A Retrospective Disease Surveillance Based Approach in the Investigation and Linkage of Human Brucellosis to Animal Sources: One Health Approach Complementary Strategy Applicable in Nomadic Pastoralism, a Case Study of Turkana County, Kenya.

1. A Retrospective Disease Surveillance Based Approach in the
Investigation and Linkage of Human Brucellosis to Animal Sources: One
Health Approach Complementary Strategy Applicable in Nomadic
Pastoralism, a Case Study of Turkana County, Kenya.
The One Health Umbrella, Developed by the One Health Sweden and One Health Initiative Autonomous Pro-Bono Team
Written by:
Stephen Olubulyera
Senior Public Health Specialist|Epidemiologist|Health Systems Strengthening
Specialist|Researcher|IT Enthusiast
Ministry of Health
Turkana County

2. A Retrospective Disease Surveillance Based Approach in the
Investigation and Linkage of Human Brucellosis to the Animal Sources:
One Health Approach Complementary Strategy Applicable in Nomadic
Pastoralism, a Case Study of Turkana County, Kenya.
Stephen Olubulyera1
Abstract
The research provides an insight on a retrospective disease surveillance based approach that
will be fundamental in the investigation and linkage of human brucellosis (zoonotic disease)
to animal sources, domestic and wild animals. The retrospective disease surveillance based
approach complements One Health Approach. One Health Approach is a collaborative and
transdisciplinary initiative working locally, nationally and globally to improve the health of
humans, animals and the environment (Aguirre et al., 2016). Despite One Health Approach
having a working framework, teething challenges are preventing the initiative from working
effectively. A revamp of the approach with the provision of clear procedural designs,
engagement of respective stakeholders with clearly stated roles, the establishment of a one-
health network system with well-defined funding mechanisms and incorporation of the
approach in the existing health infrastructure and systems are fundamentally required
(Vesterinen et al., 2019). The retrospective disease surveillance based approach utilises the
available health and animal husbandry system structures. The approach leverages on the
outpatient diagnosis and laboratory testing services availed at the health facility setups and
disease surveillance initiative programs such as Community Event-Based Surveillance
(CeBS) being implemented at the community level.
Brucellosis is the most rampant zoonotic disease affecting the nomadic population in Kenya.
The disease transmission made possible because of poor devastating levels of environmental
sanitation and personal hygiene brought about by scarce or lack of adequate water as well
as behavioural characteristics or habits that arise from the nomadic pastoralism settings.
Being that consumption of unpasteurized milk, meat and contact with the animal is a cultural
practice in most pastoral communities across Kenya. Identification of a suspected brucellosis
case is established through diagnosis from a clinician or veterinarian for animals, a
confirmation of a brucellosis case is done by conducting diagnostic laboratory serological
and microbiological brucellosis tests, blood samples are cultured in a modified biphasic
medium(Morales-Garcia et al., 2015).
The research paper gives insight on how the surveillance team working under the One Health
Approach can retrospectively conduct disease surveillance by utilising the already
established human health and animal husbandry infrastructure to investigate and link a
confirmed brucellosis human case to a specific herd of animal source in a specified
geographical location(with exact geo-coordinates). This will facilitate vaccination and
treatment of the diseased herd thus preventing and mitigating the spread of the infection to
humans and other herd whilst controlling the migration of the infectious disease through
human, animal or the environment. Identification, treatment and vaccination of human and

3. animals who encountered the herds and sanitising of the environment are some of the
expected results.
Introduction
An effective coordination and efficient management of efforts across all sectors are
fundamental in addressing critical global health issues such as infectious diseases outbreaks
and antimicrobial resistance. One Health Approach is an integral effort of attaining optimal
health for people, animal and the environment. Addressing complex health challenges
require a well-designed, multistage and multi-sectoral support system. An increased risk of
emerging, re-emerging diseases and health threats are driven by dynamic changes in the
environment that destabilize the interfaces of human and animal health. Defined as the
cohesive effort of multi-sectors working for the attainment of optimal health for the people,
animal and the environment, One Health approach apply different collaborative models
within and across countries to promote effectiveness and efficiency in managing health
threats. Community-Based Surveillance and Community Event-Based Surveillance are
disease and event surveillance models that complement the One Health Approach initiative.
Multiple operational challenges have been a hindrance of universal defining, such as
recognizing complex global health challenges for collaboration and action. Countries are
always attending to competing challenges thus integrations and support of One Health
Approach across the board becomes difficult. Various health, veterinary and environment
professionals are involved in the implementation of the One Health Approach at the
management and community level. Being that three different fields of study and area of
operations are clamped into one, equitable funding is required for multi-sectoral
engagement to prevent imbalanced participation among human, animal, environmental and
ecosystem professionals (Vesterinen et al., 2019).
Brucellosis is a global zoonotic disease, one of the most widespread diseases in the
world. Brucella arbutus, Brucella melitensis, and Brucella suis are Brucella species that cause
the disease in humans and domestic animals. The mode of disease infection to humans is
through consumption of raw milk, fermented milk produced from unpasteurized milk and
by contact of infected animals or animal by-products such as meat and skins (Morales-Garcia
et al., 2015). In the inception of WHO in 1948, brucellosis was a disease of public health
importance, this is due to the physical suffering, reduced work output for those infected, as
well as decrease livestock productivity(Mableson, Okello, Picozzi, & Welburn, 2014).
Vaccination of livestock against brucellosis is beneficial to public health and three times
more profitable from a health and community perspective (Zinsstag et al., 2018).
A retrospective approach involves tracing back disease transmission pathway using models,
suitability of the intermediate host and factors contributing to the progression of the disease
in human and animals whilst considering all other possible environmental and climatic
factors supporting or promoting the thriving of the infection or disease. The retrospective
approach simply means tracing back the steps from the confirmed disease or event

4. (progression), the number of possible infections from laboratory investigations and the
potential number of intermediary host that are significant in calculating the case fatality rate
and developing the spread of infection models respectively.
Materials and Methodology
Being that the retrospective approach in the investigation and linkage of human brucellosis
to animal sources is a new strategy and it has yet to be fully explored, methodology and
insights on its implementation will be outlined and highlighted in this section.
For the implementation of this approach efficiently and effectively; there will be collation
and collection of secondary data from diagnosed and confirmed cases that attend the
hospitals and laboratories for testing respectively. For efficiency of the process, a team of
health professional is involved in various department or sections, at hospital and community
setups.
Health Facility Setup.
Outpatient and Inpatient Department: Diagnosis of Brucellosis Disease
Medical Practitioners: Clinical Officer or Nurse is involved in the diagnosis of brucellosis
disease as per the description. He or she captures the information of the patient, place of
residence including major landmarks and name of kraal/community setup and village.
Laboratory Department: Confirmatory Tests: Serological and Microbiological Brucella tests
Brucellosis disease is confirmed through serological and microbiological Brucella test, a
laboratory confirmatory test, done by a Medical Laboratory Technologist.
Results from the laboratory are sent to the outpatient or inpatient department to facilitate
drug prescription to the patient.
Sources of Data in this section is the Diagnosis Register and Confirmatory, Laboratory
Register.
Information of patients of the laboratory-confirmed brucellosis cases is collected by the
Clinical Officer and it’s cascaded to the Community Health Assistant (Community Level):
Confidentiality of the adhered to during this process.
Community Level
At the community level, community health strategy and surveillance systems that exist such
as Community Health Volunteers and Community Event-Based Surveillance respectively will
be tasked with tracing the specific village the brucellosis cases resonated from. The
Community Health Assistant shares the information and task the Community Mobilisers,
Community Health Volunteers, and Community Animal Disease Reporters to:
1) Backtrack on the specific village the brucellosis case originated from,
2) Identify and locate the herd of animals that produce milk or meat for consumption.
Geolocation of the village, the herd of animals, various water points and animal interaction
points are captured via KoboCollect or Open Data Kit Applications.

5. Feedback of this information is relayed back to the Community Health Assistant who passes
it to the Clinical Officer or Nurse whose health facility covers the village or population.
This information is communicated to the One Health task force that constitutes of the
Epidemiologists, Veterinary and Environmentalist at SubCounty Level.
The task force undertakes a collaborated, coordinated and multisector response to tackle the
situation: conduct a risk assessment and setting up of mitigation measures
1. Assess the health status of the available animals in the area: this is through taking animal
blood samples for laboratory analysis for Brucella, and conduct vaccination against the
disease in the village and nearby villages: Task undertaken by Veterinary and Animal
Health Assistance.
2. Epidemiologist: Risk assessment of human transmission and conduct health promotion
and sensitization on control mitigation and prevention strategies. Community Health
Volunteers could also identify more human cases presenting with similar signs and
symptoms.
3. Environmentalist: Assessment of the possibilities of environmental factors that support
transmission and inefficiency in control protocols and prevention measures despite
deploying the mitigation measures.
Health Facility Setup-Outpatient and Inpatient Department: Diagnosis of Diseases-Laboratory Department:
Confirmatory Tests: Serological and Microbiological Brucella tests-Community Level-Community Event Based
Surveillance Program-Community Mobilisers-Community Disease Reporters-Community Health Volunteers-
Community Health Assistant -Animal Health Assistant- -SubCounty-Epidemiologist(SubCounty Disease
Surveillance Coordinator)-SubCounty Veterinary Officer

6. Flow Diagram: A Retrospective Disease Surveillance Based Approach in the Investigation and Linkage of Human Brucellosis
to Animal Sources
Health Facility Level
Names of the confirmed
Brucellosis cases with specific
residential information
including physical landmarks
(from Health Facility)
The CHA tasks CHVs to
identify the specific
area and other
brucellosis suspected
cases. CM and CDR are
tasked with tracing and
locating the probable
infected livestock in the
jurisdiction, areas of
interaction and
whether there has been
visible signs and
symptoms of brucellosis
disease on the herd of
animals. Data is
collected via Open Data
Kit: Geolocation and
Information on the herd
of animals
Ministry
of Health
Community
Level
One Health Initiative
a) Risk Assessment
b) Treatment of human
cases
c) Taking animal blood
samples for Laboratory
testing.
d) Vaccination of animals
against Brucellosis
e) Health Promotion at
community level
(1)
(2)
(3)
(3)
(4)
(5)
CM-Community Mobiliser
CDR- Disease Reporter-Animal

7. Expected Results
A coordinated network of specialists implementing retrospective disease surveillance
approach in the investigation and linkage of zoonotic diseases at the community level. The
approach does not necessarily apply to brucellosis only but to other similar zoonotic
diseases such as anthrax, hydatidosis and rabies. This approach will geologically and
specifically identified a Brucella diseased herd of animals thus facilitate prioritization when
it comes to resource mobilization for vaccination and establishing environmental mitigation
measures to support control of transmission of the infection to human or animal.
Besides, implementation of the strategy will ensure enhancement of sensitization of
community and health promotion on prevention and treatment of brucellosis disease in
areas where it is prone.
The implementation of retrospective disease surveillance based approach in the
investigation and linkage of human brucellosis to the animal source will complement the One
Health Approach. This will establish and provide a One Health complementary network,
which can be used in the retrospective investigation and linkage of any zoonotic disease to
establish source, and together with the available human resource on the network, holistically
design and implement prevention, control and treatment of the cases respectively.
Public Health Implications of the Strategy
Treatment of brucellosis disease in domestic animals by use of antibiotics has been
determined to be unsuccessful; this is due to the intracellular survival and adaptability in the
macrophages of Brucella (Khurana et al., 2021). Brucellosis is a disease of public health
importance since it has an economic impact both on human and animal health. Infertility in
both sexes and late-term abortions are some of the economic losses experience and brought
about by brucellosis disease in animals. According to World Health Organization, brucellosis
is one of the neglected zoonotic disease occurring in highly poverty-stricken developing
countries. Vaccination of the herd with the specified host species is the most efficient
strategy for the elimination and eradication of brucellosis disease. (Dadar, Tiwari, Sharun, &
Dhama, 2021).
The retrospective disease surveillance based approach complements one health approach.
One Health is an integral approach to control the transmission of zoonotic diseases in
endemic areas. Implementation of the strategy will establish a mechanism of tracing
zoonotic disease to the specific source; livestock or herd of animals thus ensure easy
quarantine, control and prevention of further transmission of the disease.
Hospital Setup: Brucellosis cases diagnosed and confirmed at hospital setups will trigger a
passive response at the community level, which will be fundamental in the control of further
transmission of the zoonotic disease. Data collected at the health facility level is used to
retrospectively trace the spread, transmission, and occurrence of the disease. The Clinical
Officer, Nurse and Medical Laboratory Technologist are integral at this level.

8. Community Level: The information collected of the brucellosis cases will be used to
geographically analyses the occurrence of the disease at the community level; trace the herd
of the suspected diseased animals while considering interaction with other herds of animals
and humans as well as environmental factors influencing transmission. Use of applications
such as KoboCollect and Open Data Kit to capture geo-codes (longitudes’ and latitudes) of the
geographical location of the suspected diseased animals, water points, possible points of
interactions will be shared to facilitate the development of patterns and trends at the county
level. Communication of community-based events of animals experiencing sign and
symptoms of brucellosis disease infection will be made to the nearest health facility as well
as the County level.
County or SubCounty Level: After receiving a report from the Community through
Community Health Assistant, which is verified by the facility in charge of the nearest health
facility. The Epidemiologist (SCDSC), the SubCounty Veterinary officer and the
Environmentalist implement a coordinated and multidisciplinary response in the affected
area to conduct a risk assessment of the degree and the possibility of further transmission of
the disease respectively. Blood samples for animals will be collected for laboratory
confirmatory tests and gene-expert to determine the type of Brucella the herd of animals has
been infected with, which will be fundamental in the prescription of treatment, whenever
possible. The suitable effective and efficient mitigation measures for the control and
prevention of the transmission of human-animal and ecosystem zoonotic disease is
collectively reached by the multidisciplinary team and implemented concurrently.
Data collected using the questionnaire on KoboCollect or ODK is analysed and utilized in the
coordination of geographical environmental mitigation measures. The information will also
be used to prioritise vaccination in areas with the herd of animals that are gravely affected
by the zoonotic disease and pin-point areas of possible human-animal interaction where
there is a high transmission of the disease hence provide a corrective measure. The
information will geo-link animal cases with human cases, which will assist in prioritizing
areas for conducting mass treatment of humans and sensitize the community through
behaviour change communication, including health promotion.
Limitations
The aim of the retrospective disease surveillance based approach is to
compliment One Health, therefore most of the limitations fall under the system it is meant to
strengthen:
1. Funding: funding for One Health initiatives have been a challenge. One Health Approach
incorporates several specialists, departments and ministries.
2. Laboratory Services: The serological and microbiological diagnostic test for Brucella is
only available in well-equipped laboratories, this means there will be challenges in the

9. coordination and sample transportation to other areas with the available service: might
not be available at County Government Level.
3. One Health Approach is still ineffective and inefficient: The existing systems working
independently, not cohesively. The approach is not fully operational, it is still a challenge:
coordinating a multidisciplinary team working in three ministries that have different
priorities.
4. Human Resource: There is a lack of adequate human resource depending on the
respective ministries. Human resource in the respective departments in the ministries
and/or available stakeholders is also inadequate
5. Coordination and Cooperation: Integration of initiatives or mitigation activities not
well coordinated or synchronized. This has been earlier highlighted, this is because of
different governance of respective departments or ministries with competing activities
are different areas prioritized for funding.
6. More Research is needed: Further research, review and revamp on One Health
Approach is required
Recommendations for the Limitations
1. The complete devolvement of health services at County Levels: there is a need of
establishing relevant skillset through training and frequent capacity building of
specialist and machine operators; the relevant equipment and health machinery to be
made available by the National Government.
2. Human resource be made adequate; retraining of the staff could be significant in the
successful implementation of the service
3. Funds need to be available to ensure implementation of One Health is effective and
efficient
4. The Counties should select a One Health Approach Committee that will be also
cascaded to SubCounty Level: the committee should be tasked with coordinating One
Health initiatives and implementation plans which may be proposed by the
SubCounty level
5. Counties should upscale the Laboratory Services, activation and equipping of various
laboratories in SubCounty Hospitals should be prioritised.
Acknowledgements
I acknowledge my work colleagues: Dr Kevin Lomuria, Mr Gabriel Ekwom, Mr Robert Rotich,
Mr Joshua Rutto, and Mr John Njuguna for their contributions on the research concepts that
led to the successful completion and publishing of the research paper.

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11. INDEX
A flow diagram reviewing Bovine Brucellosis (Khurana et al., 2021)