Côte d’Ivoire: Country Profile

Côte d’Ivoire is a country on the coast of West Africa with a population of 29,389 million people. As part of the implementation of the International Health Regulations (IHR), Côte d’Ivoire joined the Global Health Security Agenda (GHSA). GHSA is a multisectoral initiative that aims to strengthen the country’s capacity to prevent, detect and respond to health threats, whether these threats are of animal, human or environmental origin, through the “One Health” approach. Through this initiative the government of Côte d’Ivoire identified five priority disease groups with epidemic potential or priority zoonotic diseases (PZD): mycobacterium tuberculosis, brucellosis, rabies, viral hemorrhagic fevers such as Ebola and Marburg, and respiratory illnesses such as highly pathogenic avian influenza. Under the leadership of the Technical Working Group on Risk Communication, One Health stakeholders developed a national communication strategy that includes a combination of social and behavioral change interventions capable of bringing about the necessary changes in knowledge, perceptions, attitudes, beliefs and practices within the targeted populations in order to enable them to make appropriate decisions to protect themselves from any health threat but particularly the five PZD groups.

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Bovine tuberculosis is caused by the bacterial species Mycobacterium bovis and causes bovine tuberculosis in farm animals (and tuberculosis in other wild animals). In 2016, according to WHO estimates, 147,000 new cases of zoonotic TB were reported in humans, including 12,500 deaths. The apparent prevalence rate of bovine tuberculosis established on the basis of bibliographic data between 1969 and 2010 and human tuberculosis outbreaks in Côte d’Ivoire is 2.1%.

Brucellosis is a bacterial infection with a global incidence of about 500,000 cases per year worldwide and a prevalence of more than 10 cases per 100,000 population in some countries. Humans become infected through contact with sick animals, ingestion of fresh unpasteurized or unboiled milk, or fresh cheese. Brucellosis has a significant impact on the health and productivity of livestock, thus greatly reducing their economic value and work performance. In Côte d’Ivoire, the first cases of brucellosis were reported in 1970 with a national prevalence was 10.8%. Brucellosis was once again detected in 2008 with an estimated prevalence of 8.8% in central Côte d’Ivoire and 10.3% in the savannah woodlands. Despite interventions to control brucellosis, the northern region of Côte d’Ivoire remains an area infected by this disease. Indeed, the prevalence of brucellosis is 10.5% in cattle and 5.3% in humans in the departments of Niakaramandougou and Korhogo (Kanouté et al., 2017).

Rabies remains a widespread disease worldwide, responsible for tens of thousands of deaths each year. It is most often transmitted by dogs. In Côte d’Ivoire, rabies is endemic. Despite the existence of an effective post-exposure prophylaxis, it remains a concern. According to epidemiological surveillance data, approximately 11,000 people are exposed to rabies risk each year. Children are the most affected group.

Viral Hemorrhagic Fevers (VHF)

Crimean Congo Hemorrhagic Fever (CCHF): CCHF is a viral disease involving fever, muscle pain, dizziness, gastrointestinal issues, and ultimately hemorrhagic symptoms. The virus is tick-borne and spreads by way of domestic and wild animals such as sheep, cattle, goats, ostriches and hares. Human-to-human transmission can occur, and risk groups include health care providers, workers in abattoirs, and livestock handlers. Tick prevention and control is the main preventative measure.

Lassa fever: Lassa fever is a serious disease transmitted by contact with secretions (urine, feces, blood) of infected mice and rats. it is manifested by fever, muscle pain, generalized weakness, diarrhea. Cote d’Ivoire was under the threat of the Lassa fever epidemic in 2017 and 2018, when the epidemic was waning in some countries in the West African sub-region. In late 2019, when cases of Lassa fever were detected in Liberia and Sierra Leone, an investigation have detected the presence of the reservoir of the germ in Cote d’Ivoire.

Ebola and Marburg: Ebola virus disease (EVD) is an infection caused by a virus of the filovirus family to which the Marburg virus also belongs. Humans are contaminated either by direct contact with infected bats (a rare event), or by handling infected animals found dead or sick in forests (a more frequent event). Human-to-human transmission is also possible and occurs through direct contact with the blood, secretions, organs or biological fluids of infected individuals. The risk of epidemics in bordering countries and the significant movement of populations between them and Côte d’Ivoire necessitate a strong early warning system.

Dengue: Dengue is a viral disease transmitted by mosquitoes. It has spread rapidly in recent years. In Côte d’Ivoire, suspected dengue cases were first reported in April 2017. As of July 11, 2017, 623 suspected cases, including two fatal cases (case fatality rate: 0.3%), had been notified. The main predisposing factors for the occurrence of outbreaks are the high density of mosquito breeding sites, the rainy season, and the poor knowledge of communities about how mosquitoes breed and bite.

Yellow fever: Caused by the yellow fever virus, the disease causes fever, chills, headache, muscle pain, nausea, and may lead to jaundice and hemorrhaging. The virus is transmitted by mosquitoes as well as nonhuman primates. Prevention is mainly through vaccination of people at risk as well as mosquito control.

Respiratory diseases

Avian influenza is an infection by an influenza virus that can affect almost all species of birds, wild or domestic. It can be highly contagious, especially in chickens and turkeys, and can lead to extremely high mortality, especially in factory farms. The avian influenza virus sometimes infects other animal species, including pigs. In Côte d’Ivoire, the first outbreak of avian influenza was notified in April 2006 on a traditional backyard farm with 7 chickens and 10 ducks. By September 2017, 42 outbreaks had been identified and notified with 122,707 poultry culled.

Find a more detailed summary of the PZDs in the national communication strategy for risks linked to the five priority zoonotic disease groups in Côte d’Ivoire (2019-2022).

There are several key organizations involved in health risk communication in Côte d’Ivoire under three main categories: state organizations, international organizations and civil society organizations. More information on One Health activities can be found on the One Health platform.

One Health Landscape – click here for web accessible version

Paysage One Health de CDI – cliquez ici pour la version accessible sur le Web

With funding from USAID, Breakthrough ACTION conducted a literature review on behavioral factors related to the PZDs in Côte d’Ivoire. The study reviewed qualitative, quantitative, and communication intervention evaluation studies related to the identified disease groups and conducted among West African populations since 1980.

The literature on Mycobacterium diseases suggests: i) incomplete adherence to treatment by some TB patients for reasons still unknown, thus increasing the number of “lost to follow-up”; ii) avoidance of TB patients by some health providers for fear of being contaminated; iii) reliance on traditional medicine for the treatment of Buruli ulcer due to persistent beliefs.

For bacterial and parasitic infections, the literature reports: i) informal production of foodstuffs of animal origin (particularly milk) due to the economic vulnerability of small producers, ii) reintroduction into the commercial circuit of dairy products refused by the industrial dairy for the same reasons of economic vulnerability, and iii) clandestine slaughter of animals outside of official control procedures coupled with ritualization of the said slaughter.

With regard to viral hemorrhagic fevers (VHF) and Arboviruses, risky practices related to Ebola (slaughtering, marketing and consumption of game despite bans; hiding the sick or bodies/risky funeral rites) have developed within the population under the combined influence of diversified rumors, beliefs and denial of the disease. Other behaviors have been observed among health care workers (reticence or even stigmatization of “suspect cases”) due to the fear of being contaminated.

Behaviors related to respiratory disease epidemics, such as avian influenza, are mostly observed in rural areas, through small-scale extensive farming where poultry is left to roam freely and without any real attention. This is to allow them to feed by wandering between the houses of the village and in the fields. In addition, these small-scale farmers are, by habit, prone to unhygienic practices in the management of their livestock, and tend to resort to self-medication rather than to a veterinarian (whose services are considered costly) in case of need.

Finally, rabies is accompanied by practices such as abandonment or incomplete adherence to treatment by some patients. These practices, due to poverty and ignorance, contribute to the rabies epidemic. In addition, there is a reluctance on the part of some health care providers to follow up on people for fear of being attacked by the patient.

Read the literature review

Informed by this review and taking into account the need for a deeper understanding of behavioral drivers of the PZDs, Breakthrough ACTION collected qualitative data in 2018 with the institutional support of the Ministry of Animal Resources and Fisheries (through the Directorate of Veterinary Services) and the Ministry of Health and Public Hygiene (through the National Institute of Public Hygiene). Data were collected in Abidjan, Korhogo, Bouaké and Man on the social, cultural and individual determinants of risk behaviors for five priority groups of zoonotic diseases in Côte d’Ivoire: Mycobacterium diseases; bacterial and parasitic infections; viral hemorrhagic fevers (VHF) and Arbovirus; respiratory diseases; and rabies.

These data show a typology of risk behaviors that are structured around i) unsafe interactions with animals, i.e., all contacts that actors in the animal and animal products sector regularly have with animals without the minimum safety measures required to avoid exposure to possible contamination ii) the marketing of tainted (sick or dead) animals, iii) the consumption of these risky animals by the population, consciously or unconsciously, iv) the non-application of basic hygiene rules, v) the practical handling of animals to the detriment of veterinary care.

Several determinants explain these risky behaviors. First, there are social determinants that take the form of pejorative perceptions of the veterinarian and veterinary care, unfavorable perceptions of zoonotic disease prevention measures, and prejudices about zoonotic diseases. Second, there are cultural determinants in the form of culturally instilled maxims and risky death rituals. Finally, the individual determinants that reside in i) the general population’s lack of knowledge about zoonoses, ii) the approximate knowledge of zoonoses among the actors of the animal sector linked, among other things, to the weakness or even the lack of information of these actors about zoonoses, and iii) constraining economic factors.

These data reveal 3 preliminary conclusions. First, the risk behaviors for contamination and propagation of the five groups of zoonoses studied are multiple, diversified and widespread throughout the four study sites. Secondly, the social, cultural and individual determinants at the origin of these risk behaviors act as a set of legitimate factors in the eyes of the actors encountered. Third, beyond the social, cultural and individual determinants, the risks of zoonotic disease outbreaks could be fueled by other factors such as the morphology of the animal sites and institutional weaknesses in the response to zoonotic risks.

Read the formative research report

The large Ebola outbreak that began in rural Guinea in December 2013 demonstrated the urgent need for risk communication and community engagement (RCCE) to quickly identify and contain infectious disease outbreaks. The recent re-emergence of Ebola in Guinea in 2020 made the response to COVID-19 more complex and required an integrated response. USAID commissioned Breakthrough ACTION-Côte d’Ivoire to support Ebola prevention and response to prevent Ebola from crossing the border between Guinea and Côte d’Ivoire and to prepare the population to recognize symptoms, seek care, and get vaccinated. The Breakthrough ACTION team conducted a rapid survey (n=2000) to explore perceptions of desired Ebola prevention and care-seeking behaviors in Abidjan and the border regions of Guinea (Kabadougou, Bafing, and Tonkpi) in order to develop communication messages on Ebola prevention in Côte d’Ivoire.

The proportion of people with low knowledge of Ebola (score below 60%) is much higher in the Bafing region (57.7%) and in the Kabadougou region (54%). The area of residence seems to be an explanatory factor for the low level of knowledge. Indeed, 48% of adults surveyed in rural areas have a lower level of knowledge of the disease, compared to 24.7% in urban areas. The level of knowledge is lower among individuals living in the border areas of Guinea compared to those living in Abidjan. Men have a higher level of knowledge of Ebola than women.

The proportion of adults with a high attitude score is higher in Abidjan 1 (63.6%), Abidjan 2 (51.4%) and Tonkpi (56.8%) health regions compared to the other regions. The proportion of individuals with a high attitude score is greater in urban areas than in rural areas. Men have statistically higher attitude scores than women. Attitude is related to education level, with those with at least primary education having a higher attitude score than those with no education.

Individuals living in Abidjan 1 and 2 health regions have better Ebola prevention practices than people in other health regions in the border regions of Guinea. More than three-quarters of the individuals surveyed in Abidjan have a practice score between 80% and 100%, which is much higher than the proportions in the other regions. Individuals living in urban areas have very good Ebola prevention practices compared to those living in rural areas.

More than 90% of the people surveyed answered that they had never received an Ebola vaccine. Of these 90%, 67.7% are willing to accept the vaccine if it is free and 86.4% are willing to be tested if they learn that they have been in contact with a person with Ebola. The majority (more than half) of respondents want to know if the vaccine has any side effects before getting vaccinated. 15% of respondents said they had heard something negative about the Ebola vaccine. The most common negative ideas heard were that the vaccine would give them Ebola or another virus (64.1%) or that the vaccine would not work well (41.4%).

Overall, less than 2% of respondents had crossed the border into Guinea in the past three months. 47% of the study population had heard information about Ebola in the past month. The most heard information was about modes of transmission (12.7%), means of prevention (12.9%) and symptoms of the disease (12.3%). Television remains the main channel (70.3%) through which adults surveyed said they heard information about Ebola. About half of those surveyed who had heard about Ebola said they had been exposed to the messages at least five (5) times in almost all the health regions visited.

Read the full report

In early 2021, the Breakthrough ACTION team collaborated with the Technical Working Group on Antimicrobial Resistance (AMR) to conduct a qualitative research study. The study aimed to analyze determinants of behaviors that intersect with stewardship and resistance to antimicrobials, a rapidly growing phenomenon in Côte d’Ivoire, in a context where health authorities are trying, with the support of development partners, to provide effective and sustainable responses in accordance with the global initiative “One Health”. The study involved individual interviews conducted in March and April 2021 in four sites (Abidjan, Bouaké, Agnibilékrou and San Pedro) with a sample of 126 individuals. Participants included people from the general population (men and women); informal sellers of antimicrobials for humans and animals; farmers of poultry, cattle, sheep, goats, pigs, etc.; health professionals such as physicians, veterinarians, pharmacists; and health regulation experts). Three major conclusions emerge from the study with respect to the individual, sociocultural and structural determinants that drive the development of AMR. First, in terms of individual determinants, AMR is fueled by practices in the household, livestock handling settings, and healthcare and veterinary settings. For example, medication misprescribing and misuse occur for both animals and humans. While the problem of AMR is recognized by at least some sub-populations included in the study, the threat of AMR is distant compared to the immediate financial and medical needs. Second, in terms of socio-cultural determinants, risk behaviors are driven by specific beliefs and representations associated with both disease and the medications themselves. For example, traditional and experiential knowledge are trusted in decision-making about treatment approaches for animals moreso, in some cases, than formal veterinary authorities. Thirdly, individual and sociocultural determinants thrive in a structural environment marked by poverty that directs many users to the “black market” for medicines, which is itself continually flooded with prohibited or defective pharmaceutical products often carried across borders with little regulatory oversight.

Read the full report.

Using formative research to inform policies and programming

The formative, qualitative research conducted by Breakthrough ACTION informed a campaign to combat rabies in Côte d’Ivoire, particularly highlighting the value of the rabies vaccine as a prevention method. Read more about the rabies campaign in a recent blog post. The research was also used in the development of the Communication Plan to address rabies in Côte d’Ivoire developed in January 2021.

Qualitative research conducted on antimicrobial resistance informed the national communication plan for the fight against AMR.

The research on EVD was used to develop the National Communication Plan for the prevention of EVD in the context of COVID-19 in Côte d’Ivoire.

Managing rumors to stop outbreaks

A rumor is an act of communication containing unverified, false, or harmful information and can take the shape of misinformation, disinformation, or malinformation. An infodemic is a health emergency during which rumors are circulating or there is simply too much information, preventing individuals from accessing credible information about how to protect themselves. The Joint External Evaluation 3.0 highlights infodemic management as a priority under R5, the Risk Communication and Community Engagement indicator.

Beginning in 2019, Breakthrough ACTION and the Technical Working Group on Risk Communication (TWG-RC) have worked together to envision a system for detecting and managing rumors that would leverage mobile technology and community-based trusted liaisons who are in touch with communities. In March 2020, under the leadership of the Government of Côte d’Ivoire, Breakthrough ACTION launched the rumor tracking system. Working in partnership with the 143 and 106 health hotlines and key informants recruited in two districts, Breakthrough ACTION collected, analyzed, and visualized rumor data in a central database built on the open source software District Health Information System 2 (DHIS2). Key informants listened and reported de-identified rumors that they heard in the course of their work. Rumors identified in the course of calls to the national 143 hotline were also entered into the system. After a 6 month pilot period, the system was found to be useful and relevant for key stakeholders. Project staff continued to work with the TWG-RC to implement and expand the system. In the subsequent years as COVID-19 dominated the health landscape and was declared an infodemic by the World Health Organization, Breakthrough ACTION added social media listening and expanded the presence of key informants to 110 districts.

The system, now called the Infodemic Management System (IMS), is more than the database; it includes the human resources to collect and analyze data, financial investments to sustain the people and technology, the databases and data management processes, and the procedures in place for responding to rumors with communication best practices and rapidly scaling to respond to outbreaks. Part of the system involves preparing infodemic insights briefs, which summarize an integrated analysis of emerging and ongoing rumors using data from key informants, hotlines, and social listening. The briefs are done routinely every 2-3 months. Examples can be viewed here.

Infodemic brief OCT – NOV 2023

Infodemic brief DEC 2023- FEB 2024

In the case of outbreaks, a rapid analysis can be done on an ad hoc basis, as in the case of the dengue response.

Infodemic brief on dengue (JAN – FEB 2024)