History of veterinary public health in the Eastern Mediterranean and Africa

Brucellosis, rabies, salmonellosis, anthrax and hydatidosis are among the main zoonotic diseases which constitute a threat to human health and welfare. Surveillance, prevention and control of such zoonoses and related food-borne diseases are problems of considerable magnitude. Despite their obvious importance, relatively few systematic control efforts have been made by national authorities. Major constraints include the scarcity of public health veterinarians and related sub-professional staff to plan and implement adequate surveillance and control of zoonoses, and the lack of appropriate legislation and adequate laboratory services. Veterinarians have been contributing to public health for many years, but despite considerable efforts by the World Health Organisation (WHO), the Food and Agriculture Organisation of the United Nations (FAO) and other organisations in establishing veterinary public health (VPH) programmes over several decades, the veterinarian as a career specialist in public health is a relatively new phenomenon. In the last decade, emphasis has been placed on: --supporting the training and development of human resources to promote VPH services and cover all its components --promoting and upgrading national epidemiological surveillance and control programmes for the major zoonotic and food-borne diseases --cooperating and assisting in local production of safe and effective vaccines, primarily for the control of rabies and brucellosis. The most encouraging aspects of the present situation is the growing awareness among governments of the need to develop programmes for the control of zoonoses and related food-borne diseases.     

Organisation of veterinary public health in Africa.

Veterinary public health (VPH) is not integrated into the mainstream of public health services in Africa. There are no formal mechanisms within government public health services through which veterinary skills and resources can be effectively harnessed to bear upon community health. There is no conscious, overt or substantial effort by public authorities to incorporate VPH services in the overall approach to public health. VPH activities cover mainly the control of the major animal diseases transmissible to man (zoonoses), meat inspection and, to a limited degree, the quality control of milk, fish and their products. These services are carried out by the Veterinary Services of the Ministry of Agriculture in each country. Concerning education, only 7 of the 28 schools of veterinary medicine in Africa have separate departments where VPH subjects such as epidemiology, food hygiene, zoonoses, biostatistics, community health, public administration, preventive medicine and other related fields are taught by public health-trained and oriented staff. Elsewhere the teaching of VPH subjects is delegated to staff whose foremost interests are in pathology, microbiology and clinical medicine. Postgraduate training in VPH is fast developing in the veterinary schools of Nigeria, Kenya and Uganda. Political instability, war, famine and poverty which deplete human and material resources, lack of intersectorial cooperation in matters of public health and lack of vigour on the part of the veterinary profession as a whole to assert its broader role in the community also contribute to the poor organisation of VPH in Africa. International collaboration in VPH is spearheaded by the Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO). These agencies, along with the Office International des Epizooties (OIE) and other international organisations or groups, are active in promoting the development of VPH programmes by setting guidelines on the organisation and management of VPH, coordinating control programmes for the major zoonoses and providing financial and technical expertise.     

Private sector, human resources and health franchising in Africa

In much of the developing world, private health care providers and pharmacies are the most important sources of medicine and medical care and yet these providers are frequently not considered in planning for public health. This paper presents the available evidence, by socioeconomic status, on which strata of society benefit from publicly provided care and which strata use private health care. Using data from The World Bank's Health Nutrition and Population Poverty Thematic Reports on 22 countries in Africa, an assessment was made of the use of public and private health services, by asset quintile groups, for treatment of diarrhoea and acute respiratory infections, proxies for publicly subsidized services. The evidence and theory on using franchise networks to supplement government programmes in the delivery of public health services was assessed. Examples from health franchises in Africa and Asia are provided to illustrate the potential for franchise systems to leverage private providers and so increase delivery-point availability for public-benefit services. We argue that based on the established demand for private medical services in Africa, these providers should be included in future planning on human resources for public health. Having explored the range of systems that have been tested for working with private providers, from contracting to vouchers to behavioural change and provider education, we conclude that franchising has the greatest potential for integration into large-scale programmes in Africa to address critical illnesses of public health importance.     

Control of zoonoses in Cyprus

The excellent results achieved in the control of animal diseases in Cyprus have allowed the Veterinary Services to take a leading role in the elimination, surveillance and investigation of important zoonoses. The programmes for the control of echinococcosis, brucellosis, bovine tuberculosis, anthrax and taeniasis, and the measures taken to prevent the importation of rabies are described. Public awareness of the risks posed by the presence of zoonoses and the efficient and effective intersectoral co-operation achieved between the veterinary, medical, public health and other Government services and non-governmental organisations are considered to be the key to the successful control of zoonoses in Cyprus.     

南非公立医院改革的主要做法与特点

相对于私立医院占有五分之三的卫生支出为20%的人群提供服务,南非公立医院约使用五分之二的卫生支出,为南非80%的人群提供医疗卫生服务,但面临着资源不足和人力短缺的问题。为此,南非政府着重建立公平导向的卫生管理体制,加大政府财政投入,重点保障基层公立医院发展,探索公私合作,在优先保障弱势人群基本医疗服务的同时,动员可利用的所有医疗资源,着力保障居民公平地获得基本医疗卫生服务。改革的主要特点是建立以基本医疗卫生保健为基础的医疗管理体制,以更公平的方式分配医疗资源,建立公私合作机制,动员民营机构力量,优先保障居民对基本医疗卫生服务的可及性和公平性。这些经验对于同属于发展中国家的中国有良好启示。     

Organization of the public health services in Latin America and the Caribbean]

The organisation of veterinary public health (VPH) services in countries of Latin America and the Caribbean has resulted from an historical process which has consolidated the structure of these services and the concept of VPH. This concept comprises five principal plans of action: promotion of animal health in order to increase the production of protein of animal origin; protection of foods for human consumption; vigilance, prevention, control and eradication of zoonoses; promotion of environmental protection, together with the development of biomedical models. These plans of action serve the purpose of improving human health and well-being, which is essential for the socioeconomic development of populations. Within this context, the authors describe the organisation of VPH services for health and agriculture, which have a part to play in intersectorial collaboration and in social participation. Finally, an account is given of progress in the control of rabies, brucellosis and tuberculosis, and the organisation of integrated programmes for food protection and also the control and eradication of foot and mouth disease. Technical cooperation with the Pan American Health Organisation (PAHO) assists these activities and intersectorial coordination, principally between health and agriculture.     

Economic impact of animal diseases on production systems in South America: case studies]

The authors discuss the relative importance of the livestock sector in South America, in developing countries and in countries world-wide. The development of animal health services is highlighted and the new challenges which these services must meet, with respect to the restructuring of international trade, are described. The economic impact of animal diseases and of disease control is evaluated by taking a regional approach and by analysing production systems. A classification of production systems is accompanied by case studies on the economics of animal health. Emphasis is placed on national control programmes, diseases which affect reproduction, parasitic diseases and mastitis, with particular reference to the livestock sector of Colombia. The authors suggest that integrated livestock development programmes include the management of animal health and production information. A change of attitude is also recommended with greater participation of those involved. The need to co-ordinate sustained research initiatives is stressed.     

Integrating reproductive health: myth and ideology.

Since 1994, integrating human immunodeficiency virus/sexually transmitted disease (HIV/STD) services with primary health care, as part of reproductive health, has been advocated to address two major public health problems: to control the spread of HIV; and to improve women's reproductive health. However, integration is unlikely to succeed because primary health care and the political context within which this approach is taking place are unsuited to the task. In this paper, a historical comparison is made between the health systems of Ghana, Kenya and Zambia and that of South Africa, to examine progress on integration of HIV/STD services since 1994. Our findings indicate that primary health care in Ghana, Kenya and Zambia has been used mainly by women and children and that integration has meant adding new activities to these services. For the vertical programmes which support these services, integration implies enhanced collaboration rather than merged responsibility. This compromise between comprehensive rhetoric and selective reality has resulted in little change to existing structures and processes; problems with integration have been exacerbated by the activities of external donors. By comparison, in South Africa integration has been achieved through political commitment to primary health care rather than expanding vertical programmes (top-down management systems). The rhetoric of integration has been widely used in reproductive health despite lack of evidence for its feasibility, as a result of the convergence of four agendas: improving family planning quality; the need to improve women's health; the rapid spread of HIV; and conceptual shifts in primary health care. International reproductive health actors, however, have taken little account of political, financial and managerial constraints to implementation in low-income countries.     

Private health insurance: implications for developing countries

Private health insurance is playing an increasing role in both high- and low-income countries, yet is poorly understood by researchers and policy-makers. This paper shows that the distinction between private and public health insurance is often exaggerated since well regulated private insurance markets share many features with public insurance systems. It notes that private health insurance preceded many modern social insurance systems in western Europe, allowing these countries to develop the mechanisms, institutions and capacities that subsequently made it possible to provide universal access to health care. We also review international experiences with private insurance, demonstrating that its role is not restricted to any particular region or level of national income. The seven countries that finance more than 20% of their health care via private health insurance are Brazil, Chile, Namibia, South Africa, the United States, Uruguay and Zimbabwe. In each case, private health insurance provides primary financial protection for workers and their families while public health-care funds are targeted to programmes covering poor and vulnerable populations. We make recommendations for policy in developing countries, arguing that private health insurance cannot be ignored. Instead, it can be harnessed to serve the public interest if governments implement effective regulations and focus public funds on programmes for those who are poor and vulnerable. It can also be used as a transitional form of health insurance to develop experience with insurance institutions while the public sector increases its own capacity to manage and finance health-care coverage.     

Organisation of veterinary public health in the south Asia region.

In the South Asia region vast human populations are exposed daily and with considerable intensity to close contact with vast animal populations and their excreta. There is no veterinary public health unit in the World Health Organisation (WHO) South-East Asia Regional Office (SEARO) in New Delhi (India), the Western Pacific Regional Office (WPRO) in Manila (Philippines) or the Eastern Mediterranean Regional Office (EMRO) in Alexandria (Egypt). However, these offices do support a number of activities on zoonoses and food-borne diseases in WHO member countries of the region. Maintenance of the health of farmers and of their families (often termed "rural health") has assumed increasing importance in most member countries of the region. In most of the countries, there is no actual veterinary public health unit functioning as a national body common to the ministries of health and agriculture. Among the commonest zoonotic diseases prevalent in member countries are rabies, brucellosis, Japanese encephalitis, echinococcosis, tuberculosis, visceral leishmaniasis, taeniasis, salmonellosis, campylobacteriosis and leptospirosis. A national plan is necessary for each country to give priority to controlling these diseases, based on health systems research or primary health care, with intersectoral and regional cooperation through the South Asian Association for Regional Cooperation (SAARC) under Technical Cooperation among Developing Countries (TCDC). There should be a strong unit for veterinary public health in all WHO regional offices to coordinate zoonotic disease surveillance, training and control programmes in countries of the region.     

Compendium of animal rabies prevention and control, 2011

Rabies has one of the highest case-fatality ratios of any infectious disease. This report provides recommendations for public health officials, veterinarians, animal control officials, and other parties engaged in rabies prevention and control activities and should serve as the basis for standardizing procedures among jurisdictions. The recommendations regarding domestic animal vaccination, management of animals exposed to rabies, and management of animals that bite humans are the core elements of animal rabies control and human rabies prevention. These updated 2011 guidelines include the national case definition for animal rabies and clarify the role of the CDC rabies laboratory in providing confirmatory testing of suspect animals. The table of rabies vaccines licensed and marketed in the United States has been updated, and additional references have been included to provide scientific support for information in this report.     

Defining and assessing evidence for the effectiveness of technical assistance in furthering global health

Abstract In an era when health resources are increasingly constrained, international organisations are transitioning from directly managing health services to providing technical assistance (TA) to in-country owners of public health programmes. We define TA as: 'A dynamic, capacity-building process for designing or improving the quality, effectiveness, and efficiency of specific programmes, research, services, products, or systems'. TA can build sustainable capacities, strengthen health systems and support country ownership. However, our assessment of published evaluations found limited evidence for its effectiveness. We summarise socio-behavioural theories relevant to TA, review published evaluations and describe skills required for TA providers. We explore challenges to providing TA including cost effectiveness, knowledge management and sustaining TA systems. Lastly, we outline recommendations for structuring global TA systems. Considering its important role in global health, more rigorous evaluations of TA efforts should be given high priority.     

Animal production and animal health and their relationship with veterinary public health in Latin America and the Caribbean

The authors analyse the relationships which exist, in terms of programmes, sectors and institutions, between animal health, animal production and veterinary public health on the one hand, and between each of these three sectors and public health in general on the other. The most important common factor is food safety. Undernutrition, which affects some 60 million inhabitants of Latin America and the Caribbean, is still the most important public health problem in this part of the world. While it is known that the major cause of undernutrition is the low gross domestic product and uneven distribution of wealth, increased animal production and productivity would provide the key to an improvement in the situation. The concept of animal health, in its broadest sense, implies optimum animal production in a given region and during a specified period of time. Veterinary public health has functions and objectives which are crucial for food safety: protection and hygiene of foods, and control of the use in animal production of substances toxic to human beings (such as heavy metals, hormones and insecticides). Within the area of transmissible diseases, the authors discuss control measures for zoonoses. Besides the specific subject of interdisciplinary relationships in regard to zoonoses, the authors stress the importance of joint work conducted in the research, development and implementation of laboratory diagnostic activities and the production and quality control of antigens and vaccines. The production of laboratory animals is another sphere of common activity and research, and it cannot be said that such work is specific to any one of the three disciplines. Moreover, the fields of health, animal health and veterinary public health share the same methods and strategies, and reciprocal benefits could be more significant than the objectives of individual programmes. Reference is made to the organisation of state services and their adaptation to administrative de-centralisation, particularly at the local level.     

Public health issues related to animal and human spongiform encephalopathies: memorandum from a WHO meeting.

The transmissible spongiform encephalopathies (TSE) include bovine spongiform encephalopathy (BSE), which was first described in 1986 in the United Kingdom but has occurred subsequently in several other countries. This Memorandum reviews the existing state of knowledge on all the known spongiform encephalopathies, and evaluates the pathways of transmission and associated hazards. The possible implications of the animal diseases, especially BSE, with regard to the use of animal tissues as animal feed, human food, and in the preparation of medicinal and other products for human use are discussed, with recommendations to national health authorities on appropriate measures to minimize the consequences of BSE to public and animal health.     

Anthrax and wildlife

Although livestock anthrax is declining in many parts of the world, with an increasing number of countries probably truly free of the disease, anthrax remains enzootic in many national parks and even in some game ranching areas. These infected areas can present a persistent risk to surrounding livestock, which may otherwise be free of the disease, as well as a public health risk. The authors use as examples the national parks in southern Africa, the Wood Buffalo National Park in northern Alberta, Canada, and the deer ranching counties in south-west Texas, United States of America, to present the range of problems, epidemiology, and control procedures. While many advances have been achieved in the understanding of this disease, research is required into the genotypic grouping of anthrax isolates, improved field diagnostic techniques, and oral vaccines, as well as to provide a better understanding of spore survival in soil and the ecology of the disease under natural conditions.     

Defining and assessing evidence for the effectiveness of technical assistance in furthering global health

Abstract

In an era when health resources are increasingly constrained, international organisations are transitioning from directly managing health services to providing technical assistance (TA) to in-country owners of public health programmes. We define TA as: ‘A dynamic, capacity-building process for designing or improving the quality, effectiveness, and efficiency of specific programmes, research, services, products, or systems’. TA can build sustainable capacities, strengthen health systems and support country ownership. However, our assessment of published evaluations found limited evidence for its effectiveness. We summarise socio-behavioural theories relevant to TA, review published evaluations and describe skills required for TA providers. We explore challenges to providing TA including cost effectiveness, knowledge management and sustaining TA systems. Lastly, we outline recommendations for structuring global TA systems. Considering its important role in global health, more rigorous evaluations of TA efforts should be given high priority.     

Bioterrorism alleging use of anthrax and interim guidelines for management--United States, 1998

From October 30 through December 23, 1998, CDC received reports of a series of bioterroristic threats of anthrax exposure. Letters alleged to contain anthrax were sent to health clinics on October 30, 1998, in Indiana, Kentucky, and Tennessee. During December 17-23 in California, a letter alleged to contain anthrax was sent to a private business, and three telephone threats of anthrax contamination of ventilation systems were made to private and public buildings. All threats were hoaxes and are under investigation by the Federal Bureau of Investigation (FBI) and local law enforcement officials. The public health implications of these threats were investigated to assist in developing national public health guidelines for responding to bioterrorism. This report summarizes the findings of these investigations and provides interim guidance for public health authorities on bioterrorism related to anthrax.     

The prevention and management of congenital syphilis: an overview and recommendations

The continued occurrence of congenital syphilis is an indictment of the inadequate antenatal care services and poor quality of programmes to control sexually transmitted infections. More than 1 million infants are born with congenital syphilis each year. Despite national policies on antenatal testing and the widespread use of antenatal services, syphilis screening is still implemented only sporadically in many countries, leaving the disease undetected and untreated among many pregnant women. The weak organization of services and the costs of screening are the principal obstacles facing programmes. Decentralization of antenatal syphilis screening programmes, on-site testing and immediate treatment can reduce the number of cases of congenital syphilis. Antenatal syphilis screening and treatment programmes are as cost effective as many existing public health programmes, e.g. measles immunization. Diagnosis of congenital syphilis is problematic since more than half of all infants are asymptomatic, and signs in symptomatic infants may be subtle and nonspecific. Newer diagnostic tests such as enzyme immunoassays, polymerase chain reaction and immunoblotting have made diagnosis more sensitive and specific but are largely unavailable in the settings where they are most needed. Guidelines developed for better-resourced settings are conservative and err on the side of overtreatment. They are difficult to implement in, or inappropriate for, poorly-resourced settings because of the lack of investigative ability and the pressure on health facilities to discharge infants early. This paper offers recommendations for treating infants, including an approach based solely on maternal serological status and clinical signs of syphilis in the infant.     

The impact of climate change on the epidemiology and control of Rift Valley fever

Climate change is likely to change the frequency of extreme weather events, such as tropical cyclones, floods, droughts and hurricanes, and may destabilise and weaken the ecosystem services upon which human society depends. Climate change is also expected to affect animal, human and plant health via indirect pathways: it is likely that the geography of infectious diseases and pests will be altered, including the distribution of vector-borne diseases, such as Rift Valley fever, yellow fever, malaria and dengue, which are highly sensitive to climatic conditions. Extreme weather events might then create the necessary conditions for Rift Valley fever to expand its geographical range northwards and cross the Mediterranean and Arabian seas, with an unexpected impact on the animal and human health of newly affected countries. Strengthening global, regional and national early warning systems is crucial, as are co-ordinated research programmes and subsequent prevention and intervention measures.