Multi-criteria decision analysis as an innovative approach to managing zoonoses: results from a study on Lyme disease in Canada

Bridging Food Systems and One Health: A key to preventing future pandemics?

Food Systems and One Health are two approaches increasingly known for the holistic perspective they bring when addressing the issues that concern them: food and health. This systematic literature review aims to explore the evidence for using these approaches in a concerted manner to better manage zoonoses. By zoonoses management, we refer to improving the ability to address current zoonoses as well as preventing future ones. A total of 98 scientific articles were screened, of which 29 were considered eligible due to their focus on operationalizing each approach to help address zoonoses, as well as a combination of the two. Most articles implement One Health to prevent zoonoses by guiding stakeholders in concerted and participatory decision-making processes. However, the One Health approach can also be adopted via data modelling. Several articles refer to the monitoring and evaluation process of One Health initiatives to prevent zoonoses and discuss best practices to successfully implement the approach. Contrastingly, only three studies adopt a Food System approach to manage zoonoses, despite the profound connections existing between our food systems and the emergence of zoonotic risks. We conclude that there is a lack of integration between the One Health and Food System approaches to manage zoonoses. We also show that experts call for integration, so that not only human, animal, plant, and environmental health are considered, but also the socio-economic trade-offs when monitoring and developing strategies to manage zoonoses. This can be reversed, enabling zoonotic risks to be addressed when planning for our food systems of tomorrow.

Spatial multi-criteria decision analysis for the selection of sentinel regions in tick-borne disease surveillance

BACKGROUND

The implementation of cost-effective surveillance systems is essential for tracking the emerging risk of tick-borne diseases. In Canada, where Lyme disease is a growing public health concern, a national sentinel surveillance network was designed to follow the epidemiological portrait of this tick-borne disease across the country. The surveillance network consists of sentinel regions, with active drag sampling carried out annually in all regions to assess the density of Ixodes spp. ticks and prevalence of various tick-borne pathogens in the tick population. The aim of the present study was to prioritize sentinel regions by integrating different spatial criteria relevant to the surveillance goals.

METHODS

We used spatially-explicit multi-criteria decision analyses (MCDA) to map priority areas for surveillance across Canada, and to evaluate different scenarios using sensitivity analyses. Results were shared with stakeholders to support their decision making for the selection of priority areas to survey during active surveillance activities.

RESULTS

Weights attributed to criteria by decision-makers were overall consistent. Sensitivity analyses showed that the population criterion had the most impact on rankings. Thirty-seven sentinel regions were identified across Canada using this systematic and transparent approach.

CONCLUSION

This novel application of spatial MCDA to surveillance network design favors inclusivity of nationwide partners. We propose that such an approach can support the standardized planning of spatial design of sentinel surveillance not only for vector-borne disease BDs, but more broadly for infectious disease surveillance where spatial design is an important component.

Multi-criteria decision analysis for supporting the selection of subclinical mastitis screening tests to use in large- and small-scale dairy farms in Türkiye

The production of high-quality and safe milk is closely associated with the udder health of dairy cows. While there are many mastitis diagnostic tests/methods available, choosing the most appropriate diagnostic test for a sustainable udder health control program could be a challenge. This study was aimed at selecting tests for the screening of subclinical mastitis on small- and large-scale dairy farms in Türkiye, using multi-criteria decision-making methods. An integrated approach employing the analytical hierarchy process (AHP) and technique for order preference by similarity to ideal solution (TOPSIS) together was used to select subclinical mastitis screening tests for on-farm use. While the AHP determines the weights of the evaluation criteria, the TOPSIS provides a final ranking. Nine different subclinical mastitis screening (SCM) methods (DeLaval somatic cell counter, PortaSCC test, California mastitis test (CMT), rapid culture, portable/hand-held electrical conductivity meter, infrared thermography, leukocyte esterase strip test, milk pH, UdderCheck test) were analyzed on the basis of five selection criteria (the market availability of the test, the diagnostic accuracy of the test, the cost of the test, the cow-side use of the test, and the practicality of the test). The selection criteria were determined based on literature review and stakeholder input. The weighting of the criteria with the AHP was based on the pairwise comparison of the criteria by stakeholders. The criteria were weighted from 1 to 9 according to their relative importance as follows: "1: equally important," "3: moderately important," "5: strongly important," "7: very strongly important," "9: extremely important," and "2, 4, 6, 8: intermediate values." Final ranking of SCM tests with the TOPSIS was based on the stakeholder evaluations of fulfillment of the criteria by the alternatives. The most appropriate screening test for both large- and small-scale dairy farms was determined to be the CMT. The CMT is a very useful, easy to perform, and low-cost tool for detecting subclinical mastitis. Being a major element of udder health control programs, the CMT, if regularly used on dairy farms in Türkiye, would enable the culling of chronically infected animals and the reduction of mastitis-associated economic losses. Furthermore, regular CMTs would contribute to reducing milk SCC and improving milk quality. In conclusion, multi-criteria decision-making methods not only provide a systematic approach that may assist both veterinarians and farmers in deciding on the best choice among the different tests available for the screening of subclinical mastitis but also offer potential benefits to policymakers, researchers, and other industry stakeholders.

Collaborative Modeling of the Tick-Borne Disease Social-Ecological System: A Conceptual Framework

Hard-bodied ticks have become a major concern in temperate regions because they transmit a variety of pathogens of medical significance. Ticks and pathogens interact with hosts in a complex social-ecological system (SES) that influences human exposure to tick-borne diseases (TBD). We argue that addressing the urgent public health threat posed by TBD requires an understanding of the integrated processes in the forest ecosystem that influence tick density and infection prevalence, transmission among ticks, animal hosts, and ultimately disease prevalence in humans. We argue that collaborative modeling of the human-tick SES is required to understand the system dynamics as well as move science toward policy action. Recent studies in human health have shown the importance of stakeholder participation in understanding the factors that contribute to human exposure to zoonotic diseases. We discuss how collaborative modeling can be applied to understand the impacts of forest management practices on ticks and TBD. We discuss the potential of collaborative modeling for encouraging participation of diverse stakeholders in discussing the implications of managing forest ticks in the absence of large-scale control policy.

Multi-Criteria Decision Analysis for Assessing Social Acceptance of Strategies to Reduce Antimicrobial Use in the French Dairy Industry

To respond to the antimicrobial resistance (AMR) threat, public health entities implement policies aiming to reduce antimicrobial use (AMU) in livestock systems, in which policy success and sustainability might be subject to the social acceptability of the novel regulatory environment. Therefore, consistent methods that gather and synthesize preferences of stakeholder groups are needed during the policy design. The objective of this study was to present a methodology for evaluating the acceptability of potential strategies to reduce AMU using multi-criteria decision analysis (MCDA) using French dairy industry as a model. Preference-ranking organization methods for enrichment evaluations were applied to rank stakeholders' acceptance of four different potential AMU reduction strategies: 1. Baseline AMU regulations in France; 2. Total interdiction of AMU; 3. Interdiction of prophylaxis and metaphylaxis AMU; and 4. Subsidies to reduce AMU by 25%. A total of 15 stakeholders (consumers, n = 10; farmers, n = 2; public health representatives, n = 3) representing the French dairy sector and public health administration participated in the acceptance weighting of the strategies in relation with their impact on environmental, economic, social, and political criteria. We established a MCDA methodology and result-interpretation approach that can assist in prioritizing alternatives to cope with AMR in the French dairy industry or in other livestock systems. Our MCDA framework showed that consumers and public health representatives preferred alternatives that consider the restriction of AMU, whereas farmers preferred to maintain baseline policy.

Criteria for selecting sentinel unit locations in a surveillance system for vector-borne disease: A decision tool

Objectives

With vector-borne diseases emerging across the globe, precipitated by climate change and other anthropogenic changes, it is critical for public health authorities to have well-designed surveillance strategies in place. Sentinel surveillance has been proposed as a cost-effective approach to surveillance in this context. However, spatial design of sentinel surveillance system has important impacts on surveillance outcomes, and careful selection of sentinel unit locations is therefore an essential component of planning.

Methods

A review of the available literature, based on the realist approach, was used to identify key decision issues for sentinel surveillance planning. Outcomes of the review were used to develop a decision tool, which was subsequently validated by experts in the field.

Results

The resulting decision tool provides a list of criteria which can be used to select sentinel unit locations. We illustrate its application using the case example of designing a national sentinel surveillance system for Lyme disease in Canada.

Conclusions

The decision tool provides researchers and public health authorities with a systematic, evidence-based approach for planning the spatial design of sentinel surveillance systems, taking into account the aims of the surveillance system and disease and/or context-specific considerations.

A Rapid Literature Review of Multi-Criteria Decision Support Methods in the Context of One Health for All-Hazards Threat Prioritization

Background

Multi-Criteria Decision Analysis (MCDA) is a decision support tool that can be used in public health emergency management. The use of a One Health lens in MCDA can support the prioritization of threats and interventions which cut across the human, animal, and environmental domains. Previous literature reviews have focused on creating a snapshot of MCDA methodological trends. Our study provides an update to the MCDA methods literature with key considerations from a One Health perspective and addresses the application of MCDA in an all-hazards decision-making context.

Methods

We conducted a literature search on MEDLINE, EMBASE, SCOPUS, the CAB database, and a limited online gray literature search in partnership with a librarian from Health Canada. Articles were limited to those published in the year 2010 or later in a high-income setting (OECD member countries).

Results

Sixty-two articles were included for synthesis. Of these articles, most were Canadian studies (20%); and prioritized health risks, threats, and interventions in the human domain (69%). Six commonly used prioritization criteria were identified: threat, health, intervention, strategic, social, and economic impact. Stakeholders were engaged in 85% of studies and commonly consisted of government groups, non-governmental groups, subject matter experts, and the public. While most articles (65%) included elements of One Health based on our definition, only 5 studies (9%) explicitly acknowledged One Health as a guiding principle for the study. Forty seven percentage of studies noted that MCDA was beneficial in supporting the decision-making process.

Conclusion

Current literature on health prioritization presents some variability in the depth of integration of the One Health framework and on the use of various MCDA methodologies given prioritization objectives. Studies which applied a comprehensive One Health approach, prioritized disparate threats, or conducted cyclical prioritizations for governing bodies were broad in scope, but sparse. The results of our review indicate the need for better guidance on the integration of a One Health approach and the use of various MCDA methods given the main prioritization objectives.

Co-production of knowledge as part of a OneHealth approach to better control zoonotic diseases

There is increased global and national attention on the need for effective strategies to control zoonotic diseases. Quick, effective action is, however, hampered by poor evidence-bases and limited coordination between stakeholders from relevant sectors such as public and animal health, wildlife and forestry sectors at different scales, who may not usually work together. The OneHealth approach recognises the value of cross-sectoral evaluation of human, animal and environmental health questions in an integrated, holistic and transdisciplinary manner to reduce disease impacts and/or mitigate risks. Co-production of knowledge is also widely advocated to improve the quality and acceptability of decision-making across sectors and may be particularly important when it comes to zoonoses. This paper brings together OneHealth and knowledge co-production and reflects on lessons learned for future OneHealth co-production processes by describing a process implemented to understand spill-over and identify disease control and mitigation strategies for a zoonotic disease in Southern India (Kyasanur Forest Disease). The co-production process aimed to develop a joint decision-support tool with stakeholders, and we complemented our approach with a simple retrospective theory of change on researcher expectations of the system-level outcomes of the co-production process. Our results highlight that while co-production in OneHealth is a difficult and resource intensive process, requiring regular iterative adjustments and flexibility, the beneficial outcomes justify its adoption. A key future aim should be to improve and evaluate the degree of inter-sectoral collaboration required to achieve the aims of OneHealth. We conclude by providing guidelines based on our experience to help funders and decision-makers support future co-production processes.

Maximising Societal Benefit From the Control of Neglected Zoonoses: Identifying Synergies and Trade-Offs in the Control of Taenia solium

Interventions to control or eradicate neglected zoonoses are generally paid for through the public purse and when these interventions focus on the animal hosts, they are often expected to be performed and financed through the state veterinary service. The benefits of control, however, accrue across the human, animal, and environmental spaces and enhance both public and private interests. Additionally, disease control interventions do not take place in a vacuum and the indirect impacts of our actions should also be considered if the societal benefit of interventions is to be maximised. With the caveat that unintended consequences can and will occur, pre-identifying potential synergies and trade-offs in our disease control initiatives allows for them to be considered in intervention design and monitored during programme roll-out. In this paper, using a One Health approach with the example of Taenia solium control, we identify potential indirect impacts which may arise and how these may influence both our choice of intervention and opportunities to optimise the animal, environmental, and societal benefits of control through maximising synergies and minimising trade-offs.

Identification and prioritization of strategies to tackle COVID-19 outbreak: A group-BWM based MCDM approach

The world is reeling in the midst of the novel coronavirus pandemic with fear of rising toll due to the deadly virus. Decision making during a pandemic outbreak has numerous challenges. Covid19 has become a challenging problem for organizations, countries and the world at large. It is even more complicated when governments and medical care communities are changing their priorities based on the growing challenges and level of effectiveness of measures taken in other countries. In this study, a potential application of a well-known MCDM method called the Group Best-Worst Method is presented to overcome such challenges and draw the strategies to handle COVID19 outbreak. The methodology is applied to rank the 10 identified strategies based on their relative importance provided by multiple groups of stakeholder. These strategies focus on social distancing, medical care, essential commodities, financial support to poor people, public awareness, overall impact of COVID19, digital surveillance of infected or doubtful people, maintaining the economy of the country, and an effect on industries. Furthermore, the local and global weights along with ranking order of strategies are obtained. A sensitivity analysis has also been done to show the change in global weights and ranking order of strategies.

System Thinking and Citizen Participation Is Still Missing in One Health Initiatives - Lessons From Fifteen Evaluations

Tackling complex public health challenges requires integrated approaches to health, such as One Health (OH). A key element of these approaches is the integration of knowledge across sectors, disciplines and stakeholders. It is not yet clear which elements of knowledge integration need endorsement to achieve best outcomes. This paper assesses 15 OH initiatives in 16 African, Asian and European countries to identify opportunities to improve knowledge integration and to investigate geographic influences on knowledge integration capacities. Two related evaluation tools, both relying on semi-quantitative questionnaires, were applied to two sets of case studies. In one tool, the questions relate to operations and infrastructure, while the other assigns questions to the three phases of “design,” “implementation,” and “evaluation” of the project life cycle. In both, the question scores are aggregated using medians. For analysis, extreme values were identified to highlight strengths and weaknesses. Seven initiatives were assessed by a single evaluator external to the initiative, and the other eight initiatives were jointly assessed by several internal and external evaluators. The knowledge integration capacity was greatest during the project implementation stage, and lowest during the evaluation stage. The main weaknesses pointing towards concrete potential for improvement were identified to be a lack of consideration of systemic characteristics, missing engagement of external stakeholders and poor bridging of knowledge, amplified by the absence of opportunities to learn and evolve in a collective process. Most users were unfamiliar with the systems approach to evaluation and found the use of the tools challenging, but they appreciated the new perspective and saw benefits in the ensuing reflections. We conclude that systems thinking and associated practises for OH require not only specific education in OH core competencies, but also methodological and institutional measures to endorse broad participation. To facilitate meta-analyses and generic improvement of integrated approaches to health we suggest including knowledge integration processes as elements to report according to the COHERE guidelines.

Quantitatively evaluating the cross-sectoral and One Health impact of interventions: A scoping review and case study of antimicrobial resistance

BACKGROUND

Current frameworks evaluating One Health (OH) interventions focus on intervention-design and -implementation. Cross-sectoral impact evaluations are needed to more effectively tackle OH-issues, such as antimicrobial resistance (AMR). We aimed to describe quantitative evaluation methods for interventions related to OH and cross-sectoral issues, to propose an explicit approach for evaluating such interventions, and to apply this approach to AMR.

METHODS

A scoping review was performed using WebofScience, EconLit, PubMed and gray literature. Quantitative evaluations of interventions that had an impact across two or more of the human, animal and environment sectors were included. Information on the interventions, methods and outcome measures found was narratively summarised. The information from this review informed the construction of a new approach to OH-related intervention evaluation, which then was applied to the field of AMR.

RESULTS

The review included 90 studies: 73 individual evaluations (from 72 papers) and 18 reviews, with a range of statistical modelling (n = 13 studies), mathematical modelling (n = 53) and index-creation/preference-ranking (n = 14) methods discussed. The literature highlighted the need to (I) establish stakeholder objectives, (II) establish quantifiable outcomes that feed into those objectives, (III) establish agents and compartments that affect these outcomes and (IV) select appropriate methods (described in this review) accordingly. Based on this, an evaluation model for AMR was conceptualised; a decision-tree of intervention options, a compartmental-microeconomic model across sectors and a general-equilibrium (macroeconomic) model are linked. The outcomes of this multi-level model (including cost-utility and Gross Domestic Product impact) can then feed into multi-criteria-decision analyses that weigh respective impact estimates alongside other chosen outcome estimates (for example equity or uncertainty).

CONCLUSION

In conclusion, stakeholder objectives are key in establishing which evaluation methods (and associated outcome measures) should be used for OH-related interventions. The stated multi-level approach also allows for sub-systems to be modelled in succession, where resources are constrained.

Development of an Index for the Inspection of Aedes aegypti Breeding Sites in Brazil: Multi-criteria Analysis

BACKGROUND

Aedes aegypti is a vector for the transmission of diseases such as dengue fever, chikungunya, Zika fever, and yellow fever. In 2016, over 1 million cases of these diseases were reported in Brazil, which is an alarming public health issue. One of the ways of controlling this disease is by inspecting and neutralizing the places where A. aegypti lays its eggs. The Ministry of Planning, Development, and Administration of Brazil maintains the inspection statistics.

OBJECTIVE

We propose a multi-criteria analysis to create an index for A. aegypti inspections reported through the Ministry of Planning, Development, and Administration system of Brazil.

METHODS

Based on the repository from urban cleaning services combined with data on inspections conducted by government agencies in several Brazilian cities and municipalities, we selected and combined metrics, which we further ranked using the analytic hierarchy process methodology. We also developed risk maps based on the analytic hierarchy process ranking of the A. aegypti breeding sites.

RESULTS

Based on our analysis and the available data, the priority for inspections should consider the number of sick people (weight 0.350), medical evaluations (weight 0.239), inspections (weight 0.201), mosquito breeding sites (weight 0.126), and days of absence from work (weight 0.096).

CONCLUSIONS

The proposed index could aid public health practitioners in preventing the appearance of new A. aegypti breeding sites. This information technology application can help solve such public health challenges.

Multi-criteria decision analysis approach for strategy scale-up with application to Chagas disease management in Bolivia

OBJECTIVE

Design and build a strategy construction and evaluation software system to help stakeholders to develop viable strategies to expand (and adapt) the Chagas Platform healthcare model through the primary healthcare system in Bolivia.

METHODS

The software was built based on a ranking of medical Interventions and Actions (needed to support Interventions' implementation) needed for comprehensive management of Chagas Disease in Bolivia. The ranking was performed using a Multi Criteria Decision Analysis (MCDA) methodology adapted to the WHO's building blocks framework. Data regarding the criteria and the rankings was obtained through surveys and interviews with health care professionals working on Chagas disease. The Analytical Hierarchy Process was used to construct the decision criteria weights. Data Envelopment Analysis was used to identify the Interventions that lay on the efficiency frontier of outcomes and the complexity of associated Actions. These techniques were combined with integer programing tools using the open-source software R to build a decision-making tool to assess the outcomes and complexity of any combination of Interventions and Actions. This model and tool were applied to data concerning the care of Chagas disease in Bolivia collected through surveys of experts. The tool works by loading the data from each specific context.

RESULTS

The initial set of Interventions and Actions recommended after analysis of the survey data was further refined through face-to-face interviews with field experts in Bolivia, resulting in a strategy of 18 Interventions and 15 Actions. Within the WHO model the Leadership and Governance building block came up as the one needing more support with Actions such as the inclusion of Chagas into Annual Municipal Operational Plans by appointing local and provincial coordinators.

CONCLUSION

This project established the suitability of the model for constructing healthcare strategies. The model could be developed further resulting in a decision-making tool for program managers in a wide range of healthcare related issues, including neglected and/ or prevalent diseases. The tool has the potential to be used at different stages of decision making by diverse stakeholders in order to coordinate activities needed to address a health problem.

Evaluation of the Control Options of Bovine Tuberculosis in Ethiopia Using a Multi-Criteria Decision Analysis

Bovine tuberculosis (BTB) is a zoonotic bacterial infection caused by Mycobacterium bovis and is characterized by the development of granulomatous lesions in the lymph nodes, lungs and other tissues. It poses serious public health impacts and food security challenges to the agricultural sector in terms of dairy and meat productions. In Ethiopia, BTB has been considered as a priority disease because of its high prevalence in urban and peri-urban dairy farms. However, there has not been any national control program in the country. Thus, in order to initiate BTB control program in the country, information on control options is needed to tailor the best option for the Ethiopian situation. The objective of this study was to identify, evaluate and rank various BTB control options in Ethiopia using a multi-criteria decision analysis based on preference ranking organization method for enrichment evaluations (PROMETHEE) approach while accounting for the stakeholders' preferences. Control options were evaluated under two scenarios: with (scenario 1) and without (scenario 2) bacillus Calmette–Guérin (BCG) vaccination. Nine potential control options were identified that include combinations of three control options (1) test and slaughter with or without government support, (2) test and segregation, and (3) BCG vaccination. Under scenario 1, BCG vaccination, BCG vaccination and test and slaughter with partial compensation by government, and BCG vaccination and test and slaughter with full compensation by government were the top three ranked control options. Under scenario 2, test and slaughter with full compensation by government was the preferred control option, followed by test and segregation supported by test and slaughter with full government compensation, and test and slaughter with half compensation by government. Irrespective of the variability in the weighting by the stakeholders, the sensitivity analysis showed the robustness of the ranking method. In conclusion, the study demonstrated that BCG vaccination, and test and slaughter with full compensation by government were the two most preferred control options under scenarios 1 and 2, respectively. National level discussions were strongly recommended for further concretization and implementation of these control measures.

Zoonotic Diseases: Etiology, Impact, and Control

Most humans are in contact with animals in a way or another. A zoonotic disease is a disease or infection that can be transmitted naturally from vertebrate animals to humans or from humans to vertebrate animals. More than 60% of human pathogens are zoonotic in origin. This includes a wide variety of bacteria, viruses, fungi, protozoa, parasites, and other pathogens. Factors such as climate change, urbanization, animal migration and trade, travel and tourism, vector biology, anthropogenic factors, and natural factors have greatly influenced the emergence, re-emergence, distribution, and patterns of zoonoses. As time goes on, there are more emerging and re-emerging zoonotic diseases. In this review, we reviewed the etiology of major zoonotic diseases, their impact on human health, and control measures for better management. We also highlighted COVID-19, a newly emerging zoonotic disease of likely bat origin that has affected millions of humans along with devastating global consequences. The implementation of One Health measures is highly recommended for the effective prevention and control of possible zoonosis.

Evaluation of the COVID-19 Pandemic Intervention Strategies with Hesitant F-AHP

In this study, a hesitant fuzzy AHP method is presented to help decision makers (DMs), especially policymakers, governors, and physicians, evaluate the importance of intervention strategy alternatives applied by various countries for the COVID-19 pandemic. In this research, a hesitant fuzzy multicriteria decision making (MCDM) method, hesitant fuzzy Analytic Hierarchy Process (hesitant F-AHP), is implemented to make pairwise comparison of COVID-19 country-level intervention strategies applied by various countries and determine relative importance scores. An illustrative study is presented where fifteen intervention strategies applied by various countries in the world during the COVID-19 pandemic are evaluated by seven physicians (a professor of infectious diseases and clinical microbiology, an infectious disease physician, a clinical microbiology physician, two internal medicine physicians, an anesthesiology and reanimation physician, and a family physician) in Turkey who act as DMs in the process.

Finding the match between healthcare worker and expert for optimal audit and feedback on antimicrobial resistance prevention measures

Background

The potentials of audit and feedback (AF) to improve healthcare are currently not exploited. To unlock the potentials of AF, this study focused on the process of making sense of audit data and translating data into actionable feedback by studying a specific AF-case: limiting antimicrobial resistance (AMR). This was done via audit and feedback of AMR prevention measures (APM) that are executed by healthcare workers (HCW) in their day-to-day contact with patients. This study’s aim was to counterbalance the current predominantly top-down, expert-driven audit and feedback approach for APM, with needs and expectations of HCW.

Methods

Qualitative semi-structured interviews were held with sixteen HCW (i.e. physicians, residents and nurses) from high-risk AMR departments at a regional hospital in The Netherlands. Deductive coding was succeeded by open and axial coding to establish main codes, subcodes and variations within codes.

Results

HCW demand insights from audits into all facets of APM in their working routines (i.e. diagnostics, treatment and infection control), preferably in the form of simple and actionable feedback that invites interdisciplinary discussions, so that substantiated actions for improvement can be implemented. AF should not be seen as an isolated ad-hoc intervention, but as a recurrent, long-term, and organic improvement strategy that balances the primary aims of HCW (i.e. improving quality and safety of care for individual patients and HCW) and AMR-experts (i.e. reducing the burden of AMR).

Conclusions

To unlock the learning and improvement potentials of audit and feedback, HCW’ and AMR-experts’ perspectives should be balanced throughout the whole AF-loop (incl. data collection, analysis, visualization, feedback and planning, implementing and monitoring actions). APM-AF should be flexible, so that both audit (incl. collecting and combining the right data in an efficient and transparent manner) and feedback (incl. persuasive and actionable feedback) can be tailored to the needs of various target groups. To balance HCW’ and AMR-experts’ perspectives a participatory holistic AF development approach is advocated.

Shifting to foot-and-mouth disease-free status without vaccination: Application of the PROMETHEE method to assist in the development of a foot-and-mouth national program in Uruguay

Foot-and-mouth disease (FMD) is highly contagious, and the introduction of FMD virus in countries free of the disease can result in large epidemics, similar to those observed in the United Kingdom, Japan, and Uruguay. Many countries or regions of South America are recognized as "FMD-free with vaccination" or "FMD-free without vaccination." Uruguay has been certified as FMD-free with vaccination, and the transition to the status of FMD-free without vaccination has been discussed among the stakeholders of the Ministry of Livestock Agriculture and Fisheries (MGAP in Spanish). This study illustrates how the Preference Ranking Organization Method for Enrichment Evaluation (PROMETHEE) can identify and rank alternative actions to be used in the national FMD program in Uruguay. It uses multiple-criteria decision analysis (MCDA) to structure the problem comprehensively. This helps to identify critical issues and potential solutions when planning a national FMD program for a country with a disease-free without vaccination status. The analysis highlighted the following perspectives: i) the importance of communication strategies as the country changes to "FMD-free without vaccination" status, as well as potential challenges such as a lack of trust in government; ii) the importance of enhancing epidemiological capacity and data management to allocate resources better and provide feedback from the surveillance system; iii) the need to re-evaluate the animal health compensation strategy to stimulate biosecurity and disease reporting; and iv) the importance of assisting the backyard pig sector given the risks it carries and the complexity of dealing with because of its informality, the educational status of its owners, and the lack of formal assistance by veterinary services. The results suggests that the MCDA approach could be a useful tool for animal health agencies when planning a program to eliminate FMD (as well as other diseases) in a structured way because it helps to identify which alternatives would yield more effective results and it helps to address future challenges.

Evaluation of Multicriteria Decision Analysis Algorithms in Food Safety: A Case Study on Emerging Zoonoses Prioritization

Decision making in food safety is a complex process that involves several criteria of different nature like the expected reduction in the number of illnesses, the potential economic or health-related cost, or even the environmental impact of a given policy or intervention. Several multicriteria decision analysis (MCDA) algorithms are currently used, mostly individually, in food safety to rank different options in a multifactorial environment. However, the selection of the MCDA algorithm is a decision problem on its own because different methods calculate different rankings. The aim of this study was to compare the impact of different uncertainty sources on the rankings of MCDA problems in the context of food safety. For that purpose, a previously published data set on emerging zoonoses in the Netherlands was used to compare different MCDA algorithms: MMOORA, TOPSIS, VIKOR, WASPAS, and ELECTRE III. The rankings were calculated with and without considering uncertainty (using fuzzy sets), to assess the importance of this factor. The rankings obtained differed between algorithms, emphasizing that the selection of the MCDA method had a relevant impact in the rankings. Furthermore, considering uncertainty in the ranking had a high influence on the results. Both factors were more relevant than the weights associated with each criterion in this case study. A hierarchical clustering method was suggested to aggregate results obtained by the different algorithms. This complementary step seems to be a promising way to decrease extreme difference among algorithms and could provide a strong added value in the decision-making process.

Evaluation of Influenza Intervention Strategies in Turkey with Fuzzy AHP-VIKOR

In this study, a fuzzy AHP-VIKOR method is presented to help decision makers (DMs), especially physicians, evaluate and rank intervention strategies for influenza. Selecting the best intervention strategy is a sophisticated multiple criteria decision-making (MCDM) problem with potentially competing criteria. Two fuzzy MCDM methods, fuzzy analytic hierarchy process (F-AHP) and fuzzy VIsekriterijumska optimizacija i KOmpromisno Resenje (F-VIKOR), are integrated to evaluate and rank influenza intervention strategies. In fuzzy AHP-VIKOR, F-AHP is used to determine the fuzzy criteria weights and F-VIKOR is implemented to rank the strategies with respect to the presented criteria. A case study is given where a professor of infectious diseases and clinical microbiology, an internal medicine physician, an ENT physician, a family physician, and a cardiologist in Turkey act as DMs in the process.

A framework for adaptive surveillance of emerging tick-borne zoonoses

Significant global ecological changes continue to drive emergence of tick-borne zoonoses around the world. This poses an important threat to both human and animal health, and highlights the need for surveillance systems that are capable of monitoring these complex diseases effectively across different stages of the emergence process. Our objective was to develop an evidence-based framework for surveillance of emerging tick-borne zoonoses. We conducted a realist review to understand the available approaches and major challenges associated with surveillance of emerging tick-borne zoonoses. Lyme disease, with a specific focus on emergence in Canada, was used as a case study to provide real-world context, since the process of disease emergence is ongoing in this country. We synthesize the results to propose a novel framework for adaptive surveillance of emerging tick-borne zoonoses. Goals for each phase of disease emergence are highlighted and approaches are suggested. The framework emphasizes the needs for surveillance systems to be inclusive, standardized, comprehensive and sustainable. We build upon a growing body of infectious disease literature that is advocating for reform to surveillance systems. Although our framework has been developed for tick-borne zoonoses, it is flexible and has the potential to be applied to a variety of other vector-borne and zoonotic diseases.

Economic Analysis of Vaccination Programs: An ISPOR Good Practices for Outcomes Research Task Force Report

This report provides recommendations for budget holders and decision makers in high-, middle, and low-income countries requiring economic analyses of new vaccination programs to allocate scarce resources given budget constraints. ISPOR's Economic Evaluation of Vaccines Designed to Prevent Infectious Disease: Good Practices Task Force wrote guidelines for three analytic methods and solicited comments on them from external reviewers. Cost-effectiveness analyses use decision-analytic models to estimate cumulative changes in resource use, costs, and changes in quality- or disability-adjusted life-years attributable to changes in disease outcomes. Constrained optimization modeling uses a mathematical objective function to be optimized (e.g. disease cases avoided) for a target population for a set of interventions including vaccination programs within established constraints. Fiscal health modeling estimates changes in net present value of government revenues and expenditures attributable to changes in disease outcomes. The task force recommends that those designing economic analyses for new vaccination programs take into account the decision maker's policy objectives and country-specific decision context when estimating: uptake rate in the target population; vaccination program's impact on disease cases in the population over time using a dynamic transmission epidemiologic model; vaccination program implementation and operating costs; and the changes in costs and health outcomes of the target disease(s). The three approaches to economic analysis are complementary and can be used alone or together to estimate a vaccination program's economic value for national, regional, or subregional decision makers in high-, middle-, and low-income countries.

Stakeholder perceptions of foot-and-mouth disease control in South Africa

Foot-and-mouth disease (FMD) prevention and control is a challenge worldwide but the situation in southern Africa is particularly complex because the virus is endemic in wild African buffalo (Syncerus caffer). The objective of this study was to compare stakeholder perceptions of the FMD control methods employed to restrict FMD virus to the infected zone of South Africa. Data collection was performed using an online questionnaire distributed to FMD experts, government veterinarians, private livestock veterinarians, people involved within the wildlife sector, and "other" occupation groups including the general public. Data were also collected using semi-structured participatory group discussions with government animal health technicians (AHT) and communal cattle owners directly affected by FMD control measures. Evaluated control methods were the disease control fence bordering the western boundary of the Greater Limpopo Transfrontier Conservation Area, clinical surveillance of livestock, movement control of cloven-hoofed animals and products, and routine FMD vaccination of cattle. These management procedures were scored according to a set of technical, economic, and ethical criteria by stakeholders, who also weighted the criteria according to their perceived importance. Scores and weights were aggregated using an additive linear model to rank control methods. Sensitivity analysis was performed using a stochastic model to explore the effects of varying inputs and the exclusion of scores from randomly selected respondent groups on the ranking of control methods. The deterministic analysis assigned the highest ranking to the disease control fence and the lowest to routine vaccination of cattle. The fence had the highest ranking in 40% of the stochastic iterations, and second, third and fourth in 26%, 20% and 14% of iterations, respectively. The inputs from the AHT and people involved in the wildlife sector were the most influential for ranking the fence as the preferred control option. The most influential criteria were the feasibility of the fence as a control option and its influence on the economics of the communal cattle owners, livestock industry in the FMD free zone, and the government. The disease control fence was the highest ranking control option but further investigations are necessary to understand the reasons for stakeholder perceptions.

Knowledge integration in One Health policy formulation, implementation and evaluation

The One Health concept covers the interrelationship between human, animal and environmental health and requires multistakeholder collaboration across many cultural, disciplinary, institutional and sectoral boundaries. Yet, the implementation of the One Health approach appears hampered by shortcomings in the global framework for health governance. Knowledge integration approaches, at all stages of policy development, could help to address these shortcomings. The identification of key objectives, the resolving of trade-offs and the creation of a common vision and a common direction can be supported by multicriteria analyses. Evidence-based decision-making and transformation of observations into narratives detailing how situations emerge and might unfold in the future can be achieved by systems thinking. Finally, transdisciplinary approaches can be used both to improve the effectiveness of existing systems and to develop novel networks for collective action. To strengthen One Health governance, we propose that knowledge integration becomes a key feature of all stages in the development of related policies. We suggest several ways in which such integration could be promoted.

How have systematic priority setting approaches influenced policy making? A synthesis of the current literature

BACKGROUND

There is a growing body of literature on systematic approaches to healthcare priority setting from various countries and different levels of decision making. This paper synthesizes the current literature in order to assess the extent to which program budgeting and marginal analysis (PBMA), burden of disease & cost-effectiveness analysis (BOD/CEA), multi-criteria decision analysis (MCDA), and accountability for reasonableness (A4R), are reported to have been institutionalized and influenced policy making and practice.

METHODS

We searched for English language publications on health care priority setting approaches (2000-2017). Our sources of literature included PubMed and Ovid databases (including Embase, Global Health, Medline, PsycINFO, EconLit).

FINDINGS

Of the four approaches PBMA and A4R were commonly applied in high income countries while BOD/CEA was exclusively applied in low income countries. PBMA and BOD/CEA were most commonly reported to have influenced policy making. The explanations for limited adoption of an approach were related to its complexity, poor policy maker understanding and resource requirements.

CONCLUSIONS

While systematic approaches have the potential to improve healthcare priority setting; most have not been adopted in routine policy making. The identified barriers call for sustained knowledge exchange between researchers and policy-makers and development of practical guidelines to ensure that these frameworks are more accessible, applicable and sustainable in informing policy making.

Assessing Interventions to Manage West Nile Virus Using Multi-Criteria Decision Analysis with Risk Scenarios

The recent emergence of West Nile virus (WNV) in North America highlights vulnerability to climate sensitive diseases and stresses the importance of preventive efforts to reduce their public health impact. Effective prevention involves reducing environmental risk of exposure and increasing adoption of preventive behaviours, both of which depend on knowledge and acceptance of such measures. When making operational decisions about disease prevention and control, public health must take into account a wide range of operational, environmental, social and economic considerations in addition to intervention effectiveness. The current study aimed to identify, assess and rank possible risk reduction measures taking into account a broad set of criteria and perspectives applicable to the management of WNV in Quebec under increasing transmission risk scenarios, some of which may be related to ongoing warming in higher-latitude regions. A participatory approach was used to collect information on categories of concern to relevant stakeholders with respect to WNV prevention and control. Multi-criteria decision analysis was applied to examine stakeholder perspectives and their effect on strategy rankings under increasing transmission risk scenarios. Twenty-three preventive interventions were retained for evaluation using eighteen criteria identified by stakeholders. Combined evaluations revealed that, at an individual-level, inspecting window screen integrity, wearing light colored, long clothing, eliminating peridomestic larval sites and reducing outdoor activities at peak times were top interventions under six WNV transmission scenarios. At a regional-level, the use of larvicides was a preferred strategy in five out of six scenarios, while use of adulticides and dissemination of sterile male mosquitoes were found to be among the least favoured interventions in almost all scenarios. Our findings suggest that continued public health efforts aimed at reinforcing individual-level preventive behaviours combined with the application of larvicides to manage the risk of WNV infection are the interventions most acceptable and effective at reaching current management objectives now and under future theoretical transmission risk.

Multi-Stakeholder Decision Aid for Improved Prioritization of the Public Health Impact of Climate Sensitive Infectious Diseases

The effects of climate change on infectious diseases are an important global health concern and necessitate decisions for allocation of resources. Economic tools have been used previously; however, how prioritization results might differ when done using broader considerations identified by local stakeholders has yet to be assessed. A multicriteria decision analysis (MCDA) approach was used to assess multi-stakeholder expressed concerns around disease prioritization via focus groups held in Quebec and Burkina Faso. Stakeholders weighted criteria and comparisons were made across study sites. A pilot disease prioritization was done to examine effects on disease rankings. A majority of identified criteria were common to both sites. The effect of context specific criteria and weights resulted in similar yet distinct prioritizations of diseases. The presence of consistent criteria between sites suggests that common concerns exist for prioritization; however, context-specific adjustments reveal much regarding resource availability, capacity and concerns that should be considered as this impacts disease ranking. Participatory decision aid approaches facilitate rich knowledge exchange and problem structuring. Furthermore, given multiple actors in low- and middle-income countries settings, multi-actor collaborations across non-governmental organizations, local government and community are important. Formal mechanisms such as MCDA provide means to foster consensus, shared awareness and collaboration.

Can the EVIDEM Framework Tackle Issues Raised by Evaluating Treatments for Rare Diseases: Analysis of Issues and Policies, and Context-Specific Adaptation

BACKGROUND

The multiplicity of issues, including uncertainty and ethical dilemmas, and policies involved in appraising interventions for rare diseases suggests that multicriteria decision analysis (MCDA) based on a holistic definition of value is uniquely suited for this purpose. The objective of this study was to analyze and further develop a comprehensive MCDA framework (EVIDEM) to address rare disease issues and policies, while maintaining its applicability across disease areas.

METHODS

Specific issues and policies for rare diseases were identified through literature review. Ethical and methodological foundations of the EVIDEM framework v3.0 were systematically analyzed from the perspective of these issues, and policies and modifications of the framework were performed accordingly to ensure their integration.

RESULTS

Analysis showed that the framework integrates ethical dilemmas and issues inherent to appraising interventions for rare diseases but required further integration of specific aspects. Modification thus included the addition of subcriteria to further differentiate disease severity, disease-specific treatment outcomes, and economic consequences of interventions for rare diseases. Scoring scales were further developed to include negative scales for all comparative criteria. A methodology was established to incorporate context-specific population priorities and policies, such as those for rare diseases, into the quantitative part of the framework. This design allows making more explicit trade-offs between competing ethical positions of fairness (prioritization of those who are worst off), the goal of benefiting as many people as possible, the imperative to help, and wise use of knowledge and resources. It also allows addressing variability in institutional policies regarding prioritization of specific disease areas, in addition to existing uncertainty analysis available from EVIDEM.

CONCLUSION

The adapted framework measures value in its widest sense, while being responsive to rare disease issues and policies. It provides an operationalizable platform to integrate values, competing ethical dilemmas, and uncertainty in appraising healthcare interventions.

Acceptability of tick control interventions to prevent Lyme disease in Switzerland and Canada: a mixed-method study

Background

Lyme disease control strategies may include tick control interventions in high risk areas. Public authorities may be interested to assess how these types of interventions are perceived by the public which may then impact their acceptability. The aims of this paper are to compare socio-cognitive factors associated with high acceptability of tick control interventions and to describe perceived issues that may explain their low acceptability in populations living in two different regions, one being an endemic region for LD since the last 30 years, the Neuchâtel canton, in Switzerland, and another where the disease is emerging, the Montérégie region, in Canada.

Methods

A mixed methods’ design was chosen. Quantitative data were collected using web-surveys conducted in both regions (n = 814). Multivariable logistic regressions were used to compare socio-cognitive factors associated with high acceptability of selected interventions. Qualitative data were collected using focus group’s discussions to describe perceived issues relative to these interventions.

Results

Levels of acceptability in the studied populations were the lowest for the use of acaricides and landscaping and were under 50 % in both regions for six out of eight interventions, but were higher overall in Montérégie. High perceived efficacy of the intervention was strongly associated with high acceptability of tick control interventions. A high perceived risk about LD was also associated with a high acceptability of intervention under some models. High level of knowledge about LD was negatively associated with high acceptability of the use of acaricides in Neuchâtel. Perceived issues explaining low acceptability included environmental impacts, high costs to the public system, danger of individual disempowerment and perceptions that tick control interventions were disproportionate options for the level of LD risk.

Conclusion

This study suggests that the perceived efficacy and LD risk perception may be key factors to target to increase the acceptability of tick control interventions. Community-level issues seem to be important considerations driving low acceptability of public health interventions. Results of this study highlight the importance for decision-makers to account for socio-cognitive factors and perceived issues that may affect the acceptability of public health interventions in order to maximize the efficacy of actions to prevent and control LD.

Vulnerability of Brazilian municipalities to hantavirus infections based on multi-criteria decision analysis

Background

Hantavirus infection is an emerging zoonosis transmitted by wild rodents. In Brazil, high case-fatality rates among humans infected with hantavirus are of serious concern to public health authorities. Appropriate preventive measures partly depend on reliable knowledge about the geographical distribution of this disease.

Methods

Incidence of hantavirus infections in Brazil (1993–2013) was analyzed. Epidemiological, socioeconomic, and demographic indicators were also used to classify cities’ vulnerability to disease by means of multi-criteria decision analysis (MCDA).

Results

From 1993 to 2013, 1752 cases of hantavirus were registered in 16 Brazilian states. The highest incidence of hantavirus was observed in the states of Mato Grosso (0.57/100,000) and Santa Catarina (0.13/100,000). Based on MCDA analysis, municipalities in the southern, southeastern, and midwestern regions of Brazil can be classified as highly vulnerable. Most municipalities in northern and northeastern Brazil were classified as having low vulnerability to hantavirus cardiopulmonary syndrome.

Conclusions

Although most human infections by hantavirus registered in Brazil occurred in the southern region of the country, a greater vulnerability to hantavirus was found in the Brazilian Midwest. This result reflects the need to strengthen surveillance where the disease has thus far gone unreported.

Adaptation and Evaluation of a Multi-Criteria Decision Analysis Model for Lyme Disease Prevention

Designing preventive programs relevant to vector-borne diseases such as Lyme disease (LD) can be complex given the need to include multiple issues and perspectives into prioritizing public health actions. A multi-criteria decision aid (MCDA) model was previously used to rank interventions for LD prevention in Quebec, Canada, where the disease is emerging. The aim of the current study was to adapt and evaluate the decision model constructed in Quebec under a different epidemiological context, in Switzerland, where LD has been endemic for the last thirty years. The model adaptation was undertaken with a group of Swiss stakeholders using a participatory approach. The PROMETHEE method was used for multi-criteria analysis. Key elements and results of the MCDA model are described and contrasted with the Quebec model. All criteria and most interventions of the MCDA model developed for LD prevention in Quebec were directly transferable to the Swiss context. Four new decision criteria were added, and the list of proposed interventions was modified. Based on the overall group ranking, interventions targeting human populations were prioritized in the Swiss model, with the top ranked action being the implementation of a large communication campaign. The addition of criteria did not significantly alter the intervention rankings, but increased the capacity of the model to discriminate between highest and lowest ranked interventions. The current study suggests that beyond the specificity of the MCDA models developed for Quebec and Switzerland, their general structure captures the fundamental and common issues that characterize the complexity of vector-borne disease prevention. These results should encourage public health organizations to adapt, use and share MCDA models as an effective and functional approach to enable the integration of multiple perspectives and considerations in the prevention and control of complex public health issues such as Lyme disease or other vector-borne and zoonotic diseases.

Social and Economic Aspects of the Transmission of Pathogenic Bacteria between Wildlife and Food Animals: A Thematic Analysis of Published Research Knowledge

Wildlife is a known reservoir of pathogenic bacteria, including Mycobacterium bovis and Brucella spp. Transmission of these pathogens between wildlife and food animals can lead to damaging impacts on the agri-food industry and public health. Several international case studies have highlighted the complex and cross-sectoral challenges involved in preventing and managing these potential transmission risks. The objective of our study was to develop a better understanding of the socio-economic aspects of the transmission of pathogenic bacteria between wildlife and food animals to support more effective and sustainable risk mitigation strategies. We conducted qualitative thematic analysis on a purposive sample of 30/141 articles identified in a complementary scoping review of the literature in this area and identified two key themes. The first related to the framing of this issue as a 'wicked problem' that depends on a complex interaction of social factors and risk perceptions, governance and public policy, and economic implications. The second theme consisted of promising approaches and strategies to prevent and mitigate the potential risks from transmission of pathogenic bacteria between wildlife and food animals. These included participatory, collaborative and multidisciplinary decision-making approaches and the proactive incorporation of credible scientific evidence and local contextual factors into solutions. The integration of these approaches to address 'wicked problems' in this field may assist stakeholders and decision-makers in improving the acceptability and sustainability of future strategies to reduce the transmission of pathogenic bacteria between wildlife and food animals.

From Lyme disease emergence to endemicity: a cross sectional comparative study of risk perceptions in different populations

Background

Lyme disease (LD) is a tick-borne emerging disease in Canada that has been endemic in many temperate countries for decades. Currently, one of the main approaches for LD prevention is the promotion of individual-level preventive behaviors against ticks. Health behaviors are influenced by individual and social factors, one important of which is risk perception. This study aims to describe and compare risk perception of LD, within and between general populations and experts living in two different regions: the Neuchâtel canton in Switzerland, where LD is endemic, and the Montérégie region in Québec (Canada), where LD is emerging.

Method

A web-based survey was conducted in both study regions (814 respondents) in 2012, and a questionnaire was administered to 16 experts. Comparative analyses of knowledge, risk exposure and different components of LD risk perception were performed. Multivariate analyses were used to calculate a global risk perception score and to identify determinants of risk perception in both regions.

Results

In Montérégie, only 15% of the survey respondents had a good level of knowledge of LD compared to Neuchâtel where 51% of survey respondents had good levels of knowledge. In Montérégie, 24% of respondents perceived themselves as being at high or very high risk of contracting LD vs 54% in Neuchâtel; however, a higher percentage of respondents from this region believed that personal protection was simple to carry out (73% vs 58% in Montérégie). Based on the population surveys, almost all of the identified determinants of risk perception were different between both populations except for gender. A good level of knowledge, living in the risk zone and knowing someone who has had LD increased risk perception, while a high level of education and being 18–34 years of age decreased this perception. The majority of the studied components of risk perception were different between populations and their regional experts.

Conclusion

This study suggests that risk perception of LD differs between populations and regional experts living in different epidemiological situations. Monitoring of knowledge and risk perception in local populations may help to better target LD communication efforts in accordance with population specific attributes thereby enhancing prevention efficacy.

Context analysis for epidemic control in the Netherlands

When epidemics occur, experts advise the Ministries on effective control measures. There is uncertainty in the translation of epidemiological evidence into effective outbreak management interventions, due to contradicatory problem perspectives, diverse interests and time pressure. Several models have been developed that aim to integrate societal context information in risk assessment to improve the feasibility and the implementation of adviced measures. The current study explored the views of relevant public officials on this issue using the Rapid Risk Assessment of Acute Public Health Events model of the World Health Organization. Eighteen public officials involved in infectious disease risk assessment and policy making in the Netherlands participated in semi-structured qualitative interviews. Their experiences, expectations and expert opinions on the use of societal context information for infectious disease outbreak control were explored. Most interviewees consider information on societal context necessary for infectious disease risk management. However, different perspectives exist on which information is relevant, and how, when, why and by whom it should be obtained. We conclude that outbreak control could benefit from systematically gathered information on the societal context. This requires identifying which information is beneficial and selecting or designing methods to obtain it. Explicit stakeholder assessment seems a first step.