Post Outbreak Evaluation Of One Health Integrated Interventions Of Rift Valley Fever And Crimean Congo Haemorrhagic Fever In Kiboga And Kiruhura Districts, Uganda


 Objective: Following containment of Rift Valley Fever (RVF) and Crimean Congo Hemorrhagic Fever (CCHF) outbreaks, a post evaluation of the use of a one health approach in management of the reported viral haemorrhagic fevers was conducted in the affected districts of Kiboga and Kiruhura districts in Uganda. This was done through a cross sectional study using participatory epidemiology tools, mainly observation and key informant interviews. Results: The findings indicated that the interventions employed had been successful in the management of the outbreaks and multidisciplinary approach enabled containment of these hemorrhagic fever outbreaks in the districts. Although the outbreaks had been contained, delays could have been minimized by undertaking laboratory diagnosis at district level instead of transporting samples to national referral laboratories in Entebbe. Response to the RVF and CCHF challenge could have been delayed by dependence on funding of central government and non governmental organizations due to failure to plan and allocate funds for surveillance and mitigation of diseases outbreaks at district local government levels.


Introduction
Evidence has demonstrated that using a One health approach that consists of multidisciplinary teams of health, community workers, environmental and veterinary specialists can improve preventive public health interventions for these zoonotic conditions [1]. This includes establishing environmental monitoring and case surveillance systems to aid in the prediction and control of future outbreaks, surveillance through close monitoring for infections in animal and human populations, education that raises awareness about transmission dynamics as well as practices to mitigate the risk [1]- [3]. It was in the interest of this study to undertake an evaluation of the extent to which the multidisciplinary one health approach was envisaged in the management of the RVF and CCHF outbreaks so as to identify the successes to be built on and areas for improvement.

Study design
A Cross sectional study was conducted using participatory epidemiology tools from 20 th  [4], [5].

Study Population
For key informants, the study included persons whose profession or position of power enabled them to get involved in the RVF or CCHF outbreak management for the period of  (Table 1).

Results
Data collected was analyzed and summarized into three key themes with corresponding subthemes according to the objectives of this study as described by Braun and Clarke [6].
Details of the findings are shown in table 2. were intensified through community mobilization and radio talk shows -Communication channels established to ease information flow -Writing surveillance reports each month instituted -Attempts to mobilize funds for the outbreak undertaken -Isolation unit made available for any other suspects at specified health facilities -Families have been asked to use bed nets and keep away empty tins to control vectors Health workers -Health workers in Kiboga treated the young man with a crimean congo hemorrhagic fever successfully -Kiruhura health workers successfully treated the RVF victim and he has since recovered -Health workers meet monthly to be sensitized and share information Veterinary workers -Restriction of livestock movements -Testing all animals before slaughtering -Provided personal protective equipments to health workers L. Mburo National park workers -Game rangers were sensitized on handling and disposal of dead wild animals -Samples were collected from wildlife and submitted to UVRI. -Capacity of laboratory technicians being equipped on diagnosis of RVF and CCHF Human hosts -Herds men are more at risk -Eating dead animals e.g in Kiruhura the young man who had RVF had previously eaten a dead calf -Working in an abattoir may expose workers to infected animals -Migrations and Refugees may facilitate transmission of hemorrhagic fevers from one area to another Environment(vectors) -Swamps and stagnant water act as homes to mosquitoes which transmit RVF -Heavy rains created more breeding grounds for mosquitoes -Bushes harbor ticks Livestock-wildlife interactions -Grazing of wild and domestic animals was found to be dangerous as 10% of zebras were found to have positive antibodies for RVF in Kiruhura District.
-Kiruhura has a challenge of farmers rotating around neighboring Districts for pasture which increases the risk of transmission Strengths -The outbreaks increased vigi stakeholders -Technical workers (h veterinarians) can now detect signs and symptoms of hemor as a result of the training and -The efforts of one health app felt on ground -Tensions due to outbreaks reduced among communities Areas for improvement -Death of the RVF case in burial was mismanaged. It wa family who reportedly opened if the deceased was their own -The CCHF patient in Kiboga himself -Decision makers at districts h the need for an emergency fu out breaks -In Kiboga stakeholders plan profile of refugees because influx whose origin and unknown.
-Provide incentives to keep response teams active -Strengthen disease reporting community level -Enforcement of quarantines in affected communities still due to many exit routes in com -Ticks and ticks resistance ha big problem in Kiruhura Distric -Communities need to be en seek for health care as opp medication -Laboratory capacity to diag and animal samples could be training the technicians an rapid field tests -Farms in affected areas need to avoid direct grazing with wi -Farmers need to follow spra using effective acaricides -Vaccination of livestock a should be supported by MAAIF

Discussion
This post-outbreak evaluation study provides evidence that considerable efforts were made in Kiboga and Kiruhura districts to use a one health approach in combating the outbreaks of RVF and CCHF. This was demonstrated by the active involvement of top administrators and heads of departments in the planning, surveillance and actual implementation of control strategies. The various stakeholders interviewed strongly agreed that it was this collective effort that enabled containment of these hemorrhagic fever outbreaks in their districts. Such achievements are practical indicators that strategic objectives set by the Uganda One Health Platform, of building resilient, sustainable systems to prevent and respond to zoonotic diseases are attainable [7]. The use of a one health approach through multi-sectoral collaboration has been recognized as an effective way of controlling and managing the globally increasing public health risks. The effectiveness of such a multidisciplinary approach can only be possible with wellstructured and resilient health systems that prioritize prevention of disease outbreaks before they occur [1], [3].
The drivers for the outbreaks were reported to be; Human associated practices such as uncontrolled migration, eating animals that died of unknown causes; Environment factors such as increased vector populations due to erratic climatic changes; Livestock-wildlife interactions encouraged by limited pasture and water resources especially during drought.
These findings suggest that RVF and CCHF outbreaks occur following synergistic interaction of human, animal and ecosystem associated factors, hence efforts by a single sector to combat these outbreaks may not pay off [3].
Although the outbreaks could have been contained, delays could have been minimized by undertaking laboratory diagnosis at district level instead of transporting samples to UVRI and NADDEC in Entebbe. Response to the RVF and CCHF challenge could have been delayed by dependence on funding of central government and non-governmental organizations due to failure to plan and allocate funds for surveillance and mitigation of diseases outbreaks at district local government levels [5], [8].
Management of RVF and CCHF outbreaks in the two districts provided an opportunity for the involved stakeholders to appreciate benefits of mitigating health challenges using a multidisciplinary approach. However, multi-sectoral one health taskforces in these districts are in the primary stages and need strengthening for better performance as it has been proposed in Uganda One Platform strategic plan [7].

Conclusions
This study indicates that top administrators and heads of departments in the planning, surveillance and actual implementation of strategies for control the outbreaks of RVF and CCHF in Kiboga and Kiruhura districts. Interaction of human-animal and environment associated factors were perceived to be the drivers of the RVF and CCHF outbreaks.
Although the outbreaks were controlled, transporting samples to UVRI and NADDEC in Entebbe could have delayed diagnosis and interventions. The interventions entirely depended on funding of central government through MOH and non-governmental organizations in both districts because no funds had been planned and allocated for surveillance and mitigation of diseases outbreaks at district local government levels.

1.
Improvement of district laboratory services by equipping district health and veterinary laboratories with Rapid diagnostic test kits to detect RVF and CCHF as well as building capacity of laboratory technicians.

2.
Continued surveillance by MOH, MAAIF and other research agencies should be done 3.
One Health interventional approach should be strengthened and encouraged other than independent entities the prevention and control of diseases.

4.
Districts should always budget for any emergences to promote preparedness to avert disease epidemics.

5.
Early warning signals should be established for quick and prompt outbreak detection for prompt management 6.
More studies to understand the dynamic epidemiology of RVF and CCHF.

7.
The government and other funding agencies should support research to develop vaccine against hemorrhagic fever (RVF and CCHF) for humans and animals.

Study limitations
Some of the contact cases were not accessed to interview them which may compromise the scope of the data obtained to extrapolate to the general population. Formal consent was also obtained from the district officials, individual index cases and the contacts who were involved in this study.

Consent to publish
Not applicable in this study.

Availability of data and materials
All necessary data has been included in this manuscript submitted. Figures of photographs in the field have been submitted as additional files.

Competing interests
Authors declare that there are no competing interests.

Funding
The study was funded by USAID through the One Health Workforce project and One Health Central and Eastern Africa (OHCEA). The funder only facilitated the process of collection of data but was not involved in the designing of the study, actual data collection, analysis and interpretation of data and in writing the manuscript.

Authors' contributions
JMK: Conception and design of study, collection, analysis and interpretation of data; drafting and critical review of manuscript, gave final approval for submission of manuscript.
PN: Conception and design of study, collection, analysis and interpretation of data; drafting and critical review of manuscript, gave final approval for submission of manuscript.
AW: Collection, critical review of manuscript, gave final approval for submission of manuscript.
JDK: Conception and design of study, critical review of manuscript, gave final approval for submission of manuscript.
WB: Conception and design of study, and critical review of manuscript, gave final approval for submission of manuscript.
All authors have read and approved the manuscript.