Controlling parasites, understanding practices: the biosocial complexity of a One Health intervention for neglected zoonotic helminths in northern Lao PDR

Consumer knowledge, attitudes, and behaviour regarding food safety - A perspective from Laos

Primary research data on food chain safety at consumer level is needed to help policymakers to decrease the risk of foodborne infections in the Lao People's Democratic Republic. Therefore, the objectives of this study are to 1) determine Lao people's food safety knowledge, attitudes, and intentions and identify the most influential factors that shape their food safety behaviour, and 2) to support the government in the development of more efficient risk communication programmes. A paper-based consumer survey was implemented to collect quantitative data on the selected topics about Laotian consumers, as well as on the equipment of households regarding the conditions and tools necessary for safe food preparation and storage. A model was developed based on the extended Theory of Planned Behaviour (TPB), and partial least squares structural equation modelling (PLS-SEM) was applied to analyse the factors that affect food safety behaviour. The elements of Knowledge and Perceived Behavioural Control positively influence behaviours, such as using separate chopping boards for raw and ready-to-eat foods. According to the model, only 10 % of the Intentions would be translated into Behaviours, which gap can be explained by the lack of a hygienic environment. Although the survey indicated that Laotian people intend to follow food safety guidelines, participants felt they lacked sufficient knowledge. This perception was validated by the knowledge test and behavioural part of the study. In the light of these findings, it is essential to raise awareness and promote food safety knowledge and interventions, such as enhancing food safety education in childhood. This would help to facilitate and encourage adopting safe practices to improve overall food safety at the consumer level, delivering positive impacts also to the food business sector.

Gender considerations in One Health: a framework for researchers

One Health research and intervention outcomes are strongly influenced by gender dynamics. Women, men, girls, and boys can be negatively affected by gender-based disadvantage in any of the three One Health domains (animal, human, and environmental health), and where this occurs in more than one domain the result may be a compounding of inequity. Evidence worldwide shows that women and girls are more likely to suffer from such gender-based disadvantage. A thoughtfully implemented One Health intervention that prioritizes gender equity is more likely to be adopted, has fewer unintended negative consequences, and can support progress toward gender equality, however there is limited evidence and discussion to guide using a gender lens in One Health activities. We propose a framework to identify key gender considerations in One Health research for development - with a focus on Low-and Middle-Income Countries. The framework encourages developing two types of research questions at multiple stages of the research process: those with a bioscience entry-point and those with a gender entry-point. Gender considerations at each stage of research, institutional support required, and intervention approaches is described in the framework. We also give an applied example of the framework as it might be used in One Health research. Incorporation of gender questions in One Health research supports progress toward more equitable, sustainable, and effective One Health interventions. We hope that this framework will be implemented and optimized for use across many One Health challenge areas with the goal of mainstreaming gender into One Health research.

Community knowledge, attitudes and practices related to Taenia solium taeniosis and cysticercosis in Zambia

BACKGROUND

Several studies on Taenia solium taeniosis / cysticercosis (TSTC) have been conducted in Zambia. However, none has assessed community knowledge, attitudes and practices related to TSTC and epilepsy.

METHODS

A community-based cross-sectional study was conducted between November and December 2022. The design consisted of a questionnaire-based survey conducted in each of the 25 purposely selected villages in Chiparamba Rural Health Centre (RHC) catchment area in Chipata district of the Eastern Province.

RESULTS

A total of 588 participants comprising 259 (44%) males and 329 (56%) females with median age of 42 years (range 17 to 92 years) were interviewed. Awareness of the signs and symptoms of taeniosis and human cysticercosis (HCC), including transmission and prevention measures was very low. Whilst the majority had heard about epilepsy, they were not able to link HCC to epilepsy. Most participants were aware of cysticerci in pigs (PCC) including its predilection sites but were not aware of mode of transmission and prevention measures. The pork meat inspection by trained professionals was also not a common practice in the area. Risk perception of T. solium infections was thus very low. Overall knowledge, attitude and practice scores related to T. solium infections and to epilepsy were very low with median scores of 0.38 (IQR 0.25-0.54) for knowledge, 0.25 (0.25-0.50) for attitudes, and 0.31 (0.25-0.44) for practices. Males had better knowledge on TSTC (median = 0.42, p = 0.017, r = 0.098) and better practice scores (median = 0.38, p = < 0.001, r = 0.154) compared to females though the effect size was small. With regards to sanitation and hygiene washing with soap and water was reported by many but only few had a hand washing facility near their latrines.

CONCLUSION

The study shows overall poor knowledge, attitudes and practices related to TSTC among the community of Chiparamba RHC in Chipata district of the Eastern Province of Zambia. This poses a serious challenge for control and elimination of T. solium infections and thus efforts to improve knowledge, attitudes and practices should be made using a One Health approach for the control and elimination of TSTC. Educational programs about TSTC transmission, signs and symptoms, prevention, management and control need to be scaled up in the study area and Zambia as a whole.

A Spatial Autocorrelation Method for Taenia solium Risk Mapping: The Case of Lao PDR

BACKGROUND

The World Health Organization has identified Taenia solium mapping tools as an important development for intensifying control in hyperendemic areas. Taenia solium has also been identified as a priority by the Lao PDR government. There is a limited understanding of the distribution of T. solium due to inherent diagnostic challenges.

METHOD

Global and local autocorrelation statistics were applied to available risk factor data sourced from national censuses to map the risk of Taenia solium in Lao PDR.

RESULTS

Approximately 50% of villages could be considered hot spots for one or more risk factors. Different risk factor hot spots co-occurred in 30% of villages. Twenty per cent of villages were classified as hot spots for the proportion of households owning pigs and another risk factor. Northern Lao PDR was the dominant high-risk area. This is consistent with passive reports, limited surveys, and anecdotal reports. One smaller area in southern Lao PDR was also identified as high-risk. This is of particular interest because T. solium has not previously been investigated in this area.

CONCLUSIONS

The methods applied provide a simple, rapid, and versatile approach that allows endemic countries to begin mapping the risk of T. solium at a sub-national level.

Foodborne zoonoses control in low- and middle-income countries: Identifying aspects of interventions relevant to traditional markets which act as hurdles when mitigating disease transmission

Globally, foodborne zoonoses are responsible for approximately one third of all foodborne disease burden and this picture is likely to worsen if consumption of animal source foods continues to rise with insufficient attention to risk mitigation. Traditional markets represent highly important nodes that can be targeted for risk mitigation; in this series of case studies, we discuss food safety interventions relevant to this nexus. We illustrate that to improve food safety within traditional markets it is essential to consider some of the motivations and incentives of the stakeholders involved and the cultural, social, and economic context in which interventions are undertaken, highlighting barriers, enablers future interventions should aim to avoid, embrace. We also conclude that a holistic approach to foodborne zoonoses control will require the institutionalization of One Health across food systems of which traditional markets are part.

The role of cooking practices in the transmission of the foodborne parasite Taenia solium: A qualitative study in an endemic area of Southern Tanzania

The pork tapeworm Taenia solium is a zoonotic food-borne parasite endemic in many developing countries causing human cysticercosis and taeniosis as well as porcine cysticercosis. It mainly affects the health of rural smallholder pig farmers and their communities, resulting in lower health status, reduced pork quality, and economic loss due to condemnation of pigs or low pricing of pork. This qualitative study aimed to identify key food related practices linked to consumption of pork at village level, of importance for transmission of taeniosis. We used an interpretivist-constructivist paradigm in a multiple case study of exploratory qualitative research design. Data was acquired through guided and probing interviews with 64 pork cooks, and 14 direct observations in four villages in a T. solium endemic area of Mbeya Region in the Southern Highlands of Tanzania. The study showed that the informants were members of communities of practice through their pork cooking practices, one community of practice for the restaurant cooks and one for the home cooks, learning, sharing, and distributing their cooking skills. Furthermore, the analysis showed that the pork cooks generally had some awareness of there being something undesirable in raw pork, but they had very diverse understandings of what it was, or of its potential harm. Major potential transmission points were identified in restaurants and in home kitchens. It appears that the pork cooks act according to socio-cultural and economic factors guiding them in their actions, including pressure from customers in restaurants, the family values of tradition in the home kitchens, and the culturally guided risk perception and appraisal. These practices might generate potential transmission points. Future research on interventions aimed at preventing the spread of T. solium taeniosis should recognise the importance of tradition and culture in risky food practices.

The prevalence of and contributors to neurocysticercosis in endemic regions

BACKGROUND

Neurocysticercosis is one of the most common causes of acquired epilepsy worldwide. Caused by Taenia solium, the infection uses pigs as an intermediate host and thus is often associated with proximity to and consumption of pigs.

OBJECTIVE

This review explores the epidemiology of neurocysticercosis in endemic regions across Africa, Asia, and Latin America and examines common risk factors in these areas.

METHODS

A literature review was conducted using pubmed to search for articles with key words including neurocysticercosis, Taenia, solium, epidemiology, and the names of countries and continents in the regions of interest.

FINDINGS

Multiple risk factors for neurocysticercosis were identified, including inadequate regulation of pig farms and food safety, poor sanitation, and water contamination. In addition, additional barriers to appropriate diagnosis and management were found, including resource limitations and poor health literacy.

CONCLUSION

Despite its global prevalence, effective limitation of neurocysticercosis is still achievable through projects which address common risk factors.

A scoping review of burden of disease studies estimating disability-adjusted life years due to Taenia solium

Background

Taenia solium is the most significant global foodborne parasite and the leading cause of preventable human epilepsy in low and middle-income countries in the form of neurocysticercosis.

Objectives

This scoping review aimed to examine the methodology of peer-reviewed studies that estimate the burden of T. solium using disability-adjusted life years.

Eligibility criteria

Studies must have calculated disability-adjusted life years relating to T. solium.

Charting methods

The review process was managed by a single reviewer using Rayyan. Published data relating to disease models, data sources, disability-adjusted life years, sensitivity, uncertainty, missing data, and key limitations were collected.

Results

15 studies were included for review, with seven global and eight national or sub-national estimates. Studies primarily employed attributional disease models that relied on measuring the occurrence of epilepsy before applying an attributable fraction to estimate the occurrence of neurocysticercosis-associated epilepsy. This method relies heavily on the extrapolation of observational studies across populations and time periods; however, it is currently required due to the difficulties in diagnosing neurocysticercosis. Studies discussed that a lack of data was a key limitation and their results likely underestimate the true burden of T. solium. Methods to calculate disability-adjusted life years varied across studies with differences in approaches to time discounting, age weighting, years of life lost, and years of life lived with disability. Such differences limit the ability to compare estimates between studies.

Conclusions

This review illustrates the complexities associated with T. solium burden of disease studies and highlights the potential need for a burden of disease reporting framework. The burden of T. solium is likely underestimated due to the challenges in diagnosing neurocysticercosis and a lack of available data. Advancement in diagnostics, further observational studies, and new approaches to parameterising disease models are required if estimates are to improve.

Stakeholder Analysis on Ecosystem Services of Lake Manyara Sub-basin (Tanzania): How to Overcome Confounding Factors

Ecosystem services are a telling concept to discuss the integrated management of natural resources, such as integrated water and soil, with non-academic stakeholders. Stakeholders have different perceptions regarding the management of various ecosystem services, which is challenging when aiming to develop and foster sustainable ecosystem management. We performed a stakeholder analysis as part of a social-ecological study in preparation of a decision support system for integrated water management within the Lake Manyara sub-basin (LMSB), Tanzania. The area includes a National Park and UNESCO Biosphere Reserve. A group discussion listed 26 stakeholders, categorized according to the sector, influence, and interest. The stakeholders were grouped into six functional categories: local Non-Governmental Organisations (NGOs), other civil society groups, Belgian and international NGOs, authorities, academics associated to international donors and the private sector. We empirically identified advantages, shortcomings and associated risks when performing a stakeholder analysis with an interest-influence matrix. Confounding factors may include, e.g., the omission of important stakeholders, a different understanding of 'influence' and 'interest', or the omission of fragile groups. Instead of 'low' or 'high' interest and influence, we propose the terms 'supportive', 'potentially supportive', 'unsupportive', 'not interested', 'low or no influence' and 'antagonistic'. Further, we consider stakeholders who directly extract resources from the social-ecological system (SES) as a separate category, because of their direct dependence and impact on the SES. This improved stakeholder analysis framework for developing decision support systems in water basins can contribute to better analysis, understanding and management of aquatic social-ecological systems in general.

Community perceptions and acceptability of mass drug administration for the control of neglected tropical diseases in Asia-Pacific countries: A systematic scoping review of qualitative research

Background

Preventative chemotherapy and mass drug administration have been identified as effective strategies for the prevention, treatment, control and elimination of several NTDs in the Asia-Pacific region. Qualitative research can provide in-depth insight into the social dynamics and processes underlying effective implementation of and adherence to mass drug administration programs. This scoping review examines published qualitative literature to examine factors influencing community perceptions and acceptability of mass drug administration approaches to control NTDs in the Asia-Pacific region.

Methodology

Twenty-four peer reviewed published papers reporting qualitative data from community members and stakeholders engaged in the implementation of mass drug administration programs were identified as eligible for inclusion.

Findings

This systematic scoping review presents available data from studies focussing on lymphatic filariasis, soil-transmitted helminths and scabies in eight national settings (India, Indonesia, Philippines, Bangladesh, Laos, American Samoa, Papua New Guinea, Fiji). The review highlights the profoundly social nature of individual, interpersonal and institutional influences on community perceptions of willingness to participate in mass drug administration programs for control of neglected tropical diseases (NTD). Future NTD research and control efforts would benefit from a stronger qualitative social science lens to mass drug administration implementation, a commitment to understanding and addressing the social and structural determinants of NTDs and NTD control in complex settings, and efforts to engage local communities as equal partners and experts in the co-design of mass drug administration and other efforts to prevent, treat, control and eliminate NTDs.

Conclusion

For many countries in the Asia-Pacific region, the “low hanging fruit has been picked” in terms of where mass drug administration has worked and transmission has been stopped. The settings that remain–such as remote areas of Fiji and Papua New Guinea, or large, highly populated, multi-cultural urban settings in India and Indonesia–present huge challenges going forward.

Qualitative research can provide in-depth insight into the social dynamics and processes underlying effective implementation of and adherence to mass drug administration programs. This scoping review examines published qualitative literature to examine factors influencing community perceptions and acceptability of mass drug administration approaches to control neglected tropical diseases (NTDs) in the Asia-Pacific region. Our analyses highlight the profoundly social nature of individual, interpersonal and institutional influences on community perceptions of willingness to participate in mass drug administration programs for control of NTDs. For many countries in the Asia-Pacific region, the “low hanging fruit has been picked” in terms of where mass drug administration has worked and transmission has been stopped. The settings that remain–e.g. remote areas of Fiji and Papua New Guinea, or large, highly populated, multi-cultural urban settings in India and Indonesia–present huge challenges going forward. Future NTD research and control efforts would benefit from a stronger qualitative social science lens to mass drug administration implementation, a commitment to understanding the socio-structural determinants of NTDs and NTD control in complex settings, and engaging local communities as equal partners and experts in the co-design of mass drug administration and other efforts to prevent, treat, control and eliminate NTDs.

"There are many fevers": Communities' perception and management of Febrile illness and its relationship with human animal interactions in South-Western Uganda

Diagnosing the causative agent of febrile illness in resource-limited countries is a challenge in part due to lack of adequate diagnostic infrastructure to confirm cause of infection. Most febrile illnesses (>60%) are non-malarial, with a significant proportion being zoonotic and likely from animal origins. To better characterize the pathways for zoonotic disease transmission and control in vulnerable communities, adequate information on the communities' experiences and lexicon describing fever, and their understanding and perceptions of risk pathways is required. We undertook an ethnographic study to understand behaviors, exposures, and attitudes toward fever at the community level. Our hope is to better elucidate areas of priority surveillance and diagnostic investment. A focused ethnography consisting of participant observation, informal conversations, 4 barazas (community meetings), and formal ethnographic interviews (13 Focus group discussions and 17 Key informant interviews) was conducted between April and November 2015 in Kasese and Hoima Districts in Uganda. Perception of illness and associated risk factors was heavily influenced by the predominant livelihood activity of the community. The term "fever" referred to multiple temperature elevating disease processes, recognized as distinct pathological occurrences. However, malaria was the illness often cited, treated, or diagnosed both at the health facilities and through self-diagnosis and treatment. As expected, fever is as an important health challenge affecting all ages. Recognition of malarial fever was consistent with a biomedical model of disease while non-malarial fevers were interpreted mainly through ethno etiological models of explanation. These models are currently being used to inform education and prevention strategies and treatment regimens toward the goal of improving patients' outcomes and confidence in the health system. Development of treatment algorithms that consider social, cultural, and economic contexts, especially where human-animal interaction is prevalent, should factor animal exposure and zoonotic illnesses as important differentials.

Zoonotic enteric parasites in Mongolian people, animals, and the environment: Using One Health to address shared pathogens

BACKGROUND

Cryptosporidium spp. and Giardia duodenalis are important zoonotic enteric pathogens of One Health concern for humans, animals, and the environment. For this study, we investigated parasite prevalence and risk factors among rural, peri-urban, and urban households and environments of Mongolia.

METHODS

This cross-sectional study implemented a household risk factor survey at 250 home sites along with sample collection from humans, animals, flies, and drinking water. Multiplex real-time PCR analysis was conducted to look for Cryptosporidium spp. and/or Giardia duodenalis within household samples.

RESULTS

Lab analysis found one or both zoonotic parasites at 20% of the participating households (51/250). Human samples had a parasite prevalence of 6.4% (27/419), domestic animals at 3.3% (19/570), pooled filth flies at 14.8% (17/115), and drinking water samples at 2% (5/250). Parasite presence at the household was significantly associated with a household's use of an improved drinking water source (OR 0.27; CI 0.12-0.61; p = < 0.01), having an indoor handwashing site (OR 0.41; CI 0.19-0.92; p = 0.03), domestic animal ownership (OR 2.40; CI 1.02-5.65; p = 0.05), and rural location (OR 0.50; CI 0.25-0.98; p = 0.04). Household use of an improved drinking water source remained significant in the multivariate model (OR 0.16; CI 0.04-0.68; p = 0.01).

CONCLUSION

In Mongolia, public and veterinary health are intertwined, particularly for rural herding households. Increased access to safe water, sanitation and hygiene infrastructure could help prevent further transmission of zoonotic enteric parasites. Public health interventions, policy and messaging should utilize a One Health framework employing joint leadership from local human and animal health sectors.

A qualitative assessment of the context and enabling environment for the control of Taenia solium infections in endemic settings

BACKGROUND

Taenia solium (T. solium), is a zoonotic helminth causing three diseases namely; taeniasis (in humans), neurocysticercosis (NCC, in humans) and porcine cysticercosis (PCC, in pigs) and is one of the major foodborne diseases by burden. The success or failure of control options against this parasite in terms of reduced prevalence or incidence of the diseases may be attributed to the contextual factors which underpin the design, implementation, and evaluation of control programmes.

METHODOLOGY/PRINCIPAL FINDINGS

The study used a mixed method approach combining systematic literature review (SLR) and key informant interviews (KII). The SLR focused on studies which implemented T. solium control programmes and was used to identify the contextual factors and enabling environment relevant to successful inception, planning and implementation of the interventions. The SLR used a protocol pre-registered at the International prospective register of systematic reviews (PROSPERO) number CRD42019138107 and followed PRISMA guidelines on reporting of SLR. To further highlight the importance and interlinkage of these contextual factors, KII were conducted with researchers/implementers of the studies included in the SLR. The SLR identified 41 publications that had considerations of the contextual factors. They were grouped into efficacy (10), effectiveness (28) and scale up or implementation (3) research studies. The identified contextual factors included epidemiological, socioeconomic, cultural, geographical and environmental, service and organizational, historical and financial factors. The enabling environment was mainly defined by policy and strategies supporting T. solium control.

CONCLUSION/SIGNIFICANCE

Failure to consider the contextual factors operating in target study sites was shown to later present challenges in project implementation and evaluation that negatively affected expected outcomes. This study highlights the importance of fully considering the various domains of the context and integrating these explicitly into the plan for implementation and evaluation of control programmes. Explicit reporting of these aspects in the resultant publication is also important to guide future work. The contextual factors highlighted in this study may be useful to guide future research and scale up of disease control programmes and demonstrates the importance of close multi-sectoral collaboration in a One Health approach.

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 descriptive study of zoonotic disease risk at the human-wildlife interface in a biodiversity hot spot in South Western Uganda

Zoonotic diseases pose a significant health challenge at the human-wildlife interface, especially in Sub-Saharan Africa where ecosystem services contribute significantly to local livelihoods and individual well-being. In Uganda, the fragmented forests of Hoima district, form part of a "biodiversity and emerging infectious disease hotspot" composed of communities with high dependency on these wildlife protected areas, unaware of the associated health risks. We conducted a cross-sectional mixed methods study from March to May 2017 and interviewed 370 respondents, using a semi-structured questionnaire from eight villages neighbouring forest fragments in Hoima District, Uganda. Additionally, a total of ten (10) focus group discussions (FGDs) consisting of 6-10 men or women were conducted to further explore the drivers of hunting and perception of zoonotic disease risks at community level. Qualitative and quantitative data were analysed using content analysis and STATA version 12 respectively. We found twenty-nine percent (29.0%, CI: 24.4-33.9) of respondents were engaged in hunting of wildlife such as chimpanzee (Pan troglodytes) and 45.8% (CI: 40.6-51.0), cane rats (Thryonomyidae spp). Acquisition of animal protein was among the main reasons why communities hunt (55.3%, CI: 50.1-60.4), followed by "cultural" and "medicinal" uses of wildlife and or its parts (22.7%, CI: 18.6-27.4). Results further revealed that hunting and bushmeat consumption is persistent for other perceived reasons like; bushmeat strengthens the body, helps mothers recover faster after delivery, boosts one's immunity and hunting is exercise for the body. However, respondents reported falling sick after consumption of bushmeat at least once (7.9%, CI: 5.3-11.1), with 5.3% (CI: 2.60-9.60) reporting similar symptoms among some family members. Generally, few respondents (37.0%, CI: 32.1-42.2) were aware of diseases transmissible from wildlife to humans, although 88.7% (CI: 85.0-92.0) had heard of Ebola or Marburg without context. Hunting non-human primate poses a health risk compared to edible rats (cane rats) and wild ruminants (cOR = 0.4, 95% CI = 0.1-0.9) and (cOR = 0.7, 95% CI = 0.2-2.1) respectively. Study suggests some of the pathways for zoonotic disease spillover to humans exist at interface areas driven by livelihoods, nutrition and cultural needs. This study offers opportunities for a comprehensive risk communication and health education strategy for communities living at the interface of wildlife and human interactions.

Effects of 'The Vicious Worm' educational software on Taenia solium knowledge among key pork supply chain workers in Zambia

The neglected zoonotic cestode Taenia solium is endemic in many low- and middle-income countries, including Zambia. The parasite infects humans and pigs, inflicting high socioeconomic and disease burdens in endemic areas. Health education is regarded as an important component in T. solium control and previous studies indicate that ‘The Vicious Worm’ may be an effective T. solium health education tool for Tanzanian medical and agricultural professionals and Zambian primary school students. This study aimed to assess the effects of health education using ‘The Vicious Worm’ among Zambian pork supply chain workers, because the pork supply chain greatly influences food safety and security in Zambia. Half-day educational workshops using ‘The Vicious Worm’ and subsequent follow-up sessions were organized in the Lusaka and Katete districts of Zambia in March and April 2019. Questionnaires were administered before, after, and three weeks after the use of ‘The Vicious Worm’ to assess the program’s impact on knowledge uptake and short-term retention. Focus group discussions were conducted to assess the program’s user experience and the participants’ beliefs, attitudes, and insights. In total, 47 pork supply chain workers participated: 25 from Lusaka and 22 from Katete. Overall, knowledge about T. solium was significantly higher (p<0.001) both immediately after, and three weeks after the use of ‘The Vicious Worm’ compared to baseline knowledge. Focus group discussions indicated incipient attitudinal and behavioral change, as well as a positive reception of the software; with participants describing the software as simple, educative, and useful to share knowledge. The study results indicate that workshops using ‘The Vicious Worm’ may be effective for short-term T. solium health education among key pork supply chain workers. Follow-up studies are required to assess long-term effects, transfer of knowledge and behavioral change. However, educational interventions with ‘The Vicious Worm’ could be considered for integrated T. solium control programs in sub-Saharan Africa, especially if the educational content is further simplified and clarified.

The tapeworm Taenia solium causes epilepsy and severe headaches in humans and economic losses to smallholder farmers in endemic areas where free-roaming pigs, poor sanitation and informal animal slaughter are prevalent. Treatment of human taeniosis and interventions in pigs (vaccination and anthelmintic treatment) have been established as essential tools to achieve short-term control, but health education will be crucial to sustain long-term control. ‘The Vicious Worm’ is a specific T. solium health education tool aiming to convey simple and meaningful messages concerning disease prevention and control. Previous studies found significant knowledge increases after the use of the educational tool in Tanzanian medical and agricultural professionals, and Zambian primary school students. We organized half-day educational workshops using ‘The Vicious Worm’ for pork supply chain workers at two study sites in Zambia, with follow-up visits three weeks later. We found a significant increase in participants’ knowledge, both immediately and three weeks after the health education. Furthermore, the program was well received and potentially led to attitudinal and behavioral change that could deter the propagation of T. solium. We conclude that ‘The Vicious Worm’ educational interventions may contribute to a safer pork supply chain and we encourage its implementation in future T. solium control strategies.

A Review of Antimicrobial Resistance in Poultry Farming within Low-Resource Settings

The emergence, spread, and persistence of antimicrobial resistance (AMR) remain a pressing global health issue. Animal husbandry, in particular poultry, makes up a substantial portion of the global antimicrobial use. Despite the growing body of research evaluating the AMR within industrial farming systems, there is a gap in understanding the emergence of bacterial resistance originating from poultry within resource-limited environments. As countries continue to transition from low- to middle income countries (LMICs), there will be an increased demand for quality sources of animal protein. Further promotion of intensive poultry farming could address issues of food security, but it may also increase risks of AMR exposure to poultry, other domestic animals, wildlife, and human populations. Given that intensively raised poultry can function as animal reservoirs for AMR, surveillance is needed to evaluate the impacts on humans, other animals, and the environment. Here, we provide a comprehensive review of poultry production within low-resource settings in order to inform future small-scale poultry farming development. Future research is needed in order to understand the full extent of the epidemiology and ecology of AMR in poultry within low-resource settings.

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.

Chicken eggs, childhood stunting and environmental hygiene: an ethnographic study from the Campylobacter genomics and environmental enteric dysfunction (CAGED) project in Ethiopia

BACKGROUND

Childhood stunting and malnutrition condemn millions of people globally to a life of disadvantage and cognitive and physical impairment. Though increasing egg consumption is often seen as an important solution for low and middle income countries (including Ethiopia), emerging evidence suggests that greater exposure to poultry feces may also inhibit child growth due to the effects of enteric bacteria, especially Campylobacter, on gut health.

METHODS

In this rapid ethnographic study, we explored village poultry production, child dietary practices, and environmental hygiene conditions as they relate to Campylobacter risk and intervention in 16 villages in Haramaya Woreda, Eastern Ethiopia.

RESULTS

In the study area, we found that women assumed primary responsibility to care for both chickens and children: in feeding, housing, and healthcare. Most chickens were free-range local indigenous breeds, and flock sizes were small and unstable due to epidemics, seasonal trends, reproductive patterns, and lack of food. Generally, eggs were seen as "too luxurious" to be eaten, and were predominantly sold at local markets for scarce cash, despite high malnutrition rates. Local narratives of extreme poverty, social dietary norms, parental fatalism, and lack of "dietary consciousness" (as it was called) were invoked to explain this. We found that homesteads were highly contaminated with human and animal feces. Although community members viewed chicken feces and poultry gastrointestinal contents as particularly noxious in comparison to other animals because of their feeding behaviour, they did not relate them to any particular disease. Shared human-animal housing and childcare practices place children at high risk of exposure to enteric bacteria from animal manure, despite daily routines designed to manage the domestic landscape.

CONCLUSIONS

Addressing childhood stunting and malnutrition through egg production in rural landscapes like Haramaya must navigate three distinct health and care regimes: for children, chickens, and home environments. Interventions should be based on a holistic approach to social and economic empowerment, one that considers both women and men and integrates nutrition, health, and community change as its overarching goal.

Qualitative Research for One Health: From Methodological Principles to Impactful Applications

The One Health concept has inspired a rich vein of applied research and scholarly reflection over the past decade, yet with little influence from qualitative methodologists. With this overview, we describe the underpinning assumptions, purposes, and potential pitfalls of data collection techniques and methods of data analysis in key qualitative research methodologies. Our aim is to enhance One Health collaborations involving qualitative researchers, veterinary epidemiologists, and veterinary economists. There exist several distinct traditions of qualitative research, from which we draw selectively for illustrative purposes. Notwithstanding important distinctions, we emphasize commonalities and the potential for collaborative impact. The most important commonality is a shared focus on contextualizing human behavior and experience–culturally, economically, historically, and socially. We demonstrate that in-depth attention to context can assist veterinary economists and epidemiologists in drawing lessons from the implementation of policies and programs. In other words, qualitative researchers can assist One Health teams in distilling insights from “success stories,” but also from adverse events and unintended consequences. As a result, qualitative researchers can contribute to One Health research and policy discussions by formulating more accurate and contextually-relevant parameters for future quantitative studies. When performed well, qualitative methodologies can help veterinary economists and epidemiologists to develop impactful research questions, to create more accurate and contextually-relevant parameters for quantitative studies, and to develop policy recommendations and interventions that are attuned to the political and socio-cultural context of their implementation. In sketching out the properties and features of influential methodologies, we underscore the value of working with seasoned qualitative researchers to incorporate questions about “what,” “how,” and “why” in mixed-methods research designs.

MICHELINdb: a web-based tool for mining of helminth-microbiota interaction datasets, and a meta-analysis of current research

BACKGROUND

The complex network of interactions occurring between gastrointestinal (GI) and extra-intestinal (EI) parasitic helminths of humans and animals and the resident gut microbial flora is attracting increasing attention from biomedical researchers, because of the likely implications for the pathophysiology of helminth infection and disease. Nevertheless, the vast heterogeneity of study designs and microbial community profiling strategies, and of bioinformatic and biostatistical approaches for analyses of metagenomic sequence datasets hinder the identification of bacterial targets for follow-up experimental investigations of helminth-microbiota cross-talk. Furthermore, comparative analyses of published datasets are made difficult by the unavailability of a unique repository for metagenomic sequence data and associated metadata linked to studies aimed to explore potential changes in the composition of the vertebrate gut microbiota in response to GI and/or EI helminth infections.

RESULTS

Here, we undertake a meta-analysis of available metagenomic sequence data linked to published studies on helminth-microbiota cross-talk in humans and veterinary species using a single bioinformatic pipeline, and introduce the 'MICrobiome HELminth INteractions database' (MICHELINdb), an online resource for mining of published sequence datasets, and corresponding metadata, generated in these investigations.

CONCLUSIONS

By increasing data accessibility, we aim to provide the scientific community with a platform to identify gut microbial populations with potential roles in the pathophysiology of helminth disease and parasite-mediated suppression of host inflammatory responses, and facilitate the design of experiments aimed to disentangle the cause(s) and effect(s) of helminth-microbiota relationships. Video abstract.

To Really Know the Disease: Creating a Participatory Community Education Workshop about Taenia solium Focused on Physical, Economic, and Epidemiologic Evidence

Cysticercosis, caused by Taenia solium, is a neglected disease that causes preventable epilepsy. We conducted an experiential learning workshop in northern Peru to educate community members on T. solium transmission and motivate participation in community-led prevention and control. The workshop included presentation of local economic and epidemiologic data, followed by hands-on participation in pig dissection, group discussion of the T. solium life cycle, and viewing of eggs and nascent tapeworms with light microscopes. Among heads of household, we used community survey data to compare knowledge of the three-stage parasite life cycle at baseline and 2 months postworkshop. Knowledge of the life cycle increased significantly after the workshop, with greater gains for workshop attendees than non-attendees. Prior knowledge and workshop attendance were significant predictors of postworkshop knowledge. The use of local evidence and experiential learning positively affected knowledge of T. solium transmission, laying the foundation for subsequent community-engaged control efforts.

Systematic review of the effectiveness of selected drugs for preventive chemotherapy for Taenia solium taeniasis

Background

Preventive chemotherapy is a useful tool for the control of Taenia solium taeniasis and cysticercosis. The aim of this systematic review is to assess the scientific evidence concerning the effectiveness and safety of different drugs in preventive chemotherapy for T. solium taeniasis in endemic populations.

Methods

A systematic review was conducted of controlled and uncontrolled studies, assessing the efficacy and adverse effects (among other outcomes) of albendazole, niclosamide and/or praziquantel for preventive chemotherapy of T. solium taeniasis. A comprehensive search was conducted for published and unpublished studies. Two reviewers screened articles, completed the data extraction and assessment of risk of bias. A meta-analysis of cure rate and relative reduction in prevalence was performed. The protocol for this review was registered on the International prospective register of systematic reviews (PROSPERO), number CRD42018112533.

Results

We identified 3555 records, of which we included 20 primary studies reported across 33 articles. Meta-analyses of drug and dose showed that a single dose of praziquantel 10mg/kg, albendazole 400mg per day for three consecutive days, or niclosamide 2g, resulted in better cure rates for T. solium taeniasis (99.5%, 96.4% and 84.3%, respectively) than praziquantel 5mg/kg or single dose albendazole 400mg (89.0% and 52.0%, respectively). These findings have a low certainty of evidence due to high risk of bias in individual studies and heterogeneity in combined estimates. In relation to side-effects, most studies reported either no or only mild and transient side-effects within the first three days following drug administration for all drugs and doses.

Conclusion

Evidence indicated that praziquantel 10mg/kg, niclosamide 2g, and triple dose albendazole 400mg were effective as taenicides and could be considered for use in mass drug administration programs for the control of T. solium taeniasis. Evidence was not found that any of these drugs caused severe side effects at the indicated doses, although the extent of the available evidence was limited.

Taeniasis and cysticercosis caused by Taenia solium are considered, by the WHO, to be neglected tropical diseases. Preventive chemotherapy for taeniasis in endemic populations is a useful tool for control of the parasite. Preventive chemotherapy can be implemented by treating the whole population in endemic areas at regular intervals (known as mass drug administration). While different drugs, doses and regimes have been used there were still uncertainties about which drugs and dose have the best efficacy while considering adverse effects. We conducted a systematic review of the best available literature to inform a WHO guideline for preventive chemotherapy. We found that praziquantel 10mg/kg, niclosamide 2g, and triple dose albendazole 400mg (400mg per day for three consecutive days) are all effective. Proven side-effects were mild and short-lived, when they did occur.

Zoonotic transmission of intestinal helminths in southeast Asia: Implications for control and elimination

Intestinal helminths are extremely widespread and highly prevalent infections of humans, particularly in rural and poor urban areas of low and middle-income countries. These parasites have chronic and often insidious effects on human health and child development including abdominal problems, anaemia, stunting and wasting. Certain animals play a fundamental role in the transmission of many intestinal helminths to humans. However, the contribution of zoonotic transmission to the overall burden of human intestinal helminth infection and the relative importance of different animal reservoirs remains incomplete. Moreover, control programmes and transmission models for intestinal helminths often do not consider the role of zoonotic reservoirs of infection. Such reservoirs will become increasingly important as control is scaled up and there is a move towards interruption and even elimination of parasite transmission. With a focus on southeast Asia, and the Philippines in particular, this review summarises the major zoonotic intestinal helminths, risk factors for infection and highlights knowledge gaps related to their epidemiology and transmission. Various methodologies are discussed, including parasite genomics, mathematical modelling and socio-economic analysis, that could be employed to improve understanding of intestinal helminth spread, reservoir attribution and the burden associated with infection, as well as assess effectiveness of interventions. For sustainable control and ultimately elimination of intestinal helminths, there is a need to move beyond scheduled mass deworming and to consider animal and environmental reservoirs. A One Health approach to control of intestinal helminths is proposed, integrating interventions targeting humans, animals and the environment, including improved access to water, hygiene and sanitation. This will require coordination and collaboration across different sectors to achieve best health outcomes for all.

Effects of 'The Vicious Worm' educational tool on Taenia solium knowledge retention in Zambian primary school students after one year

BACKGROUND

Taenia solium is a neglected zoonotic parasite endemic throughout many low-income countries worldwide, including Zambia, where it causes human and pig diseases with high health and socioeconomic burdens. Lack of knowledge is a recognized risk factor, and consequently targeted health educational programs can decrease parasite transmission and disease occurrence in endemic areas. Preliminary assessment of the computer-based education program 'The Vicious Worm' in rural areas of eastern Zambia indicated that it was effective at increasing knowledge of T. solium in primary school students. The aim of this study was to evaluate the impact of 'The Vicious Worm' on knowledge retention by re-assessing the same primary school students one year after the initial education workshops.

METHODOLOGY/PRINCIPAL FINDINGS

Follow-up questionnaires were administered in the original three primary schools in eastern Zambia in 2017, 12 months after the original workshops. In total, 86 pupils participated in the follow-up sessions, representing 87% of the initial workshop respondents. Knowledge of T. solium at 'follow-up' was significantly higher than at the initial 'pre' questionnaire administered during the Vicious Worm workshop that took place one year earlier. While some specifics of the parasite's life cycle were not completely understood, the key messages for disease prevention, such as the importance of hand washing and properly cooking pork, remained well understood by the students, even one year later.

CONCLUSIONS/SIGNIFICANCE

Results of this study indicate that 'The Vicious Worm' may be an effective tool for both short- and long-term T. solium education of rural primary school students in Zambia. Inclusion of educational workshops using 'The Vicious Worm' could be recommended for integrated cysticercosis control/elimination programs in sub-Saharan Africa, particularly if the content is simplified to focus on the key messages for prevention of disease transmission.

Review of Biological and Chemical Health Risks Associated with Pork Consumption in Vietnam: Major Pathogens and Hazards Identified in Southeast Asia

Foodborne illness is a difficult public health burden to measure, with accurate incidence data usually evading disease surveillance systems. Yet, the global scope of foodborne disease and its impacts on socioeconomic development make it an important health risk to address, particularly in low- and middle-income countries. In Vietnam, rapid development has seen large-scale commercial operations rise to coexist amongst traditional value chains in the food landscape, most of which operates outside of a domestic food safety network. Rapid socioeconomic development has also seen an increase in meat consumption, with pork being the most consumed meat product nationally. Expanding pork value chains, and the increasing diversity of actors within them, facilitates the growth and propagation of hazards which are passed onto Vietnamese consumers. In order to guide illness prevention and governance efforts, this review was conducted to examine health risks associated with pork consumption in Vietnam. Synthesis of the available literature provided evidence that Salmonella spp. bacteria are a major cause of foodborne illness from Vietnamese pork products. However, contaminants of global concern, including Salmonella spp. and Trichinella spiralis, occur alongside those considered neglected tropical diseases, such as Taenia solium. Infections and complications associated with ingestion of Streptococcus suis bacteria are also an issue, with Streptococcus suis infections usually limited to occupational infections amongst meat handlers in modernised value chains. A risk factor underscoring transmission of Trichinella spiralis, Taenia solium, and Streptococcus suis in Vietnam that emerges from the literature is the consumption of dishes containing raw or undercooked pork. Available data indicates that infections associated with raw pork consumption disproportionately affect men and people in regional mountainous areas of northwest Vietnam, where many of Vietnam’s ethnic minority communities reside. In addition, epidemiological data from recorded disease outbreaks that result from raw pork consumption demonstrate that these outbreaks usually follow major sociocultural events such as weddings, funerals, and Lunar New Year celebrations. Potential health impacts resulting from residues of antibiotics and heavy metals are also cause for concern, though the direct links between chemical contaminants in food and the development of disease are difficult to conclusively deduce.

Sociocultural dynamics that influence Chagas disease health care in Colombia

Chagas disease (CD) is a Latin America endemic and neglected tropical disease that affects primarily poor people living in rural areas. Its current low profile leads to many diagnostic, treatment, and control challenges. This study aimed to identify and characterize the sociocultural dynamics that influence CD health care in Colombia. Data for our ethnographic study was collected in 2013 and included participant observation in two main endemic areas in Colombia. In addition, 81 people belonging to four groups (patients and family members; health care workers; researchers; and officers) were recruited through snowball sampling technique and participated in informal and semi-structured interviews. People from the first two groups also participated in social cartography excercises. Data analysis resulted in the identification of three main sociocultural dynamics. Local Understandings: Patients reported confusions around disease transmission, treatment effectiveness and development of future complications. Providers' Knowledge and Training: Failures in professional's knowledge and training mostly affect the primary level of care in rural areas. Professionals undergo minimal training during medical school and lack access to continuous education. In contrast, clinicians working at tertiary university hospitals or at the CD unit of the Colombian National Institute of Health (NIH) exhibited great knowledge and competency. Health Care System Barriers: The Colombian market-based health care reform augmented access barriers, which impacted CD care greatly. We identified geographic and bureaucratic itineraries that depended on type of insurance plan, insurance contracts with service providing institutions, and levels of care. This study shows that people's experience of these sociocultural dynamics vary depending on their mobility from rural to urban contexts. It unveils the importance of analyzing the structure of the health care system. In the Colombian case, its for-profit orientation has become one of the most important obstacles for comprehensive, integrated, and timely health care responses.

Improved methods to capture the total societal benefits of zoonotic disease control: Demonstrating the cost-effectiveness of an integrated control programme for Taenia solium, soil transmitted helminths and classical swine fever in northern Lao PDR

BACKGROUND

Control and elimination of zoonotic diseases requires robust information about their effect on both human and livestock health in order to enable policy formulation and the allocation of resources. This study aimed to evaluate the cost-effectiveness of controlling Taenia solium taeniasis/cysticercosis in both humans and pigs, and soil-transmitted helminths (STH) in humans by integrating their control to on-going human and animal health control programmes in northern Lao People's Democratic Republic.

METHOD

A cross-sectional study was carried out in 49 households, focusing on the prevalence of T. solium taenias/cysticercosis and soil transmitted helminths before and after a twelve month intervention. The village data was collected using a semi-structured questionnaire through a door-to-door survey. The village data was then projected to the wider northern Lao PDR population using stochastic modelling and cost-effectiveness ratio (after aggregating the net cost to capture both human and animal health parameters) and GDP per capita as a threshold, to determine the cost-effectiveness of the integrated control of T. solium taeniasis/ cysticercosis and STH, assuming linear scaling out of the intervention. The zoonotic DALY (zDALY) approach was also used as an alternative method of estimating the cost-effectiveness ratio of controlling T. solium taeniasis/cysticercosis in humans and pigs.

FINDINGS

Using cost-effectiveness analysis after aggregating the net cost and control of T. solium taeniasis/cysticercosis alone as the base case, the study found that simultaneous control of T. solium taeniasis/cysticercosis in humans and pigs, STH in humans and Classical Swine Fever (CSF) in pigs was USD 14 per DALY averted and USD 234 per zDALY averted using zDALY method hence considered highly cost-effective whereas controlling T. solium taeniasis/cysticercosis without incorporating STH and CSF was the least cost-effective (USD 3,672 per DALY averted). Additionally, the cost-effectiveness of controlling T. solium taeniasis/cysticercosis in people and pigs using zDALY as an alternative method was USD 3,662 per zDALY averted which was quite close to our findings using the aggregate net cost method.

CONCLUSION

The study showed that control of T. solium taeniasis/cysticercosis alone in humans and pigs is not cost-effective in northern Lao PDR whereas control of STH is. Consequently, integrating T. solium taeniasis/cysticercosis control with other cost-effective programmes such as STH and CSF markedly improved the cost-effectiveness of the intervention. This is especially important in low resource countries where control of zoonotic neglected tropical diseases could be integrated with the human and animal health sectors to optimize use of the limited resources.

TRIAL REGISTRATION

Australia New Zealand Clinical Trials Registry (ANZCTR) ACTRN12614001067662.

Understanding perceptions on 'Buruli' in northwestern Uganda: A biosocial investigation

Background

An understudied disease, little research thus far has explored responses to Buruli ulcer and quests for therapy from biosocial perspective, despite reports that people seek biomedical treatment too late.

Methods and findings

Taking an inductive approach and drawing on long-term ethnographic fieldwork in 2013–14, this article presents perspectives on this affliction of people living and working along the River Nile in northwest Uganda. Little is known biomedically about its presence, yet ‘Buruli’, as it is known locally, was and is a significant affliction in this region. Establishing a biosocial history of ‘Buruli’, largely obscured from biomedical perspectives, offers explanations for contemporary understandings, perceptions and practices.

Conclusions/Significance

We must move beyond over-simplifying and problematising ‘late presentation for treatment’ in public health, rather, develop biosocial approaches to understanding quests for therapy that take into account historical and contemporary contexts of health, healing and illness. Seeking to understand the context in which healthcare decisions are made, a biosocial approach enables greater depth and breadth of insight into the complexities of global and local public health priorities such as Buruli ulcer.

Buruli ulcer, a neglected tropical disease, has been described as an emerging public health problem in parts of sub-Saharan Africa. One of the challenges highlighted by the World Health Organisation (WHO) is improving access to biomedical healthcare. A research priority is thus to determine local understandings of skin disorders such as Buruli ulcer, and social-cultural factors that influence health-seeking. This article explores perspectives on Buruli among fisherfolk in northwestern Uganda along the River Nile, where the ulcer has previously been documented. The findings are based on a long-term ethnographic study of health, healing and illness in this region, and integrate insights from biomedical and social sciences. This biosocial approach demonstrates that, rather than seeking therapy late, people in this region sought treatment from local herbalists promptly when signs of skin lesions appeared. This was not because of non-biomedical understandings of disease. The reasons why people continue to trust local herbalists as experts in Buruli can be found in the historical context of how ulcers have been understood and managed, and the broader context of quests for therapy in this region. While the findings relate to where this study took place, the lessons learnt and biosocial approach used could be usefully applied in other settings where Buruli ulcer is endemic, and for understanding the local context of other neglected diseases and global health priorities.

Animal influence on water, sanitation and hygiene measures for zoonosis control at the household level: A systematic literature review

INTRODUCTION

Neglected zoonotic diseases (NZDs) have a significant impact on the livelihoods of the world's poorest populations, which often lack access to basic services. Water, sanitation and hygiene (WASH) programmes are included among the key strategies for achieving the World Health Organization's 2020 Roadmap for Implementation for control of Neglected Tropical Diseases (NTDs). There exists a lack of knowledge regarding the effect of animals on the effectiveness of WASH measures.

OBJECTIVES

This review looked to identify how animal presence in the household influences the effectiveness of water, hygiene and sanitation measures for zoonotic disease control in low and middle income countries; to identify gaps of knowledge regarding this topic based on the amount and type of studies looking at this particular interaction.

METHODS

Studies from three databases (Medline, Web of Science and Global Health) were screened through various stages. Selected articles were required to show burden of one or more zoonotic diseases, an animal component and a WASH component. Selected articles were analysed. A narrative synthesis was chosen for the review.

RESULTS

Only two studies out of 7588 met the inclusion criteria. The studies exemplified how direct or indirect contact between animals and humans within the household can influence the effectiveness of WASH interventions. The analysis also shows the challenges faced by the scientific community to isolate and depict this particular interaction.

CONCLUSION

The dearth of studies examining animal-WASH interactions is explained by the difficulties associated with studying environmental interventions and the lack of collaboration between the WASH and Veterinary Public Health research communities. Further tailored research under a holistic One Health approach will be required in order to meet the goals set in the NTDs Roadmap and the 2030 Agenda for Sustainable Development.

Towards a science of global health delivery: A socio-anthropological framework to improve the effectiveness of neglected tropical disease interventions

BACKGROUND

Over the last decade, implementation research and a science of global health delivery have emerged as important vehicles to improve the effectiveness of interventions. Efforts to control neglected tropical diseases (NTD) operate in challenging circumstances and with marginalized populations, making attention to context-specific details particularly relevant. Socio-anthropological insights have much to offer a science of NTD delivery. In this paper, an accessible and actionable framework for understanding NTD intervention effectiveness, based on socio-anthropological research, is presented and its utility for program planning and monitoring and evaluation is outlined.

METHODOLOGY/PRINCIPAL FINDINGS

The framework was developed inductively by comparatively analyzing three rapid ethnographic studies undertaken in Eastern Africa (2010-2013) on three different large-scale NTD interventions: rabies elimination in Tanzania, sleeping sickness control in Uganda and the prevention of parasitic worms in Zambia. The framework includes five "intervention domains" where the effectiveness of these interventions was negotiated and determined at the local level. This involves: 1) the terrain of intervention (including seasonality and geographical variability); 2) community agency (including local knowledge, risk perceptions, behaviors, leadership and social pressure); 3) the strategies and incentives of field staff (skills, motivations, capabilities and support); 4) the socio-materiality of technology (characteristics of intervention tools and the adoption process itself); and 5) the governance of interventions (policy narratives, available expertise, bureaucracy, politics and the utilization of knowledge). The paper illustrates the importance of each of these domains by drawing on the case study research, presenting lessons learnt and practical recommendations for how such insights could improve intervention delivery.

CONCLUSIONS/SIGNIFICANCE

To help close the gap between efficacy and effectiveness in NTD programs, it is important that field staff: 1) generate meaningful knowledge about contextual factors; 2) use this knowledge to tailor field strategies; and 3) create routine mechanisms to account for the dynamic process of implementation itself. The framework presented here offers a simple analytical tool to strengthen these knowledge-to-action relationships existing project planning tools, drawing on the insights of socio-anthropology.

Barriers to Participation in a Community-Based Program to Control Transmission of Taenia solium in Peru

Infection of the brain with Taenia solium larvae (neurocysticercosis) is a leading cause of preventable epilepsy worldwide. Effective and sustainable strategies to control parasite transmission in rural endemic communities are needed to prevent the disease. Surveillance and targeted intervention around infected pigs (ring control strategy) have been shown to be effective when carried out by research teams. However, this strategy has not been implemented or tested as a community-based program. In this small trial in northern Peru, eight villages were randomly assigned to community-led surveillance and treatment (five villages, 997 residents) or control (three villages, 1,192 residents). In intervention villages, community-led surveillance and reporting were promoted by community health workers, radio advertisement, and school and household education. Each suspected pig infection was verified, with confirmed cases resulting in treatment with niclosamide for taeniasis and oxfendazole for pigs in clusters of homes nearby. No incentives beyond human and pig treatment were offered. Control villages received basic disease education but no treatment intervention in response to reports. Despite 14 case reports, community-based replication of ring control strategy did not replicate prior results. After 12 months, there was no change in seroincidence in intervention villages between the baseline and study end, and no difference compared with control villages. There was no difference in prevalence of taeniasis or porcine cysticercosis at study end. Community members described lack of knowledge as the main reason for not reporting infected pigs. Further exploration of methods to transfer ring strategy and other control interventions for cysticercosis to the community is needed.

Views from many worlds: unsettling categories in interdisciplinary research on endemic zoonotic diseases

Interdisciplinary research on zoonotic disease has tended to focus on ‘risk’ of disease transmission as a conceptual common denominator. With reference to endemic zoonoses at the livestock–human interface, we argue for considering a broader sweep of disciplinary insights from anthropology and other social sciences in interdisciplinary dialogue, in particular cross-cultural perspectives on human–animal engagement. We consider diverse worldviews where human–animal encounters are perceived of in terms of the kinds of social relations they generate, and the notion of culture is extended to the ‘natural’ world. This has implications for how animals are valued, treated and prioritized. Thinking differently with and about animals and about species' boundaries could enable ways of addressing zoonotic diseases which have closer integration with people's own cultural norms. If we can bring this kind of knowledge into One Health debates, we find ourselves with a multiplicity of worldviews, where bounded categories such as human:animal and nature:culture cannot be assumed. This might in turn influence our scientific ways of seeing our own disciplinary cultures, and generate novel ways of understanding zoonoses and constructing solutions.

This article is part of the themed issue ‘One Health for a changing world: zoonoses, ecosystems and human well-being’.

Preliminary assessment of the computer-based Taenia solium educational program 'The Vicious Worm' on knowledge uptake in primary school students in rural areas in eastern Zambia

OBJECTIVE

The zoonotic helminth Taenia solium is endemic in Zambia, causing human (taeniasis and (neuro)cysticercosis) and pig (porcine cysticercosis) diseases with high health, social and economic burdens. We aimed to evaluate the impact of a health educational program intended to lead to powerful and cumulative improvements in knowledge, attitudes and practices that decrease parasite transmission and disease occurrence.

METHODS

Half-day health education workshops were conducted in three primary schools in the highly endemic Eastern Province of Zambia, using the computer-based T. solium educational program 'The Vicious Worm'. Questionnaires were administered before and after the educational component to determine the program's impact on knowledge uptake in primary school students.

RESULTS

In total, 99 students participated: 38 males and 61 females, with a median age of 14 years (range 10-18 years). Baseline general knowledge of T. solium, including awareness of the different human and pig disease states, and disease diagnosis, treatment and prevention, was quite high (average score 62%) and consistent across all three study areas. Participants' knowledge had significantly increased after the educational component, particularly regarding parasite transmission and disease prevention.

CONCLUSION

Preliminary assessment of 'The Vicious Worm' indicates it is an effective tool for the short-term T. solium education of primary school students in Zambia. Follow-up studies are planned to assess the longer term impact of the program on knowledge uptake in the study neighbourhoods. Inclusion of tailored 'The Vicious Worm' educational workshops should be considered in integrated cysticercosis control programs in endemic areas of sub-Saharan Africa.

Controlling Taenia solium and soil transmitted helminths in a northern Lao PDR village: Impact of a triple dose albendazole regime

Taenia solium taeniasis-cysticercosis and soil-transmitted helminths (STHs) are parasitic Neglected Tropical Diseases endemic throughout Southeast Asia. Within Lao PDR, a remote northern hill tribe village had previously been identified as a hyper endemic focus for T. solium. To reduce this observed prevalence, a One Health intervention covering both pigs and humans was implemented, which included two Mass drug administrations (MDA1 and MDA2) for village residents using a triple dose albendazole 400mg treatment regime. In addition to the effect on T. solium levels, the dual impact of this anthelmintic regime on STHs within the community was also monitored. Faecal samples were collected pre and post MDA1 and MDA2 and analysed for the presence of Taenia species and the STHs Ascaris lumbricoides, Trichuris trichiura and hookworm species. The McMaster technique was used to measure the changes in both prevalence and intensity of infection. Molecular characterisation of Taenia and hookworm species was conducted to detect zoonotic species. The level of taeniasis within the sampled population decreased by 79.4% after MDA1, remained steady during the five month inter-treatment interval and decreased again by 100% after MDA2. The prevalence of STHs decreased by 65.5% and 62.8% after MDA1 and MDA2 respectively; however an increase to 62.1% of pre MDA1 levels was detected during the inter-treatment interval. Individually, hookworm prevalence decreased by 83.4% (MDA1) and 84.5% (MDA2), A. lumbricoides by 95.6% and 93.5% and T. trichiura by 69.2% and 61%. The intensity of infection within the sampled population also decreased, with egg reduction rates of 94.4% and 97.8% for hookworm, 99.4% and 99.3% for A. lumbricoides and 77.2% and 88.5% for T. trichiura. Molecular characterisation identified a T. solium tapeworm carrier from 21.6% (13/60) of households in the village. T. saginata was identified in 5% (3/60) of households. The zoonotic hookworm A. ceylanicum was detected in the resident dog population. These results suggest that the triple dose albendazole 400mg treatment regime achieved a significant reduction in the level of taeniasis whilst simultaneously reducing the STH burden within the village. The increased STH prevalence detected between MDAs reflects the need for behavioural changes and a sustained chemotherapy programme, which may also need to include the resident dog population.

Human taeniasis: current insights into prevention and management strategies in endemic countries

Human taeniasis is a zoonotic condition resulting from infection with the adult stages of Taenia saginata ("beef tapeworm"), Taenia solium ("pork tapeworm") or Taenia asiatica ("Asian tapeworm"). Although these parasites have a worldwide distribution, the overwhelming burden is felt by communities in low- and middle-income countries. This is particularly true for T. solium, whereby infection of the central nervous system with the larval stage of the parasite (neurocysticercosis) is a major cause of acquired epilepsy in low-resource settings. With a focus on endemic countries, this review provides an insight into the prevention and management of human taeniasis, concluding with some recent case studies describing their implementation. Discussion of the opportunities and challenges regarding current fecal and serological diagnostic assays for detecting Taenia spp. highlights the importance of accurate and accessible diagnostic options for the field situation. The lack of long-term impact on the parasites' lifecycle from human anthelmintic treatment, coupled with the propensity for adverse reactions, highlights the importance of a "two-pronged" approach that considers the relevant animal hosts, particularly in the case of T. solium. Aside from the therapeutic options, this review reiterates the importance of adequate assessment and consideration of the associated behavioral and policy aspects around sanitation, hygiene and meat inspection that have been shown to support parasite control, and potential elimination, in endemic regions.

Integrating market chain assessments with zoonoses risk analysis in two cross-border pig value chains in Lao PDR

Objective

Lao PDR’s recent accession to the World Trade Organization necessitates a greater understanding of the patterns and risk of livestock production in order to better align national policy with the Agreement on the Application of Sanitary and Phytosanitary Measures. This eco-health study was conducted to improve understanding of the interrelations between market chains and zoonotic infection risks at two strategic cross border points between Lao PDR, Thailand and Viet Nam.

Methods

Information gained from smallholder farmer/trader interviews was integrated with serological surveys for pig-associated zoonoses—including hepatitis E virus (HEV), Taenia solium (T. solium) and trichinella—to identify potential linkages between disease risk and pig production and slaughter in low input systems common across the country.

Results

Trichinella and HEV exposure was high in both humans and pigs in both study areas, significantly associated with pig slaughter and the subsequent consumption and handling of raw pork products. T. solium demonstrated a strong geographical and ethnic association with the northern study area bordering Vietnam. With the right knowledge and accessible, affordable inputs, the majority of smallholder farmers indicated a willingness to invest more in pig production, which could simultaneously improve livelihoods and decrease exposure to HEV, Trichinella, and T. solium through increased access to formal markets and an improved slaughter processes.

Conclusion

The linkages identified when assessing disease risk in the context of potential economic and cultural drivers of transmission highlight the importance of a systems-based approach for the detection and control of zoonotic disease, and contributes to an improved understanding of the Lao PDR livestock sector.

Reprint of "Assessing the impact of a joint human-porcine intervention package for Taenia solium control: Results of a pilot study from northern Lao PDR"

Following confirmation that a remote village of approximately 300 inhabitants in northern Lao PDR was hyperendemic for the Neglected Tropical Disease Taenia solium, a pilot human-porcine therapeutic control intervention was implemented between October 2013 and November 2014. Mass drug administration with a three day albendazole 400mg protocol was offered to all eligible humans in October 2013 and March 2014. At these times, and again in October 2014, eligible village pigs received the anti-cysticercosis TSOL18 vaccination and an oral dose of oxfendazole anthelmintic at 30mg/kg, both repeated one month later. Community and individual human taeniasis prevalences were estimated via copro-antigen ELISA of volunteered human faecal samples prior to October 2013, and again in January 2015, in order to examine the short term impact of the intervention.

The potential of positive deviance approach for the sustainable control of neglected tropical diseases

Neglected tropical diseases (NTDs) have gained much attention in recent years due to the support from various agencies. However, the main approach to combat NTDs has been to cure rather than to prevent. As many NTD infections are closely linked with human behaviors such as hygienic practices and tradition, behavior change is also very crucial to prevent relapse or reinfection. Therefore, we would like to suggest a potential new approach—the positive deviance approach—to tackle NTDs by focusing on the preventive phase. What makes this approach unique is that the solution comes from the affected population themselves and not from the expert outsiders. Preventive chemotherapy that relies on outside aid has serious sustainability issues as reinfection is also high after the aid program has ended. Learning from the success story in Vietnam on preventing childhood malnutrition, the positive deviance approach could end the spread of NTDs once and for all by making full use of the available local solutions.

ZOONOTIC ENCOUNTERS AT THE SLAUGHTERHOUSE: PATHWAYS AND POSSIBILITIES FOR THE CONTROL OF CYSTIC ECHINOCOCCOSIS IN NORTHERN MOROCCO

This study traces the biosocial dynamics of Echinococcus granulosus – a zoonotic tapeworm spread between dogs, livestock and people – at slaughterhouses in Morocco. One of the most important parasitic zoonoses worldwide, this neglected cestode is responsible for a debilitating, potentially life-threatening, human disease and significant livestock production losses. Transmission can be interrupted, among other ways, by restricting dogs from eating cyst-infected livestock viscera. Recent epidemiological studies in Sidi Kacem province, northern Morocco, found that government-operated slaughterhouses were ‘hotspots’ for hydatid cysts in livestock and infection in dogs. An ethnographic approach was used to compliment these studies, exploring ‘how’ and ‘why’ cysts were being openly discarded. All seven visited slaughterhouses had low levels of hygiene, oversight and infrastructure. This was described locally as perpetuating a sense of ‘chaos’ that normalized (un)hygienic practices and justified the ignoring of state rules and regulations. However deference to ‘poor’ infrastructure, both physically and symbolically, served to under-emphasize local institutional logics, which were mediated by prevailing risk perceptions, economic practices and local socio-political norms. These included inter-departmental government relationships, the motivation of veterinary technicians, the political lobbying of butchers and market-based mitigation strategies. The study shows the importance of understanding E. granulosus from a biosocial perspective, and the need for more long-term, participatory and integrated ‘One Health’ approaches for neglected zoonotic diseases.

Assessing the impact of a joint human-porcine intervention package for Taenia solium control: Results of a pilot study from northern Lao PDR

Following confirmation that a remote village of approximately 300 inhabitants in northern Lao PDR was hyperendemic for the Neglected Tropical Disease Taenia solium, a pilot human-porcine therapeutic control intervention was implemented between October 2013 and November 2014. Mass drug administration with a three day albendazole 400mg protocol was offered to all eligible humans in October 2013 and March 2014. At these times, and again in October 2014, eligible village pigs received the anti-cysticercosis TSOL18 vaccination and an oral dose of oxfendazole anthelmintic at 30mg/kg, both repeated one month later. Community and individual human taeniasis prevalences were estimated via copro-antigen ELISA of volunteered human faecal samples prior to October 2013, and again in January 2015, in order to examine the short term impact of the intervention.

Taenia solium Taeniasis and Cysticercosis in Southeast Asia

Human taeniasis/cysticercosis caused by the pork tapeworm Taenia solium has been identified as a potentially eradicable disease by the International Task Force for Disease Eradication of the World Health Organization. In southeast Asia, T. solium taeniasis/cysticercosis is considered one of the major neglected tropical diseases afflicting the region. In the last few decades, a considerable effort has been invested toward establishing the epidemiology and burden of disease in several southeast Asian countries. Moreover, further evidence is emerging as to understanding the dynamics of disease transmission and cultural, political, and socioeconomic factors influencing the success of control and eradication efforts within the region. However, despite major collaborations by several champion groups, advances have been slow and little remains known about the complete epidemiology of taeniasis/cysticercosis and the barriers to programmatic success. This review article aims to address the above issues with a further focus on the challenges to control and eradicate taeniasis/cysticercosis within the southeast Asia region.

Endemicity of Zoonotic Diseases in Pigs and Humans in Lowland and Upland Lao PDR: Identification of Socio-cultural Risk Factors

In Lao People’s Democratic Republic pigs are kept in close contact with families. Human risk of infection with pig zoonoses arises from direct contact and consumption of unsafe pig products. This cross-sectional study was conducted in Luang Prabang (north) and Savannakhet (central-south) Provinces. A total of 59 villages, 895 humans and 647 pigs were sampled and serologically tested for zoonotic pathogens including: hepatitis E virus (HEV), Japanese encephalitis virus (JEV) and Trichinella spiralis; In addition, human sera were tested for Taenia spp. and cysticercosis. Seroprevalence of zoonotic pathogens in humans was high for HEV (Luang Prabang: 48.6%, Savannakhet: 77.7%) and T. spiralis (Luang Prabang: 59.0%, Savannakhet: 40.5%), and lower for JEV (around 5%), Taenia spp. (around 3%) and cysticercosis (Luang Prabang: 6.1, Savannakhet 1.5%). Multiple correspondence analysis and hierarchical clustering of principal components was performed on descriptive data of human hygiene practices, contact with pigs and consumption of pork products. Three clusters were identified: Cluster 1 had low pig contact and good hygiene practices, but had higher risk of T. spiralis. Most people in cluster 2 were involved in pig slaughter (83.7%), handled raw meat or offal (99.4%) and consumed raw pigs’ blood (76.4%). Compared to cluster 1, cluster 2 had increased odds of testing seropositive for HEV and JEV. Cluster 3 had the lowest sanitation access and had the highest risk of HEV, cysticercosis and Taenia spp. Farmers which kept their pigs tethered (as opposed to penned) and disposed of manure in water sources had 0.85 (95% CI: 0.18 to 0.91) and 2.39 (95% CI: 1.07 to 5.34) times the odds of having pigs test seropositive for HEV, respectively. The results have been used to identify entry-points for intervention and management strategies to reduce disease exposure in humans and pigs, informing control activities in a cysticercosis hyper-endemic village.

In Lao PDR, pigs are an important source of food and income and are kept by many rural residents. This study investigated five diseases that are transmitted between pigs and humans (zoonoses), namely hepatitis E, Japanese encephalitis, trichinellosis, cysticercosis and taeniasis. Humans and pigs in Lao PDR were tested for antibodies against the agents (pathogens) responsible for these diseases. Human participants were classified into three groups or "clusters" based on hygiene and sanitation practices, pig contact and pork consumption. Cluster 1 had low pig contact and good hygiene practice. Cluster 2 had moderate hygiene practices: around half used toilets and protected water sources; most people washed their hands after using the toilet and boiled water prior to consumption. Most people in this cluster were involved in pig slaughtering, drank pigs’ blood and were more likely test positive for antibodies against hepatitis E and Japanese encephalitis viruses. Finally, people in cluster 3 had lowest access to sanitation facilities, were most likely to have pigs in the household and had the highest risk of hepatitis E, taeniasis and cysticercosis. The diseases in this study pose a significant threat to public health and impact pig production. This study identified characteristics of high-risk individuals and areas with high disease burden and could be used to target future disease control activities to those most vulnerable.

One Health: competing perspectives in an emerging field

Over the last decade, One Health has attracted considerable attention from researchers and policymakers. The concept argues that the fields of human, animal and environmental health ought to be more closely integrated. Amid a flurry of conferences, projects and publications, there has been substantial debate over what exactly One Health is and should be. This review summarizes the main trends in this emerging discussion, highlighting the fault lines between different perspectives on One Health. Some have shown that One Health's call to synthesize knowledge from different disciplines can lead to better interventions. Others, however, argue that One Health's challenge to existing practice must go further, and set out a vision that foregrounds the social and economic drivers of disease. Meanwhile, recent examples of One Health in practice highlight the potential but also the challenges of institutionalizing cooperation. We also discuss the promise and pitfalls of using complexity theory to tackle multifaceted problems, and consider how the One Health concept has been brought to bear on other issues, such as emerging new technologies. Ultimately, One Health is an important and worthwhile goal, and requires a debate that clarifies both the competing uses and the political nature of the project.

Integrated health messaging for multiple neglected zoonoses: Approaches, challenges and opportunities in Morocco

Integrating the control of multiple neglected zoonoses at the community-level holds great potential, but critical data is missing to inform the design and implementation of different interventions. In this paper we present an evaluation of an integrated health messaging intervention, using powerpoint presentations, for five bacterial (brucellosis and bovine tuberculosis) and dog-associated (rabies, cystic echinococcosis and leishmaniasis) zoonotic diseases in Sidi Kacem Province, northwest Morocco. Conducted by veterinary and epidemiology students between 2013 and 2014, this followed a process-based approach that encouraged sequential adaptation of images, key messages, and delivery strategies using auto-evaluation and end-user feedback. We describe the challenges and opportunities of this approach, reflecting on who was targeted, how education was conducted, and what tools and approaches were used. Our results showed that: (1) replacing words with local pictures and using "hands-on" activities improved receptivity; (2) information "overload" easily occurred when disease transmission pathways did not overlap; (3) access and receptivity at schools was greater than at the community-level; and (4) piggy-backing on high-priority diseases like rabies offered an important avenue to increase knowledge of other zoonoses. We conclude by discussing the merits of incorporating our validated education approach into the school curriculum in order to influence long-term behaviour change.

Cultural drivers and health-seeking behaviours that impact on the transmission of pig-associated zoonoses in Lao People's Democratic Republic

Pig rearing is an important income source in the Lao People's Democratic Republic (PDR), with many smallholder farmers using traditional free-range pig production systems. Despite the potentially significant health risks posed by pig production regarding pig-associated zoonoses, information on the sociocultural drivers of these zoonoses is significantly lacking. This review summarises the existing sociocultural knowledge on eight pig-associated zoonoses suspected to be endemic in Southeast Asia: brucellosis, Q fever (Coxiella burnetii), trichinellosis, hepatitis E virus, leptospirosis, Japanese encephalitis, Streptococcus suis and Taenia solium taeniasis-cysticercosis. It summarises current knowledge on these diseases grouped according to their clinical manifestations in humans to highlight the propensity for underreporting. A literature search was conducted across multiple databases for publications from 1990 to the present day related to the eight pig-associated zoonoses and the risk and impact connected with them, with Lao PDR as a case study. Many of these pig-associated zoonoses have similar presentations and are often diagnosed as clinical syndromes. Misdiagnosis and underreporting are, therefore, substantial and emphasise the need for more robust diagnostics and appropriate surveillance systems. While some reports exist in other countries in the region, information is significantly lacking in Lao PDR with existing information coming mainly from the capital, Vientiane. The disease burden imposed by these zoonoses is not only characterised by morbidity and mortality, but directly impacts on livelihoods through income reduction and production losses, and indirectly through treatment costs and lost work opportunities. Other factors crucial to understanding and controlling these diseases are the influence of ethnicity and culture on food-consumption practices, pig rearing and slaughter practices, hygiene and sanitation, health-seeking behaviours and, therefore, risk factors for disease transmission. Published information on the knowledge, attitudes and beliefs of people regarding pig zoonoses and their risk factors is also extremely limited in Lao PDR and the broader Southeast Asian region. The need for more transdisciplinary research, using a One Health approach, in order to understand the underlining social determinants of health and their impacts on health-seeking behaviours, disease transmission and, ultimately, disease reporting, cannot be more emphasized.