Reducing antimicrobial use in chicken production in Vietnam: Exploring the systemic dimension of change.

Antibiotic use in livestock production is one of the drivers of antibiotic resistance and a shift towards better and reduced antibiotic usage is urgently required. In Vietnam, where there are frequent reports of the misuse and overuse of antibiotics, little attention has been paid to farmers who have successfully changed their practices. This qualitative study aims to understand the transition process of Vietnamese chicken farmers toward reduced antibiotic usage. We conducted semi-structured interviews with 18 chicken farmers, 13 drug sellers, and 5 traders using participatory tools and a socio-anthropological approach. We explored the farmers' histories, current and past antibiotic usage, methods used to reduce antibiotic use, and motivations and barriers to changing practices. Through the thematic analysis of the farmers' transcripts, we identified technical, economic, and social factors that influence change. Out of eighteen farmers, we identified ten farmers who had already reduced antibiotic usage. The main motivations included producing quality chickens (tasty and safe) while reducing farm expenditures. Barriers were related to poor biosecurity in the area, market failures, and the farmers' lack of knowledge. Innovation led to overcome these obstacles included the local development of handmade probiotics and the organization of farmer cooperatives to overcome economic difficulties and guarantee product outlets. Knowledge was increased by workshops organized at the communal level and the influence of competent veterinarians in the area. We showed that the transition process was influenced by several components of the system rather than by any individual alone. Our study demonstrated that local initiatives to reduce antibiotic use in Vietnamese chicken production do exist. As changes depend on the system in which stakeholders are embedded, systemic lock-ins must be removed to allow practices to change. The promotion of locally-developed solutions should be further encouraged.

Different kettles of fish: Varying patterns of antibiotic use on pig, chicken and fish farms in Lao PDR and implications for antimicrobial resistance strategies.

The rapid intensification of the livestock sector in Southeast Asia has been found to be associated with an expanding use of antibiotics (ABU) and the rise of antimicrobial resistance (AMR) in both humans and livestock. This study aimed to explore the views and practices of commercial pig, poultry and fish farmers regarding antibiotics in Lao People's Democratic Republic, where data on antibiotic use and AMR remain scarce. A multistage cluster sampling method, based on the random selection of villages in two provinces of Vientiane, was used. A total of 364 farmers, corresponding to 454 farm units, were surveyed using a questionnaire and farm visits. This study found a widespread use of antibiotics (261 out of the 454 farm units used antibiotics). The predominance of antibiotics considered critically important antibiotics for human medicine was of great concern. Results from a logistic regression model showed that antibiotics were found less frequently in fish farm units compared to pig and poultry farm units, and more frequently in specialized farms than in livestock-fish farms. Multiple factor analysis and hierarchical cluster analysis revealed three profiles of farmers, each with distinct patterns on knowledge, attitudes and practices regarding ABU and AMR. Cluster 1 held a positive attitude regarding preventive measures and information about antibiotics. In cluster 2, there was a view that antibiotics should be used for prophylactic treatment such as disease prevention. Cluster 3 was characterized by farmers with weak knowledge who were unfamiliar with antibiotics and uncertain about details concerning antibiotic use. This cluster was associated with a significantly lower use of antibiotics than the two other clusters in the regression model. The results of this study may help the Laotian government to adapt strategies to control AMR by focusing on the use of critical antibiotics and prophylactic treatments and by tailoring measures to farmers' profiles.

A participatory epidemiological and One Health approach to explore the community's capacity to detect emerging zoonoses and surveillance network opportunities in the forest region of Guinea.

The Ebola virus disease epidemic that threatened West Africa between 2013 and 2016 was of unprecedented health magnitude. After this health crisis, studies highlighted the need to introduce community-based surveillance systems and to adopt a One Health approach. This study aimed to provide preparatory insights for the definition of a community-based surveillance system for emerging zoonoses such as viral hemorrhagic fevers in Guinea. The objective was to explore the disease detection capacity and the surveillance network opportunities at the community level in two pilot areas in the forest region of Guinea, where the epidemic emerged. Based on a participatory epidemiological and One Health approach, we conducted Focus Group Discussions with human, animal and ecosystem health actors. We used a range of participatory tools, included semi-structured interviews, ranking, scoring and flow diagram, to estimate the local knowledge and perception of diseases and clinical signs and to investigate the existing health information exchange network and its related strengths and weaknesses. The results showed that there is heterogeneity in knowledge of diseases and perception of the clinical signs among actors and that there are preferred and more effective health communication channels opportunities. This preparatory study suggests that it is necessary to adapt the case definitions and the health communication channels to the different actors who can play a role in a future community-based surveillance system and provides recommendations for future surveillance activities to be carried out in West Africa.

Engaging Stakeholders in the Design of One Health Surveillance Systems: A Participatory Approach.

Many One Health surveillance systems have proven difficult to enforce and sustain, mainly because of the difficulty of implementing and upholding collaborative efforts for surveillance activities across stakeholders with different values, cultures and interests. We hypothesize that only the early engagement of stakeholders in the development of a One Health surveillance system can create an environment conducive to the emergence of collaborative solutions that are acceptable, accepted and therefore implemented in sustainable manner. To this end, we have designed a socio-technical framework to help stakeholders develop a common vision of their desired surveillance system and to forge the innovation pathway toward it. We implemented the framework in two case studies: the surveillance of antimicrobial resistance in Vietnam and that of Salmonella in France. The socio-technical framework is a participatory and iterative process that consists of four distinct steps implemented during a workshop series: (i) definition of the problem to be addressed, (ii) co-construction of a common representation of the current system, (iii) co-construction of the desired surveillance system, (iv) identification of changes and actions required to progress from the current situation to the desired situation. In both case studies, the process allowed surveillance stakeholders with different professional cultures and expectations regarding One Health surveillance to gain mutual understanding and to reconcile their different perspectives to design the pathway toward their common vision of a desired surveillance system. While the proposed framework is structured around four essential steps, its application can be tailored to the context. Workshop facilitation and representativeness of participants are key for the success of the process. While our approach lays the foundation for the further implementation of the desired One Health surveillance system, it provides no guarantee that the proposed actions will actually be implemented and bring about the required changes. The engagement of stakeholders in a participatory process must be sustained in order to ensure the implementation of co-constructed solutions and evaluate their effectiveness and impacts.

Perception of Drug Vendors and Pig and Poultry Farmers of Imerintsiatosika, in Madagascar, Toward Risks Related to Antibiotic Usage: A Q-Method Approach.

Antimicrobial resistance is a One Health issue that must be tackled worldwide. In order to implement effective communication strategies in Madagascar, a better understanding must be gained of practices and perceptions related to antimicrobial use at the smallholder farm level. Our study used a semi-qualitative approach, called Q methodology, to identify patterns of opinion on antimicrobial use, or its alternatives, among pig and poultry smallholders and drug vendors in the commune of Imerintsiatosika, in Madagascar. Twenty-nine breeders and 23 drug vendors were asked to rank, respectively, 38 and 45 statements, produced from semi-structured interviews and secondary data, through a 7 grade scale from -3 (totally disagree) to +3 (totally agree) about antimicrobial use, related risks and alternatives. The interview ended with a discussion around extreme statements. The Q-sortings were analyzed by factor analysis and Principal Component Analysis. Regarding antimicrobial use, antimicrobial resistance and alternatives, the breeders and drug vendors were divided according to three discourses: "A: confidence in antibiotics" (respectively, 13 and 6 individuals), "B: belief in alternatives" (7 and 7 individuals), and "C: moderate approach to antibiotic use" (6 and 6 individuals), explaining, respectively, 57 and 60% of total variance. Group A was associated with the use of antibiotics as a preventive measure, poor knowledge of resistance and low trust in alternatives. Group B considered the preventive use of antibiotics to be a major problem for antimicrobial resistance and believed that alternatives, such as vaccines, were useful preventive methods. Group C seemed to have a hazy opinion. The presence of three main points of view offers the possibility to adapt awareness messages. Group B might also be used as a showcase to reduce the amounts of antibiotics used by the two other groups. This study revealed different practices and risk perceptions related to antimicrobial use that must be better characterized and accurately quantified.

One Health Surveillance: A Matrix to Evaluate Multisectoral Collaboration.

The international community and governmental organizations are actively calling for the implementation of One Health (OH) surveillance systems to target health hazards that involve humans, animals, and their environment. In our view, the main characteristic of a OH surveillance system is the collaboration across institutions and disciplines operating within the different sectors to plan, coordinate, and implement the surveillance process. However, the multisectoral organizational models and possible collaborative modalities implemented throughout the surveillance process are multi-fold and depend on the objective and context of the surveillance. The purpose of this study is to define a matrix to evaluate the quality and appropriateness of multisectoral collaboration through an in-depth analysis of its organization, implementation, and functions. We developed a first list of evaluation attributes based on (i) the characteristics of the organization, implementation, and functionality of multisectoral surveillance systems; and (ii) the existing attributes for the evaluation of health surveillance systems and OH initiatives. These attributes were submitted to two rounds of expert-opinion elicitation for review and validation. The final list of attributes consisted of 23 organizational attributes and 9 functional attributes, to which 3 organizational indexes were added measuring the overall organization of collaboration. We then defined 75 criteria to evaluate the level of satisfaction for the attributes and indexes. The criteria were scored following a four-tiered scoring grid. Graphical representations allowed for an easy overview of the evaluation results for both attributes and indexes. This evaluation matrix is the first to allow an in-depth analysis of collaboration in a multisectoral surveillance system and is the preliminary step toward the creation of a fully standalone tool for the evaluation of collaboration. After its practical application and adaptability to different contexts are field-tested, this tool could be very useful in identifying the strengths and weaknesses of collaboration occurring in a multisectoral surveillance system.

Antibiotic resistance in Vietnam: moving towards a One Health surveillance system.

BACKGROUND: The international community strongly advocates the implementation of multi-sectoral surveillance policies for an effective approach to antibiotic resistance, in line with the One Health concept. To comply with these international recommendations, the Vietnamese government has issued an inter-ministerial surveillance strategy for antibiotic resistance, including an integrated surveillance system. However, one may question the ability and willingness of surveillance stakeholders to implement the collaborations required. To assess the feasibility of operationalising this strategy within the national context, we explored the role of key stakeholders in the strategy, as well as their abilities to comply with it. METHODS: We conducted a qualitative approach based on an iterative stakeholder mapping and analysis, in three distinct steps: (1) a description of the structure of the national surveillance strategy (literature review, key informant interviews); (2) an analysis of the key stakeholders' positions regarding the strategy (semi-structured interviews); (3) the identification of factors influencing the operationalisation of the collaborative surveillance strategy (comparison of data collected at the first and second steps). RESULTS: The mapping of the surveillance system, as well as the characterisation of key stakeholders according to organisational and functional attributes, underlined that inter-sectoral surveillance initiatives do exist, but that the organisation of the national surveillance system remains highly silo-oriented. Based on stakeholder perspectives, we identified seven factors that may influence the implementation of the One Health strategy at national level: governance and operational frameworks, divergence of institutional cultures, level of knowledge, technical capacities, allocation of resources, conflicting commercial interests and influence of international partners. CONCLUSIONS: The study suggests that the operationalisation of the collaborative surveillance strategy requires the full adhesion of stakeholders and the provision of appropriate resources. Based on these findings, we have proposed a guidance framework together with recommendations to move towards a more suitable governance and operational model for One Health surveillance of antibiotic resistance in Vietnam. To lever and promote successful inter-sectoral collaboration, a participatory "learning by doing" process could be applied to guide, frame and mentor stakeholders through the identification of appropriate levels of collaboration, depending on the expected positive impacts on the value of surveillance.

Benefit-Cost Analysis of Foot-and-Mouth Disease Vaccination at the Farm-Level in South Vietnam.

This study aimed to analyze the financial impact of foot-and-mouth disease (FMD) outbreaks in cattle at the farm-level and the benefit-cost ratio (BCR) of biannual vaccination strategy to prevent and eradicate FMD for cattle in South Vietnam. Production data were collected from 49 small-scale dairy farms, 15 large-scale dairy farms, and 249 beef farms of Long An and Tay Ninh province using a questionaire. Financial data of FMD impacts were collected using participatory tools in 37 villages of Long An province. The net present value, i.e., the difference between the benefits (additional revenue and saved costs) and costs (additional costs and revenue foregone), of FMD vaccination in large-scale dairy farms was 2.8 times higher than in small-scale dairy farms and 20 times higher than in beef farms. The BCR of FMD vaccination over 1 year in large-scale dairy farms, small-scale dairy farms, and beef farms were 11.6 [95% confidence interval (95% CI) 6.42-16.45], 9.93 (95% CI 3.45-16.47), and 3.02 (95% CI 0.76-7.19), respectively. The sensitivity analysis showed that varying the vaccination cost had more effect on the BCR of cattle vaccination than varying the market price. This benefit-cost analysis of biannual vaccination strategy showed that investment in FMD prevention can be financially profitable, and therefore sustainable, for dairy farmers. For beef cattle, it is less certain that vaccination is profitable. Additional benefit-cost analysis study of vaccination strategies at the national-level would be required to evaluate and adapt the national strategy to achieve eradication of this disease in Vietnam.

A Q Method Approach to Evaluating Farmers' Perceptions of Foot-and-Mouth Disease Vaccination in Vietnam.

This study aims to explore the farmers' perceptions of foot-and-mouth disease (FMD) vaccination using a reflexive research method called Q methodology. A structured sample was composed of 46 farmers selected according to gender, farming experience, level of education, and production type. Statements relevant to the farmers' perceptions of and attitudes toward FMD vaccination, related to confidence, logistics, costs, and impacts of vaccination were developed. Results were analyzed by principal component analysis and factor analysis. The influence of demographics and characterized variables on the respondent's contribution to each factor was also tested. Regarding the different beliefs and behavior toward FMD vaccination, the common perceptions held by Vietnamese cattle and pig farmers were divided into three discourses named Confidence (24 subjects), Belief (12 subjects), and Challenge (6 subjects). The identified discourses represented 57.3% of the variances. Consensus points were found, such as the feeling of being more secure after FMD vaccination campaigns; the fact that farmers take vaccination decisions themselves without being influenced by other stakeholders; the opinion that FMD vaccination is cheaper than the costs of treating a sick animal; and that vaccines provided by governmental authorities are of high quality. Part of the studied population did not consider vaccination to be the first choice strategy in prevention. This raises the question of how to improve the active participation of farmers in the FMD vaccine strategy. Taking into consideration farmers' perceptions can help to implement feasible vaccination strategies at the local level.

A Blueprint to Evaluate One Health.

One Health (OH) positions health professionals as agents for change and provides a platform to manage determinants of health that are often not comprehensively captured in medicine or public health alone. However, due to the organization of societies and disciplines, and the sectoral allocation of resources, the development of transdisciplinary approaches requires effort and perseverance. Therefore, there is a need to provide evidence on the added value of OH for governments, researchers, funding bodies, and stakeholders. This paper outlines a conceptual framework of what OH approaches can encompass and the added values they can provide. The framework was developed during a workshop conducted by the "Network for Evaluation of One Health," an Action funded by the European Cooperation in Science and Technology. By systematically describing the various aspects of OH, we provide the basis for measuring and monitoring the integration of disciplines, sectors, and stakeholders in health initiatives. The framework identifies the social, economic, and environmental drivers leading to integrated approaches to health and illustrates how these evoke characteristic OH operations, i.e., thinking, planning, and working, and require supporting infrastructures to allow learning, sharing, and systemic organization. It also describes the OH outcomes (i.e., sustainability, health and welfare, interspecies equity and stewardship, effectiveness, and efficiency), which are not possible to obtain through sectoral approaches alone, and their alignment with aspects of sustainable development based on society, environment, and economy.

MERS-CoV at the Animal-Human Interface: Inputs on Exposure Pathways from an Expert-Opinion Elicitation.

Nearly 4 years after the first report of the emergence of Middle-East respiratory syndrome Coronavirus (MERS-CoV) and nearly 1800 human cases later, the ecology of MERS-CoV, its epidemiology, and more than risk factors of MERS-CoV transmission between camels are poorly understood. Knowledge about the pathways and mechanisms of transmission from animals to humans is limited; as of yet, transmission risks have not been quantified. Moreover the divergent sanitary situations and exposures to animals among populations in the Arabian Peninsula, where human primary cases appear to dominate, vs. other regions in the Middle East and Africa, with no reported human clinical cases and where the virus has been detected only in dromedaries, represents huge scientific and health challenges. Here, we have used expert-opinion elicitation in order to obtain ideas on relative importance of MERS-CoV risk factors and estimates of transmission risks from various types of contact between humans and dromedaries. Fourteen experts with diverse and extensive experience in MERS-CoV relevant fields were enrolled and completed an online questionnaire that examined pathways based on several scenarios, e.g., camels-camels, camels-human, bats/other species to camels/humans, and the role of diverse biological substances (milk, urine, etc.) and potential fomites. Experts believed that dromedary camels play the largest role in MERS-CoV infection of other dromedaries; however, they also indicated a significant influence of the season (i.e. calving or weaning periods) on transmission risk. All experts thought that MERS-CoV-infected dromedaries and asymptomatic humans play the most important role in infection of humans, with bats and other species presenting a possible, but yet undefined, risk. Direct and indirect contact of humans with dromedary camels were identified as the most risky types of contact, when compared to consumption of various camel products, with estimated "most likely" incidence risks of at least 22 and 13% for direct and indirect contact, respectively. The results of our study are consistent with available, yet very limited, published data regarding the potential pathways of transmission of MERS-CoV at the animal-human interface. These results identify key knowledge gaps and highlight the need for more comprehensive, yet focused research to be conducted to better understand transmission between dromedaries and humans.

The Added-Value of Using Participatory Approaches to Assess the Acceptability of Surveillance Systems: The Case of Bovine Tuberculosis in Belgium.

CONTEXT AND OBJECTIVE: Bovine tuberculosis (bTB) surveillance in Belgium is essential to maintain the officially free status and to preserve animal and public health. An evaluation of the system is thus needed to ascertain the surveillance provides a precise description of the current situation in the country. The evaluation should assess stakeholders' perceptions and expectations about the system due to the fact that the acceptability has an influence on the levels of sensitivity and timeliness of the surveillance system. The objective of the study was to assess the acceptability of the bTB surveillance in Belgium, using participatory tools and the OASIS flash tool ('analysis tool for surveillance systems'). METHODS: For the participatory process, focus group discussions and individual interviews were implemented with representatives involved with the system, both from cattle and wildlife part of the surveillance. Three main tools were used: (i) relational diagrams associated with smileys, (ii) flow diagrams associated with proportional piling, and (iii) impact diagrams associated with proportional piling. A total of six criteria were assessed, among which five were scored on a scale from -1 to +1. For the OASIS flash tool, one full day meeting with representatives from stakeholders involved with the surveillance was organised. A total of 19 criteria linked to acceptability were scored on a scale from 0 to 3. RESULTS AND CONCLUSION: Both methods highlighted a medium acceptability of the bTB surveillance. The main elements having a negative influence were the consequences of official notification of a bTB suspect case in a farm, the low remuneration paid to private veterinarians for execution of intradermal tuberculin tests and the practical difficulties about the containment of the animals. Based on the two evaluation processes, relevant recommendations to improve the surveillance were made. Based on the comparison between the two evaluation processes, the added value of the participatory approach was highlighted.

A framework to promote collective action within the One Health community of practice: Using participatory modelling to enable interdisciplinary, cross-sectoral and multi-level integration.

As Southeast Asia (SEA) is characterized by high human and domestic animal densities, growing intensification of trade, drastic land use changes and biodiversity erosion, this region appears to be a hotspot to study complex dynamics of zoonoses emergence and health issues at the Animal-Human-Environment interface. Zoonotic diseases and environmental health issues can have devastating socioeconomic and wellbeing impacts. Assessing and managing the related risks implies to take into account ecological and social dynamics at play, in link with epidemiological patterns. The implementation of a One Health (OH) approach in this context calls for improved integration among disciplines and improved cross-sectoral collaboration, involving stakeholders at different levels. For sure, such integration is not achieved spontaneously, implies methodological guidelines and has transaction costs. We explore pathways for implementing such collaboration in SEA context, highlighting the main challenges to be faced by researchers and other target groups involved in OH actions. On this basis, we propose a conceptual framework of OH integration. Throughout 3 components (field-based data management, professional training workshops and higher education), we suggest to develop a new culture of networking involving actors from various disciplines, sectors and levels (from the municipality to the Ministries) through a participatory modelling process, fostering synergies and cooperation. This framework could stimulate long-term dialogue process, based on the combination of case studies implementation and capacity building. It aims for implementing both institutional OH dynamics (multi-stakeholders and cross-sectoral) and research approaches promoting systems thinking and involving social sciences to follow-up and strengthen collective action.

Development of a participatory tool for the evaluation of Village Animal Health Workers in Cambodia.

In countries with a lack of primary care systems, health workers are of crucial importance to improving the delivery of health and animal health services at community level. But somehow they are rarely evaluated and usually with a top-down approach. This is the case in Cambodia, where thousands of Village Animal Health Workers (VAHWs) have been trained by the government, and where no standardized evaluation tool is available to accurately assess the situation. Based on methodology developed by the French NGO Agronomes et Vétérinaires Sans Frontières (AVSF) in Madagascar for farmers' association evaluation, we developed our own participatory methods to collect information about the VAHW context and build a criteria grid for their evaluation. In this framework, several participatory approaches were used such as problem trees, semi-structured interviews, pair-wise ranking and focus groups. The grid was built with the help of relevant stakeholders involved in the animal health system in Cambodia in order to (i) identify VAHW functions; (ii) set up criteria and associated questionnaires, and (iii) score the grid with all the stakeholders. The tool was divided into five categories of evaluation criteria: sustainability, treatment, production, vaccination and disease reporting. Our approach looked at local indicators of success developed and used by VAHWs themselves, which should lead to better acceptability of evaluation. This method gave priority to dialog aiming to engage decision makers and other stakeholders in a mutual learning process and could be applied in other countries to develop trust between health workers and official service representatives as well as to foster corrective action after evaluation.

Cluster randomised trial of the impact of biosecurity measures on poultry health in backyard flocks.

In Cambodia, most poultry are raised in backyard flocks with a low level of biosecurity, which increases the risk of spread of infectious diseases. The aim of this study was to evaluate the effectiveness of a practical biosecurity intervention based on affordable basic measures. A cluster randomised trial was conducted in 18 villages in Cambodia from November 2009 to February 2011. Generalised estimating equations were used to test the association between the intervention and mortality rates in flocks of chickens and ducks. Mortality rates in chicken flocks in intervention villages (mean 6.3%, range 3.5-13.8%, per month) were significantly higher than in control villages (mean 4.5%, range 2.0-9.7%, per month; P<0.01). Mortality rates in duck flocks in intervention villages (mean 4.1%, range 1.9-7.9%, per month) were significantly higher than in control villages (mean 2.8%, range 0.6-8.0%, per month; P<0.01). Despite good compliance among poultry owners, the biosecurity intervention implemented in this study was not associated with improvements in poultry mortality rates. These findings suggest that basic biosecurity measures may not suffice to limit the spread of infectious diseases in backyard poultry flocks in Cambodia.

Biosecurity measures for backyard poultry in developing countries: a systematic review.

BACKGROUND: Poultry represents an important sector in animal production, with backyard flocks representing a huge majority, especially in the developing countries. In these countries, villagers raise poultry to meet household food demands and as additional sources of incomes. Backyard production methods imply low biosecurity measures and high risk of infectious diseases, such as Newcastle disease or zoonosis such as Highly Pathogenic Avian Influenza (HPAI).We reviewed literature on biosecurity practices for prevention of infectious diseases, and published recommendations for backyard poultry and assessed evidence of their impact and feasibility, particularly in developing countries. Documents were sourced from the Food and Agriculture Organization (FAO) website, and from Pubmed and Google databases. RESULTS: A total of 62 peer-reviewed and non-referred documents were found, most of which were published recently (after 2004) and focused on HPAI/H5N1-related biosecurity measures (64%). Recommendations addressed measures for flock management, feed and water management, poultry trade and stock change, poultry health management and the risk to humans. Only one general guideline was found for backyard poultry-related biosecurity; the other documents were drawn up for specific developing settings and only engaged their authors (e.g. consultants). These national guidelines written by consultants generated recommendations regarding measures derived from the highest standards of commercial poultry production. Although biosecurity principles of isolation and containment are described in most documents, only a few documents were found on the impact of measures in family poultry settings and none gave any evidence of their feasibility and effectiveness for backyard poultry. CONCLUSIONS: Given the persistent threat posed by HPAI/H5N1 to humans in developing countries, our findings highlight the importance of encouraging applied research toward identifying sustained and adapted biosecurity measures for smallholder poultry flocks in low-income countries.