One Health in Vietnam

One Health in Vietnam from Training & Research to Policy Phuc Pham-Duc 1, Fred Unger 2, Hung Nguyen 2 1 Center for Public Health & Ecosystem Research (CENPHER), Vietnam One Health University Network (VOHUN), Vietnam 2 International Livestock Research Institute, Hanoi, Vietnam Regional workshop of the ComAcross project, 25-27 November 2015, Bangkok, Thailand

Outline One Health Training in Vietnam One Health Research examples From evidences to decisions Challenges and way forwards 2/1/2016 2

VOHUN (Vietnam One Health University Network) Hanoi (Network Secretariat): Hanoi School of Public Health Hanoi Medical University Vietnam National University of Agriculture Hue University of Medicine and Pharmacy Hue University of Agriculture and Forestry Bac Giang Agriculture and Forestry University Dak Lak: Tay Nguyen University - Faculty of Medicine and Pharmacy - Faculty of Veterinary and Animal Science Hochiminh City: HCMC University of Medicine and Pharmacy HCMC University of Agriculture & Forestry Thai Nguyen University of Medicine and Pharmacy Thai Nguyen University of Agriculture & Forestry Hai Phong University of Medicine and Pharmacy Thai Binh University of Medicine and Pharmacy Nam Dinh University of Nursing Vinh Medical University Can Tho University of Medicine & Pharmacy Faculty of Applied Biology and Agriculture 2/1/2016 3

OHW Objectives Objective 1 to participate with government, academia, and other key partners in defining OH workforce needs (Talking to government and private sector regarding training and research needs) (University-Government-Private Sector engagement on training and other needs) Objective 2 to assist government ministries to train the future One Health workforce (Translating these needs into creating a new graduate species to transform public health) Objective 3 to assist government ministries to train the current One Health workforce (Supporting governments and private sector by creating new in-service training initiatives) Objective 4 Support universities in strengthening faculty capacities for One Health teaching, research, and community outreach (Strengthening faculties to train the new workforce) Objective 5 Provide organizational development support to One Health networks 2/1/2016 (Strengthening networks for support of all initiatives and for sustainability)

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How to Make Your Curriculum a One Health Curriculum One Health Competencies (Core & Technical) Learning Objectives Modules Academic Curricula (pre-service) Professional Development Short Course (in-service)

Achievements A strategic planning and MoU were agreed & signed (OHW: 2015-2019) One week field trip for International Veterinary Medicine students OH clinical practices 60 students & 10 lecturers from 10 countries Seminars to introduce OH concept/approach 17 universities/schools 150 lecturers & researchers 1,500 students (Preventive Medicine, Public Health & Vet.) 2/1/2016 7

Development of OH training program (1) 1. Developed the training packages for OH elective modules for Public Health student at the HSPH 11 lessons / 2 credits 4 case study: Streptococcus suis, Leptospirosis, Rabies, Liver flukes 2. Developed the test evaluation for OH elective modules for Preventive Medicine student at the HMU 12 lessons / 3 credits 40 questions/lesson x 12 lessons 80% MCQ and 20% True/False questions 3. Developed a OH & Health Programs module at the Hai Phong UMP 11 lessons / 2 credits 2/1/2016 8

Development of OH training program (2) 4. Developing a training program for International Masters of Public Health OH orientation 7 core modules : 24 credits 7 Elective modules: 8 credits 5. Developing a training program for International Masters of Public Health majoring Environmental Health 6. Developing a zoonotic disease module for Veterinary Medicine student at the UAF 3 credits 7. Developing a OH field-based training program for human and animal health professionals 1 week (48 hours) in class 4 weeks field practices 2/1/2016 9

International Masters of Public Health (OH orientation) Program: 1 year Core modules: 24 credits Elective modules: 8 credits Thesis: 8 credits Students: Vietnam, Lao PDR, Cambodia, Indonesia, Malaysia, Thailand One Health & Zoonosis Modules 3 Credits Faculties of Animal Science & Veterinary Medicine (7 Universities) 2/1/2016 10

One Health & Zoonosis Modules (2-3 credits) Lesson 1: One Health concepts & approaches Lesson 2: Fundamentals of zoonotic diseases & ecosystem health Lesson 3: Zoonoses (bacteria & virus) Lesson 4: Zoonoses (parasites) Lesson 5: Using One Health approach in management and surveillance of zoonoses 2/1/2016 11

OH field-based training course No Subject Number of hours Theory Assignment Practice Total I In class: 5 days 1 Basic concepts of One Health 4 4 0 8 Systems Thinking 2 Zoonoses fundamental 4 0 0 4 3 Zoonoses risk analysis 4 4 0 8 4 Applied epidemiology in investigation, detection, 3 5 0 8 organization, prevention and control zoonoses 5 Sampling 0 0 4 4 6 Planning, monitoring, evaluating and reporting 4 4 0 8 7 Cooperation interdisciplines 2 1 0 3 8 Guidance in writing research proposal 1 0 0 1 9 Communication 2 2 0 4 Total 24 20 4 48 II In Field: 4 weeks III In class: 1 week Result report 0 0 12 12 2/1/2016

Strengthening University-Government Partnerships 1. Strengthening Universities-Government agencies Ministry of Health (MOH) / GDPM Ministry of Agriculture & Rural Development (MARD) /DAH Ministry of Education & Training (MOET) OH Partnerships / PAHI, Institutes: NIHE, NIVR, One Health Research 2. Strengthening Universities International organizations USAID, WHO, CDC, ILRI, FAO, IDRC, WSC, OIE, etc. OH continuing education course = OH field-based + FETP + AVET (VOHUN) (MOH) (MARD) 2/1/2016 13

Better Human and Animal Waste Management in Hanam Province, Vietnam using Ecohealth / One Health Approach What did we think? Agricultural intensification had closed relationship with ecosystem and human health. Livestock: advantages and disadvantages Livestock waste management, reuse. Any innovative changes are needed to develop the agricultural & livestock systems to increase production, at the same time preserving and enhancing natural resources. Using ecohealth approach to manage animal and human wastes

What we did so far: (NCCR North-South program) 1. Community engagement (Local authorities) 2. Research ( PhD, MSc) But more focus on Diseases : Health Status, Diseases.. Focal Issue Sanitation & Health Kim Bang district, Hanam, Vietnam What do we need? Understand the real situation of Agriculture intensification Design Implement Intervention Dissemination Communicate with Stakeholders engagement Stakeholderw orkshop Issues identified Issues Researchers stay with community (none-scientists) Human, animal health & wellbeing Environment Social- economics Community engagement

Some research activities were carried out PRA: to identify emerging problems of local communities and issues related to agricultural and human waste managements. Baseline survey: 461 households to explore the relationship between waste management practices and rural household health status in the study sites to identify the current animal waste treatment methods Health risk assessment related to biogas-wastewater Exposure assessment: 451 pig farms; Samples: 150 Quantify the microbial and chemical indicators: E. coli, Salmonella, Giardia, Cryptosporidium, BOD & COD, ph, temperature Estimate the risk of infections and diarrhea by the specific pathogens Community-based intervention Village regulation; good practice pig farm; behavior change communication. 2/1/2016 16

Risks of diarrhoea related to biogas wastewater Increasing livestock production (MARD, 2013) Environmental pollution caused by livestock waste becomes more severe (Đ.T.T.Sơn, 2011) Biogas is commonly used for treatment of livestock waste (H.K.Giao, 2010) Biogas if not properly used -> the efficiently destroyed pathogens is low (V.T.Y.Phi, 2009; Jirina, 2012) Most pig farms discharge biogas wastewater direct to public drainage (79%), irrigation (43%) (L.Q.Hương, 2014) 2/1/2016

Dose-response models (Sources: Haas et al., 1999, Howard et al., 2006) Estimated single risks of infection Where are: Quantitative Microbial Risk Assessment (QMRA) (Hazard identification Dose-response analysis Exposure assessment Risk characterization) Exponential model (Giardia & Cryptosporidium) P inf(d) = 1 exp(-rd) β-poisson model (E. coli) P inf(d) = 1 [1+ (d/id 50 )(2 1/α 1)] -α - P inf(d) : risk of infection in an individual exposed to a single pathogen dose (d) - α: infectivity constants (E. coli: 0.1778) - ID 50 : pathogen dose at which 50% of a population will be infected (E. coli: 8.6 x 10 7 ) - r: infectivity constants (Giardia: 0.02 and Cryptosporidium: 0.00467) - d (dose ingested) = μ x m μ: concentration of organism/100ml February 1, m: 2016 amount of water accidental ingested Monday seminar 18

Estimated average single risk of diarrhea Irrigating vegetable Probability of diarrhea risk by E. coli (12%), Crypto (25%), Giardia (5%) Irrigating fruit tree Irrigating corn crop Cleaning drainage Maintaining biogas 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Estimated single risk of diarrhoea Estimated single risk of diarrhoea Estimated single risk of diarrhoea

Community-based Intervention Good Practice Pig-Farm (GPPF) in Vietnam Properly treatment of animal wastes by biogas system understand the biogas operation and maintenance process aware the health risks related to biogaswastewater (human & animals) Good enforcement the village regulation on environmental sanitation Effective behavior change communication Increase skills for monitoring & prevention of animal diseases Village core group members (local authority, head of village, village health workers & para-vet.; pig holders) & Researchers Decreasing the frequency exposure to biogas-wastewater Reduction of pathogens in the biogas-wastewater (E. coli, Sal) Safe use of wastewaterirrigated products (vegetables, fish) Reduce the health risks related to biogaswastewater (human, animals) 2/1/2016 20

Community-Based Intervention 2/1/2016 21 Good Practice Pig-farm Saving time, water, electricity, money More gas for cooking Less smell, flies Improving personal hygiene practice More friendly Increasing productivity

Reducing disease risks & improving food safety in smallholder pig value chains in Vietnam (PigRisk) Risk profiling 1 Project framework 2 Risk assessment Microbial Risk Assessment Chemical Risk Assessment 3 Animal Health Risk Assessment Interventions Economics (eg health, CBA) Rapid assessment Action research 1 Action research 2 Action research 3 Value chain Economic assessment. Incentive-based interventions Randomized Control Trials (RCT) 4 Engaging stakeholders and co-generating evidence, Advocacy, Communication, OM

Risk assessment: Salmonella in pork production chain - Pig slaughterhouse and pork market. Infection risk (P) P f P p P r Exposure assessment RISK OF MICROBIAL Slaughter- CONTAMINATION IN THE CHAIN Farm Market RISK OF INFECTION FOR CONSUMERS house Fork Consumption Risk N f N p N r Pathogen concentration (N) Exposure assessment Source: Microbiological Risk Assessment Series No2-2002, No7-2008

Taskforce: Food Safety Risk Assessment Established a Taskforce of risk assessment for food safety: MOH, MARD, Institutes, Universities, Private Sectors... Analyses of food safety policy in Vietnam and how research evidence informs policy. Stakeholder workshops were conducted to identify the scope of activities and priority issues in food safety. Training courses and follow-up along with case studies of risk assessment for food safety were held. Developed the guidelines for risk assessment on food safety (both microbial and chemical hazards). Dissemination workshops to development of policy on food safety.

Capacity building Training courses for public health & veterinary professionals MOH, MARD. Developed textbooks and guidelines on food safety risk assessment. Publication of a special edition of risk assessment in a Vietnamese journal; Policy briefs developed

real situation of policy change Identified issues Research Results Policy Policy? makers changed accepted

From Evidences to Decisions Establish a working group / policy alliance group (PAG) Meetings, study site visits, dialogue, forum, etc. Mass media, communication event, linking websites Provide clear/concrete evidences, goals, targets (policy briefs) The message must be designed specifically for the policy makers to better reflect their needs The credibility of the messenger can be as important as the message itself Will & determination to move and wait for opportunities Stakeholders analysis win without fighting

Example: Topics to be discussed The government is developing a strategy for developing livestock production; How recommendations issued by Ecohealth/One Health project can better be in line with current discussions on the policy? How the Working Group can assist CENPHER to design the research results in a message targeting decision makers? Who can be the best messenger to present Ecohealth project and results to decision makers?

Moving towards a One Health approach in Vietnam MARD-MOH joint inter-ministerial circular (16) on coordinated prevention and control of zoonotic diseases (May 2013) Establishment of new DAH division on veterinary public health as well as the Emergency Operations Center located in GDPM office OH is in the national strategies Emerging Pandemic Threats activities, VAHIP, SEA-EU-NET and associated donor commitment Recognition of the need to include wildlife in animal health efforts and zoonotic risks One Health Communication Network for journalists

Challenges Institutional challenges: acceptance, policy engagement Capacity building: One Health Workforce Incentives: how to share credits, added values of One Health Deeper coordination between sectors on human and animal (and wildlife) health and the environmental agencies Improving the translation of evidence and research into policy

Summary and conclusion One Health in Vietnam - Great attention and support from different level - Training in good way, but limited research - Inter-sectoral collaboration and policies: good enabling environment Challenges and ways forward - Capacity building: One Health Workforce - More research & case studies - Deeper coordination of sectors: further (re)-organization - Resources

Acknowledgement