Creating a framework towards integrated health syndromic surveillance and response in Africa

Background: A substantial part of the population in sub-Saharan Africa live in rural areas characterized by insufficiently equipped health centres and shortages of qualified health workers. These people usually depend on agriculture and livestock but have limited access to social services including health. In Chad, over 78% of the total population lives in rural areas and 3.5% are mobile pastoralists. Previous research has shown that agro-pastoralists suffer from a broad range of diseases of mostly unconfirmed biomedical aetiology. We propose a synergistic approach of integrated “One Health” surveillance-response combining epidemiology, anthropology and advanced biomedical diagnostic with essential complementary elements to anticipate outbreaks of endemic and emerging diseases from perceived illnesses (syndromes). Community-based syndromic surveillance, coupled with mobile technology adapted to the rural agro-pastoralists context, could offer an alternative to existing surveillance systems for humans and animals. Linking such a system with the etiologic confirmation of suspected cases from freshly collected samples would increase the potential of anticipating diseases outbreaks and leads to evidence-based and locally adapted interventions. Such participatory approach to surveillance and intervention could be further used for public and veterinary health service improvement along with zoonosis integration into existing digital and open source health information system application (DHIS2) aiming at their elimination. Aim and objectives: The aim of the thesis was to establish the basis of a culturally adapted and integrated community based human and animal health syndromic surveillance and response system among agro-pastoralists in Chad. We addressed intervention effectiveness, joint human and animal health interventions, zoonosis elimination and basic requirements for syndromic surveillance in remote rural communities using modern information and communication technology. The objectives of the thesis were to: 1. Contribute to health interventions effectiveness evaluation methods; 2. Evaluate One Health approaches (e.g. joint human and animal vaccination) among mobile communities and their potential for integration into the public health system; 3. Establish a basic knowledge on syndromic surveillance and response in order to implement a feasibility study of an integrated human and animal health surveillance and response system; and 4. Estimate the potential of zoonosis elimination in developing countries (the case of bovine tuberculosis in Morocco). Approach: Effectiveness of health interventions: Equity effectiveness of maternal health service coverage in rural Chad: Inequalities and large disparities in the burden of maternal morbidity and mortality still persist within and between different population groups mainly in low income countries. Policies need to be informed by equity sensitive evidence assessing differences in health needs and particularly in the effectiveness of interventions and models of care. The aim of this paper was to assess the community effectiveness of maternal health service coverage for sedentary and mobile populations in two rural districts in Chad. The approach allowed for quantifying the health system’s determinants of effectiveness. Our results provided a baseline to monitor the progress of a health system intervention in these districts focusing on maternal and infant health. Interventions should generally focus in priority on improving community effectiveness through targeting the factors with the highest leverage among specific populations in order to foster effective and equitable health services. Vaccine hesitancy among mobile communities in Chad: Demand side barriers for vaccination among rural and mobile populations in Chad are not yet well understood. We hypothesized that these mobile pastoralists’ communities face specific demand side barriers to access vaccination services. Understanding the factors that caregivers in these communities could take into account, explicitly or implicitly, in order to decide (or not) to vaccinate a child is an essential element to tailor vaccination programmes towards increasing vaccination acceptance and uptake. Our results showed that mobile pastoralist communities face specific demand side barriers to vaccination. Understanding these barriers is essential to reduce vaccine hesitancy and increase vaccination uptake. Local health systems must plan for periodic presence of pastoralist communities in their zones of responsibility and create more mutual trust. One Health methods and approaches: Feasibility and sustainability of joint human and animal vaccination: Joint human and animal vaccination programmes (JHAVP) such as “One Health” approaches have demonstrated to be feasible; to increase health care access to hard-to-reach communities; and to save resources through sharing transport, equipment and logistics in Chad. The main objective of the study was to give an insight to the feasibility and the sustainability of JHAVP integrated as part of the public health system in Chad. Our results showed that even though its integration as a routine activity at the district level depends on the mobilization of additional financial resources, the district could benefit from JHAVP to maintain a contact network with the nomads in order to promote the use of available immunization services at district level in the long term. Trends in health surveillance and service delivery for pastoralists in West and Central Africa: In most sub-Saharan African countries, pastoralism represents an important economic resource and contributes significantly to national growth; however, challenges remain, particularly in providing social services to pastoralists (especially health and education) and in avoiding conflict with local sedentary communities and local authorities. All of this takes place while pastoralists try to maintain their mobile lifestyle within a rapidly changing ecosystem. Although considerable efforts have been made towards integrating mobile pastoralists into social services, obstacles remain to the adoption of a clear, specific and sustainable policy on pastoralism in sub-Saharan Africa. Transmission dynamics and elimination potential of zoonotic tuberculosis in Morocco: A simple compartmental deterministic mathematical model for BTB transmission in cattle and humans have been established to provide a general understanding of BTB, in particular regarding transmission to humans. Differential equations were used to model the different pathways between the compartments for cattle and humans. Scenarios of test and slaughter were simulated to determine the effects of varying the proportion of tested animals (p) on the time to elimination of BTB (individual animal prevalence of less than one in a thousand) in cattle and humans and the economic cost due to elimination.