Frontline recognition and referral readiness for selected priority zoonoses among health workers in southwestern Uganda: a One Health systems assessment
While frontline health workers in southwestern Uganda demonstrate strong awareness of priority zoonoses, a significant referral-linkage gap persists at lower-level facilities due to barriers such as inadequate diagnostic resources, unreliable transport, and weak intersectoral collaboration, highlighting the need for strengthened One Health coordination and peripheral specimen-referral systems.
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In the rolling, livestock-rich landscapes of southwestern Uganda, the boundary between human health and animal health is often thin. Here, diseases that begin in cattle, goats, or dogs can jump to people, causing outbreaks that range from the familiar to the terrifyingly severe. These are called zoonotic diseases. For a community to stay safe, the first line of defense is not a high-tech laboratory, but the local health worker who sees a sick patient. This person must recognize that the illness might be linked to an animal, decide that a sample of blood or tissue needs to be sent away for testing, and then ensure that the result comes back so the patient can be treated. If any part of this chain breaks, a small outbreak can grow into a regional crisis. The challenge is not just knowing what a disease looks like, but having the practical systems in place to move a sample from a remote clinic to a reference lab and back again.
Researchers recently set out to examine how well this system works in four districts of southwestern Uganda: Mbarara, Kazo, Kiruhura, and Ibanda. They focused on five specific priority diseases that pose a constant threat in the region: Rift Valley fever, Crimean-Congo haemorrhagic fever, Ebola, anthrax, and rabies. The team surveyed 345 health workers, including nurses, doctors, and laboratory staff, asking them about their daily work. They wanted to know two main things: first, whether these workers could correctly identify the signs and how these diseases spread; and second, whether they felt confident and able to send samples to the right place for confirmation. The study took place between late 2024 and early 2025, capturing a snapshot of the frontline reality in a region where livestock and people live in close contact.
The results revealed a story of two different worlds. On the side of knowledge, the health workers were remarkably well-prepared. Almost everyone, nearly 99.7 percent, had heard of the five diseases in question. When asked specific questions about how these illnesses spread, the answers were generally strong. For instance, most workers knew that anthrax comes from eating undercooked meat and that rabies is transmitted by the bite of an unvaccinated animal. However, there were some notable gaps. Fewer than 60 percent of the workers recognized that Rift Valley fever could be caught from contact with an aborted animal fetus or placenta, and only about 70 percent knew it could be spread by mosquitoes. While the general awareness was high, the specific details that trigger an early alarm were sometimes missing.
The more critical finding, however, concerned the ability to act on that knowledge. The researchers found a sharp divide based on where the health worker was employed. Those working at larger, better-equipped facilities like hospitals or Health Centre IVs reported that they could easily send samples for testing. In contrast, workers at smaller, lower-level facilities like dispensaries and smaller health centers faced a significant hurdle. About 20 percent of the workers at these smaller sites said they did not have a way to refer samples for testing, compared to only about 7 percent at the larger facilities. This gap was not simply because the smaller clinics lacked knowledge; even when the workers knew what to do, the path to the laboratory was often blocked. The study showed that the location of the clinic was the strongest predictor of whether a sample would actually leave the building.
When the workers did manage to send a sample, the system worked surprisingly well. Among those who referred specimens, nearly all of them, about 99.3 percent, reported that they eventually received the test results back. The results were also communicated to the patients in almost every case. However, the speed of this process was a concern. The typical time from sending the sample to getting the result was ten days, and for nearly half of the workers, that wait stretched to two weeks or longer. This delay includes the time it takes to transport the sample, run the test, and send the answer back, not just the time the machine spends analyzing the blood.
The health workers themselves identified the reasons why the system struggled at the lower levels. The most common complaint was a lack of diagnostic resources, cited by over 90 percent of respondents. Unreliable transport was the next major barrier, mentioned by 75 percent, followed closely by a lack of collaboration between human health and animal health sectors. Many workers noted that the paper-based nature of the system made it difficult to track samples and results. While the concept of "One Health"—the idea that human, animal, and environmental health are linked—was understood by some, it was not yet a daily reality for everyone. Only about 28 percent of workers said they regularly got information from veterinary officials, and many felt that the different sectors did not work together well enough.
The study concludes that the frontline workers in this region are generally ready to recognize these dangerous diseases, but the system that supports them is uneven. The ability to turn a suspicion into a confirmed diagnosis depends heavily on whether the worker is at a large hospital or a small village clinic. The researchers suggest that future efforts to prevent outbreaks should not just focus on training people to recognize symptoms, which they are already doing well. Instead, the priority must be to fix the broken links in the chain: improving the transport of samples, ensuring that small clinics have a clear path to a laboratory, and strengthening the collaboration between doctors and veterinarians. Without these practical connections, even the most knowledgeable health worker cannot stop an outbreak from spreading.
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