Creating a framework towards integrated health syndromic surveillance and response in Africa INAUGURALDISSERTATION zur Erlangung der Würde eines Doktors der Philosophie vorgelegt der Philosophisch-Naturwissenschaftlichen Fakultät der Universität Basel von Mahamat Fayiz Abakar Aus Tschad Basel, 2017 Originaldokument gespeichert auf dem Dokumentenserver der Universität Basel edoc.unibas.ch Genehmigt von der Philosophisch-Naturwissenschaftlichen Fakultät auf Antrag von Prof. Dr. Jakob Zinsstag und Prof. Dr. Sue Welburn Basel, den 18 April 2017 Prof. Dr. Martin Spiess Dekan der Philosophisch-Naturwissenschaftlichen Fakultät À la mémoire de mon cousin Abdoulaye Abdourahman, qui a quitté précipitamment This work is dedicated to my late cousin Abdoulaye Abdourahman, who left before time! إ روح إن د دارن اذي رل ل اوان Table of contents TABLE OF CONTENTS Table of contents ...................................................................................................................................... i Index of tables ........................................................................................................................................ iii Index of figures ...................................................................................................................................... iv Table of acronyms .................................................................................................................................... v I. Acknowledgement .............................................................................................................................. vi II. Summary .......................................................................................................................................... viii III. Résumé ............................................................................................................................................... x xii ................................................................................................................................................. ص IV Chapter 1: General introduction ............................................................................................................... 1 1. Country presentation: Chad............................................................................................................ 2 1.1. Geographical situation, climate, hydrography and vegetation .......................................... 2 1.2. Health and demographic situation ..................................................................................... 3 1.3. Livestock and animal health .............................................................................................. 4 2. Response and interventions effectiveness ...................................................................................... 5 2.1. Poor response effectiveness .............................................................................................. 5 2.2. Lack of methods to assess effectiveness ........................................................................... 6 3. Health surveillance: the weakest link in the chain ......................................................................... 8 4. One health methods and potential of zoonosis elimination ............................................................ 9 5. Gap of knowledge ........................................................................................................................ 12 6. Aim and objectives ....................................................................................................................... 14 6.1. Aim .................................................................................................................................. 14 6.2. Objectives ........................................................................................................................ 14 7. Collaboration and support ............................................................................................................ 14 Chapter 2: Towards equity effectiveness of maternal health service coverage: rural sedentary and mobile population in Chad ........................................................................................................... 15 Chapter 3: Vaccine hesitancy among mobile pastoralists in Chad: a qualitative study ......................... 34 Chapter 4: Evaluation of the feasibility and sustainability of joint human and animal vaccination and its integration to the public health system in Chad................................................................ 49 i Chapter 5: Trends in health surveillance and joint service delivery for pastoralists in West and Central Africa ............................................................................................................................... 67 Chapter 6: Working paper on integrated syndromic surveillance and response among rural sedentary and mobile agro-pastoralists in Chad ........................................................................... 77 Chapter 7: Transmission dynamics and elimination potential of zoonotic tuberculosis in Morocco ..... 89 Chapter 8: Cost effective control strategies for animal and zoonotic diseases in pastoralist populations ................................................................................................................................. 108 Chapter 9: Human and animal health surveys among nomads ............................................................. 117 Chapter 10: A vision for the future of pastoralism ............................................................................... 129 Chapter 11: General discussion and conclusions ................................................................................. 137 1. Health interventions effectiveness ............................................................................................. 138 2. Vaccine hesitancy among mobile pastoralists in Chad: a health system’s issue ........................ 139 3. Towards mainstreaming of joint human and animal vaccination programme: challenges and perspectives ................................................................................................................................ 140 4. Outlook on syndromic surveillance and response in Africa ...................................................... 141 5. Potential of zoonosis elimination: case of bovine tuberculosis .................................................. 144 6. Concluding remarks, recommendations towards an integrated surveillance and response system and the way forward ....................................................................................................... 145 6.1. Interventions effectiveness: lack of methods and iterative cycles of action ................. 145 6.2. Vaccines hesitancy among mobile pastoralists: a result of inadequate health services 145 6.3. Joint human and animal vaccination programmes: a “One Health” success, yet challenges remain .......................................................................................................... 145 6.4. Bovine tuberculosis: a potential candidate for elimination in developing countries? ... 146 6.5. Integrated health syndromic surveillance-response and beyond: the promising kick- off .................................................................................................................................. 146 Annexes ................................................................................................................................................ 148 i. Ethical clearances: ...................................................................................................................... 149 ii. Supporting information 1 ........................................................................................................... 153 iii. Supporting information 2 ........................................................................................................... 154 iv. Field pictures .............................................................................................................................. 155 References ............................................................................................................................................ 157 ii Index INDEX OF TABLES Table 2.1. Reasons for not attending ANC (answer possibilities in the q estionnaire) ..... 22 Table 2.2. Assessment of the effectiveness parameters .................................................. 23 Table 2.3. Utilisation of maternal health services ............................................................. 25 Table 2.4. Association between the tilisation of maternal health services, and socio- demographic and geographical variables ........................................................................ 25 Table 2.5. Sensitivity of overall effectiveness with respect to a 5- increase in single factors for sedentary pop lations and mobile pastoralists ................................................ 2. Table 3.1. S mmary of data collection ............................................................................. 39 Table 3.2. Categories of concerns abo t vaccination adapted from the literat re (0ills, 21152 Cobos, 2115) ......................................................................................................... 41 Table 3.3. 3ive most freq ently reported demand side barriers to vaccination in 4anamad5i district .............................................................................................................................