GRF One Health Summit 2012, Davos: Presentation by Susan Welburn, University of Edinburgh, United Kingdom

1. Control of "Neglected" Zoonoses:
One Health approaches for securing health and
livelihoods in developing countries
Anna Louise OKELLO & Susan WELBURN
GRF Davos One Health Summit 19-22nd Feb 2012
Session WE 3.2: Public Health and Livelihoods

2. One Health in a Changing World
• Offers the opportunity to link people, animals and environment (physical,
human and social) across Public and Private sectors
• The 21st century of “health uncertainties” will require a “new culture of
collaboration” that recognises the essential link between human, domestic
animal and wildlife health and the threat disease poses to people, their food
supplies and economies, and accepts that biodiversity is essential to
maintaining health.
• Ecosystem health demands effective integration of ecology including
disease ecology with the social and health sciences.
• ‘One Health’ seeks to shift the paradigm from an "individual," or "disease
centered," approach to a "system," or "community based," “whole of
society” approach.

3. The Challenge
• One Health presents a challenge for low resource countries that require
improved human, livestock and ecosystem health that will link
improvements in livestock production to better human and community
health.
• The condition of many of our ecosystems is changing dramatically altering
the way human populations function rapidly in the developing world.
Unknown knowns
• What are the effects of landscape configurations on the spread of certain
diseases, particularly those associated with animal vectors?
• What landscape and human settlement patterns mitigate disease spread?
• What strategies can keep systems from becoming pathological?

4. World Hunger
http://www.un.org/Pubs/chronicle/2001/issue3/0103p15.html

5. Major neglected zoonotic diseases - Hot Spots?
Open-ended List of "NZDs"
EUR EMR
Brucellosis Echinococcosis
Anthrax
Multilocular Brucellosis
Bovine tuberculosis
AMR Echinococcosis Rabies SEAR/WPR
Brucellosis
Rabies Z.Leishmaniasis Rabies
Rabies
Echinococcosis Cysticercosis/taeniosis
AFR Echinococcosis
Cysticercosis Rabies Trematodoses
Echinococcosis/Hydatidosis
Leptospirosis Echinococcosis Cysticercosis
Brucellosis Zoonotic trypanosomiasis
Cysticercosis, Leptospirosis
B.tuberculosis Zoonotic Brucellosis
leishmaniasis
B.Tuberculosis
Rabies
Z. Trypanosomiasis
Spotlight on Neglected Tropical Diseases
The Royal Society of Medicine, Saturday 28 November 2009, London, UK

6. The Forgotten Zoonoses are endemic Disease of Poverty
Unintended consequence system of prioritization (DALYs)
Funding, while logical neither fair or sensible
Evidence base is poor
Difficulties in defining the burden of these diseases
Gross under-reporting
Division of responsibility between medical and veterinary sectors is a barrier to
sustainable control
Privatisation of veterinary services e.g. in Uganda - too much too soon and animal
disease control slipped away
Zoonotic disease control fell between cracks medical and veterinary services
Expose failings in Community Public Health

7. Case Study
Sleeping Sickness - The great epidemic
1896 - devastating epidemic of Sleeping sickness in Uganda
killed an estimated 300,000 people

8. Wish you were here?
By 1908 1/3 population Busoga dead (300,000 people)

9. In 1909 Governor Bell ordered evacuation from Lake Shore

10. Case Study Sleeping Sickness
Scene set for Control 100 years Ago
Identified agent
Suspected that there were 2 forms of disease - sleeping sickness
Identified the vector
Acknowledged infection could pass to animals
Treatment proposed – Robert Koch using Atoxyl Uganda 1906
But no tools were available to control the disease

11. Case Study Sleeping Sickness
Management and Finance
After a series of epidemics (1950 and 1980) a One Health body was established
by the Government of Uganda. COCTU – Co-ordinating office for Control of
Trypanosmiasis Uganda
Textbook case of One Health = representation from MoH, MoAFF, Ministry of
Finance, Vector Control
Medical, veterinary, social scientist, economists, vector biologists, wildlife
specialists, geosciences epidemiology. What was missing?

12. Sleeping sickness cases
in affected villages,
1987
Tororo, Butaleja and
Busia districts

13. 1988
Tororo, Butaleja and
Busia districts

14. 1989
Tororo, Butaleja and
Busia districts

15. 1990
Tororo, Butaleja and
Busia districts

16. 1991
Tororo, Butaleja and
Busia districts

17. 1992
Tororo, Butaleja and
Busia districts

18. 1993
Tororo, Butaleja and
Busia districts

19. 1994
Tororo, Butaleja and
Busia districts

20. 1999 – Emerging Public Heath Crisis in Uganda
T. b. rhodesiense spreading towards T. b. gambiense

21. HAT moving around shores of Lake Kyoga
100 km
8 districts in 8 years - 18 districts now affected

22. cattle market
focus to new areas
Fevre et al., Lancet 2001
 70 cases in 18 months
 Cases near ‘Brookes Corner’
 Cattle restocking was moving
Kyoga from cattle market traffic
 Area never before at risk for HAT
 Disease was moving around Lake
infected animals from established
 1st human case reported Dec 1998
N u m
Number of cases b e r o f c a s e s
0
5
10
15
20
25
30
D e c - 9 8
J a n - 9 9
F e b - 9 9
M a r - 9 9
A p r - 9 9
M a y - 9 9
J u n - 9 9
-
J u l 9 9
A u g - 9 9
S e p - 9 9
O c t - 9 9
N o v - 9 9
D e c - 9 9
J a n - 0 0
F e b - 0 0
M a r - 0 0
Soroti Outbreak - 2000
A p r - 0 0
Month
M a y - 0 0
Month
J u n - 0 0
-
J u l 0 0
A u g - 0 0
S e p - 0 0
O c t - 0 0
N o v - 0 0
D e c - 0 0
J a n - 0 1
F e b - 0 1
M a r - 0 1
A p r - 0 1
M a y - 0 1
J u n - 0 1
-
J u l 0 1
A u g - 0 1

24. a Tira 68
a Mela 32
a Papol 371
a Tira 17
b BWP 1
c AKOC43
a Mawero 80
Parasites in cows human infective
a Mawero 85
a Bumanda 25
a Magola 18
a Iyolwa 116
In 2001 SRA (serum resistance associated
a Mela 3
a Buteba 135
a Iyolwa 147
a Katerima 311
gene) identified and adapted to field tool
a Iyolwa 125
a Mawero 32
a Mela Pig1
a Mela Pig2
c AKO C8
a Fly 97
a Tira 27
a Bumanda 146
a Mawero 65
c AKOC 15
c AKOC20
c LIRI 31
c LIRI 26
c LIRI 30
c LIRI 37
c LIRI 24
c LIRI 39
c LIRI 16
c LIRI 25
a Mela 27
a UGE
a Mawero 31
a UGI
a Mela 2
a UGJ
a UGH
a Mawero 66
a Katerima 116
a Mawero 42
a Eoketch
a UGC
a UGG 88
a UG 89/1
SRA
a UGM
c AKOC16
c LIRI 14
a Fly 73
a Papol 278
a UG 89/8
a Mapollo
a Fly 48
a UGL
b Kinuhw
b kinuc21
b bugh1
a Pmasaba
a Maaja
a Htaka
a Fnamuiza
a UGK
a UGC 88
a UGB 88
a UGA 88
a UGA
a UG 89/9
a UG 89/5
a UG 89/3
a UG 89/2
a Mela 71
a UG 89/10
% similarity
70% 80% 90% 100%
Welburn et al., Lancet 2001, 2005

25. In Practice - Cattle in Sitengo village carrying human infective parasites
T. b. rhodesiene (SRA PCR).

26. Stamp Out Sleeping Sickness – PPP Model
Beautiful Danger by Christ’l Van Puijenbroeck

27. Stamp Out Sleeping Sickness – PPP Model
Beautiful Danger by Christ’l Van Puijenbroeck

28. Stamp out Sleeping Sickness – Phase I
Cost – effective intervention for Zoonotic sleeping sickness
1. Treat the 250,000 in cattle high risk zone
with trypanocide
2. Prevent re-infection by follow on
application of RAP method ‘pour-on’
insecticides
N
4. Stop market introductions by
reinforcement of Government policy for
point of sale treatment
4. Community One Health Messaging
SOS Phase 1
SOS Phase 2
PPP Partners
Industri Kapital/ IKARE, CEVA Sante Animale, DFID RIU, WHO, COCTU
University of Makerere/ University of Edinburgh.

29. SOS Phase 1 - Emergency intervention
2006/2007 1.Remove reservoir of
SOS
human parasite in cattle
2.Provide follow-up
treatments
Physical Challenge I – 250,000 treatments across 5 districts
CEVA Sante animale provides drugs for the exercise.
IK/IKARE provided the finance for animal treatments.
Makerere Vet School – final year cohort to provide assistance to DVO system
at community level as part of training at a cost of $1US per animal treated.
DFID – Monitoring and Evaluation

30. Challenge II – Technological
How to Sustainably Prevent re-infection

31. Restricted application - innovation
 Tsetse mostly feed on legs and belly
of cattle
 Half of all feeds are on cow
 Insecticide (dip formula) applied to
tsetse predilection sites
 Cattle act as live baits
 Monthly application maintained
prevalence <1% all trypanosomes
 No re-infection with T. brucei over 6
month trial
Affordable (10 cents), quick, effective and convenient added
bonus - kills ticks
Torr and Vale, University of Greenwich

32. SOS Phase I - Achievements
 Approximately 250,000 cattle treated in 5 districts
 75% reduction of all trypanosomes in cattle (human and cattle
pathogens)
 Far fewer sleeping sickness cases after rains – cases clustered near
markets
 Northwards spread of sleeping sickness contained – no epidemic
 First time undergraduate vets exposed to in-field
experience/community service
PROOF OF CONCEPT ESTABLISHED

33. SOS Phase I - Challenges
 Challenge of spreading SOS message underestimated
 Some community level resistance due to lack of communication
 Farmers sometimes confused as also other activities occurring
 Difficulties in ensuring continuous product supply, also into
remote areas
 Cross talk between medical and veterinary and vector control
does not translate into action
 Treatment at point of sale not undertaken – continued re-infection

34. Evolution of SOS – building sustainability
Emergency
intervention + follow-
2006/2007 SOS
up treatments
Establishment of
InTracs Building
sustainability
3V Vet Initiative Creating awareness
2008
Provision of vet
service
Solution
3V Vet Initiative – sustainable veterinary entrepreneurship

35. SOS - 3 V Vet initiative
 5 graduate vets recruited
 Each vet allocated an district/area (territory)
 Job descriptions and clear work agenda put in place
 Map activities and actors in area – establish contacts – build trust
 Ability to move about and reach all corners of territory
 Establish a spray person network to increase outreach of spraying
activity

36. SOS initiative – outputs
Emergency
2006/2007 SOS intervention + follow-
up treatments
250,000 cattle treated
InTracs
Building sustainability
2008 3V Vets Creating awareness
1.7 million people
Spray people
Approx. 80 Job creation:
3V Vets Improved health & wealth
Private vets & 20% of cattle in now
2009/2010 regularly treated –
shops
Farmer pays for CPH

37. Parallel ‘unexpected’ developments
 Incorporation of in-field activity and community service into Vet
Med Curriculum – Institutional change AFRESA - MINTRACS
 Incorporation of SOS activities into Governments 5 year plan
“Prosperity for All”
 3V Vets identified un-tapped markets
 Closer One Health working relationship with MOH, MAIFF
 Development of Tripartite plan for the NZDs elimination of
zoonotic ss within 10 year time frame (Uganda case example).

38. Phase II
 Roll-out of SOS activities under Mintracs to neighbouring Soroti District
- Additional 175,000 cattle have targeted in first round
 Roll-out of 3 V Vet initiative in parallel
- 5 new Vets recruited
 Adopt more integrated and holistic approach – veterinary students,
medicine students, agriculture students working with communities
 BUT
 Treatment of animals at point of sale needs to be reinforced
POLICY REINFORCEMENT AND ADVOCACY

39. 3 V Vet Entrepreneurship – AH distribution network
KAABONG
YU E
MB MOYO K G
IT UM
KOBOKO
ADJUMANI
KOTIDO
OLUFFE
GULU
PADER
NWOYA GULU PADER
ABIM
MOROTO
NWOYA
MOROTO
450000 540000 630000
NEBBI
OYAM
x x
{ { LIRA
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x
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{ DOKO O
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BU IS
LI A MASINDI
x x
{ { x
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{ K
KABERAMAIDO
ABERAMAIDO N APIRIPI RI
AK
AMOLATAR x
{ SOROTI
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PADER
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{ KUMI
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AK ONGO A
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KAPCHO WA
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PALLISA S O
IR NKHO
KAMULI KALIRO
ABIM
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AK EK
KAYUNGA PALLISA
Animal Drug
K O
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BUNDIBUGYO
KAMULI
M ALE
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W E
K ALE
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BUSIKI
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IGANGA T0 O O
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distribution network
KYENJOJO MUBENDE
BUGIRI
KABAROLE
M TYAN
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JINJA
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MAYUGE BUSIA
MUKONO
KAMPALA
KAMWENGE
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SEMBABULE
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IBANDA
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RU NGIRI
KU
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{
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RAKAI
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K UNG
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NTUNGAMO
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AMOLATAR SOROTI Legend
360000
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x KUMI {
x Drug Distribution point
Water bodies
NAKASONGOLA Protected areas
District boundaries
PALLISA
KAMULI SIRONKHO
NAKASEKE
KAYUNGA PALLISA 20 0 20 Kms
450000 KALIRO
540000 630000

40. Private Sector - Why SOS?
 Initially seen as a CSR effort…
Assessed as ”Investment case” Sense of
Urgency
– due diligence ”soft”
– active engagement
Strong and
Alignment of
– plan, budget and execute active partners
interest
– assign responsibilities and deliverables
– leverage knowledge and networks
– monitor, monitor, monitor
– solve problems as they occur and adjust

41. Platform for scaling-up
 “ 3 V Vet “ activity has created awareness, pull for products and spray
demand
 80 spray team businesses set up with micro-financing attached
 150,000 cattle currently commercially sprayed on regular basis
 3 V Vets established their own businesses and distribution networks
 Possible to address both improving health and creating jobs/improving
wealth in one go
 Closer working relationship medics and vets and underpinning of
COCTU
 Zoonotic SS flagged for elimination in Uganda in 10 years by WHO
 Looking to Social Investment Bonds for long term investment
 SOS TOOL KIT IN PLACE

42. Combined societal / economic viewpoint
Patient and Livestock
patient’s keepers and
household animal owners
Government
Private health veterinary & Governmenth
care providers extension ealth service
services
Private
veterinary
care providers
Acknowledgement, Alex Shaw

43. Combined societal / economic viewpoint
Patient and Livestock
patient’s keepers and
household animal owners
Government
Private health veterinary & Governmenth
care providers extension ealth service
services
Private
veterinary
care providers
is the basis on which government, donors, NGOs
should allocate resources

44. SOS - Persuasive Rates of return on investment
Assumptions about the rate at which an unchecked epidemic would
expand are based on previous experience and expert opinion
In 2009, without the SOS intervention, it is likely that we would have
experienced some 4000 new cases (majority under-reported)
WHO suggest these would treble annually, in this projection we
conservatively assume they may double
The figures of between 0.4 and 1.6 million DALYs averted (or extra life
years gained) are realistic
In addition between $15 and $60 million dollars of health care
expenditure for patients and the health services have been saved
When a money value is given to the DALYs, similar to the value of
GNP, these figures increase to a staggering $100 - $400 million
Shaw & Welburn
DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’

45. Health Implications for a 20-year scenario
The implications in terms of human life and money, can be saved by SOS
approaches, here for 4 scenarios regarded as likely by WHO’s experts
Maximum $ million Economic*
annual Million health total:
number of Year What happens DALYs costs $ million
new cases reached thereafter averted saved saved
Reduce by 1/4 each
30,000 2012 year 1.55 $57.63 $367.25
Reduce by 1/4 each
20,000 2012 year 1.14 $42.52 $275.47
Reduce by 1/2 each
20,000 2012 year 0.75 $28.17 $194.88
Reduce by 1/2 each
10,000 2011 year 0.39 $14.50 $103.25
*Discounted at 5% per annum and valuing 1 Disability adjusted life year (DALY) at $340
DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’

46. SOS - Persuasive Rates of return on investment
Assumptions about the rate at which an unchecked epidemic would
expand are based on previous experience and expert opinion
In 2009, without the SOS intervention, it is likely that we would have
experienced some 4000 new cases (majority under-reported)
WHO suggest these would treble annually, in this projection we
conservatively assume they may double
The figures of between 0.4 and 1.6 million DALYs averted (or extra life
years gained) are realistic
In addition between $15 and $60 million dollars of health care
expenditure for patients and the health services have been saved
When a money value is given to the DALYs, similar to the value of
GNP, these figures increase to a staggering $100 - $400 million
Shaw & Welburn
DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’

47. SOS – Animal Health rates of return
Restricted application RAP @ 12x applications/ annum results in average gain
20$ per bovine/year (maximum 30-40$ fertile female or working bull).
Approximately 9 - 10,000$ gained per square km ‘productive land’
15% RAP coverage is sufficient to drive Ro < 1 - 20% head of population needs treatment
resulting in a gain for 150,000 head @ 3.75M$/yr but since protection afforded in
community at herd level this translates to = 22.500M$ per year.
Shaw & Welburn - DFID-RIU ~ Uganda T&T case study ~ The cost of the ‘averted disaster’

48. Combined societal / economic viewpoint
Patient and Livestock
patient’s keepers and
household animal owners
Government
Private health veterinary & Governmenth
ONE HEALTH?
care providers extension
services
ealth service
Private
veterinary
care providers
Acknowledgement, Alex Shaw

49. POLICY AND ADVOCACY
 Treatment of animals at point of sale needs to be reinforced

50. Added Value
Long term capacity building
Intervening to control the forgotten zoonoses may be the catalyst to link the
drivers for change and lessons that have evolved
Emerging to Endemic
Move from ‘crisis response’ to a long term strengthening of public health systems
Ad hoc inter-ministerial task forces formed during zoonotic disease outbreaks e.g.
anthrax and rift valley fever, should be formalised into long-standing platforms for
risk analysis and prevention for a range of endemic disease support this evolution
Integrated Control of Neglected Zoonoses can pull together Animal Health +
Development + Human Health public actors but to achieve the necessary
impact for change need to work with Private Sector

51. The role of Private sector - Lessons from NTDs
Novartis
Merck & Co Inc Continuing commitment to MDT for
Mectizan for as long as needed for leprosy;triclabendazole for fascioliasis
onchocerciasis and filariasis in Africa
Johnson & Johnson
Mebendazole for intestinal worms
GlaxoSmithKline
Albendazole for lymphatic filariasis
at least to 2020 Medpharm (generic manufacturer)
Praziquantel via Canadian voluntary funds
(0.20 US$/treatment)
Pfizer
Azithromycin for trachoma 120 Sanofi Aventis
million doses Support for drugs for sleeping
sickness treatment

52. Ceva Sante Animale

53. Improving human health
and animal production
through scientific
innovation and public
engagement
1.Build Evidence base
2.Underreporting - value
3.Intervention solutions
4.Cost effectiveness
5.One Health Solutions
6.Case study Frameworks
WHO BENEFITS AND WHO PAYS?

54. ICONZ: transforming weaknesses into strengths
Geographically Cheaper to
clustered control
Benefits of
Currently greatly control higher
Under-reported than thought
Can offer
more options
Need to control for control
In people and
animals
Dual costs bring
dual benefits

55. ICONZ Case Studies
 Uganda, Mozambique, Nigeria, Mali, Morocco, Tanzania
Zambia
 Anthrax, Rabies, Leishmaniasis, Echinococossis, Zoonotic
trypanosomiasis, Brucellosis, Cysticercosis and Bovine TB.
 Teams comprising medics, vets, biomedical scientists
 In country partnerships with human animal health service
providers
 Partnerships with other groups (research and control)
International Agencies, NGOs, NFP, Civil society)
 Sound epidemiological, social and economic frameworks
 Models for case studies that can be extended and applied to
other systems
 Public Engagement in disease control

56. ICONZ in 2015
 Able to calculate cost-effectiveness of a number of control
strategies from the point of view of human health in $ / DALY
averted
 Developed a case study framework that can be rolled out to
other setting to establish community burdens of zoonoses
 Better knowledge of costs to animal health so that could look at
benefit-cost to livestock sector of control strategies
 Have explored practical ways of combining these measures to
look at the total societal cost and examine overall cost-
effectiveness
 Have recommendations on how veterinary and medical sectors
could most effectively share costs

57. Can we quantify the total societal cost?
ESTIMATING
INCIDENCE:
surveys, better
reporting estimates
of under-reporting
QUANTIFYING DISEASE IDENTIFYING GROUPS
BURDEN: AT RISK:
DALYS for people Individual factors for
economic impact for people & animals,
livestock geography, poverty
How high can the benefits of control be?
Acknowledgement, Alex Shaw

58. OUTPUTS
EVIDENCE
Papers into policy
*Partnerships build evidence
One
Policy to planning and
Practice informs evidence Health practitioners
gaps/ needs
Training into programmes
Practice to people

59. Positive Indications for OH
• National/ regional platforms established as a result of HPAI investments
may lead to long term intersectoral collaboration for other zoonotic diseases
e.g. sleeping sickness and rabies.
• After 5 years of cooperation on emerging diseases, One Health is evolving
towards the federation of vet and health services.
• Added value of Community Public Health is starting to be factored into
interventions.
• Accelerating science and knowledge base
• Emerging funding models (Global Fund, Gates Foundation)
• Political commitment
• Increasing engagement with Private sector – PP ownership of problem

60. ICONZ Concept
‘Endemic diseases’ of ‘poor countries’ are ‘forgotten’ diseases’
Collection of evidence needed for effective MGT
1. NZDs selectively affect poor families in poor and marginalised
communities
2. Because of under-reporting their apparently low incidence is an
illusion in many cases
3. Diseases cluster in certain communities and amongst identifiable
groups at risk
4. In these communities they impose a dual burden on human and
animal (mainly livestock) health
5. Relatively simple and often low-cost tools exist to control most
NZ (although there are deficiencies)
6. Much can be achieved with health education and control of the
animal reservoir

61. ICONZ – Interventions
 Mozambique – Cysticercosis
 Nigeria - Brucellosis and Bovine TB
– BACTERIAL Intervention vaccine Brucellosis
 Mali – Rabies and Leishmaniasis
 Morocco - Rabies, Leishmaniasis, Echinococossis
– DOG Intervention – dog vaccine trial for Echinococossis
 Tanzania - Brucellosis and Bovine TB.
– BACTERIAL Intervention vaccine Brucellosis
 Zambia - Cysticercosis and soil transmitted helminths
– PIG Intervention – Community Led Total Sanitation + OXF
 Uganda – Zoonotic Trypanosomiasis
– VECTOR Intervention – Restricted application