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Table of Contents
RESEARCH ARTICLE
Year : 2022  |  Volume : 59  |  Issue : 1  |  Page : 70-78

Effectiveness of One Health approach for control of Kyasanur Forest Disease in Wayanad, Kerala, India


1 Centre for One Health Education, Advocacy, Research and Training (COHEART), Kerala Veterinary and Animal Sciences University, Pookode, Kerala, India
2 Section of Epidemiology, Vetsuisse Faculty, University of Zurich, Zurich, Switzerland
3 Department of Veterinary Public Health, Kerala Veterinary and Animal Sciences University, Pookode, Kerala, India

Date of Submission13-Jun-2021
Date of Acceptance05-Oct-2021
Date of Web Publication07-Jun-2022

Correspondence Address:
Prejit
Centre for One Health Education, Advocacy, Research and Training (COHEART), Kerala Veterinary and Animal Sciences University, Pookode, Kerala-673576
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-9062.331407

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  Abstract 

Background & objectives: Kyasanur Forest Disease (KFD) is a vector borne haemorrhagic fever that is endemic in the Wayanad region located in Northern part of Kerala, India. The region is managing the outbreak well ever since the major epidemic of 2015. This was because of the successful implementation of One Health (OH) initiative concentrating on multisectoral collaboration between regional institutions involved in public, animal and environmental health domains. The article presents how OH was implemented for the first time in the district in the year 2015 and evaluates the degree OH-ness of the Initiative.
Methods: The OH approach involved trans-disciplinary stakeholder meetings and reviews, outbreak management and integrated surveillance targeting ticks, monkeys and humans. The degree of OH-ness used for addressing KFD during the year 2015 was evaluated following the protocol developed by the Network for Evaluation of One Health (NEOH). In detail, we (i) described the OH initiative and its system (Aim, stakeholders, action strategy) and (ii) scored different aspects of this initiative (i.e., OH-thinking, -planning, -working, -sharing, -learning, -organization), with values from 0 (=no OH approach) to 1 (=perfect OH approach).
Results: We obtained a median score for each aspect evaluated. We reached high scores for OH systemic organization (1.0), OH thinking (0.83) and OH working (0.83). Lower scores were attributed to OH planning (0.58), OH sharing (0.50) and OH learning (0.33). The OH index was 0.36 and OH ratio was 0.95, indicating a balance between the OH operations and supporting infrastructures.
Interpretation & conclusion: With this we could high-light some critical issues related to communication on sharing data as well as learning gaps for consideration to control future outbreaks. The strengths and weaknesses detected may be used to refine the initiative, aiming to provide a basis for the development of shared recommendations in a more OH-oriented perspective. This model of evaluation criteria will serve to create a database of OH success stories in India that will in turn help to institutionalize the approach at ministerial level. Future India is moving towards implementing a One Health, hence, this study data will provide an ideal opportunity for all sectors to control any vector borne diseases.

Keywords: Evaluation; Integrated surveillance; KFD virus; One Health; Wayanad; Zoonoses


How to cite this article:
Prejit, Hitziger M, Asha K. Effectiveness of One Health approach for control of Kyasanur Forest Disease in Wayanad, Kerala, India. J Vector Borne Dis 2022;59:70-8

How to cite this URL:
Prejit, Hitziger M, Asha K. Effectiveness of One Health approach for control of Kyasanur Forest Disease in Wayanad, Kerala, India. J Vector Borne Dis [serial online] 2022 [cited 2022 Jul 1];59:70-8. Available from: https://www.jvbd.org/text.asp?2022/59/1/70/331407


  Introduction Top


Kyasannur Forest Disease (KFD) is a vector-borne viral hemorrhagic fever caused by flavivirus[1]. While rodents usually act as non-affected reservoirs, some mammalian species such as monkeys and humans may develop severe neurological disease[2],[3]. The disease has a seasonal pattern of occurrence mostly during the dry period (December–June) when the tick population (nymphs) is abundant on the forest floor[2]. KFD was first described in 1957 in the Shimoga region of Karnataka[4],[1]. To date, KFDV is conquering new areas in the Western Ghats[3] and is now endemic in several parts of India including Goa, Tamilnadu, Maharashtra, and Kerala[5],[6],[3]. The transmission cycle of KFD is complex: it involves monkeys or rodents and tick vectors (Haemaphysalis spinigera), including their respective habitat, and humans are at risk to develop complications characterized by hemorrhage, gastrointestinal bleeding, neurological manifestation, or bronchopneumonia[7],[8]. A holistic approach is thus needed to comprehend and influence the transmission system.

The outbreak management of KFD by collaborative action of different sectors and integrated surveillance targeting ticks-monkeys-humans help in early detecting the viral circulation and reducing the risk of infection. Research and policy processes are increasingly relying on transdisciplinary cooperation among a multitude of governmental, non-governmental, and private actors from local to global levels[9]. Considering the complex transmission cycle of KFD, a trans-disciplinary approach and multisectoral collaboration between institutions involved in public, animal, and environmental health domains are better to prevent KFD transmission, as compared to a unisectoral approach. Over the last decade, there has been growing interest for the OH approach implementation in health research, systems and services[10]. Here we describe a long-term OH response model which was established in 2015 KFD outbreak and that is directed towards overcoming outbreak scenarios of future. By following the evaluation protocol developed by the Network for Evaluation of One Health (NEOH), our evaluation quantitatively assessed how far the KFD surveillance system complies with the One Health (OH) multisectoral approach. In detail, we quantified different aspects of the OH approach: the thinking and planning at the basis of the implementation of the outbreak management; the commitment and involvement of actors and the infrastructure enabling a collaborative working and information sharing and the individual and institutional gain in knowledge resulting from the initiative. Expected outcomes of this approach included new insights unachievable by single-sector research initiatives, and hence potentially leading to new cross-sectorial solutions.


  Material & Methods Top


Background of outbreak

The study involves evaluating the degree of OH-ness to manage the vector-borne disease, KFD. The health authorities reported that the index KFD case was a 28-year-old male forest guard who had a history of handling a dead monkey in the Kurichad forest range in Wayanad during fire line work in the forest in December 2014[11]. He was admitted with high-grade fever, vomiting, diarrhea, malaise, and hypotension. Laboratory confirmation of KFD was done by detection of KFDV viral RNA by Real-time PCR (Polymerase chain reaction) from Manipal center for virus research. The outbreak started in January 2015 and continued till June 2015[3],[6]. During this outbreak season, a total of 184 cases of KFD were reported from the district[11]. Simultaneously, 18 Monkey deaths were reported in the area indicating an ongoing epizootic within the forest[11].

Developing an OH initiative in Wayanad and defining the stakeholder’s role

The Centre for One Health Education, Advocacy, Research and Training (COHEART) serves as a pioneer institution to propagate the One Health concept in Kerala (India). Following the outbreak of viral hemorrhagic fever that was confirmed to be KFD in 2015, we conducted a stakeholder workshop inviting all stakeholders that were identified to play a role in disease control. The stakeholders’ workshop was attended by the District Medical officer (Health), District Epidemiologist, District Animal Husbandry Officer, Chief veterinary officer, District Forest officer- North/ South, Faculties of Department of Veterinary Microbiology, Parasitology and Veterinary Public Health of Veterinary University, Tribal Development officer and representatives from various other government departments. The workshop decided on collaborative action and came up with the protocol of action to be followed by various sectors to control the outbreak. This could be considered as the unique One Health Initiative (OHI) in Kerala in the aspect of collaborative action towards disease control.

Assessment of the OH-ness of the initiative

For evaluation of the OH approach towards control of KFD Wayanad during 2015, the Network for Evaluation of One Health (NEOH) evaluation framework was used for the first time in India. It uses a system-based approach and aims to relate six OH process characteristics, namely, operational aspects (thinking, planning, and working) and supporting infrastructure aspects (sharing, learning, and systemic organization). It consists of a mixed-methods approach, including a descriptive and qualitative assessment with a semi-quantitative scoring for the evaluation of the degree and structural balance of OH-ness[9],[12]. The six different aspects of an OH approach were scored using standardized aspect-specific assessment tools: OH thinking, OH planning, OH working, OH sharing, OH learning, and systemic organization[9],[12]. This is an extensive question-based survey. Each section of OH planning, working, etc consisted of series of questions and an associated scoring system with values between 0 and 1 as well as spider diagrams, with a score of 1 reflecting a full realization of the different OH characteristics (ideal scenario). The evaluation involved a formative approach such as in-depth interview, field visit, workshop, stakeholder/actor questionnaire, discussion of evaluation outcomes. For stakeholder interviews, COHEART organized 2 days Interface Meet. The stakeholders interviewed were representatives of the District Medical officer (Health), District Epidemiologist, District Animal Husbandry Officer, District Forest Officer, Faculties of Veterinary University. They represented a majority of the stakeholders who steered the KFD outbreak response 2015 and had voluntarily participate in the workshop following our invitation. The questionnaire comprised of the following components as detailed below as the NEOH evaluation protocol[9],[12].

OH thinking

To assess the way actors and stakeholders think in and about the OH initiative and the system in which it operates (the context), the following dimensions were measured: (a) Integrated Approach to Health, Environment, Sustainability (b) Broadness of the initiative and match to context, (c) Project design and (d) Consideration of systems features (i.e., how the initiative conceptualizes the system in which it operates). Some of the indicators used for scoring include the degree of formal analysis and deliberation in the process of establishing objectives, elaborating a theory of change that matches the objectives, degree of dialog, and negotiation among multiple perspectives in elaborating objectives.

OH planning

This is to evaluate planning and resource allocations in the initiative. The scoring criteria included identification and engagement of sectors, actors, and stakeholders, Reflexivity and adaptiveness, Competencies (to evaluate the availability of required competencies for implementation), and Resource allocation. The indicators for stakeholder engagement were the degree of formal analysis and deliberation in identifying sectors, disciplines, stakeholders, and actors of relevance to the problem. The adequacy of budget and staffing were considered for achieving objectives of resource allocation.

OH system organization

To assess the systemic organization of the initiative, the criteria focused on leadership skills and criteria for effective teamwork. The scoring criteria included: Bridging knowledge (of team members, actors, and stakeholders); team structure and skills; external and internal stakeholder networks for the intensity of collaboration; focus on innovation.

OH working

To assess the interdisciplinary and participatory engagement in OH Initiatives, the following scoring criteria were included viz., Leadership (to assess the leadership’s capacity to coordinate participatory processes), Conflict resolution (Assesses the ability to manage conflicts), Power distribution (Assesses the balance of power and influence within the initiative, to make all voices heard).

OH sharing

The scoring criteria considered to evaluate the extent and methods of information and data sharing infrastructures in OH initiatives were, (a) general information and awareness, (b) sharing of data (c) sharing methods and results, and (d) institutional memory and resilience to change. Some of the indicators used for scoring the criteria mentioned above include the number of initiative members with access to data, with access to information on methods, and with access to information on results. This also includes the number of mechanisms to ensure long-term institutional memory for data, methods, and results.

OH learning

To evaluate the learning infrastructure of the initiative the scoring criteria focused on adaptive and generative individual learning; adaptive and generative team learning; adaptive and generative organizational learning; direct and general learning environment. Various indicators assessed were the frequency of presenting new information to individual members of the initiative, frequency of individuals putting new information into practice and improving procedures, competencies, and technologies, revising underlying paradigms, assumptions, beliefs, and norms, frequency of team discussions of different views and perspectives to support decision making, exploring complex views and assumptions in a move to build new ideas, views, or approaches. The scores for each assessed OH aspect were plotted onto the spokes of a spider diagram to allow visualization of the overall project integration and balance between operational and infrastructure aspects.

Ethical statement

The authors declare that the work described has not involved experimentation on humans or animals nor does it involve any patients.


  Results and Discussion Top


One Health initiative

Multistakeholder governance may include formal institutions and regimes to enforce compliance, as well as informal arrangements that people and institutions either have agreed to or perceive to be in their interest[13]. Here we describe the OH response model for addressing zoonoses threat with special reference to KFD that was followed for the first time in Wayanad. The strategy for OH implementation involved a series of seven steps as follows. The first step was the communication between stakeholders. When KFD outbreak was first confirmed (Index case), the human health sector communicated to the veterinary sector on the positive case report of a forest guard that occurred in the kurichad forest range of Wayanad. The veterinary sector on epidemiological investigation observed the history of few monkey deaths that were reported in the area. Both, the human health and the animal health sectors visited some of the hot spots, collected samples, and sent them to the laboratory. They then discussed the results. The next step was to develop a joint protocol of action.

COHEART conducted a stakeholder workshop inviting the District Medical Officer (Health), District Animal Husbandry Officer, District Forest Officer- North/ South, Veterinary University, Tribal Development officer, and others. The workshop decided the protocol of action to be followed by various departments and jointly submitted the same to the District administrator. The District Administrator released orders for the action protocol. The next step included a leadership to spearhead the control activities. District Administrator acted as the leader for handling the crisis in the district and he/she identified nodal officers from each of the acting departments who could take care of the duty at the functional 24x7 control room. The next step was multisectoral collaboration and coordination actions between human health, animal health, and other allied sectors. Based on the proceeding released by the District administrator, collaborative activities of various sectors were implemented [Figure 1]. These are broadly categorized as action from public/human health sector, animal health sector and other allied sectors (including environment related). For example, if any death of monkey is observed in a forest area, the environment health sector (forest department) conveys the information to animal health sector (Chief Veterinary officer or District Epidemiologist of Animal Husbandry Department and Veterinary university) who then performs postmortem examinations. The post mortem samples will be handed over to Human Health sector (Health department) for laboratory confirmation. This action continued from February to July 2015. Each sectors and department within the sector used to update their activities on a daily reporting system which was reviewed by the weekly/ fortnight review meeting under the chairmanship of the District Administrator. This review meeting discussed the gaps, difficulties, and current status of the threat and how can the threat be controlled. The crisis lasted up to June 2015[6]. This was followed by long-term action plans i.e., future actions, and research to control the threat was developed based on experience gathered during the intervention. This includes a preparedness plan to prevent the threat from occurring in the future and also a research plan for human- tick and monkey surveillance that was put forward by research institutes to a suitable funding agency.
Figure 1: One Health collaborative action strategy for control of KFD in Wayanad, India 2015

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Assessment of the OH-ness of the initiative

Evaluating complex multistakeholder initiatives at the science-policy interface is a challenge for which there are currently no frameworks that are accepted within or across disciplinary communities[9]. Network for Evaluation of One Health (NEOH) framework is considered the ideal tool for OH evaluation and is used in the present study. After the data and information were collected, the OH-ness of the initiative to control KFD was assessed using the Microsoft Excel spreadsheets with explanations, guidelines, and pre-defined calculation formulae for the overall measurement of knowledge integration capacity in multi stakeholder governance[9],[12]. This is an ideal tool for assessing the comprehensively operationalizing knowledge integration capacities throughout the policy cycle. By the evaluation protocol, we first defined and later scored the six different aspects considered to be essential for a perfect OH approach: OH thinking, OH planning, OH Organization, OH working, OH sharing, and OH learning. Scores ranged from 0 (=no OH approach) to 1 (=perfect OH approach) and were allocated corresponding to the scoring key provided by the respective evaluation tool.

Degree of OH-ness

Although in recent years OH-based studies have increasingly gained attention in scientific literature, no validated guidelines for quantitative measurement of OH-activities have been available previously[14]. In the present study, the degree of OH-ness was evaluated and results are depicted in a spider diagram [Figure 2], with the surface area and shape illustrating the degree of OH implementation and the balance between the operational and the supporting means. We reached high scores for OH systemic organization (1.0), OH thinking (0.83) and OH working (0.83). Lower scores were attributed to OH planning (0.58), OH sharing (0.50) and OH learning (0.33). The operational levels of the initiative are the main strengths, (namely, OH thinking, working and organization), indicating a comprehensive multidimensional approach and transdisciplinarity. On the other hand, weaknesses in the supporting infrastructure (namely OH sharing, learning, and planning). Each of these six aspects is defined more clearly in 3–5 criteria, and each criterion is operationalized through several indicators, which are formulated as questions[9]. The approach in our study shows a well-integrated effort with certain limitations. We could observe a weakness in the infrastructure, and supporting means for the initiative with critical issues relating to communication, resource allocation and learning gaps. In another study for evaluation of One Health approach for Control of Antibiotic Resistance, relatively high scores were obtained for planning, thinking, and systemic organization[15]. The author also suggests the realization of true intersectoral collaboration as the challenge that results in low scores for sharing and learning, which is also seen in the present study.
Figure 2: Spider diagram representing the scores allocated to the elements Thinking, Planning Working, Learning, Sharing and systemic organization of the OH-ness assessment on a scale from 0 to 1 for each element.

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OH thinking

One Health thinking was scored 0.83. The thinking involved in KFD control approach was designed in a stakeholder workshop, as a reaction to a 2015 outbreak event and subsequently implemented through the district government. The scores of the considered criteria are indicated in [Figure 3] and were as follows: Integrated Approach to Health, Environment, Sustainability (1.0), Project design (0.83) and Consideration of systems features (0.66). The high score that was obtained for OH thinking (0.83) indicates a highly integrated approach, covering diverse dimensions at differing scales and incorporating many perspectives. It aims to understand disease patterns and trends, prevalence of pathogens in vectors, abundance of vectors, incidence in human reservoirs and identifying where to intervene to control disease transmission. All the three components of One Health such as human, animal, and environmental concerns are correctly addressed. While thus reflecting the perspectives of several sectors, the stakeholder selection and engagement was mostly done in an ad hoc manner, is mostly restricted to government agencies, and the project design does not reflect non-governmental perspectives. It was based on a comprehensive consideration of different aspects of relevance to KFD, but a more formal approach to assessing disease incidence and prevalence could reveal additional opportunities / leverage points for surveillance and control. Networking in the initiative was relatively complex, including interaction within and between work groups, within and between sectors (i.e., the animal and public health sector) and between stakeholders and the general population (trans-societal). Similar findings were observed by other authors[16].
Figure 3: Diagram representing the weightage of score for different criteria in OH thinking

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OH planning

The planning score is built on the assumption that careful planning of tasks and activities in line with the initiative’s objectives and goals in an OH way necessitates careful and balanced allocation of resources to all tasks and objectives under consideration of the integrated nature of the program[17]. One Health planning score was 0.58. It was calculated according to the match between tasks, resources, and responsibilities. The scores of the considered criteria [Figure 4] were as follows: Identification and engagement of sectors, actors, and stakeholders (0.3), Reflexivity and adaptiveness (0.49), Competences (0.66) and Resource allocation (0.66). Such questions and other elements underpin the OH approach and contribute directly to OH outcomes, therefore planning may influence other assessments of the OH initiative under consideration (such as working, sharing, learning and systemic or-ganization)[18]. The planning of the OH approach provides much of the required resources and competences, and secures complete commitment since it was implemented within the core activities of the involved government agencies. However, some core funding specific to KFD surveillance would strengthen the approach and allow for own lab resources and other specific purposes to improve the system. One Health planning aspect analysis further depicted that essential stakeholders and sectorial actors were identified and described, but their full engagement was lacking. The initiative was planned to aim at sustainable health outcomes. Participating institutions from human and animal health sectors (health service department; animal husbandry department; health professionals working in human care, animal care; and academia and reference laboratory) and the formal and informal communication and networking generated are planned to achieve the aim. For each of the planned activities, according to the formulated objectives, matching of roles, responsibilities, and competencies was clearly established but resource allocation was limited. For example, some stakeholders could not have sufficient funds to mobilize procurement of personal protective equipment’s deemed essential for handling infected samples. While there were initial stakeholder workshops and meetings between agency heads are taking place at a regular basis, a formal process for reflection and adaptation would support continuous improvement and learning.
Figure 4: Diagram representing the weightage of score for different criteria in OH planning

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OH systemic organization

This assessment probes whether implementation of the OH initiative was facilitated by change-oriented leadership and effective teamwork, and therefore is closely related to and influenced by OH Planning[18]. The Systemic organization was scored a near perfect 1.0, the tool focusing on leadership skills and criteria for effective teamwork. The scores of the considered criteria were: Bridging knowledge, External stakeholder network and Internal team structure [Figure 5]. In contrast to the present study is the evaluation of One Health-ness of Cysticercosis Surveillance Design in Portugal where the Systemic organization was scored low (0.5)[19] and reported an unbalanced Task-oriented, relationship-oriented, and change-oriented leaderships. The initiative in the present study records strong teamwork and leadership. Though this are mostly limited to government agencies, the organization of team members and stakeholders is highly formalized and well defined, since it is conducted within the core processes of several institutions. Bridging persons, who have responsibilities to several departments and stakeholder groups could further strengthen the exchange and integration of knowledge, especially, since there is no central integration unit to which information flows are directed. There were nodal officers identified from each department who also acted as key contact persons. Leadership of the overall approach was informal, through coordination between department heads, and District Administration acting as bridge-building institution, which is considered a successful model. While this model guarantees each department’s ability to execute the processes in its responsibility according to its technical expertise, a regular and formalized co-steering process would enhance transparency, and provide opportunities for reflection, to detect shortcomings, and define opportunities for improvement. Such a formalized process could also foster the inclusion of tribal stakeholders, which are currently under-represented in program implementation and decision making. Including their perspectives could suggest additional components for KFD surveillance and control.
Figure 5: Diagram representing the weightage of score for different criteria in OH organization

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OH working

Multisectoral collaboration brings together people with different skills, expertise, experience, backgrounds, and often from varying epistemologies with the aim to tackle complex problems with a high societal stake that require an understanding of the human behaviour[20],[21]. OH working relate to integrating transformation knowledge in policy implementation. The score of One Health working was 0.83 and is schematically represented in [Figure 6]. The scores considered criteria such as: Leadership (0.83), Conflict resolution (0.66), Power distribution (1.0). Importance was given for transdisciplinary and the degree of cross-disciplinary working and leadership enabling an innovative approach to the problem. The parameter’s assessed included broadness; collaboration; transdisciplinary balance; cultural and social balance; and flexibility and adaptation. The initiative was organized in interrelated and interdependent working packages, which may involve different sectors and disciplines from diferent fields of expertise within human and animal health. A flexible coordination, broad and inter-sectorial initiative between professionals coming from animal health, human health and the environmental component areas was developed that worked well. Although human health and animal health sectors dominate; disciplines, methods, and scales of analysis were diverse. Disciplines involved include human and animal medicine, entomology, public health, laboratory and diagnostics and epidemiology from academic and non-academic, governmental and non-governmental fields in the human and animal health sectors. There was a reasonable degree of interaction between actors from the different disciplines. There were difficulties in enforcing the methodology of the initiative and in the communication between governmental institutions. The aim seemed clear to all, there were face-to-face meetings, but part of its implementation still lacks the approval of government institutions. Being a long-term outbreak response and systematic surveillance plan, the initiative can adapt to internal and external changes that may influence its implementation. The deficiencies identified in other studies reported that the working characteristics was related to gender imbalance (i.e., male domination) and a disparity in the representation of different disciplines, which could be partly due to a lack of open-mindedness toward other disciplines and sectors[15]. In contrast, there was no gender imbalance in our study and a fair representative was there from both genders.
Figure 6: Diagram representing the weightage of score for different criteria in OH working

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OH sharing

Information sharing is described to be one of the basic criteria for OH-studies[22]. One Health sharing was scored less (0.50), reflecting poor data and information sharing infrastructure. The scores included sharing of general information and awareness (0.49), sharing of data (0.33) and sharing methods (0.66) and results and institutional memory, and resilience to change (0.49). A diagram representing the weightage of the score for different criteria in OH sharing is shown in [Figure 7]. The observations revealed a major drawback in the initiative where no official mechanism existed to facilitate sharing of information, although regular (daily/weekly) reports and workshops were implemented. Meeting organized at the District Administration level occurred as deemed necessary and usually happened at fortnight intervals. While results and methods are shared, and also made public at several events, few specific procedures exist that formalize these processes. The system uses peer-reviewed publications and conferences to share relevant data resulting in new knowledge production. Compliance with confidentiality and data protection issues need to be tackled since it may interfere with data sharing and accessibility. Institutional memory and safeguarding access to data and information in case of change are not organized. Plenty of data is available through specific experts (and was presented during the interface meet day). This information has also led to the creation of guidelines for KFD surveillance and control, which were accepted as governmental directives and as such made binding on a national level. Overall, these processes are, however, informal and ad hoc, which reduces data availability, data safety, and the creation of resilient institutional memories. Thus, improving the sharing (of data, materials, and results) would enhance team members’ acquaintance with knowledge and observations from other departments, inspire dialogue, reflection and adaptation, further improving knowledge integration in the approach. Streamlining mechanisms of data sharing would also enhance the public visibility of this successful program, foster mutual learning beyond regional borders, and allow scientific analysis and joint publication of the produced knowledge. Interestingly, the shortcomings of OH-sharing identified in the study were also major deficit identified in several other One Health initiatives worldwide such as the OH approach for Cysticercosis in Portugal[19], West Nile in Italy[16], Anti-Microbial Resistance (AMR) in Copenhagen[15], Dog obesity cases in Europe[14] and Brucellosis Control in Malta and Serbia[18].
Figure 7: Diagram representing the weightage of score for different criteria in OH sharing

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OH learning

We attributed the lowest score for One Health learning (0.33), which assessed the learning infrastructure. Although the organizational, team, and individual learning levels are interconnected and influence each other, the highest median score was obtained at the organizational level (0.66) and team (0.66) followed by individual (0.33) levels [Figure 8]. These finding were in consensus with that of the West Nile Fever-initiative[16] and also for Copenhagen AMR initiative[15]. The general learning environment was less supportive of adaptive and generative learning (0.16). These results show that organizations involved in the initiative provide low-level support for the individual level. While information provision (basic learning) is generally regarded as frequent, adaptations of procedures and technical processes are observed more rarely, and fundamental changes of approaches and perspectives were not observed. Improving the learning aspects would enhance stakeholders’ and team members’ acquaintance with insights and observations from other departments, inspire dialogue, reflection and adaptation, and thus improve knowledge integration in the approach. Indeed, OH learning characteristics were also scored low in the West Nile Fever-initiative[16]. And in AMR initiative in Copenhagen[15] observed difficulty to extract information about the output of the consortium in terms of publications in the NEOH framework.
Figure 8: Diagram representing the weightage of score for different criteria in OH learning

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The OH index calculated in the study was 0.36, which according to the NEOH framework can be interpreted as a mediocre level of implementation of an OH approach in the initiative. The OH ratio was 0.95, indicating a balance (close to 1) between the OH operations and supporting infrastructures. The formulae for calculating the index and ratio are provided in the manuscript by Rüegg et al. (2018)[12].

Conflict of interest: None


  Conclusion Top


The Kyasanur Disease response system in Kerala is a well-institutionalized approach. It is very comprehensive and addresses the major dimensions of One Health and sustainability. It is mainly operationalized through a collaboration of several governmental institutions. The evaluation protocol developed by NEOH and applied in the present study represents an innovative tool to assess the degree of OH implementation of a health-related initiative that can be used to evaluate OH initiative in India. Our evaluation could observe pronounced OH understanding in the organization and working dimensions, which corresponds to the implementation phase of the policy cycle. It is also visible in the thinking dimension that corresponds to the agenda-setting and policy formulation phase. The degree of integration is lesser in the planning, sharing, and learning dimensions, which correspond to the policy formulation and evaluation phases of the policy cycle, respectively. With this, we could highlight some critical issues related to communication and learning gaps. The initiative is broad and inter-sectoral, but there is low involvement of the non-scientific community. Weakness in sharing data and moving towards building new ideas was detected. The main recommendations are (a) to expand the stakeholder network to non-governmental actors including tertiary hospitals and community leaders, especially in the policy formulation stage (b) Organizing joint activities such as public awareness campaigns which in the present initiative had a sector-specific approach (c) The inclusion of social and print media in the initiative would enhance its current implementation, and potentially provide additional perspectives for the public to know more about the disease (d) There should be enhanced procedures for co-steering, dialogue, reflection, storage and sharing of data and information, and learning. Such measures would not only increase visibility, appreciation, and exchange of the approach with other surveillance initiatives beyond regional borders, but also facilitate formalized opportunities for evaluating successes and shortcomings, and for revising and improving the approach if required (e) There is a need to further broaden the knowledge base on which the surveillance and control are building, enhance its legitimacy and cultural pertinence to the affected population, and enable its improvement and adaptation, through dedicated processes for integration of the knowledge that is created throughout the approach. Further, (f) It would be ideal to use the NEOH evaluation tools as a checklist during the project design and planning phase to identify the limitations of the study and stakeholder engagement, which might be corrected before the study begins or during the study period.



 
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