People, animals and infectious disease transmission: A new synthesis

Lead Research Organisation: Durham University
Department Name: Anthropology

Abstract

Most emerging and re-emerging diseases in the world are animal diseases that can cross over into human populations. There is great concern that some of these diseases - like 'bird flu' for example - have the potential to develop into deadly pandemics that could cause widespread infection and devastation. Meanwhile, other animal diseases are already causing a terrible impact upon some of the poorest populations the world. For example, Lassa fever, a focus of this research, is a disease present in rats in parts of West Africa. People in rural areas where the rats live come into contact with rats frequently because the rats live close to people's homes and enter them to look for food. People can catch Lassa fever when they come into contact with the blood, urine or faeces of rats. Lassa fever is also spread from humans to other humans. Often this happens in hospitals, because barrier nursing techniques are inadequate. Although 80% of people who catch Lassa fever don't show any symptoms, in the remaining 20% of people the disease is severe. Deafness is a common complication, occurring in roughly one third of cases. Lassa fever is the most common cause of deafness in West Africa, and kills up to 10,000 people every year.

Lassa fever and other diseases that move between animals and humans are of enormous concern to international health agencies who are developing programmes to manage and research these diseases. However, in anthropology there have only been a few studies of these diseases. This proposal argues that anthropologists have an important contribution to make to the study of diseases like Lassa fever. In particular, it argues that knowledge gained in other areas of anthropology, such as the study of human relations with animals and the study of human relations with material objects can be usefully applied to understanding how diseases like Lassa fever are spread. Anthropological work on animals can help us understand better the kinds of social practices that bring humans and animals into contact, by describing in detail how humans and animals live together, how humans hunt and eat animals, and so on. Meanwhile, anthropological work on how people use material objects, especially medical objects like gloves and needles, can help shed light on the reasons for transmission in health settings. For example, work carried out in a Kenyan hospital by the proposed Future Research Leader showed that nurses were so frightened of catching HIV that they would wear the same gloves for long periods of time and potentially put patients at risk of cross-transmission. Meanwhile, family members often refused to wear gloves when they were helping to care for their relatives, because this would have symbolised a lack of love and care. If we want to understand how it is that diseases like Lassa fever come to be spread within hospitals, and what kinds of interventions might reduce transmission risk, this kind of detailed knowledge is very useful.

The transmission of Lassa fever will be the main topic of the research, and the researcher will write a major academic book on the subject. She will do fieldwork in Sierra Leone with health workers, policy makers and people who live in the risk area for the disease. She will also write articles, some of them for academic audiences, and some directed towards policy makers and organisations who are trying to intervene on Lassa fever by reducing infection and improving treatment. Beyond the project on Lassa fever, the researcher will also set up a network to promote anthropological study of human-animal diseases. She will hold a workshop on this subject and launch a website which will be a useful source of information to academics and non-academics. In order to build this research network and develop her own intellectual contacts, the researcher will work in Berlin for 7 months as a visiting researcher.

Planned Impact

Lassa fever is a highly dangerous disease with a significant burden in parts of Sierra Leone, Guinea, Liberia and Nigeria. The World Health Organisation suggest that as many as 500,000 people may be affected by the disease annually. It is neglected in terms of both funding and research, partly due to the legacy of war in two of these countries which has made research work and the development of effective health systems responses difficult. Health systems in the region are typically strained, often lacking even basic material, let alone the barrier nursing equipment needed to treat suspected Lassa patients. The anti-viral drug Ribavirin which is the only known effective treatment to Lassa is expensive and difficult to administer, and in Sierra Leone is only available in the specialist Lassa ward at Kenema (Borchert personal communication).

Given limited available resources and a lack of knowledge about perceptions of stakeholders regarding the effectiveness of existing interventions and priorities for action, this research will include a programme of participatory action research and will work in partnership with key stakeholders in Sierra Leone. This engagement will allow the researcher to refine her research questions in order to optimise the potential impact of the research. The goals of the impact strategy are to develop a knowledge base around the following: (1) existing health systems interventions to manage Lassa fever and how these are perceived by those who are involved in them and those who are the target of such interventions; and (2) an awareness of gaps in interventions from the perspective of key stakeholders and their sense of how future interventions should be prioritised. Analysed alongside the ethnographic data which will be generated in this project on the management of Lassa within hospitals and homes, with a particular focus on practices that might create situations of risk, and the increased knowledge about how rats and humans cohabit and how this might shape transmission dynamics, this knowledge base will have the potential to develop key recommendations to improve health systems and public health responses to the disease. The guidance of the advisory committee and the planned dissemination strategies (see pathways to impact) are particularly relevant to meeting these goals. Beneficiaries of this research therefore include people at risk of contracting Lassa fever; service users of health systems in Sierra Leone; health workers, policy makers and health managers in Sierra Leone and other countries with a Lassa fever burden; and non governmental organisations involved in interventions around Lassa fever.

By building awareness and ownership among a key stakeholders and including them in refining research questions and dissemination activities to co-produce knowledge, it is envisaged that the research will be better received and will generate more relevant knowledge. For this reason, the research outputs are likely to have the capacity to influence specific policies and policy makers. Furthermore, beyond stakeholders in Sierra Leone, other beneficiaries include international NGOs and research consortia with an interest in Lassa. Preliminary conversations between the applicant and the One Health Initiative (a not-for-profit group which aims to bring together insights from veterinary and human medicine) indicate a strong interest in the proposed research and have pinpointed their newsletter as a useful outlet for the discussion and promotion of research findings. Other key international stakeholders whom the PI will endeavour to bring on board with the fellowship through networking activities include the NGO MSF, who manage most outbreaks of Lassa fever and are a key repository of knowledge on Lassa management as well as a potential beneficiary of the research

Publications

10 25 50
 
Description At this stage, the project is on track with data collection progressing well. Although initial fieldwork was delayed by the Ebola outbreak, key enabling factors have been the appointment of a Sierra Leonean research assistant since February 2016 who has been leading on data collection and data management for the project. Strong relations with the Sierra Leonean advisors, Dr Donald Grant and Prof Foday Sahr have helped the research assistant to gain the necessary access to research participants. The support of Dr Grant's colleagues at Kenema Government Hospital has been particularly helpful as they have provided access to key research participants. We are also grateful to Kenema Government Hospital and especially the Lassa Fever team for providing essential institutional support to the project, particularly office accommodation for the research assistant.
Key outputs to date include over 40 interviews with a range of participants; field based observations in affected communities; hospital-based observations at Kenema Government Hospital; and a participatory research workshop held in September 2016 with a large group of stakeholders involved in management of Lassa fever.

The overall aim of this project was to study transmission pathways of Lassa Haemorrhagic Fever and responses to the disease at health systems and household levels in Sierra Leone. The research is using ethnographic fieldwork on transmission pathways and health sector management of Lassa Viral Haemorrhagic Fever to explore three key questions;
(1) What kinds of interactions between humans, rats and objects within homes and hospitals, may encourage, curtail or prevent viral transmission?
(2) How does the problem of 'transmission' shape responses at the institutional and domestic level through household/community, national and global mechanisms?
(3) How has the management of Lassa Fever been affected by the Ebola Virus Disease epidemic in Sierra Leone?
In order to answer these questions we have carried out 25 interviews with health workers and hospital-based staff, including lab technicians, specialist Lassa nurses, and Lassa outreach staff in key sites of Lassa control including Kenema Government Hospital, Nixon Memorial Hospital and Panguma Mission Hospital. These research activities have increased our understanding of how Lassa Fever is managed within district level health systems and some of the issues and concerns faced by health workers. Some of the findings of this work fed into our participatory action research workshop held at Lwala Resort in September 2016.
In addition to this research within health facility, the project research assistant has carried out participant observation during 6 field trips led by the Lassa outreach team from Kenema government hospital following suspected and confirmed cases of Lassa fever. She has carried out interviews with community members, and relatives of people with Lassa Fever and carried out observations of the Lassa outreach work. We have also interviewed 12 survivors of Lassa Fever about their experiences with the disease.
In addition to fieldwork in Sierra Leone, which will be carried about by the PI and a Sierra Leonean fieldworker, the PI has also been undertaking interview-based and historical work in the UK.
Key Preliminary Findings
(1) Lassa Management

• All health workers we have interviewed know about Lassa Fever and are aware of clinical presentation and symptoms.
• There are clear functioning systems in place to manage clinical cases and for follow up case investigation
• However, these systems tend to be reactive rather than preventative. In most cases clinical condition is already very severe before patients are referred for specialist treatment.
• Anecdotal evidence suggests that some patients with fever are not attending health facilities because they are still frightened of Ebola.
• In peripheral health settings, staff cannot always rule out other fevers including malaria and typhoid, so Lassa can go unnoticed until it is very severe, especially when there is no bleeding.
• Specialist staff at the Lassa Ward have extensive IPC knowledge. Our interview and observational data suggests they are very careful with IPC, especially after their experiences with Ebola.
• Although IPC use is better integrated across other health settings including other sites in KGH some non-Lassa nurses are not using IPC systematically and are at risk of contracting the disease.
• Some Lassa patients are being identified at triage at KHG but others are slipping through. The triage system is not effectively identifying all people who are sick with Lassa fever, putting staff and other patients at risk.
(2) Domestic Management

• Most people we have interviewed know about Lassa Fever, but many think it is transmitted by the shrew (rather than M. Natalensis)
• Most people find rats to be a pest in their homes because they steal food and make a lot of noise at night time. They would like to control them. Some use poisons and some keep cats, but others do not like cats.
• Poor maintenance of houses and the storage of food inside makes rat infestation more likely (= poverty may be a significant risk factor for the disease)
• Children are particularly likely to hunt and eat rats, and may be more at risk than adults
• People who have eaten rats for years and never been sick are unlikely to stop eating rats when these provide a tasty source of protein.
• It can be a big shock for families who get a case of Lassa fever, and this sometimes makes them reluctant to engage with health authorities We have received a 6 month no-cost extension to the project to account for delays in fieldwork that were caused by the Ebola epidemic and the pregnancy of a research assistant on the project.
Exploitation Route Overall, whilst we have made excellent progress with the planned interviews with health staff, we need to complete the planned fieldwork at the community level and increase the size of our data set in relation to affected communities, outreach activities and modes of domestic control of rats. Also, we plan a follow-up participatory workshop to see the progress of action plans made during the first workshop as part of our pathways to impact activities.
In the UK, the PI will continue with carrying out interviews with scientists and relief workers who have been involved in Lassa control in Sierra Leone in addition to leading the work of publication and project outputs.
Sectors Agriculture, Food and Drink,Healthcare

 
Description Owing to the ideas and research I was developing within the FRL award, I was in the perfect position to join an interdisciplinary research team responding to the Ebola outbreak in Sierra Leone. Our research work on the management of Ebola within Primary Health Units impacted the work of the national Ebola Response Consortium, who commented that 'the research provided a useful insight into the complexity of IPC attitudes and practice...[and] has reinforced the approach that we were/are taking ie) sustained supervisions and mentorship'. 2017 Report Update: As part of pathways to impact activities the PI organised an action research workshop in September 2016. This presented the insights our ongoing research on at Lassa management in broad terms including case management, domestic disease control interventions, and disease surveillance, through interviews and observations. In the light of initial research findings, the workshop sought to document perceptions of a range of stakeholders regarding the effectiveness of existing health systems interventions and to develop priorities for action and recommendations for improvements. In particular, we wanted to harness opportunities and insights following recent experiences during the Ebola outbreak. What could be learnt or improved in relation to Lassa management at this time? It is envisaged that the insights from the workshop will be published as a scientific article and a report for stakeholders. This is currently in development. The aim of the workshop was to develop a comprehensive knowledge base around the following: (1) Existing health systems interventions to manage Lassa fever and how these are perceived by those who are involved in them (2) An awareness of gaps in interventions from the perspective of key stakeholders and their sense of how future interventions should be prioritised. The workshop involved the following activities: (1) Collaborative mapping of existing Lassa fever interventions, successes, and gaps in services (2) Developing a list of desired interventions and ranking these in order of importance and feasibility (3) Thinking about how community management can better intersect with wider health systems (4) Generating an action plan to make these changes These activities were undertaken using participatory methods such as group brainstorming, map drawing and ranking exercises. Workshop Facilitators included: Dr Donald Grant (MOHS); Dr Robert Samuels (MOHS); Dr Rashid Ansumana (Mercy Hospital); Dr Hannah Brown (Durham University) Invited Participants included representatives from Bo and Kenema DHMTs; Clinicians and laboratory staff working in affected areas; representatives from the NGO and humanitarian sectors; and national and international researchers working on Lassa fever. 2018 update: Results from our research have been published in leading public health journals with potential for wide scholarly and practical influence. I have met with the Senior Director for strategy and policy in the Institute of the President, Sierra Leone and am preparing material to present him during a field visit in May 2018.
Sector Healthcare
Impact Types Societal,Policy & public services

 
Description 'Care in Crisis: Ethnographic Perspectives on Humanitarianism. Workshop funding. Co-organiser.
Amount € 9,600 (EUR)
Organisation Fritz Thyssen Foundation 
Sector Charity/Non Profit
Country Germany
Start 02/2018 
End 02/2018
 
Description Durham Doctoral Scholarship for Abby King, lead supervisor
Amount £100,000 (GBP)
Organisation Durham University 
Sector Academic/University
Country United Kingdom
Start 01/2018 
End 12/2020
 
Description Durham Doctoral Scholarship for Danson Mwangi as lead supervisor
Amount £96,500 (GBP)
Organisation Durham University 
Sector Academic/University
Country United Kingdom
Start 09/2016 
End 08/2019
 
Description Durham Doctoral Scholarship for Katalin Bobowick as second supervisor
Amount £96,500 (GBP)
Organisation Durham University 
Sector Academic/University
Country United Kingdom
Start 09/2016 
End 08/2019
 
Description Royal Thai Government Scholarship for Lila Warawatsunthon as lead supervisor
Amount £100,000 (GBP)
Organisation Government of Thailand 
Sector Public
Country Thailand
Start 10/2017 
End 09/2020
 
Description IRC Ebola response collaboration 
Organisation International Rescue Committee
Country United States 
Sector Charity/Non Profit 
PI Contribution I worked alongside IRC on an action research project with health workers to improve use of PPE at peripheral health centres in Eastern Sierra Leone at the height of the Ebola outbreak. Co-authored publications emerging from this project are currently under review.
Collaborator Contribution We worked in health centres where IRC had been engaged for many years. They led the logistics of the research intervention.
Impact PARTICIPATORY ACTION TO REINFORCE INFECTION PREVENTION & CONTROL FOR EBOLA VIRUS DISEASE IN SIERRA LEONE A mixed-methods, participatory study. Final Report, May 2015 'Improving Ebola infection prevention and control in primary health care facilities in Sierra Leone: a mixed-methods study' published by BMJ Global Health 'Health care providers on the frontlines: A qualitative investigation of the social and emotional impact of delivering health services during Sierra Leone's Ebola epidemic'. Published by Health Policy and Planning.
Start Year 2014
 
Description Ministry of Health, Sierra Leone 
Organisation Ministry of Public Health and Sanitation, Sierra Leone
Country Sierra Leone 
Sector Public 
PI Contribution I am collaborating with Col Foday Sahr, Professor of Medicine at University of Sierra Leone and Dr Donald Grant, Clinician, Kenema District Hospital as part of the pathways to impact for this award
Collaborator Contribution Colonel Sahr and Dr Grant are advisers on the grant and are supporting me in managing the grant and maximising access.
Impact There is one publication output from this collaboration: Brown, Hannah, Kelly, Ann H., Marí Sáez, Almudena, Fichet-Calvet, Elisabeth, Ansumana, Rashid, Bonwitt, Jesse, Magassouba, N'Faly, Sahr, Foday & Borchert, Matthias (2015). Extending the 'social' Anthropological contributions to the study of viral haemorrhagic fevers. PLOS Neglected Tropical Diseases 9(4): e0003651. Other outputs are delayed because fieldwork could not commence until the Ebola outbreak had subsided. During 2016 the following outputs have been added: September 2106 - Participatory Action Research Workshop, Kenema Publications: (2016) Bonwitt, J., Sáez, A.M., Lamin, J., Ansumana, R., Dawson, M., Buanie, J., Lamin, J., Sondufu, D., Borchert, M., Sahr, F., Fichet-Calvet, E. & Brown, Hannah (2017). At home with Mastomys and Rattus: human-rodent interactions and potential for primary transmission of Lassa virus in domestic spaces. American Journal of Tropical Medicine & Hygiene (submitted) Bonwitt, Jesse, Martin Kandeh, Michael Dawson, Rashid Ansumana, Foday Sahr, Ann Kelly, Hannah Brown. Participation of women and children in hunting activities in Sierra Leone and implications for control of zoonotic infections. PLOS NTDS,
Start Year 2015
 
Description Researching Africa Network 
Organisation Durham University
Country United Kingdom 
Sector Academic/University 
PI Contribution In collaboration with Laura Routley, lecturer in Politics at Newcastle University, I have launched a new network for African Studies in the North East.
Collaborator Contribution We are sharing the administration and are looking for funding opportunities together
Impact We held a major launch event in January 2018, supported by the International Office at Durham University
Start Year 2018
 
Description Visiting Fellowship Freie Universität Berlin 
Organisation Free University of Berlin
Department Department of Social Anthropology
PI Contribution I spent five months working in the Freie Universitat, building networks in Germany and carrying out research. The workshop i organised in Mainz 2018 was a direct outcome of the time I spent in Berlin.
Collaborator Contribution They provided me with office space and academic resources
Impact Care in Crisis Workshop, Mainz 2018. Multidisciplinary - refugee studies, medical anthropology, humanitarianism
Start Year 2017
 
Description Participatory Action Research Workshop 'Post-Ebola Health systems for Lassa Fever in Sierra Leone' 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Professional Practitioners
Results and Impact Workshop plan:

This workshop will combine the insights of two on-going social science research projects that are studying the management of Lassa Fever from the community to the clinical level. Our work has looked at Lassa management in broad terms including case management, domestic disease control interventions, and disease surveillance, through interviews and observations. We will present some preliminary findings from this work during the workshop and use the insights from this research to engage in discussion about the management of Lassa fever.

In the light of initial research findings, the workshop seeks to document perceptions of a range of stakeholders regarding the effectiveness of existing health systems interventions and to develop priorities for action and recommendations for improvements. In particular, we seek to harness opportunities and insights following recent experiences during the Ebola outbreak. What can be learnt or improved in relation to Lassa management at this time?

It is envisaged that the insights from the workshop will be published as a scientific article and a report for stakeholders.

The aim of the workshop is to develop a comprehensive knowledge base around the following:

(1) Existing health systems interventions to manage Lassa fever and how these are perceived by those who are involved in them

(2) An awareness of gaps in interventions from the perspective of key stakeholders and their sense of how future interventions should be prioritised.


The workshop will involve the following activities:

(1) Collaborative mapping of existing Lassa fever interventions, successes, and gaps in services
(2) Developing a list of desired interventions and ranking these in order of importance and feasibility
(3) Thinking about how community management can better intersect with wider health systems
(4) Generating an action plan to make these changes

These activities will be undertaken using participatory methods such as group brainstorming, map drawing and ranking exercises.

Workshop Facilitators include: Dr Donald Grant (MOHS); Dr Robert Samuels (MOHS); Dr Rashid Ansumana (Mercy Hospital); Dr Hannah Brown (Durham University)

Invited Participants include representatives from Bo and Kenema DHMTs; Clinicians and laboratory staff working in affected areas; representatives from the NGO and humanitarian sectors; and national and international researchers working on Lassa fever.

Workshop outputs:

The workshop was successfully carried out as planned. The PI is currently reviewing data collected. Recordings from the workshop have been transcribed and are currently being coded for analysis in Nvivo
Year(s) Of Engagement Activity 2009,2016