderstood that other raw foods could lead to infection. The multi-layered and hierarchical structure of public health information dissemination from medical professionals to health officers and village health volunteers to villagers has contributed to information mismatch between different layers. Our study builds on others which call for multi-pronged scientific and social strategies, as well as culturally attuned approaches to public health messaging. The study raises masculinity and misinformation as relevant considerations in disease prevention. Incorporating grounded research and gendered perspectives are part of appreciating the cultural roots of raw fish consumption. Realizing the significant role of village health volunteers in information dissemination and in supplying coherent public health messages is vital for effective health campaigns.

A new transdisciplinary research model to investigate and improve the health of the public

Transdisciplinary research approaches are being applied to today's complex health problems, including the climate crisis and widening inequalities. Diverse forms of disciplinary and experiential knowledge are required to understand these challenges and develop workable solutions. We aimed to create an updated model reflective of the strengths and challenges of current transdisciplinary health research that can be a guide for future studies. We searched Medline using terms related to transdisciplinary, health and research. We coded data deductively and inductively using thematic analysis to develop a preliminary model of transdisciplinary research. The model was tested and improved through: (i) a workshop with 27 participants at an international conference in Xiamen, China and (ii) online questionnaire feedback from included study authors. Our revised model recommends the following approach: (i) co-learning, an ongoing phase that recognizes the distributed nature of knowledge generation and learning across partners; (ii) (pre-)development, activities that occur before and during project initiation to establish a shared mission and ways of working; (iii) reflection and refinement to evaluate and improve processes and results, responding to emergent information and priorities as an ongoing phase; (iv) conceptualization to develop goals and the study approach by combining diverse knowledge; (v) investigation to conduct the research; (vi) implementation to use new knowledge to solve societal problems. The model includes linear and cyclical processes that may cycle back to project development. Our new model will support transdisciplinary research teams and their partners by detailing the necessary ingredients to conduct such research and achieve health impact.

Promoting sustainability education through hands-on approaches: a tree carbon sequestration exercise in a Singapore green space

During a university class project related to climate change mitigation strategies, we utilized a university green space as a "living laboratory" for collaborative learning exercise to estimate landscape-level carbon biomass storage. The key objective of the exercise was to foster sustainability awareness with regard to the effectiveness of tree-planting initiatives to offset carbon emissions. Collaborative learning is a process by which students work together in small groups to accomplish a common goal. As experiences are active, social and student-owned, the process leads to the development of a variety of cognitive and transferable skills that are beneficial in academia and the workplace. Through data collection/analysis, the carbon biomass exercise not only allowed students to assess critically the efficacy of a tree-planting initiative as a means to sequester carbon, but they became aware of the difficulties in performing research on complex environmental issues. The intention of the research was to give students an opportunity to practice data collection, data analysis, problem solving, teamwork, communication and scientific literacy skills, meanwhile utilizing the campus open green space to enhance the knowledge discovery process. Informal assessment and discussions with students demonstrated that the activity was successful in reaching a wide range of students with varying backgrounds and initial attitudes about climate change mitigating strategies, which was our objective. Our case study demonstrates how learning objectives can be integrated with university sustainability initiatives to improve learning and student engagement. Finally, we see green spaces as dynamic settings for learning about physical processes and issues related to environmental management and sustainability.

Operationalizing One Health Employing Social-Ecological Systems Theory: Lessons From the Greater Mekong Sub-region

The idea of the interdependency of the health of humans, animals, and ecosystems emerged from the interplay of theory and concepts from medicine, public health and ecology among leading thinkers in these fields during the last century. The rationale for One Health and its focus on the “human, animal, and environmental interface” stems from this legacy and points to transdisciplinary, ecological and complex systems approaches as central to One Health practice. Demonstration of One Health's efficacy, its wider adoption and continual improvement require explicit operational criteria and evaluation metrics on this basis. Social-Ecological Systems Theory with its unique conception of resilience (SESR) currently offers the most well-developed framework for understanding these approaches and development of performance standards. This paper describes operational criteria for One Health developed accordingly, including a protocol currently being tested for vector borne disease interventions. Wider adoption of One Health is most likely to occur as One Health practitioners gain an increasing familiarity with ecological and complex systems concepts in practice employing a transdisciplinary process. Two areas in which this inevitably will be required for significant further progress, and where the beginnings of a foundation for building upon exist, include: (1) Emerging and re-emerging zoonotic diseases, and (2) successful implementation of the United Nations (UN) Sustainable Development Goals (SDGs). The former includes the challenge of stemming the threat of new microbial pathogens, anti-microbial resistant variants of existing pathogens, as well as resurgence of malaria and other recalcitrant diseases. The applicability of SESR in this regard is illustrated with two case examples from the Greater Mekong Subregion, Avian Influenza (H5N1) and Liver Fluke (Opisthorchis viverrini). Each is shown to represent a science and policy challenge suggestive of an avoidable social-ecological system pathology that similarly has challenged sustainable development. Thus, SESR framing arguably is highly applicable to the SDGs, which, to a large extent, require consideration of human-animal-environmental health linkages. Further elaboration of these One Health operational criteria and metrics could contribute to the achievement of many of the SDGs.

Temporal Variability of Faecal Contamination from On-Site Sanitation Systems in the Groundwater of Northern Thailand

We investigated the impacts of on-site sanitation systems to local groundwater. In this year-long study, we monitored the response of faecal contamination levels to hydroclimatological factors including rainfall and groundwater table. Concentration of faecal indicators-E. coli (ESC), Enterococcus (ENT), nitrate-in thirteen pairs of shallow and deep wells were determined every 7-14 days. All samples from shallow wells were tested positive for faecal contamination (ESC and ENT > 1 MPN/100 mL) but concentration varies. A maximum of 24,000 MPN/100 mL were recorded in some shallow wells. Water from deep wells showed lower susceptibility to contamination with only 4 and 23% of samples tested positive for ESC and ENT, respectively. Concentrations of ESC and ENT were lower too, with a maximum of 5 MPN/100 mL and 28 MPN/100 mL, respectively. Fluctuation in contamination among the wells was described by four archetypal responses to hydroclimatological forcing: (i) flushing during the onset of wet season, (ii) dilution over the course of the wet season, (iii) concentration during the dry season, and (iv) synoptic response to storms. Previous studies attempting to link the prevalence of faecal/waterborne diseases and temporal factors (e.g., dry vs wet season) have produced differing outcomes. Our study may help explain the relevant hydrological mechanisms leading to these varying observations. Presently, most communities in Thailand have access to 'improved' sanitation systems. However, due to the unsustainable implementation of these systems, the otherwise viable drinking-water resources in the form of the abundant local groundwater has become a genuine health hazard.

Complexity and biosemiotics in evolutionary ecology of zoonotic infectious agents

More is not automatically better. Generation and accumulation of information reflecting the complexity of zoonotic diseases as ecological systems do not necessarily lead to improved interpretation of the obtained information and understanding of these complex systems. The traditional conceptual framework for analysis of diseases ecology is neither designed for, nor adaptable enough, to absorb the mass of diverse sources of relevant information. The multidirectional and multidimensional approaches to analyses form an inevitable part in defining a role of zoonotic pathogens and animal hosts considering the complexity of their inter-relations. And the more data we have, the more involved the interpretation needs to be. The keyword for defining the roles of microbes as pathogens, animals as hosts, and environmental parameters as infection drivers is "functional importance." Microbes can act as pathogens toward their host only if/when they recognize the animal organism as the target. The same is true when the host recognizes the microbe as a pathogen rather than harmless symbiont based on the context of its occurrence in that host. Here, we propose conceptual tools developed in the realm of the interdisciplinary sciences of complexity and biosemiotics for extending beyond the currently dominant mindset in ecology and evolution of infectious diseases. We also consider four distinct hierarchical levels of perception guiding how investigators can approach zoonotic agents, as a subject of their research, representing differences in emphasizing particular elements and their relations versus more unified systemic approaches.

Untangling the proximate causes and underlying drivers of deforestation and forest degradation in Myanmar

Political transitions often trigger substantial environmental changes. In particular, deforestation can result from the complex interplay among the components of a system-actors, institutions, and existing policies-adapting to new opportunities. A dynamic conceptual map of system components is particularly useful for systems in which multiple actors, each with different worldviews and motivations, may be simultaneously trying to alter different facets of the system, unaware of the impacts on other components. In Myanmar, a global biodiversity hotspot with the largest forest area in mainland Southeast Asia, ongoing political and economic reforms are likely to change the dynamics of deforestation drivers. A fundamental conceptual map of these dynamics is therefore a prerequisite for interventions to reduce deforestation. We used a system-dynamics approach and causal-network analysis to determine the proximate causes and underlying drivers of forest loss and degradation in Myanmar from 1995 to 2016 and to articulate the linkages among them. Proximate causes included infrastructure development, timber extraction, and agricultural expansion. These were stimulated primarily by formal agricultural, logging, mining, and hydropower concessions and economic investment and social issues relating to civil war and land tenure. Reform of land laws, the link between natural resource extraction and civil war, and the allocation of agricultural concessions will influence the extent of future forest loss and degradation in Myanmar. The causal-network analysis identified priority areas for policy interventions, for example, creating a public registry of land-concession holders to deter corruption in concession allocation. We recommend application of this analytical approach to other countries, particularly those undergoing political transition, to inform policy interventions to reduce forest loss and degradation.

Role of socio-cultural and economic factors in cyprinid fish distribution networks and consumption in Lawa Lake region, Northeast Thailand: Novel perspectives on Opisthorchis viverrini transmission dynamics

Opisthorchis viverrini (Ov) is a fish-borne parasite endemic in parts of Lao PDR, Cambodia, southern Vietnam and Northeast Thailand (Isaan) where an estimated 10 million people are infected. Human Ov infection, associated with hepatobiliary complications, including cholangiocarcinoma (CCA), occurs when infected fish are consumed raw or undercooked, a longstanding cultural tradition in the region. This mixed- methods descriptive study was carried out in Isaan villages around Lawa Lake, Khon Kaen Province, known for their Ov endemicity. Focus group discussions (FGDs) and in depth interviews (IDIs) were used to explore socio-cultural determinants underlying raw fish consumption practices, and global positioning system (GPS) devices to map local fish distribution networks. Qualitative data affirmed major socio-cultural and dietary lifestyle transitions occurring consequent on recent decades of modernization policies and practices, but also the persistence of Isaan traditional raw-fish eating practices and incorrect beliefs about infection risk avoidance. Fish traders/middlemen purchase most of the catch at the lakeshore and play the dominant role in district market fish distribution networks, at least for the larger and less likely infected, fish species. The lower economic value of the small potentially-infected cyprinid fish means local fishermen typically distribute them free, or sell cheaply, to family and friends, effectively concentrating infection risk in already highly Ov infected villages. Our study confirmed the persistence of traditional Isaan raw-fish meal practices, despite major ongoing socio-cultural lifestyle transitions and decades of Ov infection health education programs. We contend that diffuse socio-cultural drivers underpin this practice, including its role as a valued cultural identity marker. A "fish economics" factor was also evident in the concentration of more likely infected fish back into local villages due to their low economic value at district market level. The complexity of factors supporting "risky" fish-eating traditions in Isaan underscores the importance of integrated liver fluke infection control strategies to draw on transdisciplinary knowledge beyond biomedicine and also embrace participatory protocols for engaging communities in developing, implementing and evaluating interventions.

Social network analysis of food sharing among households in opisthorchiasis endemic villages of Lawa Lake, Thailand

Consumption of raw fish is a well-documented risk factor for Opisthorchis viverrini infection. Sharing of food, especially raw fish recipes may influence the spread of disease through a community. Using social network analysis of an ego network, we investigated food sharing among households in an Opisthorchis-endemic area. Network centrality properties were used to explain the differences in O. viverrini transmission and control between villages with a low and high prevalence of infection. Information on demography and O. viverrini infection in 2008 from villagers in the Lawa Lake area was extracted from the Tropical Disease Research Center database. The two villages that had the lowest and the highest O. viverrini infection at the household level were recruited. Ten percent of households of each village were randomly sampled. Participatory epidemiology and face-to-face structured interviews guided by a social network questionnaire were used to collect data on livelihood, agricultural patterns, food sources, raw fish eating habits, and other food sharing during daily life and social gatherings. The number of contacts including in-degree and out-degree varied from 0 to 7 in the low-infection village and 0 to 4 in the high-infection village. The mean number of contacts for the food-sharing network among the low- and high-infection villages was 1.64 and 0.73 contacts per household, respectively. Between these villages, the mean number of out-degree (p=0.0125), but not in-degree (p=0.065), was significantly different. Food-sharing differed in numbers of sharing-in and sharing-out between the two villages. Network analysis of food sharing may be of value in designing strategies for opisthorchiasis control at the community level.

Experimental and modelling investigations of Opisthorchis viverrini miracidia transmission over time and across temperatures: implications for control

Transmissibility is a significant factor in parasite fitness. The rate and magnitude of parasite transmission affect prevalence and infection intensity in individual hosts and are influenced by environmental factors. In this context, the objectives of this study were: (i) to experimentally assess Opisthorchis viverrini miracidia survival and infectivity over time and across temperatures; and (ii) to combine these experimental results with environmental data to build a key component of a transmission model, identifying seasonal windows of transmission risk in hyper-endemic northeastern Thailand. Five replicates of 50 O. viverrini eggs were randomly distributed and maintained under four temperature conditions (25°C, 30°C, 35°C, 40°C). Microscopic observations were performed on all experimental units over a period of 3months to record miracidia motility and mortality trends. Six infection trials were also conducted to assess infectivity of miracidia over time and across temperatures, using observations of egg hatching success and infection rates. Upon completion of experiments, data were integrated into a transmission model to create a transmission risk index and to simulate seasonal transmission risk. Miracidia survival rate and motility decreased steadily with 50% mortality observed after 2weeks. Hatching and infection success also decreased significantly after 3weeks. Temperatures over 30°C were associated with increased mortality and decreased infectivity. When incorporating local environmental parameters into our model, we observed low transmission risk during the dry season and increasing transmission risk at the onset of the rainy season, culminating with the highest risk in September. We believe that our results provide the first estimates of O. viverrini miracidia survival and transmission potential under variable temperature conditions and suggest that high temperature treatment (>40°C) of fecal waste could be an efficient control strategy.

Balancing biomedical and ecological perspectives in research framing of liver fluke and cholangiocarcinoma in NE Thailand

This review examines the association of Asian liver flukes and cholangiocarcinoma (CCA) from the standpoint of two contrasting research perspectives: that aligned with the biomedical model predominantly employed to date; and, that aligned with ecological (and evolutionary) thinking increasingly being used to frame research questions that address this association in Northeast Thailand. An examination of the assumptions that underlie most of this research, requisite of evidence-based health research, shows how a broadened research frame that incorporates 'ecologic' perspectives provides alternatives to the prevailing scientific interpretations and public narrative. A more balanced and integrative research approach that combines elements of the biomedical model and ecologic models of health is suggested to overcome the limited progress toward the reduction of liver fluke infection prevalence and CCA incidence in this region. Similarly, this approach presents an opportunity to further enhance collaborative research programs involving Parasitology and the complementary fields in the health sciences.

The role of evolutionary biology in research and control of liver flukes in Southeast Asia

Stimulated largely by the availability of new technology, biomedical research at the molecular-level and chemical-based control approaches arguably dominate the field of infectious diseases. Along with this, the proximate view of disease etiology predominates to the exclusion of the ultimate, evolutionary biology-based, causation perspective. Yet, historically and up to today, research in evolutionary biology has provided much of the foundation for understanding the mechanisms underlying disease transmission dynamics, virulence, and the design of effective integrated control strategies. Here we review the state of knowledge regarding the biology of Asian liver Fluke-host relationship, parasitology, phylodynamics, drug-based interventions and liver Fluke-related cancer etiology from an evolutionary biology perspective. We consider how evolutionary principles, mechanisms and research methods could help refine our understanding of clinical disease associated with infection by Liver Flukes as well as their transmission dynamics. We identify a series of questions for an evolutionary biology research agenda for the liver Fluke that should contribute to an increased understanding of liver Fluke-associated diseases. Finally, we describe an integrative evolutionary medicine approach to liver Fluke prevention and control highlighting the need to better contextualize interventions within a broader human health and sustainable development framework.