Operationalizing a community-based One Health surveillance and response in Adadle district of Ethiopia
Abstract
Surveillance of human and animal health is often carried out separately worldwide, which leads to the under-reporting of zoonotic and emerging diseases. Early cross-information between wildlife, domestic animal and public health sectors may reduce both exposure and cost of outbreaks. We have assessed the feasibility of a One Health Surveillance and Response System (OHSRS) in the Adadle district of Ethiopia in the Somali Region (SRS), with regard to integration into the existing regional surveillance-response system in the Somali Region of Ethiopia (SRS). To meet the objectives of a surveillance-response system, we established a One Health Surveillance and Response Unit (OHSRU) at the district level. Community Animal Health Workers, Community Health Workers (CHWs), and both human and animal health district staff and regional experts were trained together on the OHSRS. An inception workshop was held with all relevant stakeholders. To ensure the active engagement of communities in the surveillance response system, a Community-Based Emergency Fund (CBEF) and CAHW cost recovery mechanisms were established. All public and animal health staff of different administration levels were linked together. Human and animal health information was collected and shared effectively among sectors. This approach helped bridging the physical separation between the public and animal health sectors in disease surveillance in the Adadle district. Joint interventions, such as disease outbreak investigations and community awareness were initiated by the OHSRU. We demonstrated that the OHSR was successfully operationalized in Adadle districts and contributed to improving the early detection and response of zoonotic diseases. However, technical barriers, cost-effectiveness, legality of data and ethical safeguarding, along with political commitment should be addressed to effectively operationalize the OHSR in the whole region. Designing the OHSR through the existing surveillance system, engaging communities and other relevant sectors using a participatory process is an important contribution to a sustainable OHSR.
One Health Impact Statement
In this research work, the public and animal health sectors collaborated in data collection and initiated joint interventions. By integrating the surveillance operational costs for disease outbreak investigation and cost of public health associated with zoonotic diseases can be reduced as One Health surveillance and response lead to early detection and response to zoonotic diseases. As one health is collaborative efforts multispectral, multidisciplinary and transdisciplinary, i.e. involvement of all relevant sectors including community members and different disciplines in the launching workshop of surveillance system helped to define and agree the role of each sectors or partner’s in the One Health approach. This played a curtail role in the success of the approach. Lessons learned from this work can be used for further improvement in One Health approach in different settings.
Introduction
About 75% of emerging diseases are of animal origin, and approximately 60% of infectious organisms affecting humans are zoonotic (Taylor et al., 2001). Zoonotic diseases kill about 2.5 million people annually worldwide (Grace et al., 2012). Rabies alone causes 59,000 human deaths and over 3.7 million Disability-Adjusted Life Years (DALYs) annually (Hampson et al., 2015). Besides the public health consequences, zoonotic diseases cause significant adverse economic impacts across the world. As early as 2012, the World Bank recommended engaging in a systemic approach for zoonosis control, considering integrated surveillance response and control of human and animal diseases, primarily for economic reasons (Zinsstag et al., 2020b). For this, a One Health Surveillance and Response System (OHSRS) has been suggested, where multiple sectors including the human, animal and environmental sectors do cooperate. One Health (OH) would be most effective to address future emerging and re-emerging zoonotic diseases (Bhatia, 2020; Zinsstag et al., 2020b). International organizations such as the World Health Organization (WHO), the Food and Agriculture Association of the United Nations (FAO) and the World Organization for Animal Health (OIE) have encouraged multi-sectoral collaboration since 2010 to reduce the public health and economic impacts of emerging and re-emerging diseases that arise from human-animal-environment interface (FAO et al., 2017; WHO, 2022). Although an OH approach has been recommended by international organizations and scientists to address the complexity that arises at human-animal-environment interfaces, most surveillance systems run separately and do not collaborate in the early detection of emerging and re-emerging diseases (Wendt et al., 2015), with a few exceptions (Paternoster et al., 2017).
Evidence shows that there is a high burden of zoonotic infectious diseases, especially in Low and Middle-Income Countries (LMICs), including Ethiopia (Grace et al., 2012). A recent cross-sectional study in the Somali region revealed exposure of both human and livestock to Rift Valley Fever (RVF), brucellosis and Q-fever, highlighting the importance of collaboration between the human and animal health sectors to control zoonotic diseases (Ibrahim et al., 2021). Although there are disease surveillance systems in both the human and livestock sectors in Ethiopia, the collaboration between sectors in disease surveillance is weak (WHO, 2016), which may lead to the failure of detection of emerging and re-emerging zoonotic diseases. The feasibility of community-based integrated disease and surveillance in pastoral areas for early detection and response of disease outbreaks has been demonstrated (Osman et al., 2021). However, the operationalization of OHSRS remains a challenge worldwide (Lee and Brumme, 2013). In Ethiopia, the collaboration between the animal health and public health sectors for zoonotic disease surveillance and response needs to be improved. The purpose of this study was to assess the feasibility of operationalizing an OHSRS in the Adadle district of SRS to improve the weak collaboration in disease surveillance response between the human and animal sectors.
Methods
STUDY AREA
Adadle district is one of the 93 districts of the Ethiopian Somali Regional State (Fig. 1) with total a population of 120,816 (CSA, 2022b). A total of 95% of the population are pastoralists with subsistence livestock production. The district has huge livestock resources estimated at 409,806. The main livestock species raised in the area include sheep, goats, cattle, camel and equines. The area is semi-arid with an average annual rainfall of 358 mm and temperature of 32°C, respectively (CSA, 2022a; 2022b).
STUDY DESIGN
Establishment of a One Health surveillance and response unit
Before the start of the intervention, an inception workshop gathered all relevant stakeholders to agree on the role of each actor in the surveillance-response system. A One Health Surveillance and Response Unit (OHSRU) was established in the health offices of the Adadle district. Two health professionals, one focal person for animal health and one for human health surveillance were assigned to the unit (Fig. 2) and coordinated the integrated human-animal health surveillance and response from September 2019 to December 2020. The staff were representatives from the public health and livestock and resource development offices, but extra remuneration was provided to them for their additional tasks related to the surveillance. Since the animal and human health coverage in remote pastoral areas of the Somali region is low, the surveillance started at the community level, where community Human Health Workers (CHWs) and Community Animal Health Workers (CAHWs) actively engaged in the system to ensure that as many cases as possible were reported to the unit. In addition, we held a series of community meetings to reach a consensus on the system and improve disease detection.
Reporting and response
The surveillance system was designed on the basis of the existing surveillance system of the livestock and health sectors, with the only difference being cross-communication between both surveillance systems (Fig. 3). The system incorporated the existing list of notifiable diseases in people and animals, according to the Ministry of Health and the Ministry of Agriculture of Ethiopia (EHNRI, 2012; Ethiopia Ministry of Agriculture, 2020). Human notifiable diseases were reported on a weekly basis, but immediately notifiable diseases and other emergency conditions were reported to the nearby health facilities and subsequently to the OHSRU as soon as they were detected by CHWs. Livestock disease outbreaks were reported by CAHWs to the animal health staff and OHSRU as soon as they were detected. Adverse health events with more than two cases in livestock or humans were also reported. Approximately 50 Ethiopian Birr (equivalent to 1 USD) in mobile air time credit was provided to the CHAWs and CHWs for reporting. The reporting was made via direct calls or emails. As CHAWs and CHWs became more aware of each other’s work, they established closer relationships and spontaneously informed each other in face-to-face meetings. To ensure the collaboration between health professionals in order to detect and respond to zoonotic disease emergencies as early as possible, all health professionals at different administration levels involved in this project were interlinked. For instance, CHWs and CAHWs, human and animal health staff at the kebele level, and human and animal disease surveillance focal persons at the district level exchanged disease information. Similarly, concerned experts at the regional level were interlinked and shared disease information. Sharing of health information was done on a weekly basis, but when zoonotic disease was suspected the information was shared to the region immediately. The OHSRU was responsible for disease recording, compiling data, sharing and disseminating the health information to the district offices and respective regional bureaus.
Responses were organized through the existing system for both sectors. A detailed OHSRS schematic is summarized in Fig. 4. Furthermore, to improve the response at the community level, a community emergencies fund (CBEF) for humans and a CAHW Cost Recovery Mechanism (CRM) for livestock were created through a participatory process. For the CBEF, the local communities contributed a small sum of money, 50 Ethiopian Birr (1 USD) per month, while the Jigjiga One Health Initiative (JOHI) project provided initial capital as an incentive and served as technical backup for those engaged in the CBEF. Ambulance services for life-threatening cases were organized for four CBEF village beneficiaries. For the CAHW’s CRM, starter kits (drug and equipment) were provided and the communities paid for the services so that treatment services would be sustained. As collaborative efforts, joint suspected zoonotic disease outbreak investigation (sample collection) and response (awareness creation) were undertaken by OHSRU. Otherwise, for both livestock and humans, sample diagnosis and vaccination campaigns were made through the existing routine health systems. For example, diagnosis and vaccination for human immediately notifiable diseases such as measles and polio took place at Ethiopian public health institutes and health bureaus. Similarly, livestock diseases were diagnosed at the Jigjiga Regional Laboratory and the National Animal Health Diagnostic Center (NAHDIC), and vaccination against highly contagious diseases such as lumpy skin disease and sheep and goat pox were conducted by the livestock bureau and its partners.
Data management and statistical analysis
Databases for both human and animal disease reporting structures were created for the OHSRU. Data were entered and stored in Microsoft Excel™ sheets in the Adadle district. Descriptive analysis was applied to assess the most common diseases reported in humans and livestock.
Furthermore, to measure the time to detection and response for emergency diseases, the date of first case reporting, sample collection, sample shipment to the diagnostic laboratory, reception of the sample, the sample result and initiation of response were recorded. All data were cleaned and analyzed using STATA 14 (StataCorp, Texas, USA).
Ethical clearance and data protection
The study protocol was reviewed and approved by the Ethics committee of Jigjiga University (RERC/022/2020). The participants were informed about the purpose of the study. For any identified reported disease, each individual was advised to seek health care at the nearby health centers or posts. Emergencies like complicated births or accidents were managed together with district health centers or hospitals through the existing health services. Furthermore, only an identification number for each patient was used in the database to keep patient information anonymous, and only authorized persons had access to the data.
Results
DISEASE SURVEILLANCE AND RESPONSE
Human disease surveillance
During the intervention period from September 2019 to December 2020, CHWS reported 1202 cases, of which 669 were notifiable diseases and 533 cases were non-notifiable diseases or other syndromes. A summary of diseases and syndromes/other health conditions and the key signs associated with each disease or syndrome is provided in Table 1.
| Disease or syndrome | Signs and symptoms |
|---|---|
| Malaria | Fever, Chills, Vomiting, Nausea |
| Malnutrition | Children less than 5 years old, emaciated and progressive weight loss, bilateral edema and middle arm circumference <11 cm |
| Typhoid fever | Gradual onset of intermittent fever, headache, abdominal pain |
| Dysentery | Diarrhea with visible blood and abdominal pain |
| Meningitis | Sudden onset of fever and neck stiffness |
| Tuberculosis | Chronic cough, weight loss, unresponsive to other antibiotics and sweating during night |
| Measles | Fever, cough, maculopapular (nonvascular) generalized rash and conjunctivitis (red eyes) |
| Polio | Children less than 15 years old with signs of paralytic illness |
| Other syndromes | Diarrhea, bloat, abdominal pain, sometimes vomiting and anorexia, coughing, fever, malaise, arthralgia, nasal discharge, tachypnea and difficulty in breathing in some cases |
Malaria was the most common weekly reported disease (40.1%) followed by Severe Acute Malnutrition (SAM) (25.6%) and typhoid fever (20.5%). Furthermore, 14 and three cases of measles and suspected acute flaccid paralysis, respectively, were reported. Further details are summarized in Fig. 5.
Following measles and polio suspected cases, serum and fecal samples were sent to EPHI for confirmation. Three out of five serum samples submitted for measles cases were positive for the measles virus. However, none of the samples were positive for polio (Table 2). Since measles is a highly contagious disease with significant public health impacts, the regional health bureau together with its partners immediately vaccinated children at risk against measles in Adadle. Measles and polio suspected cases were detected as early as immediately and samples were submitted to EPHI in less than 3 days on average. However, the diagnostic results were obtained from EPHI on average 22 days after sample submission (range: 7–28). The interventions of ring measles vaccination were conducted within a week after the disease was confirmed. Through establishing CBEF, 558 households of vulnerable mothers and children and the community benefited from the scheme by being able to manage emergency cases and ambulance services independently.
| Tentative diagnosis | Sample type | No. sample collected | No. positive | Laboratory | Diagnostic method | Reference |
|---|---|---|---|---|---|---|
| Measles | Serum | 5 | 3 | EPHI | ELISA | Based on manufacturer instruction |
| Polio | Fecal sample | 3 | 0 | EPHI | ELISA | Based on manufacturer instruction |
| Total | 8 | 3 | 11 |
Animal disease surveillance and response
Several livestock disease outbreaks such as sheep and goat pox (Fig. 6), camel pox (Fig. 7), Contagious Caprine Pleuro-Pneumonia (CCPP) (Fig. 8), Lumpy Skin Disease (LSD) (Fig. 9), contagious ecthyma (Orf) (Fig. 10), wry neck syndrome (Fig. 11), salmonellosis, unknown or unidentified diseases were reported by CAHWS. The detailed summary of the livestock disease reporting is summarized in Tables 3 and 4.
| Tentative diagnosis | Species | Clinical signs | Local name |
|---|---|---|---|
| Lumpy Skin Disease (LSD) | Cattle | Fever, large firm nodular lesions all over the body, nasal and ocular discharge, inappetence | Burbur |
| Contagious Caprine Pleuro Pneumonia (CCPP) | Goat | Coughing, fever, difficult breathing, grunting, mucopurulent nasal discharge, reluctant to move and abduction of fore limb. Straw colored fluid in the thorax and change in color of the lung | sombab |
| Sheep and goat pox | Sheep and goat | Nodular lesions all over the body, mucopurulent nasal discharge, fever, inappetence and pox lesions around hairless areas of the body | geedcanole |
| Brucellosis | Sheep and goat | Mass abortion at late gestation, retained placenta and death in some cases | dhicis |
| Salmonellosis | Sheep and goat | Fetid watery diarrhea, sometimes dysentery, fever, depression and dehydration, and death in lamb & kids | |
| Pasteurellosis | Sheep and Goat | Coughing, mucopurulent nasal discharge, fever and death in lamb and kids | cunabarashe |
| Wry neck syndrome | Camel | Twisted neck (S-shaped), death in severe cases, loss of appetite and weight loss | shinbir |
| Unknown camel disease 1 | Camel | Swelling that starts at the head and later diffusely throughout the body, other non-specific clinical signs | korbarar |
| Unknown camel disease 2 | Camel | Sudden death high mortality, fever, emphysema, pale liver, rarely coughing and nasal discharge | New disease |
| Complex camel pneumonia | Camel | Coughing, mucopurulent nasal discharge, fever, inappetence & weight loss | Laxawgal, dhugato |
| Camel pox | Camel | Nodular lesions around the body, especially around the muzzle, nasal discharge, inappetence, fever and death in young camels | Furuq |
| Contagious ectyma (orf) | Camel | Raised nodules around the mouth and muzzle in camel calves, difficulty suckling, emaciation |
| Tentative diagnosis | Sample type | No. sample collected | No. positive | laboratory | Diagnostic method | Reference |
|---|---|---|---|---|---|---|
| RFV & brucellosis | Serum | 76 | 15 brucellosis | NAHDIC | ELISA | Based on manufacturer instruction |
| CCPP | Serums | 45 | 36 | NAHDIC & JRL | ELISA | Based on manufacturer instruction |
| Camel pox | Serum | 3 | 3 | NAHDIC | ELISA | Based on manufacturer instruction |
| Salmonellosis | Fecal & whole blood | 7 | 6 | JRL | Isolation and identification | Harvey and Price (1979) |
| Pasteurellosis | Nasal swab | 8 | 6 | JRL | Isolation and identification | Quinn et al. (2002) |
| Complex camel pneumonia | Nasal swab | 8 | 5 | JRL | Isolation and identification | Barrow (1993) |
| Total | 147 |
Following disease outbreaks, appropriate samples were collected, stored, labeled and transported to the Jigjiga Regional Veterinary Laboratory (JRVL) or to the National Animal Health and Diagnosis Center (NAHDIC) for etiologic diagnosis. Consequently, the regional livestock bureau, in collaboration with its partners, vaccinated 161, 100 and 19,990 livestock against sheep pox and goat pox and LSD, respectively to control the disease and subsequently reduce the impact of the disease outbreak on the livelihood of communities. However, vaccination campaigns and etiological identification were delayed. Sample submission to the laboratory ranged from 7 to 29 days and obtaining laboratory results from NAHDIC in Addis Ababa ranged from 7 to 23 days. However, the regional laboratory in Jigjiga provided results within 3 days. Vaccination against livestock diseases varied from as early as 9 days up to 3 months. Beyond this time, no intervention took place at all (Fig. 12). For instance, though CCPP is a highly contagious disease, goats were not vaccinated against the disease and as a result, a second wave occurred in two consecutive years. On the other hand, since vaccination coverage was low compared to the animal population at risk, a second wave of sheep and goat pox, LSD and camel pox outbreaks occurred again for a second time in two consecutive years. This shows that timely response to disease outbreaks depends on the availability of the resource or the ability to mobilize the resources at the time of the outbreak. However, CAHWs CRM enabled the community to get treatment services for endemic diseases and outbreaks.
Collaboration between stakeholders in disease surveillance, sharing information and response
In total, 28 CHWs (14) and CAHWs (14), one of each from every kebele (14), as well as district human and animal health staff at different levels, were trained on OHSR and ultimately involved in the surveillance system (Fig. 3). Trained CAHWs, CHWs, and human and animal health staff shared Human and Animal Health Information (HAHI) at the village and kebele level, and it was subsequently reported to OHSRU, where it was systematically analyzed and then disseminated to the regional level through email or direct call in order to initiate joint interventions. At the regional level, HAHI was shared through the regional One Health task force, with emails and direct calls between the regional experts. The daily exchange of HAHI at the village level where diseases erupted enabled the detection of suspected zoonotic disease outbreaks earlier. At the district level, the exchange of the HAHI depended on the village report (whether a zoonotic disease was reported or not), so the communication occurred on a weekly basis to be efficient. However, if there is a zoonotic disease report human and animal health staff in the OHSRU immediately exchange the health information and organize joint disease outbreak investigation if necessary. Since the regional communication was guided by the district report, the communication between the sectors at that level occurred whenever there was a zoonotic disease report.
In Ethiopia, in human and animal surveillance systems there are notifiable zoonotic diseases such as rabies, anthrax, avian influenza and Severe Acute Respiratory Pneumonia (SARS) (EHNRI, 2012; Ethiopia Ministry of Agriculture, 2020). However, the Adadle district health officers from both sectors were not aware that these diseases were also notifiable for the other sector.
“We meet every day on other business, but I didn't know that some of the notifiable diseases in public health surveillance such as rabies, RVF and anthrax are also listed as notifiable diseases in animals. After the training and initiation, now we always share the reports of both sectors and follow up if there is ongoing zoonotic disease” health office expert
Over the course of the implementation of this project, we observed mass abortions in sheep and goats, which is a key clinical sign for RVF, along with two unknown camel disease outbreaks, where it was uncertain if they had zoonotic potential. Both CHWs and CAHWs reported abortion cases to the OHSRU and closely monitored the outbreak situations. They conducted community awareness on the transmission of disease to reduce the risk of the spread of the disease between humans and animals. Similarly, for the unknown camel disease outbreaks, community awareness was provided by the CAHWs and CHWs to reduce the exposure of people to the disease if it turned out to be a zoonotic disease. For instance, CAHWs in Todob Kebele described the situation: “during mass abortion or unknown camel diseases as soon as I realized there was an outbreak, immediately I communicated to the CHWS and other staff about the outbreaks… and started community awareness because it could be RFV or brucellosis which are zoonotic or another zoonosis of unknown origin…. Outbreaks of mass abortion or other unknown diseases had occurred several times but this is the first time that I collaborated with health staff and tried to prevent transmission of zoonotic disease to our community… This is the result of training on zoonotic disease detection...”.
Regarding mass abortion in caprine and ovine species, all CHW and health staff were alerted to assess for signs of RVF in humans for early detection of the disease and reporting to concerned bodies. Communities were also informed about preventive measures like avoiding contact with animals and not drinking raw milk. Furthermore, 52 human Tuberculosis (TB) cases were detected during the study period. Since tuberculosis can also have zoonotic origin, CAHWs and CHWs monitored the livestock of any individuals affected with TB. There are no prominent clinical signs in animal TB, and we did not test animals using the tuberculin test, so no animal TB cases were identified. Nevertheless, the CAHWs and CHWs promoted awareness among the communities about the transmission of tuberculosis between humans and livestock such as avoiding consumption of raw milk. Similar community awareness activities were conducted during the outbreaks of unknown camel disease.
Discussion
In this article, we report the development of an innovative OHSRS system complementing the existing surveillance system of the regional health bureau and the livestock bureau, without creating a parallel system.
Integrated human and livestock disease surveillance has been conducted using different approaches. Most of the studies were cross-sectional studies where human and animal disease data were collected and analyzed together to determine the correlation between human and animal diseases, but sharing of data between sectors did not occur (Osoro et al., 2015; Thumbi et al., 2015; Ibrahim et al., 2021). In other studies, data on livestock collected through passive or active surveillance were systematically collected and analyzed to predict zoonotic disease occurrence. In these approaches, data sharing between collaborating sectors happened through email, platforms or meetings but not at all different levels of surveillance (Shuai et al., 2006; Epp et al., 2008; Paternoster et al., 2017). Integrated human and animal disease surveillance approaches depend on the objective of the surveillance and the structural organization of the country sectors (Bordier et al., 2020). To our knowledge, this is the first study that established One Health surveillance and response at different hierarchical levels (low to high) to operationalize One Health surveillance and response. Communication and frequency of communication between sectors and professionals are crucial for integrated disease surveillance. Depending on the importance to detect zoonotic diseases earlier, the frequency of the communication was different at different levels of administration. The frequency of the communication strategy, i.e. daily basis at the village level, weekly basis or as soon as possible at the district level and when suspected outbreaks occurred at regional level, was effective for timely detection and efficiency to monitor zoonotic diseases. This is similar to the frequency of exchange of health information in existing systems for zoonotic diseases (animal health and public health) and other communicable disease at different levels of administration (EHNRI, 2012; Ethiopia Ministry of Agriculture, 2020). The frequency of the communication of our surveillance system can be fitted to the existing surveillance system.
Collaboration at all levels of administration, coupled with active engagement of the community, allowed the implementation of both passive and active surveillance in an integrated approach. Outbreak investigation and interventions were initiated by alerts from the community health workers, which helped to detect zoonotic diseases earlier. Early detection of zoonotic disease in livestock would lead to lower cost and public health impact (Zinsstag et al., 2020b) including unusual health events in the surveillance allowed for the detection of unidentified livestock outbreaks. For instance, unknown camel diseases with unknown public health significance were detected by CAHWs, and then CAHWs, CHWs and other health staff exchanged disease information and followed the cases in humans to detect if cases also emerged in humans, or if there were increased episodes in humans. Our OHSRS was able to detect future zoonotic outbreaks because of the established communication between human and animal health in a remote area (Azhar et al., 2010). The presence of OHSRU at a district level, coupled with the communication network of the staff at all levels including the village level, contributed to bridge the physical separation of both sectors and increased the communication between sectors. Both issues were previously major challenges for disease surveillance and response (WHO, 2016).
An adequate response is essential to prevent zoonotic diseases. But in most of the zoonotic disease surveillance and response, there is an insufficient response to zoonotic diseases, especially in livestock (Moise-Silverman, 2022). To improve the response, we have established CAHWs CRM and the CBEF using a transdisciplinary approach, which has been reported as useful for health care systems in remote communities (Zinsstag and Crump, 2022). These services played a crucial role in the response. However, these services are insufficient to respond to highly contagious diseases such as measles, sheep and goat pox, camel pox and other zoonotic disease outbreaks. Therefore, the active involvement of public and animal health sectors to control such diseases in their sectors is critical. Otherwise, if there is not enough response to disease outbreaks, the community may become discouraged and not report outbreaks.
For effective One Health surveillance and response, the health system of the both sectors require strengthening as human and animal health are interlinked (Strupat and Marschall, 2020). We observed that most of the animal health facilities were not functional in the district and were not providing satisfactory services, while human health facilities suffered from shortages of drugs, diagnostic equipment and consumables. Therefore, further improvements are recommended, such as functional health facilities with better diagnostic capacity, training of staff on zoonotic diseases, and improved awareness of health staff and communities. For example, during mass abortions, the CAHWS, CHWs and other staff trained on zoonotic disease surveillance and transmission educated and raised awareness to reduce the risk of disease spread to communities.
Delays in laboratory diagnosis and response allow the spread of disease. For early detection of outbreaks, the response timeline is crucial. Measuring the time lapse from the exposure of the disease agent to the initiation of a public health intervention is very important to halt the spread of diseases (Buehler et al., 2004). Our study showed there were delays to diagnosis that occurred from sample submission until obtaining the result for highly contagious diseases and suspected zoonotic diseases. These delays could be because the diagnosis took place at the national laboratory which is far from the pastoralist areas and also busy with the processing of many samples. The delayed diagnosis was also reported in Ghana for highly pathogenic avian influenza outbreaks (Tasiame et al., 2020). Conversely, rapid identification of zoonotic pathogens leads to successful control (Tasiame et al., 2020). Regional governments may need to increase capacity at regional laboratories to shorten the time to detection and response, which is important for the early identification of zoonotic threats (Buehler et al., 2004). Furthermore, to improve the delay in diagnosis, we recommend establishing One Health diagnostic laboratories in pastoral areas, like the one initiated by JOHI at Jigjiga University (JJU), which has the capacity to diagnose zoonotic diseases (Zinsstag et al., 2020a). A similar One Health laboratory was established and operationalized in Kenya (Falzon et al., 2019). Both sectors benefit from having One Health laboratory, as they can share physical structures, which reduces the operational costs required to run the laboratory (Weltbank, 2012).
Implementing such a new integrated approach requires resources, and collaborating sectors should agree on operational aspects (Bhatia, 2020). In Ethiopia, resources are allocated for both public and animal health surveillance. However, resources are usually not allocated for collaborative activities. Budget constraints have been challenging for the implementation of One Health approaches over the last decades (Lee and Brumme, 2013). FAO, OIE and WHO signed a collaborative agreement to reduce threats that can arise at the interface of human-animal environment. This kind of agreement opened a door for international organizations to support developing countries in terms of multisectoral collaboration. Like other developing countries, Ethiopia benefited from such agreements. There are several non-governmental organizations, such as FAO, WHO, Vétérinaires Sans Frontières Suisse, the One Health Central and Eastern Africa (OHCEA) and JOHI, supporting the country with interdisciplinary capacity building, joint zoonotic disease outbreak investigation, One Health research development and technical coordination mechanisms (Revue Scientifique et Technique/Office International des Épizooties, 2019; Zinsstag et al., 2020a). However, the sectors needed to mobilize and harmonize their available resources to establish an effective and sustainable OHSRS approach in Ethiopia. As described by Roth et al. (2003), the cost of such a joint intervention can be shared based on the proportion of the benefit to each sector from the intervention.
Data management is a critical element in an OHSRS. Ethical issues in sharing data and silos existing between the professionals have been reported as challenges to the implementation of One Health surveillance in different settings (Johnson et al., 2018; Bordier et al., 2020). In our study, we tried to manage the issues related to data ethics by using an ID number for the patients and livestock owners in the database, and in this way, we kept the personal information anonymous and focused on the general epidemiological information of the population. However, to make an OHSRS part of disease surveillance in a region or country, issues related to data legality and ethics of data sharing should be clearly defined and agreed between the sectors, based on international recommendations (Degeling et al., 2015).
Synergistic capacity building is essential to strengthening the cooperation between sectors in disease surveillance and response, but it remains challenging (Johnson et al., 2018). Interdisciplinary training is recommended for successful collaboration between stakeholders (Bhatia, 2020). In Ethiopia, training on disease surveillance systems for human and animal health professionals is usually planned and offered separately, but these trainings can be offered jointly to equip staff with multidisciplinary knowledge. This requires harmonization of public health and animal health surveillance guidelines and manuals and collaborative agreement on capacity building between the stakeholders. Several universities offer One Health master programs and courses worldwide (Stärk et al., 2015). In Ethiopia, JJU, in collaboration with the University of Basel, the Swiss Tropical and Public Health Institute and the Armauer Hansen Research Institute, is implementing the 10-year JOHI project to establish Jigjiga University as a center of excellence in One Health in pastoral contexts (Zinsstag et al., 2020a; Erkyihun et al., 2022). The graduates from these programs will contribute to One Health operationalization, research and policy development, and prepare guidelines and manuals related to One Heath approaches.
Finally, other prerequisites for an OHSR are political commitment and cost-effectiveness of the system. Cross-sector economic analyses demonstrated that interventions in the animal reservoir cost less than those focused solely on human health (Zinsstag et al., 2009). On the other hand, if the disease is detected earlier in animals or the environment, the cumulative cost will be lower than when the disease spreads to humans and turns becomes a pandemic (Zinsstag et al., 2020b). In West Nile virus surveillance in the Emilia-Romagna region of Italy, a One Health approach where the information from animals (horses) and the environment (mosquito surveillance) was used to guide a public health intervention (blood donation). Using a One Health approach led to comparative cost savings (Paternoster et al., 2017). In addition, primary interventions to control pandemics focusing on early detection and prevention of novel pathogens decrease economic loss associated with years of potential life lost due to emerging diseases and have considerable benefit for all sectors (Bernstein et al., 2022).
In the last few years, Ethiopia progressed considerably in utilizing One Health approaches and prepared a national One Health strategic plan (2018–2022), prioritized zoonotic diseases and established a One Health National steering committee and technical working group to improve the multispectral collaboration in zoonotic disease surveillance and response (Revue Scientifique et Technique/Office International des Épizooties, 2019; Zinsstag et al., 2020a). To decentralize these efforts, a regional One Health steering community was established in SRS in 2019. To accelerate these efforts and ensure smooth and fruitful collaboration and coordination between sectors, we proposed an operational framework for One Health disease surveillance and response based on the experience of this intervention and the assumptions of Bordier et al. (2020). In this framework, we identified three levels where collaboration in emerging and reemerging zoonotic disease surveillance and response may occur: (i) district level; (ii) regional level; (iii) federal level. The detailed major tasks and sectors for collaboration are summarized in the framework (Fig. 13).
CONCLUSION
A lot of effort has gone into improving One Health approaches in Ethiopia. A main challenge was the operationalization of OHSR, which is a cornerstone for the early detection and response of emerging and reemerging zoonotic diseases. Our study highlighted the feasibility of operationalization of OHSR, where human and animal disease information is collected in an integrated way, shared among sectors and disseminated to the concerned bodies at different levels of administration. We believe that designing an OHSR through the existing disease surveillance system, the presence of an OHSRU, the network between both human and animal health staff at all levels of administration, engaging the community in the disease surveillance and response, the establishment of a One Health task force and interdisciplinary training contributed to the success of the OHSR. However, to scale up OHSR in the Somali region or other parts of the country, traditional barriers between sectors and silos must be overcome. Moreover, participatory discussions should be held to resolve technical challenges, such as around data legality and feasible coordination mechanisms, and define interdisciplinary training, resource mobilization, harmonization and allocation of resources for collaborative activities. In addition, further research on One Health development, political commitment, strategic policy and demonstration of the cost-effectiveness of the system are indispensable to move toward One Health surveillance response.
CONFLICT OF INTEREST
The authors have no conflicts of interest to declare.
ETHICS STATEMENT
The authors confirm that the research meets any required ethical guidelines, including adherence to the legal requirements of the study country.
ACKNOWLEDGMENT
We are thankful for the community health workers and community animal health workers who were actively involved in the study. We also thank the health professionals at the district and regional levels for their assistance.
AUTHOR CONTRIBUTIONS
All authors contributed equally to the development of this article.
FUNDING STATEMENT
This study was funded by Jigjiga University One Health Initiative and Biovision Foundation (http://www.biovision.ch/).
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Submitted: 21 June 2022
Issue publication date: 1 January 2023
Accepted: 12 April 2023
Published online: 26 June 2023
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