"When a dog bites someone": community and service provider dynamics influencing access to integrated bite case management in Chad

This study aims to identify factors on the community, the human health and the animal health provider level that determine access to Post Exposure Prophylaxis (PEP) and animal rabies diagnosis in the light of a future integrated bite case management (IBCM) approach for rabies control in Chad. The study was embedded in an overall project conducted from 2016 to 2018, to determine rabies burden and vaccine demand in West and Central Africa. Data collection took place during the projects closing workshops with stakeholders organized between August and September 2018 in the three study zones in Chad covering Logone Occidental and Ouaddai province and parts of Hadjer Lamis and Chari Baguirmi province. A qualitative approach based on focus group discussion and in-depth interviews was used to get insights on access to care and animal investigation after suspected rabies exposure. A total of 96 participants, including 39 from the community (bite victims, dog owners) and 57 human and animal health providers (health center managers, chief veterinary officers, chief district medical officers, chiefs of livestock sectors) contributed to the study. Based on an existing conceptual framework of access to health care, several points of dissatisfaction were identified, in particular the unaffordability of human rabies vaccine for PEP (affordability) and the distance to travel to a health facility in case of a bite (accessibility). In addition, there are unfavorable attitudes observed highlighted by the importance given to traditional or local rabies care practices to the detriment of PEP (acceptability) and a low level of knowledge among Chadian communities regarding bite prevention, coupled with a very inadequate information and awareness system regarding the disease (adequacy). As for human and veterinary health services, both sectors suffer from insufficient resources for PEP on the human health and rabies diagnosis on the veterinary side impacting negatively on availability and accessibility of both these services. Action to improving provision of rabies health services and increasing knowledge about risk and prevention of the disease among the population need to be undertaken to implement IBCM, improve access to PEP and achieve the goal of eliminating dog mediated human rabies by 2030 in Chad

General insights on obstacles to dog vaccination in Chad on community and institutional level

Domestic dogs are responsible for 95% of all human rabies cases worldwide and continue to be the main reservoir for this fatal virus in African and Asian countries. Interrupting the spread of the disease in the domestic dog population is therefore necessary for long-term, sustainable rabies control. Chad has been recognized as a rabies-endemic country since 1961, but no national control strategy is in place to date and dog vaccination coverage is very low. This qualitative, descriptive study aims to describe the main barriers to dog vaccination on both the community and the institutional level from a socio-anthropological point of view in Chad. The study was embedded in an overall project conducted from 2016 to 2018, to determine rabies burden and vaccine demand in West and Central Africa, funded by GAVI, the vaccine alliance. Data collection was conducted on the occasion of the project's closing workshops with stakeholders organized between August to September 2018 in the four (4) project areas: Logone Occidental, Ouaddai, Hadjer Lamis and Chari Baguirmi. We conducted interviews and focus group discussions (FGD) among veterinary officers and dog owners. Participants were selected purposively based on their place of residence (dog owners) or work place (veterinary officers) and their previous contact with the project through reporting (dog owner) or management (veterinary officers) of a suspect dog rabies case. In each region, one FGD was organized with dog owners, and one FGD with heads of veterinary posts. At the end of the FGDs, a few participants were randomly selected for interviews. In addition, in each region an interview was conducted with the head of the livestock sector, the chief district medical officers and the head of a civil society association. The identified barriers to dog vaccination access are grouped into three main aspects: the economic, the socio-cultural and the institutional level. Economic constraints encountered relate to the cost of the vaccine itself and the expenses for transporting the dogs to the vaccination site. The cultural belief that the vaccine will have an impact on the therapeutic properties of dog meat for consumers (observed in Southern Chad), and the fact that dogs are considered impure animals in Muslim faith, which prohibits handling of dogs, are obstacles identified on the sociocultural level. At the institutional level, the unavailability of vaccines in veterinary services, the lack of communication about the law on dog vaccination, the absence of rabies in the training curricula of veterinary agents, and the lack of intersectoral collaboration limit vaccination coverage. In order to improve vaccination coverage and rabies surveillance with a view to eradicate rabies by 2030, communication strategies that are adapted to the context and that take cultural obstacles into account must be put in place in a synergy of interdisciplinary action. In addition, factors such as affordability, geographical access and availability of dog rabies vaccines needs to be addressed throughout the country. Although our study design did not allow a detailed analysis of obstacles related to socio-economic level, gender and age the broad insights gained can provide general guidance for future interventions in Chad and similar countries

The promotion and development of One Health at Swiss TPH and its greater potential

One Health, an integrated health concept, is now an integral part of health research and development. One Health overlaps with other integrated approaches to health such as EcoHealth or Planetary Health, which not only consider the patient or population groups but include them in the social-ecological context. One Health has gained the widest foothold politically, institutionally, and in operational implementation. Increasingly, One Health is becoming part of reporting under the International Health Legislation (IHR 2005). The Swiss Tropical and Public Health Institute (Swiss TPH) has played a part in these developments with one of the first mentions of One Health in the biomedical literature. Here, we summarise the history of ideas and processes that led to the development of One Health research and development at the Swiss TPH, clarify its theoretical and methodological foundations, and explore its larger societal potential as an integrated approach to thinking. The history of ideas and processes leading to the development of One Health research at the Swiss TPH were inspired by far-sighted and open ideas of the directors and heads of departments, without exerting too much influence. They followed the progressing work and supported it with further ideas. These in turn were taken up and further developed by a growing number of individual scientists. These ideas were related to other strands of knowledge from economics, molecular biology, anthropology, sociology, theology, and linguistics. We endeavour to relate Western biomedical forms of knowledge generation with other forms, such as Mayan medicine. One Health, in its present form, has been influenced by African mobile pastoralists' integrated thinking that have been taken up into Western epistemologies. The intercultural nature of global and regional One Health approaches will inevitably undergo further scrutiny of successful ways fostering inter-epistemic interaction. Now theoretically well grounded, the One Health approach of seeking benefits for all through better and more equitable cooperation can clearly be applied to engagement in solving major societal problems such as social inequality, animal protection and welfare, environmental protection, climate change mitigation, biodiversity conservation, and conflict transformation

Using and improving the PHISICC paper-based tools in the health facility laboratories: examples of Human Centered Design taking systems thinking into practice, in Côte d'Ivoire and Nigeria

BackgroundHealth workers in low- and middle-income countries are increasingly demanded to collect more and more data to report them to higher levels of the health information system (HIS), in detriment of useful data for clinical and public health decision-making, potentially compromising the quality of their health care provison. In order to support health workers' decision-making, we engaged with partners in Côte d'Ivoire, Mozambique and Nigeria in a research project to conceive, design, produce, implement and test paper-based health information tools: the PHISICC tools. Our aim was to understand the use of PHISICC tools by health workers and to improve them based on their feedback.MethodsThe design Health Facility Laboratories (HF Labs) in Côte d'Ivoire and in Nigeria were set up after months of use of PHISICC tools. Activities were structured in three phases or 'sprints' of co-creative research. We used a transdisciplinary approach, including anthropology and Human Centered Design (HCD), observations, shadowing, structured interviews and co-creation.ResultsHealth workers appreciated the standardization of the tools across different health care areas, with a common visual language that optimized use. Several design issues were raised, in terms of formats and contents. They strongly appreciated how the PHISICC registers guided their clinical decision-making and how it facilitated tallying and counting for monthly reporting. However, adherence to new procedures was not universal. The co-creation sessions resulted in modifications to the PHISICC tools of out-patient care and postnatal care.DiscussionAlthough health systems and systemic thinking allowed the teams to embrace complexity, it was the HCD approach that actually produced a shift in researchers' mind-set: from HIS as data management tools to HIS as quality of care instruments. HCD allowed navigating the complexity of health systems interventions due to its capacity to operate change: it not only allowed us to understand how the PHISICC tools were used but also how to further improve them. In the absence of (or even with) an analytical health systems framework, HCD approaches can work in real-life situations for the ideation, testing and implementation of interventions to improve health systems and health status outcomes

Advancing One human-animal-environment Health for global health security: what does the evidence say?

In this Series paper, we review the contributions of One Health approaches (ie, at the human-animal-environment interface) to improve global health security across a range of health hazards and we summarise contemporary evidence of incremental benefits of a One Health approach. We assessed how One Health approaches were reported to the Food and Agricultural Organization of the UN, the World Organisation for Animal Health (WOAH, formerly OIE), and WHO, within the monitoring and assessment frameworks, including WHO International Health Regulations (2005) and WOAH Performance of Veterinary Services. We reviewed One Health theoretical foundations, methods, and case studies. Examples from joint health services and infrastructure, surveillance-response systems, surveillance of antimicrobial resistance, food safety and security, environmental hazards, water and sanitation, and zoonoses control clearly show incremental benefits of One Health approaches. One Health approaches appear to be most effective and sustainable in the prevention, preparedness, and early detection and investigation of evolving risks and hazards; the evidence base for their application is strongest in the control of endemic and neglected tropical diseases. For benefits to be maximised and extended, improved One Health operationalisation is needed by strengthening multisectoral coordination mechanisms at national, regional, and global levels