Department of Microbiology, Immunology and Contagious Diseases, Institut Agronomique et Vétérinaire Hassan II - B.P. 6202, Rabat-Morocco
Limited capacity to design and implement programmes of surveillance, and control of animal diseases such as bovine tuberculosis, is one of the constraints restricting the ability of developing countries to promote livestock industry and to alleviate poverty. The present paper describes the contribution of an FAO Technical Cooperation Project (TCP/MOR/2904) to building and improving the capacity for surveillance and control of bovine tuberculosis in the Kingdom of Morocco. For the purpose of this paper, capacity building is defined as the building of organizational and technical abilities, behaviours, relationships and values that enable individuals, groups and organizations to enhance their performance effectively and to achieve their objectives over time. Surveillance is defined as the "systematic" collection, analysis, interpretation, and timely dissemination of health data for the planning, implementation, and evaluation of health programmes (Robinson et al., 2003). Animal disease control refers to policies and procedures aimed at preventing and minimizing the risk of spreading disease in animals in order to reduce its occurrence to an acceptable level or to eradicate it from the population.
1. STATE OF THE ART
Bovine tuberculosis is an enzootic disease caused by Mycobacterium bovis. The disease affects primarily cattle but also other domestic and wild mammals and is transmissible to humans. In developed countries, the public health significance and economic importance of this infection has resulted in the design and implementation of successful long-term programmes for control and/or eradication of tuberculosis in cattle. These are based on the "test and slaughter" method (Frye, 1995; Thoen, Karlson and Himes, 1981).
The success of these programmes is largely due to the capacity of professionals to:
assess accurately the magnitude of the disease in cattle and its public health significance or risk;
design control programme with clear objectives;
promulgate and enforce appropriate regulations;
implement sequentially, as planned, the components of the programme;
allocate appropriate and durable resources; and
evaluate and adjust (if necessary) the programme continuously.
Surveillance of bovine tuberculosis in cattle is an essential component of disease control programmes in developed countries. Periodic tuberculin testing of cattle is traditionally used as a tool for active surveillance and control of the disease. These control programmes have allowed for a dramatic decrease in the prevalence of bovine tuberculosis in developed nations (Frye, 1995). Consequently, a novel approach, based on passive slaughterhouse surveillance of bovine tuberculosis combined to tracing lesioned animals to their herds of origin with subsequent epidemiological investigation to locate herds that had been exposed to infection, has been developed (Frye, 1995). The success of this cost-effective approach depends highly on:
the capacity of meat inspectors to recognize and submit potential tuberculous lesions for laboratory examination;
the capacity of veterinary diagnostic laboratories to diagnose bovine tuberculosis by histopathology, culture and identification of tubercle bacilli;
the existence of an efficient cattle identification system that allows for effective trace-back (Frye, 1995).
During the past two decades, tremendous progress, based on molecular biology techniques, has been achieved in laboratory diagnosis and molecular epidemiology of tuberculosis (Van Embden, Schouls and Van Soolingen, 1995). These techniques are costly and require specialized laboratories and competencies. As a consequence, they are presently used for research and molecular epidemiology purposes. In developing countries, especially in Africa, bovine tuberculosis is thought to be widespread among humans. Poverty, sociocultural habits, close association between humans and animals and the HIV/AIDS epidemic are important factors in the dissemination of M. bovis infection (O'Reilly and Daborn, 1995). Despite the importance of human tuberculosis in these countries, little information is available on the epidemiology, and zoonotic implication of bovine tuberculosis (Berrada and Barajas-Rojas, 1995; Cosivi, 1997). Among the reasons that account for this situation are:
the chronic nature of the disease and the simultaneous existence of other diseases that have immediate devastating effects (i.e. FMD, PPR, CBPP, parasitic diseases, etc.) - this leads to bovine tuberculosis being considered a minor problem (Chillaud, 1992);
the insidious nature of tuberculosis - losses due to infection with tubercle bacilli are often overlooked by farmers and governments;
the lack of close cooperation between medical and veterinary professionals to address the public health significance of bovine tuberculosis; and
the limited capacity (in terms of infrastructure, human and financial resources) of developing countries to design and implement programmes of surveillance and control for bovine tuberculosis.
Developing countries, such as the Kingdom of Morocco, whose economies underwent structural adjustment and the privatization of public veterinary services during the 1980s and the 1990s, faced significant challenges in tacking zoonotic diseases such as bovine tuberculosis (Robinson, 2003; Tber, Fikri and Laghzaoui, 1995). As a consequence, in the Kingdom of Morocco, prevalence of bovine tuberculosis in dairy cattle (based on tuberculin testing) increased from an average of 1.78 percent in 1988 (4) to an average of 17.8 percent in 2004, coinciding with the interruption, in 1989, of a public-funded control programme initiated in 1976 (Fikri, 1997). Realizing the magnitude of the problem, the Moroccan Government requested FAO assistance in 2001 to design a strategy for control of bovine tuberculosis. In August 2002, FAO and the Moroccan Government signed a 302 000 US$ Technical Cooperation Project (TCP/MOR/2904). The aims of the project were to:
assess the epidemiological situation of bovine tuberculosis in the Kingdom of Morocco;
strengthen the data-analysis capacity of the Moroccan veterinary authority through the use of a Java version of TADInfo developed by FAO;
build and strengthen existing capacities for laboratory diagnosis of animal tuberculosis;
improve the capacity of slaughterers and abattoir veterinarians to recognize and to report tuberculosis in carcasses;
create public and farmer awareness of dangers/risks associated with bovine tuberculosis, ways to prevent exposure to infection and measures to control the disease in cattle; and
design a pilot plan for control of bovine tuberculosis in cattle at a regional level within the Kingdom of Morocco.
As will be shown below, capacity-building through trainings, skills development and raising awareness was the cornerstone of TCP/MOR/2904.
1.1. Building capacity for surveillance of bovine tuberculosis in the Kingdom of Morocco
1.1.1. Building technical capacity for tuberculin testing and designing epidemiological surveys
A control programme for bovine tuberculosis is based on accurate information on the prevalence and epidemiology of the disease. Surveillance of tuberculosis can be achieved either passively by monitoring tuberculosis in slaughterhouses or actively by cattle tuberculin-testing campaigns. In the Kingdom of Morocco, official reports, based on slaughterhouse monitoring, grossly underestimated the incidence of the disease compared to the true prevalence in the field. Thus, it was necessary to design and carry out a national survey on a statistically representative sample of herds. The objectives of this survey were to:
assess the herd prevalence at regional and national levels with regard to bovine tuberculosis by tuberculin testing sampled cattle herds; and
assess the prevalence of bovine tuberculosis in cattle within sampled herds.
The expertise needed to design a national survey on bovine tuberculosis was provided by international and national expert consultants recruited under TCP/MOR/2904 with specific qualifications and terms of reference. The survey was designed with the cooperation of the Moroccan veterinary authority. As designed, the survey was conducted nationwide according to a standardized and uniform method of tuberculin testing and result reporting. For this purpose, two workshop/training sessions were organized for 30 field state veterinarians practicing in different regions, under the supervision of international and national consultants. Each training session included a theoretical presentation on methods for screening, reporting and controlling bovine tuberculosis, as well as a practical workshop on tuberculin testing of cattle in selected herds. Appropriate documentation and audiovisual aids were provided to participants. Participants in the workshop were expected to extend the acquired knowledge to their peers in the veterinary services. Treatment and analysis of survey results were conducted by a national consultant with the collaboration of trained senior veterinarians.
1.1.2. Building capacity for quality control of tuberculin
Surveillance and control of bovine tuberculosis in cattle depends on tuberculin testing of animals. To ensure reliability and allow significant comparison of tuberculin test results over time it is essential to use high quality tuberculins with precise potencies. Thus, quality control of tuberculin is an important component of tuberculosis surveillance and control programmes.
In the perspective of implementing a bovine tuberculosis control programme in the Kingdom of Morocco, a senior veterinarian from the national laboratory of veterinary drug and vaccine control benefited from specialized training in a French reference laboratory for Mycobacteria spp. The training was financially supported by TCP/MOR/2904.
1.1.3. Strengthening capacity for epidemiological data analysis
Strengthening Moroccan veterinary capacity for epidemiological data analysis was the focus of a one-week mission conducted by an FAO expert in the Kingdom of Morocco. During her mission, the FAO expert trained several Moroccan senior veterinarians on the use of the Java version of TADInfo, newly developed by FAO.
1.1.4. Improving the capacity of meat inspectors to recognize and to report tuberculosis on carcasses
A uniform method for recognizing tuberculous lesions at meat inspection is an important component of disease surveillance and control programmes. It also provides solid support for the credibility of the tuberculin test and slaughter of reactors programme. For this reason, two workshop/training sessions were organized for 30 field state meat-inspector veterinarians practicing in different slaughterhouses, under the supervision of a national consultant. Each training session included a theoretical presentation on a uniform and efficient method for recognizing and reporting tuberculous lesions, as well as a practical workshop on tuberculous carcasses conducted in a selected slaughterhouse. Condemnation of carcasses due to tuberculosis was also reviewed with regard to disease forms and national regulation. Appropriate documentation and audiovisual aids were provided to participants who were expected to extend the acquired knowledge to their technicians and peers. Furthermore, the workshop represented an excellent opportunity to design a national form for uniform reporting of tuberculosis in the slaughterhouse to the central veterinary authority in charge of disease surveillance. The activities outlined above undoubtedly enhanced veterinary institutional and technical capacities, in terms of disease surveillance and control. They also helped the Kingdom of Morocco to define the magnitude of bovine tuberculosis in its cattle sector at the regional and national level.
1.2. Building and strengthening existing capacities of laboratory diagnosis of animal tuberculosis
As mentioned earlier, laboratory diagnosis of bovine tuberculosis is an important component of disease control and research programmes. Furthermore, it plays a critical role in settling disputes that may arise between farmers and veterinarians in the course of a control programme over the slaughter of reactor cattle not harbouring visible tuberculous lesions. Laboratory diagnosis of tuberculosis requires appropriate facilities, safety procedures, special skills and appropriate laboratory procedures. In the Kingdom of Morocco, there are six regional state veterinary laboratories. However, none of them had the required capacity for isolating and identifying tubercle bacilli. To build and strengthen existing capacity of these laboratories to diagnose animal tuberculosis, it was necessary to:
train personnel of these laboratories according to a set of uniform safety and laboratory procedures; and
complement the equipment of laboratories with necessary material, reagents, chemical and culture media.
For this purpose, two training sessions were organized for 14 participants practicing in the above-mentioned laboratories. Supervision was provided by an international and a national expert-consultant recruited under TCP/MOR/2904 with specific qualifications and terms of reference. Each training session included a theoretical presentation on safety procedures and laboratory methods for diagnosing animal tuberculosis, as well as a relevant practical workshop. Appropriate documentation and audiovisual aids were provided to participants. In the perspective of establishing a Mycobacteria spp reference laboratory in the Kingdom of Morocco, a senior laboratory veterinarian benefited from four weeks training in a French reference laboratory. The workshop sessions organized in the Kingdom of Morocco as well as the training provided in France were financially supported by TCP/MOR/2904. They allowed the Kingdom of Morocco to built and strengthen its capacity for laboratory diagnosis and research of animal mycobacterial diseases, including tuberculosis. Such capacity will be required while implementing a bovine tuberculosis control programme.
1.3. Building leadership
Vision and respectability are necessary components of leadership. The experiences of developed countries in the successful control of animal tuberculosis may aid in building vision to design and implement the disease control programme in the Kingdom of Morocco. For this purpose, a high-ranking Moroccan senior veterinarian made a study tour in France to exchange experiences on the possible ways to tackle animal tuberculosis.
1.4. Building farmer awareness, trust and advocacy
Public relations and educational aspects of tuberculosis control in developing countries such as the Kingdom of Morocco are critical points to consider in the course of a control programme. The intent is to increase the level of understanding of tuberculosis problems and solutions, to have a positive feedback and to build trust and support from the public as well as from the professionals involved (Berrada and Barajas-Rojas, 1995).. In addition, organizing farmers into professional organizations for the control of bovine tuberculosis was encouraged. For these purposes, several actions were undertaken in the course of TCP/MOR/2904. These included:
organizing five regional workshops for the benefit of 448 farmers;
the design and wide distribution of a poster on bovine tuberculosis;
the production and wide circulation of an extension booklet on bovine tuberculosis;
making a video on bovine tuberculosis; and
the broadcasting over several weeks of a radio programmes devoted to bovine tuberculosis.
Positive ideas and feedback from farmers were recorded following the achievement of the above listed activities.
1.5. Designing a bovine tuberculosis pilot control programme
A pilot programme for the control of bovine tuberculosis was designed by the project's consultants with the active collaboration of a panel of professionals. The programme aims at:
controlling bovine tuberculosis at a regional level within the Kingdom of Morocco and its progressive extension to other regions whenever it is possible and feasible; and
promoting healthier herds and products.
In developing this pilot control programme, several points were considered. These include:
prerequisite conditions to implement control programme (regulation, funding, cattle identification system, eligible regions, etc.);
the results of a national survey to assess herd and population prevalence of cattle tuberculosis at national and regional levels;
the estimation of annual cost to implement the pilot control programme in a specific region;
the feasibility of the programme in terms of delivery logistics and qualified human resources; and
the contribution of each professional category to the delivery of the programme.
2. UP-AND-COMING TRENDS AND DESIRED SOLUTIONS
The livestock sector plays an important role in the economy of several developing countries and contributes to alleviating poverty and malnutrition in rural communities. The human population in these countries is constantly increasing and the demand for food of animal origin will consequently follow. As a result, many changes are foreseen in coming decades. These include intensification of animal production with the subsequent risk of serious zoonotic disease problems (e.g. bovine tuberculosis) in human and animal populations to be addressed. National mechanisms and international cooperation for capacity-building in developing countries are the focuses of chapter 37 of Agenda 21 (Commission on Sustainable Development at its fourth (1996), fifth (1997) and sixth (1998) sessions) and by the United Nations general Assembly at its Special Session to review the implementation of Agenda 21. On the other hand, the FAO expert consultation on community-based public health (VPH) systems held in 2003 recommended providing support to countries for identifying and solving problems especially related to endemic and persistent zoonoses (http://www.un.org/esa/sustdev/documents/agenda21/english/agenda21chapter37.htm). Thus, regional or international assistance may be needed for some developing countries to trigger mechanisms by which the magnitude of bovine tuberculosis in animal and human populations could be addressed and to consequently build progressive capacity for surveillance and control of the disease.
3. THE WAY FORWARD
Recognizing the importance of a zoonotic disease such as bovine tuberculosis in the animal and human populations of a given country is a necessary step before decision-makers list it as a priority problem and raise national or international interest to the level that will result in building the necessary capacities for initiating an appropriate control programme. Assessing the importance of bovine tuberculosis in cattle implies the existence of an effective surveillance programme based on screening and/or slaughterhouse monitoring. Systematic tuberculin testing of cattle to determine the prevalence of bovine tuberculosis is costly and may not be feasible in many developing countries. Thus, well-designed surveys based on testing a representative sample may constitute a reliable and cost-effective alternative.
Survey results, cost estimation and technical feasibility are some of the elements to consider in designing a control programme and in outlining institutional and technical capacities to be developed. As indicated earlier, institutional and technical capacity building and strengthening helped The Kingdom of Morocco to address bovine tuberculosis as a priority problem and to design a pilot programme for surveillance and control. In this regard, FAO assistance through TCP/MOR/2904 played a critical role in this capacity building effort and in establishing farmer awareness, trust and advocacy to adhere to the proposed control plan. Moreover, it triggered a dynamic process within government agencies, professional organizations and farmers that will allow for implementation of a pilot control programme soon. The success of such a pilot programme will depend on:
the commitment of farmers, agencies and organizations involved;
the input and close cooperation of veterinary and medical agencies; and
the availability of appropriate funds.
CONCLUSION AND RECOMMENDATIONS
Through a well-designed project, a developing country such as The Kingdom of Morocco built and strengthened organizational and technical capacities for surveillance and control of bovine tuberculosis. In this regard TCP/MOR/2904 can serve as a model for other capacity building programmes in developing countries with similar levels of development. At the regional level, it is recommended that collaborating and reference centres for training, surveillance, diagnosis and research on bovine tuberculosis be established. At the international level, it is recommended that developing countries be assisted in developing and financing participatory approaches to define country needs and priorities and in so doing to strengthen human resource and institutional capabilities.
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