EcoHealth DOI: 10.1007/s10393-010-0357-3

Ó 2010 International Association for Ecology and Health

Original Contribution

Zoonotic Emerging Infectious Disease in Selected Countries in Southeast Asia: Insights from Ecohealth Delia Grace,1 Jeffrey Gilbert,1 M. Lucila Lapar,1 Fred Unger,1 Sonia Fe`vre,2 Hung Nguyen-Viet,3,4,5 and Esther Schelling3 1

International Livestock Research Institute (ILRI), 30709, Nairobi, Kenya Veterinarians Without Borders/Ve´te´rinaires Aans Frontie`res—Canada, Singapore, Singapore 3 Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute and University of Basel, Basel, Switzerland 4 Department of Water and Sanitation in Developing Countries, Eawag/Sandec (Swiss Federal Institute of Aquatic Science and Technology), Du¨bendorf, Switzerland 5 Department of Environmental Health, Hanoi School of Public Health, Hanoi, Vietnam 2

Abstract: Most emerging diseases of humans originate in animals, and zoonotic emerging infectious diseases (EIDs) threaten human, animal, and environment health. We report on a scoping study to assess actors, linkages, priorities, and needs related to management of these diseases from the perspective of key stakeholders in three countries in Southeast Asia. A comprehensive interview guide was developed and in-depth interviews completed with 21 key stakeholders in Vietnam, Lao People’s Democratic Republic, and Cambodia. We found numerous relevant actors with a predominance of public sector and medical disciplines. More capacity weaknesses than strengths were reported, with risk analysis and research skills most lacking. Social network analysis of information flows showed policy-makers were regarded as mainly information recipients, research institutes as more information providers, and universities as both. Veterinary and livestock disciplines emerged as an important ‘‘boundary-spanning’’ organization with linkages to both human health and rural development. Avian influenza was regarded as the most important zoonotic EID, perhaps reflecting the priority-setting influence of actors outside the region. Stakeholders reported a high awareness of the ecological and socioeconomic drivers of disease emergence and a demand for disease prioritization, epidemiological skills, and economic and qualitative studies. Evaluated from an ecohealth perspective, human health is weakly integrated with socioeconomics, linkages to policy are stronger than to communities, participation occurs mainly at lower levels, and equity considerations are not fully considered. However, stakeholders have awareness of ecological and social determinants of health, and a basis exists on which transdisciplinarity, equity, and participation can be strengthened. Keywords: Emerging infectious diseases, zoonotic EIDs, Southeast Asia

INTRODUCTION Correspondence to: Delia Grace, e-mail: [email protected]

Emerging infectious diseases (EIDs) have been defined as diseases of infectious origin whose incidence has increased

Delia Grace et al.

within the past two decades, or threatens to increase in the near future (Institute of Medicine (IOM), 1992). There are around 150–300 human emerging infectious diseases, and most (60–75%) of these are zoonotic, that is, transmissible between animals and humans (Taylor et al., 2001; Jones et al., 2008). Zoonotic EIDs are feared because of their potential to shift from an animal-to-human to a human-to-human transmission route with deadly results, as exemplified by the Spanish flu pandemic of 1918 and the current human immunodeficiency virus (HIV) pandemic. Indeed, some of the most important infectious human diseases originated in animals, but are now no longer zoonotic (e.g., small pox, measles, and whooping cough) (Wolfe et al., 2007). Other zoonotic EIDs are problematic because they are maintained in livestock or wild animal reservoirs. Risk to humans increases when behavior change allows levels of pathogens to soar in their animal hosts (e.g., intensive farming leading to higher levels of food-borne pathogens), or allows more contacts with humans and infected animals (e.g., recreational activity exposing to Lyme disease). Yet other zoonotic EIDs are controlled in wealthy countries, but emerging elsewhere because of poverty or neglect. Rabies and brucellosis are examples of diseases well under control in rich countries, but widespread in poor countries. The natural history and epidemiology of zoonotic EIDs has implications for their management. By definition, zoonotic EIDs occur at the interface of animal and human health: as such, a ‘‘One Health’’ approach will facilitate surveillance and control (Zinsstag et al., 2007). Moreover, zoonotic EID emergence is driven by disturbance of the host (be it human, animal, or insect), pathogen, and environment equilibrium, with the implication that sociology, farming systems, and ecology can all contribute to better understanding of the genesis and, ultimately, detection and prevention of zoonotic EIDs. As for other infectious diseases, vulnerability to zoonotic EIDs is strongly influenced by poverty, inequality, and disempowerment. Addressing these socioeconomic and political aspects is a prerequisite for lasting health improvements. Ecohealth can be defined as systemic, participatory approaches to understanding and promoting health and well-being in the context of social and ecological interactions (Waltner-Toews, 2009). Ecohealth approaches, by linking health, environmental, and social processes, offer a framework and tools for understanding and managing zoonotic EID emergence and propagation. While ecohealth encompasses disparate schools of thought, the framework

developed by Lebel (2003) and promoted by the International Development Research Centre (IDRC) (http://www. idrc.org) is well adapted to the problem of zoonotic disease in poor communities. At its core lie three values: transdisciplinary research and action involving not only different disciplines, but policy-makers and communities; participation of communities and decision-makers in research design, implementation, and evaluation; and, equity—specifically gender equity and social and economic fairness. Southeast Asia is considered a crucible for zoonotic EID emergence, as witnessed, for example, by its selection as one of five global ‘‘hotspots’’ in the United States Agency for International Development (USAID)-funded project on Emerging Pandemic Threats commencing in 2009. Rapid economic and population growth creates conditions and drivers for disease emergence (especially uncontrolled urbanization, livestock intensification with limited biosecurity, environmental degradation, and encroachment on wildlife habitats). This article reports on a scoping study undertaken by a project aimed at improving the management of zoonotic EIDs in Southeast Asia within an ecohealth framework. The objective of the study was to assess the priorities and understanding of zoonotic EIDs, and their surveillance and control from the perspective of relevant stakeholders in three countries of the Mekong region, namely, Cambodia, the Lao People’s Democratic Republic (Lao PDR), and Vietnam. Putting people at the heart of research, the first aim was to identify the individuals and institutions relevant to an ecohealth approach to zoonotic EID management, and their current work related to zoonotic EIDs, as well as their perceived capacity strengths and weaknesses. Using information flow charts, we mapped linkages between actors both to better understand existing multidisciplinarity and to help in the future building of coalitions for innovations. Shifting to a disease perspective, the study assessed zoonotic EID priorities and trends, and lastly identified research gaps from the perspective of stakeholders. The study was analyzed by a multidisciplinary team using an ecohealth perspective.

MATERIALS

AND

METHODS

The study was carried out in three countries between October 2008 and July 2009. This involved an intensive preparation phase consisting of literature review, dialogue with experts, and finally a workshop in which key informants critically

ZEIDs in SE Asia: Insights from Ecohealth

reviewed the draft interview guide (Anonymous, 2008). The interview guide was pretested in the Mekong region and minor changes made. The final guide contained open and closed questions, and had three main sections: stakeholder mapping, analysis, and identification of boundary partners; assessment and understanding of priority zoonotic EIDs; and existing capacities and capacity needs assessment. We considered the stakeholders of zoonotic EIDs to be those organizations, groups, networks, or individuals with an important role in decision-making, research, training, and education or communication about zoonotic EIDs, as well as those likely to suffer the consequences of zoonotic EIDs. A list of potentials interviewees drawn from research, governmental, and private sector institutes was established for each country through expert consultation. Attention was given to a mix between research and service, and between the three main sectors of livestock/agriculture, health, and environment. Institutes were contacted with an invitation letter and invited to nominate an interviewee. The assigned person received the interview catalogue electronically, and was asked to read the interview guide beforehand and to prepare for the interview, if necessary, with the assistance of their colleagues at the institute. Interviewers (one male, one female) were drawn from different disciplines, and had postgraduate qualifications and several years of experience in the region. During the interview, the objective of the study was presented and ambiguities clarified. The interviewee was asked to complete the form before sending an electronic copy to the interviewer. In addition, interviewees were asked to send copies, if available, of zoonotic EIDrelated reports or documents they considered relevant, and a curriculum vitae was collected from each interviewee. A small honorarium of $100 was provided, half at the end of the interview and half on receiving the completed forms. Quantitative data were entered into AccessÒ and qualitative into ExcelÒ. We used Intercooled STATA 10 for Windows (StataÒ Corporation, College Station, TX) for analyses of quantitative data and NetDraw 2.081 (Analytic TechnologiesÒ, Cambridge, MA) to visualize and analyze the information flows between actors.

RESULTS

AND

DISCUSSION

Actors A total of 21 interviews were completed (2 in Lao PDR, 5 in Cambodia, and 14 in Vietnam). This reflected the greater number of actors in Vietnam, but also that fieldwork

started first in Vietnam and so more time was available. Interviewees were from the health sector (n = 7 from human health and n = 4 from animal health), rural development (n = 4), sociology and economics (n = 4), policy (n = 1), and ecology (n = 1). There were four women and 17 men among the respondents, and the response rate was just under 50%. For a survey targeting key decision-makers with busy schedules, this was quite a high level of response; for comparison, physician surveys in the USA typically have response rates of 40–50% (Burt and Woodwell, 2005). Given the absence of a definitive sampling frame of stakeholders of zoonotic EIDs in the three countries, there is inevitable concern over identification and response bias. Stakeholders were identified by expert consultation; we found that this soon resulted in circular recommendations, indicating a small number of relevant actors (or, less plausibly, the existence of unknown actors not linked to easily identifiable actors). It should be borne in mind that there are many nonnational actors working on zoonoses issues, but we deliberately focused on national actors. Our impression was that response rate was related to self-perceived knowledge and confidence. For example, some senior staff from a university agricultural faculty were nonrespondents, because they felt that they did not have expertise in diseases. So, although we might consider them as stakeholders, they did not consider themselves as such. As a result, expert, well-informed, and self-identified zoonotic EID actors are likely to be overrepresented; we feel this is not likely to invalidate results. The interviewees identified 95 key national and/or international zoonotic EID actors as stakeholders during the interviews, of which 37 were cited more than once. The public-funded sector dominated (87% of actors), nongovernmental organizations (NGOs) were scarce (11% of actors), and the private sector was negligible (2% of actors). Private sector participation has been a longstanding preoccupation for disease-control decision-makers; our study shows how large the gap still is between aspiration and reality. We further subdivided the public sector into research institutes, policy-making and implementing bodies (departments in a government ministry), and universities. A related category is international organizations (such as World Health Organization) and nonnational organizations (such as Western universities) which are generally public or quasi-public. Outside the public sector were nongovernment organizations (research and/or development NGOs) and the private sector. Figure 1 shows the proportion of actors according to these categories.

Delia Grace et al.

Figure 1. Stakeholders involved in zoonotic emerging infectious disease research and management, in three countries in the Mekong region, according to sector.

Although most interviewees were drawn from the veterinary, agriculture, and rural development sector, a high proportion of stakeholders considered key were drawn from the medical disciplines (41%), which may reflect the preconception that human health is the preserve of the medical discipline. Animal health (18%) and rural development (17%) were also well represented among stakeholders considered key, but sociology, economics, policy, and ecology individually accounted for less than 5% of key stakeholders. A fundamental premise of ecohealth is that human health is influenced by four interacting subsystems: ecological, sociological, political, and economic, and the integration of these epistemologies is needed to ensure relevance and impact of health research (Lebel, 2003). While it is positive to note that stakeholders from these disciplines were listed, they were not well represented. For example, no actors from the disciplines of ecology, sociology, policy, or economics were listed for Lao PDR, and in Cambodia only one stakeholder from the four supporting disciplines (ecology) was identified. It seems there is an opportunity for greater integration of supporting disciplines into the control of zoonotic EIDs. Networking is another aspect of multidisciplinarity; stakeholders were aware of 12 networks relevant to zoonotic EIDs, with highest recognition of the Association of Southeast Asian Nations (ASEAN) networks, followed by the Asian Partnership for Emerging Infectious Diseases Research (APEIR) and the Mekong Basin Disease Surveillance (MBDS). Interviewees perceived these regional networks as efficient platforms for exchange of information and lessons. Transdisciplinarity has been defined in different ways, but in the IDRC ecohealth framework used in this study, it implies not only a transcendence of disciplines, but also the

participation of scientists, communities, and policy-makers in research (Lebel, 2004). We found that while policymakers were well represented in the constellation of zoonotic EID actors identified by interviewees, communities were less often cited, being mentioned by only two interviewees. Confused and overlapping mandates have long been identified as an impediment to disease control. Our study found that a promising development was the establishment, in many countries, of a specific intersectoral body for coordination and management of communicable diseases. For example, in Lao PDR, a coordination office for influenza has developed into the National Emerging Infectious Diseases Coordinating Office (NEIDCO), with a mandate covering all emerging infectious diseases. This seems to be an externality of the avian influenza pandemic which has led to a strengthening realization that different disciplines need to work together to effectively tackle zoonoses. However, this coordination body remains dependent on external funding and not integral to long-term restructuring, calling into question long-term sustainability. Stakeholders were also asked to self-evaluate their capacity in seven areas which had been identified as key to better managing zoonotic EIDs during the lengthy design phase of the study. These were: zoonotic EIDs and ecohealth, systems thinking and models, risk analysis, socioeconomic analysis, institutional analysis, networking, and research skills. Interviewees reported many strengths, but in all areas they listed more perceived areas of weakness than strength. Perceived shortfalls (where the difference between strengths and weaknesses was greatest) were highest in the areas of risk analysis and research skills (Table 1). Although the respondents reported strengths in many components of

ZEIDs in SE Asia: Insights from Ecohealth

Table 1. Self-reported capacity strengths and weaknesses in a survey of stakeholders involved in zoonotic emerging infectious disease research and management in three countries in the Mekong region Capacity area

Report area is a strength (%)

Report area is a weakness (%)

Risk analysis Research skills Systems thinking and models Networking Institutional analysis Socioeconomic studies Ecohealth

22 33 36

78 67 64

37 42 45 50

63 58 55 50

ecohealth, overall there was a lack of understanding as to what an ecohealth approach actually entails. In the open section, interviewees were given the opportunity to share their views on other strengths and weaknesses. Lack of human resources, financial resources, knowledge, data, and training, were frequently listed as challenges, as was a dependency on external funding (and, as a result, a tendency for priorities to be driven by international actors). Despite cooperation between sectors (especially medicine and veterinary/livestock) being reported as a strength, integration of all disciplines (e.g., for socioeconomic analysis) was repeatedly listed among the weaknesses. Lack of epidemiology capacity was also listed frequently as a weakness of their own institute or key partner institutions. As a special strength, the willingness of young dynamic people to learn new methods and approaches was highlighted. Another strength identified was the established cooperation between sectors and available funding for some specific approaches.

Activities The majority of interviewees reported involvement in zoonotic EID research (either as researchers or promoters of research). There was also a high involvement in awareness-raising, although this tended to follow top-down models of information transfer, as shown by references to ‘‘awareness campaigns’’ and communication strategies based more on telling communities what to do, than on learning from them. This perhaps reflects the above-noted lack of integration of sociology and economics into health extension activities. From an ecohealth perspective, it was

encouraging to observe good links to policy-makers: more than half of interviewees reported being involved in policy and/or advocacy activities, such as influencing policy or organizing exchange visits for policy-makers. Of course, this also reflects the preponderance of public sector actors among the stakeholders. Only a few interviewees reported involvement in fund-raising, which is a challenge for stakeholders in being able to set their own priorities and develop long-term research programs.

Linkages Social network analysis was used to map information flows across different types of actors engaged in zoonotic EIDs in various capacities. In general, policy-making and implementing bodies were seen to be recipients of information more than providers of information. Their sources of information were other departments within the same or other ministries, research institutes, NGOs, and communities; only in the case of one ministry, in Vietnam, was industry seen as a source of information. One thing to note is the general lack of, or limited, feedback loops between the policy-making body and the source of information, particularly where sources are the communities or farmers; an ecohealth approach can potentially contribute to enhancing the effectiveness of this linkage. Research institutes, on the other hand, were more likely to be providers of information on zoonotic EIDs, and their main recipients were the government ministries that are usually the main source of their budgetary resources. It was also noted that, in most cases, the information flow is only one-way, that is, the research institute provides the information but does not receive feedback (or information) in return from a specific actor. However, bi-directorial information flows between research institutes and communities were present in some cases. Our study suggests that research institutes may need to expand their sources and outlets of information, to widen the scope of the influence and potential impact of their research findings, and, as a corollary, to widen their source of funding. Most universities perceived the majority of information flows to be bi-directional. This may reflect the nature of the relationship between the universities and the providers of their budgetary resources for research, from whom they receive and to whom they are required to provide information from their research activities, mostly to inform policy-making bodies. Some, but by no means all, research units in universities also have links with

Delia Grace et al.

Figure 2. Social network analysis showing perceived information flows of a medical (left) and veterinary (right) institute in the Mekong region.

communities, the private sector, and/or industry. Typically, those who have better links with private sector actors are those who receive more funding from international donors. NGOs generally engaged in research for development were, on balance, providers more than recipients of information. NGOs engaged in purely development activities were equally providers and recipients. There appears to be a lack of, or limited, feedback loop from communities and/or farmers that receive information from NGOs; this could possibly be an area where the ecohealth approach can contribute to strengthening this linkage. A noteworthy finding was that actors from the livestock sector were better connected, both across other disciplines and to communities and the private sector, than were their counterparts in the health sector. Figure 2 shows two comparable institutes located in the health and agriculture ministries, respectively, of the same country, which well illustrates this. Innovation systems thinking has introduced the concept of ‘‘boundary organizations’’ or ‘‘boundary-spanning actions’’ which help bridge gaps between research and user communities (Kristjanson et al., 2009). Veterinarians and livestock specialists have medical training, and zoonoses are usually more important in the veterinary curriculum than the medical (Schelling et al., 2005). However, in developing and transition countries of Southeast Asia, most veterinarians and livestock specialists work with animal industries or rural development. This means that the livestock disciplines are well positioned as boundary-spanners, which can help translate between medical, community development, and industry stakeholders.

Priorities Interviewees were asked which zoonotic EID they considered the most important. For a majority of respondents (66%), the number one ranked disease was avian influenza.

Avian influenza has had significant effects on the poultry industry, but is mainly of concern because of the risk that it might mutate to a strain capable of causing a human pandemic (as indeed was the case for the H1N1 influenza pandemic announced in 2009, which originated in pigs). However, in terms of actual disease burden on humans, the impact of avian influenza is almost negligible: Its morbidity and mortality is several orders of magnitude lower than the number two and three priority (rabies and leptospirosis, respectively) on the stakeholders list (the impact of which is, in turn, at least an order of magnitude lower than high disease-burden zoonoses, such as toxigenic Escherichia coli). Overall, prioritization did not well reflect disease burden caused by zoonoses. Of all the zoonoses mentioned by name, only one appears on the list of Globally Important Human Pathogens (a list of the 65 pathogens, including 29 zoonoses, responsible for most mortality) (Ecker et al., 2005). It would be interesting to explore to what extent the high priority of avian influenza among donor countries and, hence, availability of funding for this disease, together with media attention and concern among the general public, are responsible for its rank as the number one zoonotic priority in the countries studied. Moving from specific diseases to categories of diseases, we found that vector-borne disease and food-borne disease were considered most important and also to be increasing in incidence (Table 2). Although most emerging diseases are zoonoses and the majority of these have their origin in wildlife (Jones et al., 2008), the category wildlife-associated zoonoses was considered least important, and this despite the fact that stakeholders considered control was weakest and ability to detect least. Interestingly, priorities vary with sector: The health sector puts more emphasis on vectorborne and soil-borne diseases, whereas zoonoses transmitted by close contact are rated higher by the veterinary and rural development stakeholders. This probably reflects disciplinary perspectives: Dengue is an important disease in

ZEIDs in SE Asia: Insights from Ecohealth

Table 2. perceived importance, ability to detect, response, research efforts, and trend (mean and medians) of categories of zoonotic emerging infectious disease by stakeholders in three countries in the mekong regiona Category

Importance

Ability to detect

Response/Control

Research efforts

Trend

Vector-borne zoonoses Food-borne zoonoses Zoonoses transmitted by close contact Soil-borne zoonoses Wildlife-associated zoonoses

3 High; 2 medium; 1 low 2.6 (3) 2.5 (2.5) 2.2 (2) 2.1 (2) 1.7 (2)

3 Most cases; 2 some cases; 1 few cases 2.6 (3) 1.9 (2) 2.0 (2) 1.5 (1) 1.7 (2)

3 Good; 2 medium; 1 poor 2.2 (2) 1.7 (2) 1.9 (2) 1.8 (2) 1.6 (2)

3 High; 2 medium; 1 low 2.4 (2) 1.9 (2) 1.4 (1) 1.4 (1) 1.4 (1)

3 Increasing; 2 static; 1 decreasing 2.3 (2) 2.5 (3) 2.1 (2) 1.6 (2) 1.8 (2)

a

Medians in parentheses.

the region, but most transmission is human-to-human (with a minor sylvatic cycle involving monkeys), and so veterinarians may not consider that it falls within their jurisdiction. On the other hand, zoonoses transmitted by close contact with animals include the classical zoonoses (e.g., tuberculosis, brucellosis, and anthrax), which are a major focus of veterinary public health. Ecohealth thinking emphasizes the interconnectedness and interdependence of human, animal, and environmental health. The interviewees in this study demonstrated their understanding of this in listing the drivers of emerging disease. These included: climate change, deforestation, encroachment into wildlife habitats, urbanization of rats, bats, and other animals, and abuse of pesticides leading to resistance. Among the socioeconomic drivers noted by respondents were: explosion of populations, globalization, urbanization, changing food consumption habits, persistence of ‘‘wet markets’’ (open air food markets where live animals are sold), and food chains becoming longer, but with low hygiene standards. Some positive trends which can act to reduce disease emergence include increased awareness, better inspection, and greater uptake of vaccinations.

Gaps Interviewees identified 41 key research gaps. The most frequently cited were those relating to disease prioritization, burden, and risk—all issues which can obviously benefit from economic insights. Epidemiology skills was the second most cited gap. Epidemiology, with its focus on disease in populations, study design, surveys, and data analysis, has much to contribute to health research but

remains a minority discipline in most developing countries. The next most important research gap was qualitative and economic methods. Interestingly, the highest ranked technical gap (molecular epidemiology) came only in fourth place. From an ecohealth perspective, an obvious area for improvement in the study population is understanding of ecology, ecosystem health, and wildlife disease. In two of the three countries, no stakeholders from the discipline of ecology were mentioned, and in none of the countries was a surveillance system for wildlife reported, although wildlife are the most important source of new disease emergence. The Canary database, a compilation of evidence on animals as sentinels of human health hazards, offers numerous examples of how useful wildlife studies can be in surveillance and early warning (http://canarydatabase.org). Equity is considered a fundamental pillar of ecohealth. In our survey, several interviewees mentioned remote, marginalized, and poor communities as having been neglected or needing special attention, because they are most impacted by zoonotic EIDs. However, although gender has been shown to be an important factor in both risk, susceptibility, and access to health care (Grace et al., 2008), none of the interviewees made reference to this. Although respondents reported that linkages with communities existed, it appears these were mainly at lower levels of participation (Pretty, 1995), that is, researchers saw their role in ‘‘extracting information from,’’ ‘‘informing,’’ ‘‘training,’’ and educating communities, rather than learning with and from them. Without high levels of dialogue and interaction with the end-users of research, it is likely that the outputs will neither be useful nor used. In the ecohealth framework, the principle of participation

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recognizes the importance of including communities and policy-makers in the research process.

CONCLUSIONS It is not easy to obtain information from zoonotic EID stakeholders in Southeast Asia. With recent and ongoing crises, the few key people are much in demand and have little time for lengthy interviews. Moreover, there may be reluctance to provide nontechnical information that reflects beliefs, opinions, and priorities. The study was successful in using a participative and intensive process to obtain insights into the thinking of key stakeholders for zoonotic EIDs in three countries in Southeast Asia. While it is encouraging to note that stakeholders from disciplines outside the medical community were identified in the countries involved in the study, it was also clear that these are few in number and weakly linked to the human health community. Ecohealth approaches offer an opportunity to break out of the disciplinary silos that are often observed in the research and development communities, thereby potentially increasing the effectiveness and impact of research into zoonotic EIDs. There may also be an opportunity for the veterinary and livestock disciplines to act in a ‘‘boundary-spanning’’ role that can help integrate human health, agricultural development, ecological, and socioeconomic disciplines. Our study shows concern over zoonotic EIDs, awareness of socioeconomic and ecological determinants of health, an articulated need for better skills and capacity building (with an emphasis on epidemiology and social sciences, rather than technical training), and linkages between researchers, policy-makers, and communities. This suggests that the conditions are in place for ecohealth approaches to be well accepted and deliver important benefits. The ecohealth approach promotes national ownership by addressing the country’s priorities as identified by national stakeholders. Currently, many emerging infectious disease and zoonoses projects are driven by donors or the international technical implementing agency, and hence may not fully reflect local priorities. In this study, stakeholders considered prioritization of diseases a key research gap. Disease prioritization studies would not only allow national priorities to be identified, but could also serve as a model for integrating different disciplines, empowering communities, and strengthening the relationship between researchers and decision-makers.

ACKNOWLEDGMENTS This study was funded by the International Development Research Centre, Ottawa, Canada. We also acknowledge the contributions of the participants in the study from Vietnam, Lao PDR, and Cambodia.

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