Journal of Negative Results in BioMedicine A critique of the WHO TobReg's "Advisory Note" report entitled: "Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators"

Kamal Chaouachi email@example.com
62, avenue Victor Hugo92100Boulogne BillancourtFrance

Journal of Negative Results in BioMedicine A critique of the WHO TobReg's "Advisory Note" report entitled: "Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators"
10.1186/1477-5751-5-17BioMed Central Page 1 of 9 (page number not for citation purposes) Commentary Address: Researcher in Socio-Anthropology and Tobaccology, Consultant in Tobacco Control, * Corresponding author
Background and aim: The World Health Organisation Study Group on Tobacco ProductRegulation (TobReg) has issued in 2005 an "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators". "Waterpipe" smoking is now considered a global public health threat and the corresponding artefact is actually known in the world under three main terms: hookah, narghile and shisha. This important report, the first ever prepared by WHO on the subject, poses two major problems. On one hand, its bibliographical references dismiss world chief relevant studies. On the other, it contains a certain number of errors of many orders: biomedical, sociological, anthropological and historical. The purpose of the present study is to highlight, one by one, where these weaknesses and errors lie and show how this official report can be considerably improved.Results:We realise that widely advertised early anthropological studies were not taken into consideration whereas they shed a substantial light on this peculiar form of smoking and help understanding its high complexity. As for concrete errors to be found in this report, they deal with the chemistry of smoke, health-related effects, smoking patterns, description and history of the artefact and its use, gender and underage use aspects, prevention and research needs in this field.Conclusion:The scientific credibility of an international expert report may be at stake if its recommendations do not rely on sound objective research findings and a comprehensive review of the existing literature. The critical comments in this study will certainly help improve the present WHO report.

Background

The World Health Organisation Study Group on Tobacco Product Regulation (TobReg) has issued in 2005 an "Advisory Note" entitled: "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators" [1](see Figure 1). This report was prepared "in response to requests made by those Member States whose populations are exposed to this form of tobacco use" and was adopted at a meeting in Rio de Janeiro on 7-9 June 2005. This document is mainly based on a background paper drafted by Dr Thomas Eissenberg (USA) and Dr Shihadeh (Lebanon), actually commissioned for this purpose by Dr (page number not for citation purposes) Yumiko Mochizuki, Director of the WHO Tobacco Free Initiative, with the collaboration of Dr Maziak (Syria), Dr Israel and Dr Loffredo (USA) and Dr Mohamed (Egypt) [1]. Research led at the SCTS (Syrian Center for Tobacco Studies) formed an essential part of the report.

Such an official publication, which has remained uncommented so far, actually poses two major problems. The first one relates to its bibliographical references which dismiss world chief relevant studies, both in the biomedical and social sciences field. The case of the existing anthropological studies is particularly striking given the recognised importance of the socio-cultural dimension of this peculiar form of smoking. Indeed, the narghile practice is deeply rooted in a complex network of closely interrelated social, cultural and health issues in a given human context. The second problem deals with the multiple errors contained in the report. These are of many orders: biomedical, sociological, anthropological and historical.

Consequently, the aim of the present article is to highlight, one by one, where these weaknesses and errors lie and show how the WHO report can be considerably improved. We certainly share the health concerns stemming from the growing use of hookah (narghile, shisha, water-pipe) in the world. However, the scientific credibility of an international expert report may be at stake if recommendations do not rely on sound objective research findings.

In this study, we recall the importance and relevancy of the missing and glossed over references and critically review some of those cited by the authors. As for the errors, they are analysed under relevant subsections in the Results and Discussion section below.

Results and discussion

Origins

It is said (page 1) that, according to Chattopadhyay, "waterpipes have been used to smoke tobacco and other substances by the indigenous peoples of Africa and Asia for at least four centuries" [2]. The quotation is not accurate because this author does not mention, at any point, any of these facts in his article. Besides, evidence concerning the Indian origin of the hookah is weak. As a matter of fact, the most ancient traces were found in Southern or Eastern Africa [3]. For instance, bowls of water-pipes were dug out in 1971 by J.C. Dombrowski in the Lalibela cave (Ethiopia). C14 datation situated their use around years 1320 +/ -80 [3,4]. As for the large scale emergence of the narghile in society, either for an individual or collective use, historical accounts show that it was simultaneous with the appearance of the public coffee-houses and the adoption of tobacco in the Middle East region: near the end of the 16 th century and the beginning of the 17 th century (ibid.)(see Figure 2). For the authors of the report, the myth of the hookah as a safer way of smoking is as old as its invention in India. However, there is no point in insisting on the necessity of this Indian origin because it is also a myth itself.

Tar yields

According to the report (page 1), "Marketing tools associated with waterpipes and waterpipe tobacco may reinforce this unsubstantiated belief. For example, the label of a popular waterpipe tobacco brand sold in South-West Asia and North America states '0.5 nicotine and 0% tar". An investigation was actually carried on with a similar product in France [3,5,6] and we had the possibility to clarify this point by stressing the importance of parameters such as the puffing frequency, volume and others (id.). These above figures were actually obtained with light smoking parameters similar to those used for cigarette smoking. Consequently, they do not reflect a less realistic view of human hookah smoking than others where the severe conditions imposed to a hookah smoking machine allowed the production, among others, of huge quantities of tar [7,8].

The quantity of tar obviously depends on the inhalation frequency. For instance two important, not cited, studies dealt with tumbâk [9,10] and used different puffing parameters than the recent one that relied on tobamel (tobacco-molasses smoking mixture, called "mu'essel" in Arabic) [8]. The discrepancies in results are striking: the two former found a reduction by c. 50% of the tar (smoke compared with that produced by a narghile with no water inside) while the latter succeeded in producing impressive amounts of it: 802 mg for a one-hour session. The explanation lies in the fact that, in the last case, the laboratory model completely differed from actual human hookah smoking. Only a small quantity of the smoking mixture was used: 10 g instead of the average 20 g according to an important work by Hadidi [11]. The coal, of the quicklighting type, of unknown chemical composition, was kept in the same place over the tobacco-molasses mixture during the whole session, that is, almost one hour, versus 45 min [11]. This is contrary to the normal practice that involves moving it around in order to avoid "charring" the product. Puffs of a great volume (530 ml) were drawn periodically and at a fast pace: every 17 s vs. 30s [11]. In these conditions, 171 puffs were taken, vs. 90 [11]. These parameters were actually set according to a calculated average of figures collected through a smoking topography in a café. Strangely enough, the corresponding data were analysed, in their great majority, for the first 30 minutes of smoking only. Moreover, it is known that beyond that period, the interval between puffs tends to be much longer though remaining irregular. Over a whole session, the smoking variables have, randomly and in a drastic way, many ups and downs. Consequently, from a methodological standpoint, the use of an average figure over such a long span of time, particularly for puff frequency, is a serious methodological distortion. Indeed, specialists advise against the use of smoking machines in the field of cigarette, where, however, the smoking session is extremely short in comparison with the hookah: "Kozlowski likened the FTC test to trying to measure caloric intake by inventing an eating machine. A better method he said, might be to study changes in people after eating. Similarly, studying the effects of cigarettes in actual people may be better than using a machine-based system. "In other words, cut out the machine smoker as the middleman," he said" [12].

Moreover, there are also other important parameters that could change the amount and nature of the substances absorbed by the smoker: aspiration speed, pressure, water solubility of certain substances, volume of bowl, amount and temperature of water, added substances, length of the aspiration hose and others... What renders the tar dangerous is not its quantity but its quality and above all its tem-perature. In these conditions, the scientific truth is certainly to be found between these two extreme figures: neither "0% tar" as claimed on commercial tobamel packages nor "802 mg" artificially produced in unrealistic conditions in a laboratory.

As for nicotine, despite the above mentioned strain parameters, the nicotine yield, compared to that found in a single cigarette, is far from scaring the "hookah addicts" or even suggesting an explanation to their behaviour. Consequently, this issue shows that what is now needed is simulating, in a laboratory, the reality of human hookah smoking. If we want to be credible in our prevention efforts, artificial smoking, which generates great quantities of tar [7,8], should be avoided if we want to avoid confusion.

Heating and burning

The report states (page 2) that "the tobacco that is placed into the head is very moist (and often sweetened and flavoured): it does not burn in a self-sustaining manner". This sentence is confusing. First, one should talk of diverse smoking concoctions or mixtures. Only one type of tobacco, tumbâk (which is raw tobacco), is "very" moist(ened) because, before it is packed inside the bowl, it is soaked in water then squeezed to remove most of its water. The other one, referred to as "sweetened and flavoured", is differently processed. It contains glycerol. Besides, in the case of the "flavoured tobacco", it is definitely wrong to say that the mixture is burnt. It is simply heated and this is a crucial point [13]. Evidence for this is provided by the actual working temperatures that can be measured during the process. They are below or around 100°C, a figure very different from that that can be measured at the tip of a cigarette (850-900°C). In these conditions, the heat range allows chemical reactions of the Maillard type between the aldehyde functions of sugars -especially in the molasses element-and nitrogenous compounds, particularly ammonia (NH4OH) used by tobacco manufacturers to produce various aromatic compounds [3,14]. Moreover, as far as tar is concerned, all specialists know that what makes the latter hazardous and carcinogenous is not its quantities but it qualities. On one hand, these qualities depend to a great extent on the temperature at which tar is produced. On the other, knowing the crude amount of tar is useless, because its harmful components, i.e. nitrosamines, polycyclic aromatic hydrocarbons, represent a very variable and, in any case, small percentage of the total weight, which therefore is in no way a valuable index of its hazards. This is true for cigarette smoke, so that one should stop printing on cigarette packs the smoking machine tar yield, which gives the smoker a fallacious information about the real danger. This is even more true for narghile smoking, which is much more variable. Once again, we can see that hookah smoking is very peculiar in this respect. In these conditions, even second-hand smoke (pages 4 and 5 of the report) is completely different from that produced by cigarettes [15].

Children

We are informed (page 4) that "in South-West Asia and North Africa, it is not uncommon for children to smoke with their parents", citing the author of a so-called "dispatch" paper where we can read that: "It is socially acceptable for a father to offer his teenage children a puff of the nargile, in a way similar to a Frenchman offering a taste of wine to his sons and daughters" [16]. Despite the fact that this remark is quite personal and anecdotal, this does not mean at all that children "smoke with their parents", which is a totally unsupported statement in contradiction with all available anthropological data that rather describe narghile initiation as a kind of "rite of passage" [3,17].

More, recent epidemiological figures in Syria, an Arab country, are quite clear in this respect [18]: "Age of initiation differed according to method of smoking and gender. On average, men initiated use of cigarettes at age 17.9 (5.3) years and waterpipe at 25.5 (9.1) years, while women initiated use of cigarettes at 22.5 (8.4) years and waterpipe at 28.9 (9.9) years (p, 0.05 for all gender and smoking method comparisons by t test").

Women

In the same vein, we can read (page 4) that "in some countries in which cigarette smoking is concentrated among men, waterpipe smoking appears more evenly distributed between both sexes". This may be true in some countries but wrong in others. For instance, in Tunisia and Libya, cigarette smoking is still a male domain but "water-pipe" also. In these conditions, generalisation should be avoided because there is no "rule" in this field and this issue needs further comparativist anthropological research that already began for a decade now [15,19](see Figure 3).

New charcoal

The report states (page 5, 5 th conclusion) that "commonly used heat sources that are applied to burn the tobacco, such as wood cylinders or charcoal, are likely to increase the health risks because when such fuels are combusted they produce their own toxicants, including high levels of carbon monoxide, metals and cancer-causing chemicals". These potential inherent listed hazards linked to the use of the new quick-lighting commercial charcoal are wrongly attributed to the two cited references [7,8]. As far as carbon monoxide is concerned, the above mentioned studies relied only on this new charcoal and neither a comparison with natural charcoal nor an analysis of the composition of the former was carried on. There is only one study in the world which shows that a commercial charcoal yields higher levels of this gas than the natural one [20].

Concerning heavy metals, the new quick-lighting charcoal might be a source but also the tobacco itself, the aluminium foil an even the metal coating (particularly of the bowl). Therefore, as there is no study to date about the composition and health effects of this new heating source, researchers are highly encouraged to set about clarifying this issue [3,5,6,13,21].

In any case, and if we only take two striking figures, that of the scaring yields for lead and carbon monoxide, 6870 ng and 143 mg respectively [7,8], they do not reflect at all the reality of hookah smoking. For instance, the results for the lead levels are not in agreement with a previous study by Salem concluding that the content of this metal was significantly higher in cigarette than in water pipe [22]. Other data from unpublished studies show that arsenic was not even detected. This is because the hookah smoking machine that was used [7,8] was set with blown up "average" parameters supposed to reflect figures varying, in fact, in a dramatic way and over a very long period of time (one hour). This is a distorted model of actual human hookah smoking behaviour [12].

Harm reduction

In this field (page 5, 8 th conclusion), there would be "no proof that any device or accessory can make waterpipe smoking safer". For many reasons, there is no proof. For instance, and contrary to a widespread idea among tobacco control activists, the hookah market is still in the hands of "traditional" segments of the economy, particularly located in the so-called South. The producers of these devices do not possess the research facilities of an international company like RJ Reynolds, whose scientists publish their studies in international biomedical journals. For instance, there is a certain amount of literature about the Eclipse cigarette, based on the principle of narghile smoking because it heats tobacco instead of burning it. However, harm reduction techniques have already been put forward by the authors of high quality studies in the field of research on hookah smoking. For instance, Shafagoj in Jordan suggests to "motivatemanufacturers to produce HB [hubble-bubble, i.e. hookah] filters to be inserted to the mouthpiece. In addition, pH, resins or other modifications can be made to the HB water to improve its filter properties." [23]. In Arabia, Zahran early mentioned the existence of a device that obviously reduces, not to say inhibits, the production of carbon monoxide: an electric resistance used instead of the charcoal [24].

Infections

The report states (page 5, 9 th conclusion) that "sharing a waterpipe mouthpiece poses a serious risk of transmission of communicable diseases, including tuberculosis and hepatitis". This statement is wrongly attributed to researchers [25] who are not the authors of studies on such risks. In the Traditional Palestinian Woman and Narghile Figure 3 Traditional Palestinian Woman and Narghile. case of hepatitis, these studies were carried on by Habib et al. [26] and Medhat et al. [27]. As for tuberculosis, they were carried on, recently, by Munckhof et al. [28] and long before by Salem et al. [29]. Besides, the risk is not so "serious". If it had been so, the world would have witnessed corresponding epidemics over the last centuries. This did not happen. Finally, we note that plastic aseptic disposable personal nozzles are always served to patrons in the "hookah lounges" or during the fashionable home "hookah parties". Generally speaking, the risks are not clearly established because of a non-rigorous methodology (simultaneous use of other products [e.g. qât, cigarettes, bidis, etc], strongly neglected hygiene, current profile and remote and recent career of smokers not specified, etc.) [13,21].

Scenario for the epidemic

We read (paragraph 10, page 5) that "waterpipe tobacco is often sweetened and flavoured, making it very appealing; the sweet smell and taste of the smoke may explain why some people, particularly young people who otherwise would not use tobacco, begin to use waterpipes". This quotation refers to a study that actually proposed a wrong "scenario" for the recent development of shisha use in Syria [30]. According to it, the Arab information satellite television channels would be greatly responsible for the development of the hookah craze. This argument is not consistent at all and the complex answer was treated in a key document [3]. The main reason is that the old Egyptian movies, that all television watchers of the Arab world remember quite well, were already heavily featuring narghile smokers long before the recent hookah epidemic and the emergence of satellite-powered TV channels. Moreover, it is also in contradiction with a paper cited as a key reference in the report and revealing: "Old Egyptian films showed groups of men sipping mint tea or strong coffee in cafés and smoking nargile for many hours" [16]. Unfortunately, this kind of quick analysis of a complex anthropological situation has led researchers of the very teams cited in this report to wade in a similar way [31].

"Nicotine addiction"

We deem it not necessary to insist too much on the biochemical and health dimensions provided that the methodological conditions are respected in order to avoid the too frequent bias. Two critical reviews in French and Italian, among others, were published on these very aspects [3,5,6,13,21].

We also hope that in the coming future the nicotine addiction dogma will be sidestepped when tackling the dependence aspects. On one hand, it is not appropriate in the field of hookah smoking and the results of a study carried on by one of the very teams mentioned in this report, are quite clear: about 3/4 of the interviewees declared narghile use was easy to quit [32]. On the other, as far as dependence is concerned, there is a serious debate over the central role of nicotine in the dependence process [33,34]. Indeed, we are convinced that the future findings of the growing research on narghile will help reconsider the tobacco dependence issue in general and cigarette dependence in particular. People do not necessarily smoke the hookah for nicotine and another evidence for this is that the "hookah lounges" already offer herbal fruit-flavoured tobacco-free smoking mixtures to their patrons. The importance of flavours (only in the case of tobamel) would make this dependence very similar to that induced by coffee. Not only nicotine but MonoAmine Oxidase Inhibitors (MAOI), other minor low-dose potentially dependence-inducing alkaloids, ligands of opioid receptors, and other substances, might play a certain role in the dependence process [34].

Chief studies

Globally, we may wonder why controversial studies [7,8,35,36] are cited in this report while other early and useful studies led by Hoffman [9], Rakower [10] and Salem [22,29] are not. This is all the more regretful that the latter relied on traditional settings and the corresponding experiments were based on the use of the natural charcoal, not the new self-lighting one which likely causes, among others, an overproduction of carbon monoxide [20]. Indeed, what is interesting for the sake of scientific comparisons, is that one basic difference between the traditional four-century old social use of the hookah and the contemporaneous one is the nature of the heating source.

Prevention

Prevention is the most important and pressing issue and no suggested action (page 7) is given in this report whereas a public health catastrophe is looming and so many ideas could immediately be put forward to avoid it and reduce the harm caused by this new widespread form of smoking [3,5,6,13,21,37].

State of research

The report states (page 6) that "there is surprisingly little research addressing tobacco smoking using a waterpipe, especially given that there are many millions of current waterpipe smokers and that waterpipe use is spreading across the globe". It is true that very little research has been devoted to the subject. Therefore to perform an exhaustive bibliography was not a superhuman task, and the WHO report should have done it. We personally regret that the authors did not even mention the deep and early health oriented anthropological research that we carried on in this field, which contains many ideas for the desired development of prevention and cessation strategies" [3,5,6,13,21]. These documents have been widely advertised, over the years 2000-2005, among the international community of tobacco control researchers and activists, particularly through the Globalink network. English abstracts, translations and comments of their findings were disseminated on a large scale.

Drugs

One can also read that there would be research needs for "the relationship between waterpipe smoking and the use of other drugs, including marijuana" (page 6). We will point out that a 262 page scientific book, entirely dedicated to this topic, was published as early as 1997 [38].

Conclusion

We hope these comments will be useful for the future reports which, we insist, should be clear and objective, if we want them to be accepted, as far as their recommendations are concerned, by health practitioners, prevention activists, researchers and the one-day or regular smokers themselves all over the world. Methodology needs substantial improvement. The World Health Organisation Study Group on Tobacco Product Regulation itself, responsible for the publication of this very report actually concluded in a meeting: "The International Organization for Standardization (ISO) machine-based cigarette test for determining the tar, nicotine, and carbon monoxide content of cigarettes should be banned and replaced" [12]. What is true for a 5 minute cigarette smoking session is even much more true for hookah smoking session which is 10 times longer and where the puffing variables extremely deviate from an arbitrary "average" figure. In these conditions, the use of a hookah smoking machine [7,8] should be discontinued because it has led to a great deal of confusion, particularly reflected in the first report on "waterpipe smoking" ever published by WHO [1]. The 12 th core principle set out in another TobReg important report is: "Regardless of the funding mechanism adopted, it should ensure that the independence and integrity of research and testing operations are not compromised or inappropriately influenced » [39]. The same document insists that the output of research and testing laboratories be "credible and consistent with the most rigorous of international standards" (p.7, ibid.).

We invite our colleagues, particularly those working in the epidemiological field, to amend the design of their questionnaires and include one or several items related to the past and present career (ex-smoker [with quantification, detailed mention of dates an products], switching-smoker from cigarette to narghile, exclusive smoker, etc.) of the volunteers analysed in their studies [5,21,37]. This point is of utmost importance because it may render useless the corresponding results as this happened with most of the previous studies. In view of the quick development of hookah use in the world, we will definitely spare time and other resources for the benefit of the world human health.

On one hand, the strong socio-anthropological background of fashionable hookah smoking in a global world shows that the underlying social context bears similarities but also great differences with cigarette smoking [41]. On the other, it confirms that "public health is a social issue" as recently and relevantly emphasised by Dr Lee, Directorgeneral of the World Health Organisation [42].

Methods

The present work is based on a critical and thorough review of the WHO report. The findings of the studies cited by the authors are compared with the results of those not cited in that document, both in the biomedical and social sciences fields. We realised that the errors concretely deal with the following themes: the chemistry of smoke, health-related effects, smoking patterns, description and history of the artefact and its use, gender and underage use aspects, prevention and research needs in this field. Their corresponding analysis and comments are combined as far as possible and reported as subsections in the Results and Discussion section, namely: Origins; Tar yields; Heating and burning; Children; Women; New charcoal; Harm reduction; Infections; Scenario for the Epidemic; "Nicotine addiction"; Chief studies; Prevention; State of research; Drugs.

Cover of the WHO "Advisory Note" entitled "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recom-mended Actions by Regulators" Figure 1 Cover of the WHO "Advisory Note" entitled "Waterpipe Tobacco Smoking: Health Effects, Research Needs and Recommended Actions by Regulators". A Persian qalyân (1622) Figure 2 A Persian qalyân (1622). In Tabacologia, Johann Neander's masterpiece (1622). Drawing by Blon.
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AcknowledgementsThe WHO (World Health Organisation) TobReg's "Advisory Note" report entitled "Waterpipe tobacco smoking: health effects, research needs and recommended actions by regulators" was published by the Tobacco Free Initiative in 2005.TobReg is the WHO study group on Tobacco product Regulation.Competing interestsThe author(s) declare that they have no competing interests.
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Towards One Health disease surveillance: The Southern African Centre for Infectious Disease Surveillance approach

Esron D Karimuribo
Southern African Centre for Infectious Disease Surveillance
MorogoroTanzania

Kuya Sayalel
Ngorongoro Conservation Area Authority
Ngorongoro ArushaTanzania

Dar es Salaam
The Open University of Tanzania
Tanzania

Eric Beda
Southern African Centre for Infectious Disease Surveillance
MorogoroTanzania

Nick Short
Royal Veterinary College
LondonUnited Kingdom

Philemon Wambura
Southern African Centre for Infectious Disease Surveillance
MorogoroTanzania

Leonard G Mboera
Dar es Salaam
National Institute for Medical Research
Tanzania

Lughano J M Kusiluka
Dar es Salaam
The Open University of Tanzania
Tanzania

Mark M Rweyemamu
Southern African Centre for Infectious Disease Surveillance
MorogoroTanzania

SUA Morogoro
PO Box 3297Tanzania

National Institute for Communicable Diseases
2011JohannesburgJuly

Towards One Health disease surveillance: The Southern African Centre for Infectious Disease Surveillance approach
CC0F2CC9210239E68CAE81DC003D017910.4102/ojvr.v79i2.454KarimuriboE.D.SayalelK.BedaE.ShortN.WamburaP.MboeraL.G
Africa has the highest burden of infectious diseases in the world and yet the least capacity for its risk management.It has therefore become increasingly important to search for 'fit-forpurpose' approaches to infectious disease surveillance and thereby targeted disease control.The fact that the majority of human infectious diseases are originally of animal origin means we have to consider One Health (OH) approaches which require inter-sectoral collaboration for custom-made infectious disease surveillance in the endemic settings of Africa.A baseline survey was conducted to assess the current status and performance of human and animal health surveillance systems and subsequently a strategy towards OH surveillance system was developed.The strategy focused on assessing the combination of participatory epidemiological approaches and the deployment of mobile technologies to enhance the effectiveness of disease alerts and surveillance at the point of occurrence, which often lies in remote areas.We selected three study sites, namely the Ngorongoro, Kagera River basin and Zambezi River basin ecosystems.We have piloted and introduced the next-generation Android mobile phones running the EpiCollect application developed by Imperial College to aid geo-spatial and clinical data capture and transmission of this data from the field to the remote Information Technology (IT) servers at the research hubs for storage, analysis, feedback and reporting.We expect that the combination of participatory epidemiology and technology will significantly improve OH disease surveillance in southern Africa.

Introduction

Although there have been some recent advances in the diagnosis and management of human infectious diseases, they still are a significant impact and burden on global economies and public health (Jones et al. 2008).Infectious diseases are responsible for a quarter of all human deaths worldwide (King et al. 2006).Most of these are as a result of emerging infectious diseases (EIDs), defined as infections that have newly appeared in a population or have existed but are rapidly increasing in incidence or geographic range (Morse 1995).There are various drivers for the occurrence of EIDs including socio-economic, environmental and ecological factors.Analysis of origins of EIDs for longer than six decades concluded that over 60% are zoonotic of which about 72% originate in wild animals (Jones et al. 1978).It has also been observed that when considering spatial distribution of origins of infectious diseases, the majority are prevalent in and affect developing countries in the tropics, particularly in Africa and South-East Asia.

Effective disease surveillance is required to ensure freedom from EIDs or else timely intervention in order to reduce risks and impact on animal and human populations.Disease surveillance is commonly defined as an ongoing systematic collection, analysis and interpretation of data essential to the planning, implementation and evaluation of disease management practice, closely integrated with the timely dissemination of these data to those who need to know (Mboera, Rumisha & Kitua 2001;Thacker & Berkelman 1988).Although the purpose and objectives of disease surveillance may differ between different health sectors, it is generally agreed that surveillance is useful for rapid detection of new and/or foreign diseases, provides evidence of freedom from diseases within a defined geographic area or population, accurately delineates the distribution and occurrence of diseases relevant to disease control and provides evidence required to assess progress and success of disease control or rededication (FAO 2004).

Most developing countries have limited disease surveillance capacity and so need to ensure optimal use of available resources.However, previous studies indicated that both animal and human health sectors are poorly resourced in terms of both clinical and public health service provision (James & Muchiri 2006;Jones 2011;Karimuribo et al. 2011).Considering that most emerging infectious disease conditions in public health sectors, especially in tropical countries, are of animal (wildlife and domestic) origin (Jones et al. 2008;Wolfe, Dunavan & Diamond 2007), it is important to encourage collaboration between the animal and human health sectors in order to minimise risks associated with such infections.The purpose of this work is to share findings based on our experience in southern Africa focusing on the OH surveillance strategy developed by the Southern African Centre for Infectious Disease Surveillance (SACIDS).

Materials and methods

One Health surveillance

In this paper, One Health (OH) surveillance is defined as collaborative efforts between the human and animal (wildlife and domestic) health sectors to conduct systematic collection of disease event data, analysis of this data and a timely dissemination of surveillance results to guide interventions aimed to prevent or control disease in human and animal populations.

Study design

This study involved two phases.Phase 1 involved conducting a baseline survey to assess the performance of current disease surveillance in animal and human health sectors.Lessons learnt from these exercises were used to improve the design of the OH surveillance system.The second phase involved designing an OH surveillance system suitable for the southern African region.

Baseline study on assessment of surveillance systems

A rapid situation analysis was carried out in May 2010 to understand the structure and requirement of surveillance systems in the animal and human health sectors in Tanzania.This was followed by assessing the performance of the disease surveillance systems in the two health sectors by visiting animal and human health facilities in Ngorongoro district, carried out in November 2010.During field visits, individuals responsible for detection and reporting of disease events were interviewed using a structured questionnaire.A total number of 14 wards of Ngorongoro district were visited where all resident ward livestock field officers (LFO) were interviewed.The study also collected data from 13 health facilities, representing approximately 62% of all health facilities in Ngorongoro district.The exclusion of an individual health facility was based on lack of access to key personnel or disease surveillance records during the field visit.Respondents were asked to specify frequency of collection and submission of disease surveillance reports, diseases reported and constraints and challenges faced during disease surveillance in animal and human health sectors.Field data collection was complemented by visiting the District Veterinary Office (DVO) and District Medical Office (DMO) at the Ngorongoro District Council headquarters where disease surveillance reports submitted for the period from 2005 to 2010 were retrieved and analysed.

The assessment of disease surveillance in both animal and human health sectors was based on measuring the completeness and accuracy of surveillance reports focusing on a period of five years (2005-2010) before the study.Other factors that might have influenced the timely submission of disease reports such as the distance from a health facility to the district headquarters were also recorded.

Design of Southern African Centre for Infectious Disease Surveillance One Health surveillance strategy in southern Africa

A participatory approach was used at an initial project inception workshop organised to agree on study sites and surveillance approaches.During the workshop, held in January 2010, it was agreed to develop and pilot OH surveillance in three ecosystems namely Ngorongoro, Kagera River basin and Zambezi River basin.The workshop recommended initial pilot activities to be carried out in one ecosystem (Ngorongoro) and then up-scaling the approach to the other two project sites.

Implementation of the project activities in Ngorongoro ecosystems required a collaborative approach coordinated by SACIDS and National Centre for Infectious Disease Surveillance (NatCIDS).Other key collaborators in the development of the OH surveillance strategy in Tanzania were: the Ministry of Health and Social Welfare (Epidemiology unit), the Ministry of Livestock and Fisheries Development (Epidemiology section) and two academic institutions responsible for veterinary (Sokoine University of Agriculture) and medical (Muhimbili University of Health and Allied Sciences) training in the country.The project also partnered with collaborators from UK, namely the Royal Veterinary College (RVC) and Imperial College London, who assisted in sharing with the southern colleagues their experiences in infectious disease surveillance and the use of appropriate technologies and tools to support OH disease surveillance.Recommendations of the UK Foresight report on infectious diseases (Brownlie et al. 2006) were also considered whilst devising OH surveillance strategy in southern Africa.

Study sites

The current project on OH disease surveillance adopted three study sites namely Ngorongoro, Kagera River basin and Zambezi River basin ecosystems.The first ecosystem represents an area of maximum human-wildlife-domestic animal interactions.The ecosystem is located in a remote area in the Arusha region which borders Kenya in the north and the Tanzanian Serengeti ecosystem in the west.The ecosystem is predominantly inhabited by the Maasai pastoral communities who keep cattle, goats and sheep and are in close proximity with wild animals in the wildlife protected areas of Ngorongoro Conservation Area (NCA).The other two sites (Kagera River basin and Zambezi River basins) represent cross-border ecosystems where OH surveillance could be potentially effective in diagnosing and managing infectious diseases across borders.Kagera River basin is an ecosystem located in the Great Lake Region of eastern Africa which links Uganda, Rwanda, Burundi and Tanzania.The ecosystem has a relatively high incidence of communicable diseases with cross-border spread and is considered to be a high risk potential entry-point for haemorrhagic fever (especially Ebola and Marburg) which occur in the Democratic Republic of Congo (DRC).Zambezi River basin is located in the southern Africa and is the fourth largest basin in Africa after the Congo, Nile and Niger River basins.The Zambezi River has its source in Western Province of Zambia and flows through eastern Angola, Namibia (Eastern Caprivi strip), northern Botswana and through Victoria falls (shared between Zambia and Zimbabwe) before entering Lake Kariba.The project site focused on two districts of Zambia (Kazungula and Sesheke) which share international borders with Zimbabwe, Botswana, Namibia and Angola in the Zambezi River basin ecosystem.

Data analysis

Data collected during baseline study on assessment of the performance of disease surveillance systems were summarised and where applicable, descriptive statistics computed.Data trends by ward and health facilities were demonstrated using graphical presentation of the results.The names of health facilities were coded to ensure a blind contribution in disease reporting to comply with ethical clearance conditions.

Results

Baseline study on the performance of surveillance system in the animal and human health sector in Tanzania

Disease surveillance structure

The surveillance structure between the animal and human health sectors in Tanzania was found to be similar (Table 1).The initial detection of disease events in both health sectors starts in the communities where sick individuals are detected by community-based reporters.The current systems use official cadres who are the LFOs (in animal health sectors) and the health facility in-charge or Integrated Disease Surveillance and Response (IDSR) focal person (in human health sectors) to prepare and submit disease surveillance reports to the higher levels.The central coordinating level for disease surveillance and response is at the district level (DVO and DMO).The two offices are responsible for transmitting reports to higher authorities through the intermediate (zonal VICs and RMO) or sometimes directly to the central level in the ministry responsible for animal health and human health, respectively.The similarities in surveillance structures of the two health sectors offer opportunities for increased collaborations between veterinary and medical professionals with regards to disease surveillance and response.

With respect to frequency of reporting, the animal health sector demands submission of disease reports on a monthly basis using field and abattoir surveillance reports.In the case of notifiable diseases, the officials are required to report disease events immediately.Under the IDSR system, officials are required to report diseases under surveillance on weekly (epidemic-prone conditions) and monthly (epidemic-prone, diseases of public health importance and those targeted for eradication) basis.

Performance of surveillance systems

A total number of 13 human health facilities (dispensaries, health centres and hospitals) were visited and participated in this study.The facilities were located between 1 km and 237 km from the Ngorongoro District Council headquarters (Table 2).More than 69% of these facilities are owned by the local government authority, the Ngorongoro District Council.It was also found that organisations such as the Roman Catholic and the Evangelical Lutheran Churches of Tanzania run some health facilities that, in addition to offering health services, are involved in the capture and reporting of disease events in the study area.

The performance of disease surveillance in animal and human health sectors, defined by the number of surveillance reports received every month is shown in Figure 1.Overall, the reporting was better in the human health sector than in the animal health sector.There were some years such as 2008 and 2009 when the DVO did not receive a single disease report.Similarly the DMO did not receive monthly reports from human health facilities throughout 2005.Generally, some wards and health facilities performed better in submitting disease surveillance reports compared to others (Figures 2a and Figure 2b).It was clear that those wards and facilities close to the District Council headquarters submitted reports more regularly than the distant wards and facilities.

One Health surveillance strategy in southern Africa

The OH surveillance strategy was developed as a result of a participatory and consultative process summarised in Table 3. Epidemiology and disease control section, Ministry of Health and Social Welfare

Regional or international Regional or international bodies (e.g.AU/IBAR, SADC, EAC, OIE) Regional or international bodies (e.g.EAC, WHO)

Before project implementation, applications were submitted to the appropriate bodies responsible for ethical clearance in the National Institute for Medical Research (NIMR) and the Tanzania Wildlife Research Institute (TAWIRI).Holding an inception workshop for key stakeholders interested in OH surveillance was helpful in selecting study sites as well as identification of appropriate mobile technologies and tools to assist surveillance.The subsequent meetings of the NatCIDS and the Joint Technical Committee (JTC) in August and September 2010 respectively, defined the OH surveillance strategy to be adopted in Ngorongoro and later in two other project sites.The meetings agreed that the strategy should consist of two complementing systems namely:

• Community-based Active Surveillance (CAS) system which was designed to actively capture disease events in animal and human populations using simple case definitions of symptoms and syndromes occurring in communities.It was also agreed the CAS system would use community-based health reporters who would actively screen for the occurrence of disease events in human, wildlife and domestic animal populations.Data on these events would be recorded and transmitted through Android mobile phones using the Epicollect data capture application in near to real time.

Discussion

Similarities in the current disease surveillance structure in animal and human health sectors provide opportunities for DVO, District Veterinary Office; DMO, District Medical Office.collaboration between the two sectors.For instance, under the current IDSR strategy, emphasis on disease management is placed in hands of district health facility levels (Franco, Setzer & Banke 2006).Similarly, the MoLFD demands the DVO to be in-charge of managing disease epidemics in animal populations.As both the DMO and DVO work under the umbrella of the District Executive Officer, it is logical to work together in the management of disease epidemics in animal and human populations in their respective districts.This has been happened in some instances during Rift Valley fever and anthrax outbreaks in Ngorongoro district between 2006and 2009(B.M. Miran, pers. comm., 2010)).It was also found that sometimes animal and human health officials in Ngorongoro district do share vaccine storage facilities during surge demand of resources.This usually happens during disease vaccination campaigns when teams of vaccinators camping in remote areas require storage facilities for proper handling of vaccines.This experience is not new to resourcechallenged remote areas as reported in other countries where sharing resources such as transport logistics and equipment reduces costs (Schelling et al. 2007).The current OH strategy designed by SACIDS where one person (community-based health reporter) actively searches for occurrence of disease events is another good example of optimising the use of limited resources.

Findings of the baseline survey agree with previous findings of poor performance of disease surveillance in animal and human health sectors in Tanzania (Allport et al. 2005;Mboera et al. 2001).The situation is made worse with the delayed reporting of sick individuals at health facilities where disease events are normally captured.A study by Shayo et al. (2003) indicated that the majority of rural-based individuals stay at home or consult traditional healers before visiting health facilities to seek medical services.Similar findings have been reported in the animal health sectors where sick animals are usually managed by farmers or community-based animal health workers in remote areas before intervention of veterinarians (Karimuribo & Swai 2006).

The baseline study also reported a significant variation in completeness of surveillance report in both animal and human health sectors.Although some wards and health facilities seem to do better than others, the overall picture confirms poor surveillance coverage.In-depth interviews of district officials responsible for animal and human health confirmed that the lack of human resources to supervise and manage surveillance systems may seriously affect the performance of the system.This is confirmed, for example, by at the fact that there was no DVO between 2006 and 2009 in Ngorongoro when there was sharp decline in the number of surveillance reports submitted to the district headquarters.This situation was reversed in 2010 after recruiting a veterinarian to head the veterinary section in the district.Other examples were noted where poor reporting was associated with times when key IDSR staff responsible for submitting weekly or monthly reports were away from their work stations.This experience had also been reported previously by Rumisha et al. (2007) when poor disease reporting under IDSR was attributed to staff being on annual leave.

Although quantitative data on timeliness was not collected in the current study, interview with officials responsible for disease surveillance in the animal and human health sectors indicated that there is always delayed reporting, a problem which is more critical in the animal than in the human health sector.For instance, monthly reports in the animal health sector can be delayed by six to nine months before being received by the Epidemiology section (F.Kivaria, pers. comm., 2010).

In the human health sector, the timely submission of weekly and monthly reports have been reported to be only 8% and 24%, respectively (Rumisha et al. 2007).The problem of poor timely reporting is mainly attributed to the paper-based transmission of data coupled with challenging infrastructure and communication networks especially in rural areas.

Given the challenges of surveillance in the animal and human health sectors, the SACIDS designed a 'fit-for-purpose' OH surveillance strategy.The strategy is considered appropriate for southern Africa as it has taken into consideration the situations and challenges prevailing on the ground.Key considerations include the relatively higher proportion of patients receiving treatment at home from traditional healers before visiting health facilities, lack of proper diagnostic facilities at community and village levels, limited human diagnostic and mobility resources in remote areas as well as poor infrastructure for efficient communication between rural communities and district or ministry headquarters (Strasser 2003).The concept of collaborative efforts in managing infectious diseases in Tanzania and other southern African countries is not new.The emergence of innovative and appropriate technologies, approaches and tools for participatory epidemiology and disease surveillance (Hussain et al. 2005;Jost et al. 2007), such as the use of mobile technologies (Aanensen et al. 2009;Despont-Gros et al. 2005) is likely to mean that infectious disease surveillance can be improved in future.This will contribute to better public health and economic and social stability in Africa.It is also anticipated that the OH surveillance will foster stronger collaborative links between the animal and human health professionals and consequently improve management and control of infectious diseases in animal and human health sectors.

Conclusion

The approach designed by SACIDS on OH surveillance is considered suitable for detecting and containing infectious diseases in animal and human populations in countries with limited resources such as those in southern Africa.Adoption of mobile technologies and appropriate surveillance approaches will improve timely and complete capture of events that would have been otherwise have been missed using routine surveillance systems in the animal and human health sectors.It is concluded that the OH surveillance strategy is timely and relevant to sub-Saharan Africa.

•

District-based Passive Surveillance (DPS) system uses existing surveillance strategies in animal and human (IDSR) health sectors with enhanced performance through application of mobile technologies in transmission of near to real time data in the two health sectors.Collaborating with other institutions in the United Kingdom (Royal Veterinary College and Imperial College London) as well as those in South-East Asia (BIOPHICS, Ministry of Public Health Thailand, MBDS and InsTEDD, Cambodia) assisted in the improvement of the OH surveillance system developed by SACIDS.The two systems (CAS and DPS) are linked together at the data analysis point.Data collected through CAS and DPS systems from pilot sites located in Tanzania are stored centrally on a server located at SACIDS headquarters.Southern African Centre for Infectious Disease Surveillance acts as a custodian and stores data on behalf of the Ministry of Livestock and Fisheries Development and the Ministry of Health and Social Welfare who own the data.At SACIDS, data are analysed and summarised as reports that are shared with the two ministries and field-based disease management units at district headquarters.A similar model is proposed for dealing with handling data collected in Zambezi River basin when data storage and analysis is expected to be the role of the University of Zambia Veterinary School (UNZA Vet) on behalf of respective ministries responsible for animal and human health.There is still on-going discussion on an appropriate model to adopt for collecting, storage and analysis of data from the Kagera River basin which is under the auspices of the East African Community (EAC).

FIGURE 1 :
1
FIGURE 1: Efficiency of monthly disease reporting in the animal and huma Ngorongoro district from 2005 to 2010.

FIGURE 1 :
1
FIGURE 1: Efficiency of monthly disease reporting in the Ngorongoro district from 2005 to 2010.

FIGURE 1 :
1
FIGURE 1: Efficiency of monthly disease reporting in the Ngorongoro district from 2005 to 2010.DVO, District Veterinary Office; DMO, District Medical Office.

FIGURE 1 :
1
FIGURE 1: Efficiency of monthly disease reporting in the animal and human health sectors in Ngorongoro district from 2005 to 2010.

FIGURE 2 :
2
FIGURE 2: Completeness of disease reporting in the (a) animal and (b) human health sector.

TABLE 1 :
1
Similarities between disease surveillance structure in animal and human health sectors in Tanzania.
Level

TABLE 2 :
2
Health facilities and wards visited during assessment of surveillance systems in Ngorongoro district.
Name of facilityCategoryOwnerLocation, wardCatchment areaDistance to the districtpopulationheadquarters, kmArashDispensaryFaith-based OrganisationArash429152EndulenHospitalFaith-based OrganisationEndulen35 168166KakesioDispensaryDistrict CouncilKakesio3945237LoliondoHealth centreDistrict CouncilOrgosorok55695MalamboHealth centreDistrict CouncilMalambo881692NainokanokaDispensaryDistrict CouncilNainokanoka29 682226NCAADispensaryParastatal OrganisationNgorongoro4977178NgaraseroDispensaryDistrict CouncilPinyinyi1360122OldonyosambuDispensaryDistrict CouncilOldonyosambu392793SakalaDispensaryDistrict CouncilSakala14553SamungeDispensaryDistrict CouncilDigodigo546365SeroDispensaryDistrict CouncilSoitsambu280543Wasso DDHHospitalFaith-based OrganisationOrgosorok37 3451.5

TABLE 3 :
3

DateEventActors †AchievementJanuary 2010Inception workshop held at Ngurdoto MountainRepresentatives from DRC, Rwanda, Tanzania,Agreed on 3 pilot sites and technologies toLodge, Arusha TanzaniaZambia and UK. Also attended by institutionsenhance OH surveillance in southern Africainvolved in surveillance such as InstEDD,TRACNET Rwanda, P4H, FAO DPT, ImperialCollege London-EpiCollect, RVCJuly 2010Discussion with EAC Health desk on projectRepresentatives from SACIDS and EAC-Agreed on project coordination arrangementsimplementation in Kagera river basinEAIDSNetAugust 2010In-country meeting to discuss projectNatCIDS members from MUHAS, NIMR, SUA,Appointed a JTC to supervise projectimplementation in NgorongoroMoHSW and MoLFDimplementationSeptember 2010JTC meetingMembers of JTC from SACIDS, SUA, MUHAS,Defined and prioritised diseases and syndromesNIMR, MoHSW and MoLFDto focus on under OH surveillance. Agreed piloOH surveillance data to be stored at SACIDSserver on behalf of MoHSW and MoLFDSeptember-October 2010Visiting UK by SACIDS Postdoc and ICT specialist Members from SACIDS, RVC, Imperial CollegeReceived inputs on how to improve OHLondon and IoEsurveillance in Africa and use of technology(Android phones powered by Epicollect) toenhance OH surveillance. Hands on practice onuse of the Android phones or EpicollectNovember 2010Setting up data storage system at SACIDS andTeam members from SACIDS and ImperialDeveloped local capacity to use Epicollect andfield-testing of the Android phones-Epicollect inCollege Londonalso assessed performance of Android phones-TanzaniaEpicollect in NgorongoroJanuary-February 2011Development of OH surveillance guidelinesSACIDS team at SUAFirst draft of the surveillance guidelinesdevelopedFebruary 2011Visiting South-East AsiaSACIDS team (Postdoc fellow & ICT specialist)Learnt on opportunities and challenges withvisited Thailand (BIOPHICS, Epidemiologyrespect to surveillance and technologies used inBureau of the Ministry of Public Health &South-East AsiaMBDS) and Cambodia (InsTEDD)March 2011Discussion on project implementation in ZambeziSACIDS team and NatCIDS Zambia team atAgreed on project implementation in Zambeziriver basinUNZA Vetriver basin ecosystemMarch 2011JTC meetingMembers of JTC from SACIDS, SUA, MUHAS,Improved OH surveillance guidelinesNIMR, MoHSW and MoLFDJune 2011Exploratory visit, Kagera river basinSACIDS team and EACDiscussed and agreed on how to launch projectactivities in Kagera river basin ecosystemJune-July 2011Procurement of Android phones and serverSACIDS & RVCAgreed on procurement plan to initiate OHsurveillance in southern Africa

http://www.ojvr.org
AcknowledgementsWe would like to acknowledge support and cooperation received from various individuals in the Tanzanian Ministry of Livestock and Fisheries Development, Ministry of Health and Social Welfare, officials at Ngorongoro district council working with the DVO and DMO offices who assisted retrieval of disease surveillance reports.We are grateful to clinical officers, in-charge of different health facilities and wards visited in Ngorongoro district as well as community members who participated in this study.We thank our colleagues at Imperial College London particularly Dr David Aanensen and Mr Chris Powell for their valuable support in capacity building related to setting up, field-testing and use of smartphones running the EpiCollect application in southern Africa.This study was funded by the Rockefeller Foundation through a research support grant 2009 DSN 305.
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