Process evaluation of integrated West Nile virus surveillance in northern Italy: an example of a One Health approach in public health policy

https://doi.org/10.1016/j.evalprogplan.2021.101991Get rights and content

Highlights

  • West Nile virus (WNV) infection in humans and animal hosts is spreading in Europe.

  • WNV surveillance benefits from interdisciplinary, cross-sectoral collaboration.

  • Cross-sectoral surveillance systems can be evaluated using process evaluation.

  • Process evaluation is key for design and improvement of cross-sectorial surveillance.

Abstract

West Nile virus (WNV) is endemic in the Po valley area in northern Italy. Regional health authorities have implemented integrated WNV surveillance following a One Health approach, based on collaboration between human, animal and environmental health institutions. We evaluated this integrated WNV surveillance system in Emilia-Romagna, Lombardy and Piedmont regions by means of a process evaluation. We examined the system’s implementation fidelity, dose delivered and received, reach, and we identified strengths and weaknesses in the system. Qualitative and semi-quantitative data were obtained from three regional focus groups. Data were discussed in a follow up focus group, where participants suggested recommendations for improving the surveillance system.

Inter-institutional and interdisciplinary integration and the creation of a 'community of practice' were identified as key elements for effective surveillance. We identified differences in the degree of interdisciplinary integration in the three regions, likely due to different epidemiological situations and years of experience in surveillance implementation. Greater collaboration and sharing of information, public engagement and economic assessments of the integrated surveillance approach would facilitate its social recognition and guarantee its sustainability through dedicated funding. We demonstrate that a transdisciplinary research approach based on process evaluation has value for designing and fine-tuning integrated health surveillance systems.

Introduction

West Nile Virus (WNV) is an arthropod-borne Flavivirus which has worldwide distribution. It is maintained in a sylvatic cycle between mosquito vectors, mainly of the genus Culex, and birds as reservoir hosts. Birds are not usually clinically affected but develop high viral titres that are sufficient to infect mosquitoes during blood meals. Mammals, especially horses and humans, are susceptible to WNV infection but are dead-end hosts because they are unable to transmit WNV to insect vectors. After infection, most people do not develop symptoms, but about twenty percent may develop mild febrile illness (WNF) and less than one percent develop severe neurological disease (WNND). Blood transfusion and organ transplantation are additional transmission routes among people. The multiple routes of transmission and species involved result in a complex public health threat that requires a holistic approach for effective disease prevention and control.

Since it was first detected in Europe in the 1960s, the virus has spread and to date is endemic in several south and south-eastern European countries including Italy (ECDC, 2020). In Italy, WNV first appeared in horses in Tuscany in 1998 and re-emerged in 2008 with the first confirmed human cases of neurological disease in the Emilia-Romagna region (Rossini et al., 2008). West Nile Virus is endemic in the Po valley area of northern Italy where regional health authorities have implemented integrated WNV surveillance systems at regional levels within the regulatory framework of the national plan for the surveillance of human vector-borne diseases. The national plan is coordinated by the Ministry of Health which in Italy includes both public health and animal health services. West Nile Virus surveillance is based on a multi-disciplinary approach, involving experts from animal, human and environmental health (Rizzo et al., 2016). The main surveillance objective is the early detection of WNV circulation in birds (mainly corvids), mosquitoes, horses, and people, at the provincial level. Early detection triggers the rapid implementation of preventive measures at the provincial level that are aimed at reducing the risk of infection in people and horses.

A description of the WNV surveillance systems in the Emilia-Romagna, Lombardy and Piedmont regions of northern Italy has been previously reported (Angelini et al., 2010; Bellini et al., 2014; Chiari et al., 2015; Paternoster, Tomassone et al., 2017; Pautasso et al., 2016). Surveillance consists of a number of activities that are adjusted yearly according to the epidemiological situation during the previous transmission season. Surveillance activities include continuous syndromic surveillance for WNND in horses and humans, and seasonal surveillance (from April to November) for the detection of antibodies in sentinel birds and to detect the virus in wild birds and mosquitoes. After the first positive result in any animal species in any province, human blood donations and organs from people residing in, or having visited that province are screened for WNV. Since 2016, the regions of northern Italy have established data sharing mechanisms to improve surveillance sensitivity. They systematically share entomological surveillance data obtained from mosquito traps placed within 5 km of their regional and provincial borders. Thus, the detection of WNV in one of these entomological traps triggers control measures for blood and organ donations in the province(s) of that same region and also in adjacent province(s).

Since 2009 integrated surveillance for WNV has been implemented in the three regions covering the largest part of Italy’s Po valley; including Emilia-Romagna beginning in 2009, Lombardy beginning in 2014 and Piedmont beginning in 2016. The main actors in WNV surveillance come from different sectors including: 1) animal health: Istituti Zooprofilattici Sperimentali della Lombardia e dell’Emilia-Romagna (IZSLER) e del Piemonte, Liguria e Valle d’Aosta (IZSPLVA), Veterinary Services (Local Health Authorities - LHU), veterinary practitioners, horse farm owners, and hunters; 2) human health: Public Health Services (Local Health Authorities – LHU), regional blood centers, reference laboratories for human diagnostic; physicians, and hospitals; and 3) environmental health: entomology centers (Centre for Agriculture and Environment - CAA for Emilia-Romagna, Institute for Plants and Environment - IPLA for Piedmont). In this manuscript, we define ‘actors’ as a subgroup of stakeholders acting in the context of the initiative, according to Ruegg et al. (2018).

A semi quantitative evaluation of WNV integrated surveillance in Emilia-Romagna, Lombardy and Piedmont in 2016 was conducted- previously (Paternoster, Tomassone et al., 2017). The purpose of the current study was to evaluate the surveillance system and develop recommendations for improvements. We used a method called process evaluation (Saunders, Evans, & Joshi, 2005), which is an essential part of the design and testing of complex health interventions such as the WVN surveillance and response system in the Po valley. Compared to quantitative evaluations, process evaluation has the added value of clarifying how health interventions can be implemented and may provide different outcomes in different contexts. Process evaluation can provide valuable information for changing and improving health interventions. This qualitative evaluation was carried out through focus groups involving actors from all three health sectors (i.e. animal, human and environmental) and all three regions under study. The main objective of the evaluation was to identify strengths and weaknesses in system planning and implementation using the knowledge and experience of the actors involved.

Section snippets

Study design

We conducted a process evaluation of the integrated WNV surveillance system in three regions of northern Italy—Emilia-Romagna, Lombardy, and Piedmont—using focus groups. In total, we organised four focus groups including:

  • three initial focus groups, one in each of three regions under study, in order to collect information from the WNV surveillance actors in each region.

  • one follow up focus group was organised in Piedmont with participants from all three regions. The fourth focus group was used to

Strengths of surveillance planning and implementation

Participants from all three regions fully agreed on the importance of the high level of integration among actors and public health institutions present within the WNV surveillance regulatory framework. This integration reflects transdisciplinarity, a core aspect of the One Health (OH) approach. Transdisciplinarity is defined as the integration of knowledge and perspectives of different sectors and disciplines (Ruegg et al., 2018). Our qualitative data revealed an overall high level of fidelity

Discussion

In our process evaluation we analysed operational WNV surveillance systems in three regions of northern Italy. During three initial regional focus groups, we assessed the completeness of the interventions, the engagement of stakeholders, and identified barriers to implementation. In a follow-up focus group, we worked collaboratively with surveillance actors (study participants) to produce suggestions for improvement of the legislation, taking into account practical issues that could potentially

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

CRediT authorship contribution statement

MM: Data curation, Formal analysis, Investigation, Writing- Original draft preparation; GP and LT: Conceptualization, Methodology, Investigation, Formal analysis, Project administration, Resources, Writing - Original draft preparation; GB, ARF: Conceptualization, Methodology, Investigation, Formal analysis, Writing- review and editing; Regional Working groups: Investigation, Writing - review & editing; JB: Writing - review & editing.

Declaration of Competing Interest

None.

Acknowledgements

We are very thankful to Marco Tamba (IZSLER) for providing constructive comments and relevant information for this study, and for the help in organizing the focus groups. We thank Barbara Renate Vogler (Department for Poultry and Rabbit Diseases, University of Zurich) for assistance with revising this manuscript. The research started under the networking of the European COST Action TD1404 NEOH – Network for the Evaluation of One Health (NEOH).

Monica Marchino, DVM, is employed at the Experimental Zooprophylactic Institute of Piedmont, Aosta Valley and Liguria (IZSPLVA). She is attending the last year of a three-year post-graduate course in “Animal Health, Farming and Zootechnical Productions" at the University of Turin, where she graduated in 2018 with a thesis on the evaluation of WNV surveillance system in northern Italy. Her interests include the One Health approach, public and animal health, zoonoses (diagnosis, surveillance,

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    Giulia Paternoster is a veterinary epidemiologist specialised in public health with a strong interest in the epidemiology of infectious and zoonotic diseases within a One Health perspective. Giulia currently works as a research associate at the Swiss Federal Food Safety and Veterinary Office (FSVO). She completed a PhD in Epidemiology and Biostatistics at the Life Science Zurich Graduate School (LSZGS) in 2021. Previously, she worked as an epidemiologist at the Istituto Zooprofilattico Sperimentale della Lombardia e Dell'Emilia Romagna (IZSLER, Italy, between 2012 and 2016), and as a visiting researcher at Kansas State University (Kansas, USA, in 2017).

    Anna Rosa Favretto is full professor of Sociology at the University of Turin, and formerly at the University of Eastern Piedmont, Italy. Her current main fields of research concern children's health, therapeutic relationships, promotion of public health through the participation of the population, scientific and lay knowledge. Her latest research has concerned the contrast to West Nile Disease in northern Italy, antimicrobial resistance in intensive farming, therapeutic relationships in pediatrics.

    Giacomo Balduzzi, PhD, is post-doc research fellow at the University of Eastern Piedmont, Department of Law, Political, Economic and Social Sciences. He is Temporary Lecturer in 'Sociology of collective choices' and 'Participatory design in social and health fields' . He has been member of the research group “NEOH”, Network for Evaluation of One Health (Programme EU COST). His research interests concern the relationship between economy, society and local and regional systems, focusing the forms of participation of individual/collective actors in the choices and the governance of social processes.

    John Berezowski DVM, PhD is an epidemiologist working as a researcher and professor/chair in disease surveillance in the Scotland’s Rural College, Inverness, UK. He has practical experience in the design, implementation and operation of disease surveillance systems in Canada, Africa and Europe. His main research interests include developing new approaches to surveillance and developing new methods for creating information and knowledge to to support decision making in animal health, public health and One Health.

    Laura Tomassone, DVM, PhD, Master in Veterinary Epidemiology and Public Health, is researcher and lecturer at the Department of Veterinary Science, University of Turin, Italy. Her main research interests are related to the eco-epidemiology and surveillance of infectious diseases, the dynamics of zoonosis transmission, epidemiology of antimicrobial resistance, and integrated approaches to health/One Health.

    1

    See Appendix A for further details.

    2

    These authors have contributed equally to this work

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