Ebook One health: The Human– Animal–Environment interfaces in emerging infectious diseases (Part 1)

(BQ) Part 1 book “One health: The Human– Animal–Environment interfaces in emerging infectious diseases” has contents: One health and emerging infectious diseases: clinical perspectives, the historical, present, and future role of veterinarians in one health, the importance of understanding the human–animal interface,… and other contents.

Current Topics in Microbiology and Immunology

One Health: The

Human–Animal–

Environment Interfaces

in Emerging Infectious Diseases

John S Mackenzie

Martyn Jeggo

Peter Daszak

Juergen A Richt Editors

The Concept and Examples of a One

Health Approach

Current Topics in Microbiology

Honorary Editor: Hilary Koprowski (deceased)

Biotechnology Foundation, Inc., Ardmore, PA, USA

For further volumes:

http://www.springer.com/series/82

John S Mackenzie Martyn Jeggo

Peter Daszak • Juergen A Richt

The Concept and Examples

of a One Health Approach

Responsible Series Editor: Richard W Compans

123

Juergen A RichtDepartment of DiagnosticMedicine/PathobiologyKansas State University College

of Veterinary MedicineManhattan, KS

USA

DOI 10.1007/978-3-642-36889-9

Springer Heidelberg New York Dordrecht London

Library of Congress Control Number: 2013934839

 Springer-Verlag Berlin Heidelberg 2013

This work is subject to copyright All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher’s location, in its current version, and permission for use must always be obtained from Springer Permissions for use may be obtained through RightsLink at the Copyright Clearance Center Violations are liable to prosecution under the respective Copyright Law The use of general descriptive names, registered names, trademarks, service marks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use.

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Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Global health security has become a major international concern Our populationfaces imminent threats to human and animal health from the emergence andreemergence of epidemic-prone infectious diseases, linked to the significant impactthat these outbreaks are already having on national and international economies Theconcept and drivers of disease emergence were clearly documented 20 years ago inthe Institute of Medicine’s seminal 1992 report, Emerging Infections: Microbial

of zoonotic diseases and highlighted possible strategies for recognising and teracting the threats It has long been known that many of these diseases can cross thespecies barrier between humans, wildlife, and domestic animals; and indeed over 70

coun-% of novel emerging infectious diseases are zoonotic, that is, they have their origins

in animal reservoirs There have been many examples of this since the Institute ofMedicine’s report two decades ago, including the emergence of H1N1 pandemicinfluenza virus, the SARS coronavirus, Nipah and Hendra viruses, Australian batlyssavirus, Malaka virus, avian influenza H5N1 and H7N9, and MERS coronavirus,

to name but a few

These diseases remind us that the health of humans, animals and ecosystems areinterconnected, and that to better understand and respond rapidly to zoonoticdiseases at the human–animal–environment interfaces requires coordinated, col-laborative, multidisciplinary, and cross-sectoral approaches This holistic approachhas been referred to as ‘One Health’, indicative of the commonality of human andanimal medicine, and their connection to the environment Although the concept isnot new, ‘One Health’ has gained added momentum in the aftermath of the SARSepidemic of 2003 which posed the first major threat to human health and globaleconomy of the new millennium These concerns added to the mounting fears thathighly pathogenic avian influenza H5N1 could develop into next severe influenzapandemic Not only would such a pandemic lead to significant mortality andmorbidity, but the World Bank has estimated that it could cause a decline of up to

5 % of global GDP (damages of US$3 trillion), causing far-reaching disruptions inthe lives of people, communities, and countries Thus there are compelling reasons

to develop new approaches that will improve the detection, prevention, and control

of zoonotic diseases In particular, it is essential that we breakdown the old

v

concepts of professional silos and encourage a new era built around trust andmultidisciplinary, cross-sectoral approaches.

The present momentum of ‘One Health’ can also be traced in part to the 2004meeting of the Wildlife Conservation Society on ‘One World, One Health:Building Interdisciplinary Bridges to Health in a Globalized World’ The out-comes of the meeting were encapsulated in a series of 12 recommendations known

as the Manhattan Principles that set priorities for an international, interdisciplinary

a number of international ministerial meetings, including the International isterial Conferences on Avian and Pandemic Influenza (IMCAPI), which havebeen held to discuss issues relating to the spread, transmission, and possiblecontainment of highly pathogenic avian influenza (H5N1), culminating at the 2010meeting in Hanoi with the agreement between the Food and Agriculture Organi-zation (FAO), the World Organization for Animal Health (OIE), and World HealthOrganization (WHO), entitled ‘The FAO-OIE-WHO Collaboration: SharingResponsibilities and Coordinating Global Activities at the Animal–Human–Eco-systems Interfaces’ The coordination between these three international organi-zations has also led to the formation of the Global Early Warning System forMajor Animal Diseases including Zoonoses (GLEWS) which provides the intel-ligence essential to identify and ameliorate both human and animal diseases

epide-miological analyses, and risk assessments In addition, it is highly probable thatany new zoonotic disease would be detected through WHO’s new InternationalHealth Regulations (2005) which are aimed at assisting countries in workingtogether to save lives and livelihoods through a legal requirement for countries torapidly detect and report outbreaks of disease of international concern

This leadership is an essential component to operationalize ‘One Health’ ideals.Major scientific meetings have been held in Winnipeg through Health Canada and

at Stone Mountain, Georgia through the Centers for Disease Control and vention, and by a wide variety of other interested groups such as the EuropeanCommission, joint meetings of FAO-OIE-WHO, Global Risk Forum (Davos),Institute of Medicine, the World Bank, APEC, and the Asian Development Bank.Many smaller, national, and regional meetings have also been held to further localOne Health planning Of particular importance has been the information dissem-

and the more recently established One Health Global Network’s Web portal

momentum by providing a rapid means of communication and sharing data andnews As the field of One Health matures, we have also begun to see the growinginvolvement of ecologists, wildlife biologists, environmental scientists, and thefusion of the fields of ‘EcoHealth’ and ‘One Health’ There has also been con-siderable support for the ‘One Health’ approach in the United States through apartnership of major professional organizations that have formed the One HealthCommission, which brings together the American Medical Association, the

American Veterinary Medical Association, the American Public Health tion, the Infectious Diseases Society of America, the Association of AmericanMedical Colleges, and the Association of American Veterinary Medical Colleges.The inclusion of the latter two organizations is particularly relevant, breakingdown professional barriers or silos through education A number of universitiesand colleges are starting to respond with new ‘One Health’ courses; and oneuniversity, the University of Edinburgh, has developed a Masters postgraduatedegree course.

Associa-More than 200 years ago, the German writer, artist and politician, JohannWolfgang von Goethe, reminded us that: ‘‘Knowing is not enough; we must apply.Willing is not enough; we must do.’’ That epithet applies well to the ‘One Health’movement, because in the midst of all the information that has been gathered aboutthe health of humans, animals, and ecosystems, as well as the desire of manypeople in many nations and organizations to implement viable public healthsolutions, application and action are essential In this context, ‘One Health’ is not anew form of governance or a critique of existing patterns of governance Rather,

‘One Health’ is a movement dedicated to building new levels of trust and parency between disciplines, nations, organizations, and people Such trust andtransparency must begin with inspirational educational curriculums, teaching thenext generation of clinicians and veterinarians how to apply and do their own work

trans-in such a way that many others come to appreciate the necessity of ‘One Health’ trans-intackling difficult problems

As these two volumes of Current Topics in Microbiology and Immunology go

to press, many countries have established their own national ‘One Health’ policiesand/or committees, recognizing the need to integrate and coordinate their humanand animal surveillance to empower a more effective and rapid cross-sectoralresponse to zoonotic disease threats There is little doubt that the ‘One Health’concept will continue to develop and provide the coordinated, collaborative,multidisciplinary, and cross-sectoral approaches essential to develop the rapiddetection and better predictive ability so necessary for rapid response to futurethreats In particular, we envisage a greater collaboration among environmentaland ecological scientists with the animal and human health sectors of the ‘OneHealth’ movement The linkages between the underlying socioeconomic andenvironmental drivers of emerging diseases, and the threat of pandemic emergencewill likely be one area in particular where collaboration will be fruitful

The purpose of these volumes is to present an overview of the ‘One Health’movement, and in so doing, demonstrate the breadth and depth of its recent globaldevelopment The first volume has been divided into two parts The first partentitled’’ The Concept and Examples of a One Health Approach’’ examines ‘OneHealth’ from different perspectives especially that of human health and veterinarymedicine, whether domestic or wildlife, the importance of understanding thedifferent interfaces, the role of ecological science, and the compelling economicsdriving their cooperation and coordination This is then followed by a series ofexamples where a One Health approach has been useful in responding to specificdiseases in the field The second volume entitled ‘‘Food Safety and Security, and

International and National Plans for Implementation of One Health Activities’’explores the importance of ‘One Health’ in food safety and food security Theseare crucially important issues that are often not given the prominence they requireand deserve as the world seeks to feed a growing population This second volumealso describes some of the international, regional and national activities and plans

to implement ‘One Health’ approaches The final section describes additionalactivities and approaches to strengthen the ‘One Health’ movement and increaseits momentum in different ways By reading, reflecting and acting on the scale anddepth of ‘One Health’ as set out in these volumes, you will be making your owncontribution to the movement Do not underestimate the importance of thatcontribution

One Health: Its Origins and Future 1Ronald M Atlas

One Health and Emerging Infectious Diseases:

Peter Rabinowitz and Lisa Conti

The Historical, Present, and Future Role of Veterinarians

Samantha E J Gibbs and E Paul J Gibbs

Leslie A Reperant, Giuseppe Cornaglia and Albert D M E Osterhaus

The Human Environment Interface: Applying Ecosystem

Nicholas D Preston, Peter Daszak and Rita R Colwell

Melinda K Rostal, Kevin J Olival, Elizabeth H Loh

and William B Karesh

The Economic Value of One Health in Relation to the Mitigation

Barbara Häsler, William Gilbert, Bryony Anne Jones,

Dirk Udo Pfeiffer, Jonathan Rushton and Martin Joachim Otte

ix

Part II Examples of a Health approach to specific diseases

from the field

The Application of One Health Approaches

David T S Hayman, Emily S Gurley, Juliet R C Pulliam

and Hume E Field

H5N1 Highly Pathogenic Avian Influenza in Indonesia:

Peter Daniels, Agus Wiyono, Elly Sawitri, Bagoes Poermadjaja

and L D Sims

Henry Wilde, Thiravat Hemachudha, Supaporn Wacharapluesadee,

Boonlert Lumlertdacha and Veera Tepsumethanon

Daniel E Impoinvil, Matthew Baylis and Tom Solomon

Rea Tschopp, Jan Hattendorf, Felix Roth, Adnan Choudhoury,

Alexandra Shaw, Abraham Aseffa and Jakob Zinsstag

Juergen A Richt, Richard J Webby and Robert E Kahn

L D Sims and Malik Peiris

Clostridium difficile Infection in Humans and Piglets:

Michele M Squire and Thomas V Riley

M W Lightowlers

Jean Paul Gonzalez, Frank Prugnolle and Eric Leroy

Rea Tschopp, Jan Hattendorf, Felix Roth, Adnan Ali Khan Choudhury,

Alexandra Shaw, Abraham Aseffa and Jakob Zinsstag

Ronald M Atlas

animal, and environmental health Achieving harmonized approaches for disease detection and prevention is difficult because traditional boundaries of medical and veterinary practice must be crossed In the nineteenth and early twentieth centuries, this was not the case—then researchers like Louis Pasteur and Robert Koch and physicians like William Osler and Rudolph Virchow crossed the boundaries between animal and human health More recently, Calvin Schwabe revived the concept of One Medicine This was critical for the advancement of the field of epidemiology, especially as applied to zoonotic diseases The future of One Health is

at a crossroad with the need to more clearly define its boundaries and demonstrate its benefits Interestingly, the greatest acceptance of One Health is seen in the devel-oping world where it is having significant impacts on control of infectious diseases

Contents

1 Introduction 2

2 Louis Pasteur and Vaccination 2

3 Robert Koch and the Etiology of Infectious Diseases 4

4 Calvin Schwabe and Epidemiology 6

5 Contemporary Revival of One Health 8

6 Future of One Health 11

References 13

R M Atlas ( &)

University of Louisville, Louisville, KY, USA

e-mail: r.atlas@louisville.edu

Current Topics in Microbiology and Immunology (2012) 365: 1–13 1 DOI: 10.1007/82_2012_223

 Springer-Verlag Berlin Heidelberg 2013

Published Online: 25 April 2012

1 Introduction

The One Health concept aims to establish collaborations that cut across theboundaries of human, animal, and environmental health For some, the interrela-tionships between humans, animals, and the environment make a compellingreason to move forward with the development of the field of One Health.For others, though, there remains a lack of definition and a sense that a holisticapproach will obviate the specific needs of individual disciplines

Both research and practice have become highly specialized and it is difficult tobreak down the existing silos that limit the capacity for collaboration; though thiswas not the case always The roots of the One Health concept date to thelate nineteenth century—the time when Louis Pasteur and Robert Koch werepioneering the field of microbiology and Rudolph Virchow and Sir William Oslerwere establishing the basis of modern medical education and practice

Both Virchow, a major figure in human medicine in the nineteenth century whopioneered the filed of cellular pathology, and Osler, who became the preeminentfigure in medical education in the late nineteenth and early twentieth centuries, hadcollaborative relationships that crossed the divide of human and veterinary med-icine Osler taught Parasitology and Physiology at the Montreal Veterinary College

in addition to his primary duties at the medical school of McGill University; at theMontreal Veterinary College Osler conducted research on hog cholera (classicalswine fever) and other diseases of dogs and cattle; his textbook, The Principlesand Practice of Medicine (1892), set the standards for medical education (Kahn

of veterinary pathology and the establishment of public health meat inspectionprograms which today are the domain of veterinarians largely because of their

as saying: ‘‘between animal and human medicine there are no dividing lines—norshould there be.’’ (Saunders 2000)

2 Louis Pasteur and Vaccination

In his research efforts that led to the development of a rabies vaccine, Pasteurcertainly saw no dividing line Pasteur began to work on rabies in 1880 with theaim of finding a way to prevent this disease that had begun to plague Europe

He sought to build upon his success on developing a vaccine to protect chickensagainst fowl cholera By 1894, Pasteur was able to demonstrate that vaccinationwith an attenuated virus that had been passed from one species to another couldprotect dogs against rabies By exposing the spinal chords to air of rabbits that hadbeen infected by canine rabies and by transferring the infection from one rabbit

to another every 2 weeks, Pasteur was able to further reduce the virulence ofthe rabies virus He demonstrated the successful results of a preventive rabiesvaccination experiment on dogs The pre-exposure vaccination of canines is

2 R M Atlas

widely practiced today and is credited by greatly reducing the incidence of cases ofhuman rabies Pasteur then moved on to the post-exposure vaccination of humans,thereby crossing the divide of animal and human health.

Since the death of the child was almost certain, I decided in spite of my deep concern to try on Joseph Meister the method which had serve me so well with dogs…I decided to give a total of 13 inoculations in ten days Fewer inoculations would have been sufficient, but one will understand that I was extremely cautious in the first case Joseph Meister escaped not only the rabies that he might have received from his bites, but also the rabies which I inoculated into him (Pasteur 1885 ).

Three months later, Pasteur repeated the experiment on a young shepherd, Baptiste Jupille, severely bitten by a rabid dog On 26 October 1885, Pasteurshowed the promising results of his treatment against rabies in humans to theFrench Academy of Sciences From that time onwards, patients bitten by rabidanimals flocked to Pasteur’s laboratory On 1 March 1886, Pasteur presented apaper to the French Academy of Sciences with the results from the inoculation of

Jean-350 people There was a single failure, due to the fact that the treatment had beenapplied much too late, when the virus had probably already reached the nervoussystem A few months later, Pasteur reported the results of 726 inoculations At ameeting on March 1, 1886, Pasteur declared: ‘‘Rabies prophylaxis after a bite isjustified There is cause to create a rabies vaccine establishment’’ Pasteur haddiscovered the way to prevent rabies in both dogs and humans, setting the pathforward for controlling this disease This is the paradigm of the One Healthapproach

The control of dog rabies still remains the single most important factor inminimizing the public and veterinary risks of rabies in the developing world.Although there are intensive vaccination programs for the number of cases ofrabies declines, but as vaccination of dogs declines, the number of cases of rabiesincreases Tragically, there still are over 50,000 fatal human cases per year andaccording to the World Health Organization (WHO); more than 2.5 billion peopleare at risk in over 100 countries The AIDS epidemic has complicated the situation

as people afflicted with the disease increasingly abandon their dogs, makingvaccination efforts more difficult Using baited vaccines distributed in the envi-ronment for rabies control of stray dogs and wildlife, e.g., fox and raccoons, isproblematic if there are significant populations of immunocompromised individ-uals in the area

Pasteur’s work on rabies was neither done in isolation—nor was it the onlyinfectious disease where he helped pioneer vaccines to control infectious diseases

of both humans and animals Henri Toussaint and Pierre Galtier were Frenchveterinarians who also sought to develop vaccines against fowl cholera, anthrax,

vaccine that could protect poultry against fowl cholera The vaccine was ated by prolonged exposure to oxygen For his work on fowl cholera, Pasteur used

attenu-a culture of Pattenu-asterurellattenu-a multocidattenu-a thattenu-at he hattenu-ad received from Toussattenu-aint This wattenu-ascritical for the successful development of the fowl cholera vaccine

Toussaint went on to develop a vaccine against anthrax using heat killedBacillus anthracis Unfortunately, as this bacterium forms heat resistant spores, the

‘‘killed’’ vaccine was not always successful Toussaint also experimentedwith carbolic acid attenuated B anthracis Pasteur used oxygen and potassiumbicarbonate attenuated bacteria in his anthrax vaccine to protect sheep and otheranimals against anthrax For his rabies vaccine, Pasteur built upon the work ofGaltier who had shown that passage through domestic animals could alter thevirulence of the rabies virus

As a result of the demonstration that vaccines developed in the laboratory couldprevent disease in animals and humans, Pasteur set a path for the control of manyonce-deadly diseases Smallpox, once a deadly human disease, and rinderpest,

a disease of cattle that shaped the history of Africa, have been eliminated.Both attenuated and heat killed vaccines are critical in both veterinary and medicalpractice today The convergence of people, animals, and our environmenthas created a new dynamic in which the health of each group is inextricablyinterconnected Pathogens can spread great distances as a result of moderntransportation systems and global commerce

Vaccination is a core element of One Health In the developing world, it is saidthat vaccinating cattle which feed the village is seen as more important thanvaccinating children (Karen Becker, unpublished comment at the One HealthSummit, November 17, 2009) The One Health Medicine community has sought

to highlight the importance of rabies through worldwide educational programs

on World Rabies Day Clearly, the efforts to eliminate rabies that began withPasteur’s development of a rabies vaccine will need to integrate a number ofhuman, animal health, and environmental factors, i.e., a One Health approach iskey Confronting zoonoses through closer collaboration between medicine andveterinary medicine is critical and vaccines and other means of controllinginfectious diseases in animals is a critical part in protecting human public health

3 Robert Koch and the Etiology of Infectious Diseases

Pasteur’s arch rival Robert Koch also did not differentiate between infectiousdiseases of humans and animals As a child, Koch was caretaker of the family’schickens, cows, pigs, and horses Later as a family physician Koch maintainedguinea pigs, rabbits, and even apes in his district hospital at his own expense Kochhad hoped to study with Virchow but was denied the opportunity Perhaps, thatwas fortunate as Virchow was strongly opposed to the germ theory of disease.Koch would go on to develop the theory that microorganisms were the agentsresponsible for numerous human and animal diseases In 1873, Koch began hisstudies on anthrax which culminated with his demonstration that the etiology

of the disease was due to infection by the bacterium Bacillus anthracis (Koch

4 R M Atlas

humans Through his research, Koch was able to find a causal relationship betweeninfection by a specific bacterium and a specific disease in both animals andhumans.

Until late in the nineteenth century disease had been regarded as resulting from a lack of harmony between the sick person and his environment; as an upset of the proper balance between the yin and the yang, according to the Chinese, or among the four humors, according to Hippocrates Louis Pasteur, Robert Koch, and their followers took a far simpler and more direct view of the problem They showed by laboratory experiments that disease could be produced at will by the mere artifice of introducing a single specific factor—a virulent microorganisms—into a healthy animal (Dubos 1959 ).

Koch went on to study various diseases of animals in the developing world

He travelled to Cape Town and later to Egypt and East Africa to arrest epidemicoutbreaks of rinderpest in cattle Koch used blood and serum from convalescentanimals to immunize and thereby protect healthy animals While, in Africa, Kochalso studied human cases of malaria and suggested using prophylactic ingestion ofquinine and the use of netting to avoid the mosquito bites that had been shown to

be responsible for transmitting the etiologic agent of malaria The first monumentdedicated to Koch was erected on the Italian island of Brioni in recognition of hishelp in eradicating malaria there in 1900 In 1905, Koch was in Africa working onthree diseases—East Coast fever of cattle, tick borne relapsing fever of humans,and tsetse fly borne trypanosomiasis of humans and animals showing that thedisease cycles involved vectors and nonhuman reservoirs for the pathogens Kochand his colleagues, for example, showed that trypanosomes underwent develop-mental cycles in tsetse flies and tried to control the disease by ecological changes,including thinning trees, cutting back brush, and eradicating crocodiles, the source

of blood for the tsetse fly Glossina palpalis In trying to control this disease, Kochclearly recognized the importance of the environment and how specific environ-mental factors can impact animal and human health

The ecology of infectious diseases is increasingly recognized as an appropriateway of viewing animal and human health There are classic examples of howenvironmental disturbance leads to the spread of infectious disease; for example,the numerous cases of yellow fever that occurred when the Panama Canal wasbuilt as mosquitoes carried the yellow fever virus from the reservoir of monkeys inthe jungle canopy to the people constructing the canal in the exposed path wherethe jungle was cleared But even ecologically conscious development can alter theecology in ways that lead to the spread of infectious disease, e.g., the concentratedoutbreak of Lyme disease in 1975 after the town of Lyme Connecticut restoredforests, as a result houses were much closer to wooded areas allowing deer andinfected deer ticks to come in contact with more people By restoring a forest, arare disease that was known before a century became a major concern that hasspread across the United States

As proclaimed by the epidemiologist William Foege, who played a critical role

in devising the global strategy that led to the eradication of smallpox in the late1970s and in increasing immunization rates in developing countries in the 1980s,

‘‘You can’t tell the story of human health separate from animal health or

animal hosts and environmental reservoirs Disruption of the environment can lead

to transmission of animals and humans; evolution of new microbial traits can occur

in response to the changes in the environment; and reservoirs of pathogens andvirulence traits can persist in the environment, poised to enter the cycle at an

4 Calvin Schwabe and Epidemiology

Despite the clear interrelationships between human and animal disease and theenvironment, twentieth century veterinary and medical practice and researchdiverged with specialties and the intellectual silos became the norm in developedcountries Countering the movement toward separation, Calvin Schwabe sought tobring the fields of human and animal health care and infectious disease surveil-lance together It was Schwabe’s view that:

There is no difference of paradigm between human and veterinary medicine Both sciences share a common body of knowledge in anatomy, physiology, pathology, on the origins of diseases in all species (Schwabe 1964 ).

Schwabe began his career in the School of Medicine at the American University

in Beirut, Lebanon in 1956 He subsequently founded and chaired a jointDepartment of Tropical Health in the Schools of Medicine and Public Health and aDepartment of Epidemiology and Biostatistics in the School of Public Health atAmerican University He later established the Department of Epidemiology andPreventive Medicine at the University of California Davis School of VeterinaryMedicine—the first of its kind in the world at a school of veterinary medicine.There, he pioneered the use of human disease tracking techniques in the study ofanimal disease and is considered the founder of veterinary epidemiology.Schwabe is credited with originating the term One Medicine which later

Medicine had their origins in his work with Dinka pastoralists in Sudan in the1960s and reflected his broad interests in epidemiology, diseases of animalstransmissible to humans, interactions of veterinary and human medicine, parasiticzoonoses and their control, tropical health, public health practice, livestock health

in pastoral societies, ancient origins of human and veterinary medicine, and the

Today, ‘One Medicine’ is commonly referred to as ‘One Health’ worldwide The change

in terminology occurred during the first decade of the 21st century ‘‘One Health’’ evolved from the earlier used term ‘‘One Medicine,’’ which historically implied the crossing over between veterinarians and physicians One Health recognizes that humans and animals do not exist in isolation, but are parts of a larger whole, a living ecosystem, and that the activities of each member affect the others Thus, One Health considers health as a whole: that of humans, animals, and the environment they exist on (Kaplan and Scott 2011 ).

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The public health value of joining veterinary and human medical efforts indisease surveillance is especially obvious when it comes to zoonotic diseases.Take, for example, the identification of West Nile virus in the United States.

In 1999, several elderly people in New York City became fatally ill with signs ofencephalitis At the same time, crows began dying in large numbers in the samearea Because of the separation of human and animal disease diagnostic processes,initially there was no thought about a connection between them Dr TraceyMcNamara, head veterinary pathologist at the Bronx Zoo, began to investigatewhy a growing number of crows were becoming ill and dying and why a cor-morant, several flamingos, and a bald eagle at the Bronx Zoo also had died.Analyses of human blood specimens by the Centers for Disease Control andPrevention (CDC) initially suggested St Louis encephalitis (SLE), a disease thathad previously occurred in the area and is transmitted from infected birds tohumans by mosquitoes Analysis of samples from the dead zoo birds by the USDepartment of Agriculture National Veterinary Services Lab in Ames, Iowa,revealed a virus too small to be SLE virus An epidemiologist at the New YorkCity health department raised concern that the large numbers of dead birds might

be connected to the human cases of encephalitis It soon became clear that thehuman and bird deaths were being caused by the same virus and that was a newlyemerging disease Nearly 3 months after the initial outbreak, government scientistsannounced that the disease was caused by West Nile virus, which had never beforebeen found in the Western hemisphere If there had been a One Health approach tosurveillance and diagnosis, the etiology of the disease could have been revealedmuch sooner

Studies on the genes of West Nile virus suggest that it was first evolved inAfrica and also that as birds migrated from Africa to other continents of the OldWorld, they spread the virus to new bird species and eventually to mosquito

Modern molecular methods are facilitating the detection of emerging viral eases In a fascinating application of these molecular techniques, the source of theAIDS epidemic may have been identified as coming from colonial Africa a century

group M, which is responsible for human AIDS, probably originated in panzees in Cameroon before 1900 and most likely was transferred into the blood of

individual most likely infected others so that the virus moved down the Sangha andCongo Rivers into Kinshasa At that time, colonial efforts to exploit local rubberand ivory created routes to transport these resources that became pathways forinfectious disease propagation; for example, syphilis reached epidemic proportionsalong porter routes and riverside trading posts in Cameroon and throughout theCongo Basin The large population of the city of Kinshasa and the movement ofporters to carry supplies and exploited resources are postulated to have created theconditions for the AIDS epidemic that moved worldwide

Today, scientists like Nathan Wolfe are carrying out molecular analyses onviruses in the developing world Wolfe founded and directs the Global Viral

Forecasting Initiative (GVFI), which is a pandemic early warning system thatmonitors the spillover of novel infectious agents from animals into humans Themolecular surveillance being carried out by GVFI aims to characterize thediversity of viruses and other agents as they move from animals into humanpopulations, providing basic insights into how new diseases enter humans andimproving our ability to decrease the frequency of such events Given that, mostmajor diseases of humanity originate in animals and exposure to wild and domesticanimals leads to continuous spillovers of novel agents into humans, such sur-veillance may provide the necessary warning to prevent major pandemics If suchmonitoring had been in place a century ago, we might have averted the HIV/AIDSpandemic.

Indeed a fundamental goal of the One Health movement is to integrate humanand animal disease surveillance and early detection in both animal and humanpopulations There is a need to support integrated environmental, animal, andhuman health research on the factors promoting emergence of disease, on inter-ventions to prevent their occurrence, and on interventions that protect human andanimal health Modern molecular analytical tools may provide the means ofaccomplishing the necessary surveillance of emerging pathogens in animals,e.g., H5N1 avian influenza viruses, and thereby provide a way of predicting andpreventing jumps to humans of pathogens that could cause deadly pandemics

5 Contemporary Revival of One Health

A half century after Schwabe coined the term One Medicine, the WildlifeConservation Society organized a One World, One Health symposium in Sep-tember 2004 The symposium focused on the current and potential movements ofdiseases among human, domestic animal, and wildlife populations Examiningcase studies on Ebola, Avian Influenza, and Chronic Wasting Disease led to theconclusion that only by breaking down the barriers among agencies, individuals,specialties, and sectors would be able to unleash the innovation and expertiseneeded to meet the numerous serious challenges to the health of people, domesticanimals, wildlife, and the integrity of ecosystems

The group produced a list of 12 recommendations, which they called the

‘‘Manhattan Principles,’’ for establishing a more holistic approach to preventepidemic/epizootic disease and for maintaining ecosystem integrity for the benefit

of humans, their domesticated animals, and the foundational biodiversity that

need to recognize the essential link between human, domestic animal and wildlifehealth and the threat disease poses to people, their food supplies and economies,and the biodiversity essential to maintain the healthy environments and func-tioning ecosystems we all require

Two years later, the American Veterinary Medical Association (AVMA) began

an effort to foster the One Health Concept Under the leadership of Roger Mahr

8 R M Atlas

(AVMA President 2006–2007) it formed a task force chaired by Lonnie King to studythe feasibility of an initiative that would facilitate collaboration and cooperationamong health science professions, academic institutions, governmental agencies, andindustries to help with the assessment, treatment, and prevention of cross-speciesdisease transmission and mutually prevalent, but non-transmitted, human and animaldiseases and medical conditions The task force issued a report entitled One Health: A

which had as a main recommendation the formation of a One Health Commission TheAVMA was joined by the American Medical Association in trying to move forward theformation of the One Health Commission As an intermediate step, a One Health JointSteering Committee, which I chaired, was formed in 2008 to define the scope of theOne Health Commission

Commission are the: American Veterinary Medical Association, American PublicHealth Association, Association of Academic Health Centers, Association

of American Medical Colleges, Association of American Veterinary MedicalColleges, Infectious Diseases Society of America, and Iowa State University OneHealth Consortium

The mission of the One Health Commission is the establishment of closerprofessional interactions, collaborations, and educational and research opportuni-ties across the health sciences professions, together with their related disciplines,

to improve the health of people, animals, plants, and our environment Two mary goals have been identified to achieve its mission toward One Health: (1) Toinform all audiences about the importance of the One Health approach by estab-lishing a leading center for One Health communications and resources and (2) totransform the way human, animal, plant, and ecosystem health-related disciplinesand institutions work together by promoting and enabling demonstration projectsthat illustrate the importance and value of the One Health approach The aim is toestablish interdisciplinary programs in education, training, research, and estab-lished policy; provide more opportunities for information sharing related to diseasedetection and diagnosis, as well as education and research; to achieve more pre-vention of diseases, both infectious and chronic; and to foster new therapies andapproaches to treatment for unmet needs

pri-The One Health Commission convened a One Health Summit in 2008 at theNational Academies in Washington DC to raise awareness of the importance oftranscending institutional and disciplinary boundaries to improve health for all

was designed to be a forerunner to a National Academies study that would define aroadmap for advancing the One Health Concept Although there was greatenthusiasm expressed at the summit by Federal Agencies and various scientific,public health, medical, and veterinary organizations, the proposed NationalAcademies study has not moved forward with developing a One Health agendaand it remains to be seen how broadly the Commission can impact the research andpractice agenda in the United States and beyond

One of the goals of the One Health Commission is to inform all audiences aboutthe importance of the One Health approach by establishing a leading center forOne Health communications and resources This communication function seems

to be being better met by the One Health Initiative which was independentlyformed by Laura Kahn, Bruce Kaplan, and Thomas Monath; these three individ-uals brought together the public health, veterinary, and medical perspectives,respectively, and formed an effective outreach program; they have been joined byothers who support the One Health Concept The One Health Initiative aims toforge coequal, all inclusive collaborations between physicians, osteopaths, veter-inarians, dentists, nurses, and other scientific-health and environmentally related

informed of upcoming meetings and other relevant activities It also hosts thearchive for the One Health Newsletter which publishes articles about various

A major outcome of the One Health effort initiated by the American VeterinaryMedical Association was the formation by The Centers for Disease Control andPrevention of a One Health Office The One Health Office brings together CDCpersonnel and resources from multiple organizational units and disciplines to moreprecisely address the convergence of human and animal health The CDC’s OneHealth Office works to facilitate, sponsor, and coordinate research and programactivities that seek to attain optimal health for people and animals through anintegrated approach considering the interrelatedness among humans, animals, andthe environment in which they live Working together with the US Department ofAgriculture the CDC One Health Office has begun to forge the collaborative effortsthat are at the heart of the One Health movement

Growing support by government agencies is evident in a series of workshopsthat are establishing a formal process for advancing a One Health agenda

In March 2009, the Public Health Agency of Canada, in collaboration with otherCanadian ministries and several major international organizations hosted an expertconsultation titled ‘‘One World, One Health: From Ideas to Action’’ in Winnipeg,Manitoba The purpose of the consultation was to identify and shape country levelrecommended actions to globally advance the framework for advancing OneHealth The Report of the Expert Consultation concluded that moving forward theanimal, human, and ecosystem interface concepts of ‘‘One Health’’ requiredcommitment at all levels—international, regional, national, and local

The World Organization for Animal Health (OIE), Food and Agriculture nization of the United Nations (FAO), World Health Organization (WHO), andCenters for Disease Control and Prevention (CDC) convened a subsequent meeting

Orga-on 4–6 May 2010 at the StOrga-one Mountain COrga-onference Center in Atlanta, Georgia, tobuild upon the recommendations and conclusions drawn from the Winnipeg expertconsultation The meeting, entitled ‘‘Operationalizing ‘One Health:’ A PolicyPerspective-Taking Stock and Shaping an Implementation Roadmap,’’ broughttogether a select group of leaders, including specialists from national Ministries ofHealth and Agriculture, the European Commission, the UN, the World Bank, and

10 R M Atlas

other institutions from the academic, policy and economic sectors to contribute theirexpertise and experience to the discussion The participants identified ‘‘criticalenabling initiatives’’ that would promote One Health goals.

The group recognized that for One Health to become an operational realitythere would need to be a cultural change so as to appreciate the importance of theconnection between humans, animals, and ecosystems; increased visibility of thevalue added by the One Health approach in preventing, detecting, and controllingdiseases that impact both humans and animals; designated funding to supportinterdisciplinary collaborative programs; and improved collaboration in surveil-lance, communications, outbreak response, and sample sharing Seven workgroupswere formed to collaboratively develop and implement the key activities thatcollectively would result in the operationalization of One Health through training,communication, capacity building, and institutional support These groups areprogressing in developing plans

In addition to the government meetings that are trying to develop a path forwardfor One Health, there have been several major scientific and public health meetingsthat are bringing together the scientific, medical, and veterinary communities whoare finding common ground for future collaborations For example, a regional OneHealth conference was held in South Africa in 2011 The American Society forMicrobiology also organized sessions on One Health at the annual meetings of theAmerican Association for the Advancement of Sciences in 2010, 2011, and 2012.Immediately following the last of these sessions, which dealt with demonstrationprojects in the developing world, the Global Risk Forum (GRF) held a One HealthSummit in Davos Switzerland in 2012 that examined the risks and opportunitiesfor One Health from an integrative health risk management perspective ThatSummit recognized that today’s human health management requires a holistic OneHealth perspective and that only an integrative approach will ensure sustainablehealth management in an era of climate change, resource depletion, land degra-dation, food insecurity and development challenges

The first International One Health Congress, held in February 2011 in bourne Australia, was the largest One Health meeting held to date with more than

Mel-650 people from over 60 countries In addition to the themes of One Health alreadydiscussed, the Congress expanded into the area of food security and safety Theconference was quite successful in facilitating dialog A second International OneHealth Congress is planned for early 2013 in Bangkok, Thailand These meetingsseem to reflect growing support for One Health

6 Future of One Health

Despite the obvious value put forth by the proponents of One Health, there areserious challenges to the development of One Health There has yet to be agree-ment on the scope of One Health—different groups have proposed a variety of

the health of animals and humans, or economic savings, not achievable withoutcooperation of the two medicines It should just become normal that doctors and

Health Commission defines One Health differently stating that ‘‘One Health is thecollaborative effort of multiple health science professions, together with their relateddisciplines and institutions—working locally, nationally, and globally—to attainoptimal health for people, domestic animals, wildlife, plants, and our environment’’

essential, it would serve as a focal point for defining constituencies and boundaries ofrelevant activities

The One Health Initiative does not offer a specific definition but says that ‘‘TheOne Health concept is a worldwide strategy for expanding interdisciplinary col-laborations and communications in all aspects of health care for humans, animalsand the environment.’’ It states that the synergism achieved will advance healthcare for the twenty-first century and beyond by accelerating biomedical researchdiscoveries, enhancing public health efficacy, expeditiously expanding the scien-tific knowledge base, and improving medical education and clinical care ViewingOne Health this broadly suggests that it is everything for everybody, in which case

it lacks the necessary focus to impact the health of humans, animals, and theenvironment Hence, it may not be surprising it is proving difficult to gain broadacceptance for the One Health concept

Many physicians in particular object to the term holistic which often is used todescribe One Health—this may be a visceral reaction to the term ‘‘holistic medi-cine’’, which is not widely supported by physicians Also, there are those in the fields

of human medicine who see One Health as a field being championed primarily byveterinarians and they are suspicious of the motives And of course, there are thesilos that have been developed in both research and practice—it is always difficult tobreak down boundaries and foster new cross-cutting relationships

The value of One Health is best appreciated from a public health perspective,especially in the developing world where limited resources force coordinatedactions between physicians, veterinarians, and ecological conservationists

infectious diseases can easily cross geographic boundaries, especially in a time ofunprecedented global travel and commerce and because infectious agents canmove from animal hosts to human hosts and back, adapt to the ever-changingnatural environment, and cause a public health crisis that no country can afford toignore To prevent the evolving infectious diseases we know today and to preparefor the emerging infectious threats of tomorrow, we need to consider infectiousdiseases not only as they relate to human health This human–animal–environmentinterface impacts nearly all aspects of public health, including the risk of exposureand illness, the scope of disease emergence and spread, approaches to surveillanceand early warning, basic and applied research and the effectiveness of interven-tions for prevention and control The ‘‘triple threat’’, thus, demands new ways ofworking in public health and new collaborations that do not exist today

12 R M Atlas

Given that over 60 % of emerging infectious disease events is caused by thetransmission of an infectious agent from animals (zoonoses), with 75 % of theseoriginating from wildlife, employing a systematic One Health approach has greatpotential for reducing threats to global health from infectious diseases The OneHealth approach should advance health care for the twenty-first century andbeyond by accelerating biomedical research, enhancing public health efficacy,expeditiously expanding the scientific knowledge base, and improving medical

References

Atlas R, Rubin C, Maloy S et al (2010) One health—attaining optimal health for people, animals, and the environment Microbe September http://www.microbemagazine.org/index.php/09- 2010-home/2760-one-health-attaining-optimal-health-for-people-animals-and-the-

environment Accessed 1 Apr 2012

Cook RA, Karesh WB, Osofsky SA (2004) About one world, one health Wildlife Conservation Society, Bronx, New York http://www.oneworldonehealth.org Accessed 1 Apr 2012 Dubos R (1959) Mirage of health: utopias, progress, and biological change Harper and Brothers, New York Reprinted 1987 Rutgers University Press, New Brunswick

Foege WH (2004) One world, one health, Can we muddle through? http://www.oneworldonehealth.org/ sept2004/presentations/eve_foege.html Accessed 1 Apr 2012

Kahn L, Kaplan HB, Steele JH (2007) Confronting zoonoses through closer collaboration between medicine and veterinary medicine (as ‘One Medicine’) Veterinaria Italiana 43:5–19 Kaplan B, Scott C (2011) Who coined the term one medicine? One Health Newsletter, vol 4, Fall 2011

King L (2008) Triple threat to health: an imperative for one health Congressional briefing July 10, 2008 http://www.asm.org/images/pdf/KingPresentation.pdf Accessed 1 Apr 2012 Koch R (1877) The etiology of anthrax based on the developmental cycle of Bacillus anthracis Beitragen zur Biologie der Pflanzen 2:277–310

Pasteur L (1885) Methode pour prevenir la rage apres morsure Compt Rend Acad Sci 101: 765–773

Schwabe C (1964) Veterinary medicine and human health Williams and Wilkins, Baltimore Timberg C, Halperin D (2012) Tinderbox Penguin Press, New York

Williams E (2010) The forgotten giants behind Louis Pasteur Veterinary Heritage: Bulletin of the Veterinary Hist Soc 33(2):33–39

Zimmer C (2011) A planet of viruses University of Chicago Press, Chicago

Zinsstag J, Meisser A, Schelling E, et al (2011) From two medicines to one medicine to one health and beyond 1st African one health conference, Johannesburg www.sacids.org/kms/ resources/OneHealth_Johannesburg_Zinsstagetal_2011%20(2).pdf Accessed 1 Apr 2012

Part I

The Concept of One Health

Diseases: Clinical Perspectives

Peter Rabinowitz and Lisa Conti

activities for veterinary and human health care providers regarding emerginginfectious diseases, yet they could play a critical role Under current clinicalparadigms, both human and animal health professionals routinely diagnose andtreat zoonotic infectious diseases in their patients, but tend to work in parallel withlittle cross-professional communication or coordination of care For this to evolvetoward a One Health model, both types of clinicians need to see how individualcases can be ‘‘sentinel events’’ indicating environmental risk for disease emer-gence, and develop mechanisms of rapid communication about these risks Humanand animal clinicians also need to take a more proactive and preventive approach

to zoonotic diseases that includes the occupational health of animal workers infarms, laboratories, veterinary clinics, and other settings, as well as the recognition

of increased risk among immunocompromised individuals in contact with animals.This requires training in One Health clinical competencies including the ability todiagnose and treat zoonotic diseases, implement preventive care interventions forindividual patients, provide occupational health services for animal workers,recognize sentinel cases, report cases to public heath and clinical colleagues, andassess and help to intervene with environmental factors driving infectious diseaserisk in humans and animals To provide an evidence base for such competencytraining, there is a need for development and testing of innovative protocols forOne Health clinical collaborations

 Springer-Verlag Berlin Heidelberg 2013

Published Online: 11 September 2012

1 Overview: The Critical Role of Clinicians in One Health and Emerging

Infectious Diseases 18 1.1 Recognition and Treatment of Emerging Infectious Disease by Human

and Animal Clinicians 19 1.2 Clinical Prevention of Disease: Herd Health, Occupational Medicine 21 1.3 Role of the Human–Animal Bond 24 1.4 Challenges to Implementation of Clinical One Health Approaches 25 1.5 Overcoming Challenges to Clinical One Health 26 References 28

1 Overview: The Critical Role of Clinicians in One Health and Emerging Infectious Diseases

One Health is a concept that involves cooperation between professionals in human,animal, and environmental health Such professionals may work in a number ofsectors, including public health services, agriculture, environmental quality, andveterinary and human medicine To date, much of the discussion and development

of the One Health concept with respect to emerging infectious diseases hasrevolved around the role of public health and disease control agencies Despiteendorsements from professional societies, including the American MedicalAssociation, the American Veterinary Medical Association, and the AmericanAcademy of Pediatrics, there has been far less articulation of the specific OneHealth clinical activities for veterinary and human health care providers Currentmedical school curricula devote relatively little time to zoonotic diseases, andmedical school courses in One Health are virtually nonexistent In summary, OneHealth developments have proceeded without much involvement of the clinicalprofessional community In this chapter, we assert that human and animal healthclinicians have a critical role to play in One Health efforts regarding emerginginfectious diseases, and indeed unless clinicians begin to define a clear strategy forincorporating One Health principles into clinical practice, the development of OneHealth as a viable disease control paradigm will be severely hampered

This chapter will illustrate how human and animal health clinicians currentlyproviding services to individual humans and animals are already engaged withemerging zoonotic diseases We point out how clinician training and development

of enhanced clinical protocols could allow for the application of One Healthprinciples to such care, and how this could result in improved disease control Wealso describe the important role of clinicians in the preventive care of populations,including animal herds and animal workers, and how the provision of occupationalhealth services for animal workers provides an ideal nexus for One Health col-laboration between human and animal clinicians in order to prevent and detectzoonotic disease transmission at the human–animal interface Finally, we review

18 P Rabinowitz and L Conti

the significant barriers to the creation of a cadre of One Health clinicians in bothhuman medical and veterinary training centers, and outline strategies for over-coming such obstacles to achieve this vital goal.

1.1 Recognition and Treatment of Emerging Infectious Disease

by Human and Animal Clinicians

1.1.1 Current Paradigms

In their daily clinical practices, human health clinicians may diagnose and treatpatients with zoonotic infectious diseases These diseases may appear as acutedisease processes, such as salmonellosis in a child with reptile contact, or theycould manifest in more chronic fashion, such as a brucellosis infection in a hunter.Sometimes zoonotic diseases spring from asymptomatic reservoirs, such as deer-mice (Peromyscus spp) that appear not to develop clinical illness from Hantavirusinfection or the Borrelia spirochete that causes Lyme disease Yet many zoonoticpathogens cause disease in both humans and animals, and veterinarians andphysicians may find themselves treating similar disease complexes in theirrespective patients, even using similar antibiotic regimens

Examples of this cross-species virulence include Rocky Mountain spottedfever, a severe and often fatal disease in both dogs and humans caused by tick-borne Rickettsia, and avian influenza, which has devastated poultry flocks inseveral continents as well as causing hundreds of human deaths

Nevertheless, the current clinical paradigm is for human health clinicians todiagnose and treat the human patient infected with a zoonotic pathogen with littleconsideration for two critical aspects: first, whether there is a need for evaluationand treatment of the infected animal source, and second, whether the diseaseoccurrence represents an emerging infectious disease event related to changes inenvironmental and ecosystem factors As mentioned above, this approach oftreating the human disease in isolation of animal and environmental health aspectsmay stem from a perception that animals harboring infectious pathogens are oftenasymptomatic and not in need of clinical care Indeed, a common medical rec-ommendation is to remove an animal from a household, as when an obstetricianinappropriately advises that a pregnant woman avoid all cat contact to prevent

For their part, veterinarians commonly encounter infectious diseases in theiranimal patients that may have zoonotic potential Veterinary practices routinelyidentify hookworm (ancylostomiasis), roundworm (toxocariasis), and Cryptospo-ridia infestations, particularly in young companion animals (Hotez and Wilkins

there is a tendency to treat the animal and not directly deal with issues of possibleinfection occurrence in nearby humans However, veterinarians are trained to

counsel their clients about zoonotic risks, and may recommend that the client seekmedical care if symptoms should develop At the same time, it is rare for veter-inarians to directly contact their medical colleagues in the community, even if theyare treating members of the same household.

Veterinarians may also be likely to consider certain environmental factorspredisposing to disease in the animal, such as overcrowding or contact withinfected wildlife In such a situation, the occurrence of disease in the animal could

be a ‘‘sentinel case’’ providing warning of disease threat in the environment

1.1.2 How Clinicians can Evolve

A key aspect of whether practitioners are taking a One Health clinical approach isthe extent to which they are trained and capable of recognizing ‘‘sentinel’’ cases.Sentinels may indicate that preventive efforts have broken down and/or that thereare emerging hazards in the environment There have been well documentedinstances of animals serving as ‘‘sentinels’’ for human disease risk The classicexample is the ‘‘canary in the coal mine’’ where coal miners brought canaries intomine shafts because they had proved to be more susceptible than the miners to theeffects of hypoxia and carbon monoxide exposure, and would literally fall off oftheir perch when sickened by the fumes, allowing the miners time to don pro-

An example of animals serving as sentinels of infectious disease risk is thetickborne rickettsial disease Rocky Mountain spotted fever (RMSF) which, aspreviously discussed, causes clinical disease in both humans and dogs This isillustrated by a report of a fatal dog case providing warning of human disease riskand helping alert astute clinicians to human cases in the community (Paddock et al

either disregarded by human health authorities or information about them was notcommunicated between human and animal health clinicians, leading to delayed

Another well publicized example of animal sentinel disease events was the 1999emergence of West Nile virus (WNV) in the United States WNV caused an acute andfatal encephalitis in crows and other birds in Bronx NY at the same time that humans

in the area were reporting an increase in encephalitis cases The unusual pathologypattern in the affected birds was what alerted an astute veterinary clinician to the factthat this was a novel virus infection event Eventually, the human cases were also

both human health and veterinary clinicians to have recognized the cross-speciesrelevance of the cases and taken steps to notify both public health as well as eachother directly They also, ideally, would have used such case information to considerwhether there were environmental changes driving the emergence of the cases and

‘‘shared risk’’ of infection across different species that warranted further tion In terms of RMSF, for example, the patterns of abundance of the tick vector are

20 P Rabinowitz and L Conti

cases and/or case severity could signify a change in the disease ecology (Adjemian

ecological disruption and drivers of emergence is therefore a key aspect of OneHealth in clinical practice

By the same token, there are a number of situations in which infectious diseaseevents in humans may serve as sentinel events warning of infectious risks toanimal health An example would be a case of Streptococcus suis in an abattoirworker, who due to the fact that humans often receive greater diagnostic evalu-ation is diagnosed prior to the recognition of the organism in the swine herd Such

an instance represents a sentinel event with clinical importance both for the largerpopulation of animal workers as well as the hogs to which the workers areexposed Again in such cases, the veterinarian as well as the physician investi-gating the occurrence of Streptococcus suis in the herd and the animal workersmust think about what changes in agricultural practices and environmental factors

To detect animal-related infections, the physician must carry a high index ofsuspicion One way is to ask questions about the patient’s exposure to and health

of animals as part of the medical history, especially for a patient with fever,respiratory, or diarrheal disease Red flags in the history include the patients’exposure to ‘‘high risk animals’’, such as kittens, puppies, ducklings, chicks,reptiles, or other wild or exotic animals, immunocompromised animals, or animalswith diarrhea or acute respiratory infection

By the very nature of their work, veterinarians may be more attuned than theirmedical colleagues to the effects of the environment on human health The vet-erinarian knows that inadequate housing, overcrowding, pathogen-contaminatedpastures/kennels, or contact with infected wildlife can lead to infection andimpaired immunity in animals under care The veterinarian is also used to com-paring health risks across multiple species, understanding the ‘‘shared risk’’ con-cept and the need to address the root causes of a zoonotic risk situation One of thechallenges for animal health professionals then, could be to educate their humanhealth colleagues about this world view

As One Health clinicians, both human and veterinary health professionals play

a critical role on the ‘‘front lines’’ by reporting these sentinel surveillance cases to

a public health authority where critical information about disease incidence can beshared and further acted upon

1.2 Clinical Prevention of Disease: Herd Health,

Occupational Medicine

1.2.1 Preventive Care of Individual Animals

The mainstay of veterinary practice is preventative medicine ‘‘Herd health’’ isdependant upon appropriate nutrition, hygiene, vaccination, and strategic

deworming In some cases, animal vaccinations reduce the risk of both the animalpresenting with infection as well as zoonotic transmission to people This is so,

goal of strategic deworming is to eliminate individual parasite burdens as well asreduce the hazard of having hardy ova in the environment which can cause sig-nificant health problems in people For example, ocular larval migrans from dog orcat roundworm infections are a preventable cause of childhood blindness For thisreason, puppies and kittens should be dewormed starting at 2 weeks of age, thenevery 2 weeks until they can receive an age-appropriate monthly intestinal de-

can also guide appropriate pet selection to mitigate hazards to owners Should ananimal become infected with a zoonotic pathogen, timely diagnosis and treatmentand proper husbandry will serve to reduce transmission to people In these ways,veterinarians have a significant role in the public health controls of zoonoses

1.2.2 Preventive Care of Individual Humans

On the human medical side, clinicians can provide counseling to their patientsabout animal contact-risk factors Examples of preventive recommendations are asfollows:

• People at increased risk of zoonotic infection include infants and small childrenyounger than age 5, elderly, pregnant women, and immunocompromised persons

• Zoonotic disease prevention includes routine veterinary care for all pets, washing, proper hygiene in disposal of animal waste, appropriate diet for thepets, and timely treatment for diseased pets Specific recommendations for allpatients include hand-washing after handling pets and pet dishes, and avoidingcontact with animal feces and vomitus through proper disposal Pregnant womenshould avoid handling cat feces and litter, keep cats indoors, and not feed catsuncooked meat to reduce the risk of toxoplasmosis Additionally, people atincreased risk of zoonotic infection should not feed pets raw meat diets toprevent enteric pathogens

hand-• Keeping exotic pets carries increased risk of exotic pathogens, an example being

an outbreak of monkeypox in the Midwest United States traced to imported

infection risk Veterinarians can be referred to assist with appropriate pet selection

• Pets that roam outdoors or that are fed outdoors may have greater contact withwildlife and the pathogens they carry

• Particular habits of pet ownership may play a pivotal role governing sion of pet pathogens Sleeping with pets has been linked to cases of the plague,

contact, including biting, scratching, licking, and kissing, has resulted intransmission and infection from Capnocytophaga canimorsus (Valtonen et al

22 P Rabinowitz and L Conti

1.2.3 Occupational Health Services for Animal Workers

Millions of people worldwide engage in occupational activities involving animals,including farmworkers and food processing workers in animal meat and dairy pro-duction and processing, workers in fisheries, stables, kennels, pet trade and groomingfacilities, zoos, wildlife facilities, animal clinics, and research laboratories Atpresent, many if not most of these individuals receive little to no preventive healthservices related to their work exposures including exposure to zoonotic pathogens

At the same time, zoonotic pathogens often first emerge at the animal-workerinterface, and the occupational setting represents an ideal and underutilized settingfor early detection and prevention of cross-species disease transmission Forexample, the worldwide epidemic of severe acute respiratory syndrome (SARS) wasfirst noted in a chef in Hong Kong who was preparing wild animal meat for con-sumption Subsequent serological surveys of live animal market workers in Chinashowed evidence of transmission between wild animals and these workers Theemergence of Nipah virus in Malaysia took place in the setting of large-scale swineproduction in the vicinity of rain forest that was home to the wildlife reservoir of thepathogen (flying foxes—Pteropus sp.) and the first human cases were swine workers

pathogenic avian influenza was a veterinarian responding to the poultry outbreak ofH7N7 avian influenza in the Netherlands, and highly pathogenic H5N1 avianinfluenza has caused numerous deaths in humans working with poultry in either the

reassortment event leading to the worldwide pandemic of 2009 H1N1 novel enza A infection remain unknown, it is likely that the reassortment took place inswine and then crossed to human populations through a swine worker with closecontact with infected animals Since that original event, there have been documentedcases of reverse zoonotic transmission of H1N1 from infected swine workers to pigs,and this may have contributed to the recent emergence of a recombinant H3N2 strain(CDCb) The growing industrialization of agricultural animal production demands amore organized approach to infectious disease risks in concentrated animal settings,and this must include both worker health and reduction of pathogen pollution fromanimal waste

influ-Occupational Health is a discipline that focuses on the recognition and vention of hazardous exposures in the workplace setting It applies a preventivemedicine paradigm with a ‘‘hierarchy of controls’’ based on elimination of thehazard at the source and the use of engineering and other controls to reduceexposure in the environment It also involves ongoing surveillance of workers todetect ‘‘sentinel cases’’ of occupational disease, in this case zoonotic diseasetransmission events between animals and animal workers, in settings ranging frombushmeat hunting to industrialized animal production Occupational Health foranimal workers therefore must involve human, animal, and environmental health

pre-in a One Health framework pre-in order to prevent zoonotic disease transmission Itcan build off proven models of risk reduction in health care workers for infectioushazards including tuberculosis and bloodborne pathogens

Specific development of occupational health services along a One Health modelcould include expanded surveillance for animal workers to detect transmissionevents, assessment of infection risk in specific jobs and tasks, and reduction of suchrisk through animal disease control and interruption of transmission pathways byappropriate use of hygiene measures and personal protective equipment includinggloves and respiratory protection Input from animal health clinicians will be crucial

in these efforts to ensure that steps are taken in such a way to maximize both humanand animal health as well as agricultural viability and sustainability

1.3 Role of the Human–Animal Bond

While consideration of the human–animal bond may seem peripheral to a cussion of emerging infectious diseases, it really is not Our relationship withanimals plays a key role in transmission pathways This can both lead to increasedcontact between animals and humans (e.g., kissing dogs) but also to opportunitiesfor enhanced levels of care and prevention (i.e., willingness to pursue diagnostic,therapeutic, and preventive strategies for beloved pets)

dis-Majorities of surveyed households in the United States, Canada, Australia, andUnited Kingdom include at least one companion animal (Ipsos-Reid Corporation

their health care providers are more likely than not to share their living space withdogs, cats, birds, fish, reptiles, rodents, etc., noting that some of these animals mayhave been collected from the wild A growing body of evidence supports the

Companion animals are viewed as family members in many cultures and treated as

Physicians must consider that the psychosocial and physical benefits of HumanAnimal Interaction (HAI) in the context of owning pets, uses of animals for recre-ation (such as horseback riding), and in therapeutic settings For people who likeanimals, these human–animal bond benefits are thought to outweigh the risks in mostcases Physicians and veterinarians can cooperate to maximize these benefits.Several studies have shown pet owners in general to be healthier than their non-owning counterparts, controlling for confounding This includes pet owners beingmore physically active, and having lower triglyceride and cholesterol levels, anddecreased depression particularly among older adult pet owners and people with

evidence of impoverished pet owners withholding their own nourishment in favor

of their pet Additionally, during impending hurricanes, some pet owners elected

to stay in harm’s way rather than leave their pet, when no pet-friendly shelteroptions were available

Animal assisted activity (AAA) occurs in a variety of settings in which peopleinteract with (talk to, pet, groom) companion animals while the animal’s handler is

24 P Rabinowitz and L Conti

present Even in these encounters, an intense attachment can rapidly developbetween people and pets Beneficial changes in cortisol, neurohormones, and blood

residents were found to have lower cortisol levels with dog visits than with humanvisits During and after animal visits, hospitalized patients used fewer analgesics,reporting less pain and lessened depression, and heart failure patients had

Animal assisted therapy (AAT) can be used as part of a patient’s treatment plan forphysical therapy, to decreased anxiety in psychiatric patients, and decreased agitation

include increasing the number of brush strokes on a dog to exercise an impaired handand eliciting a relaxation response using horseback riding AAT in children with spastic

children with autism spectrum disorder were more likely to respond appropriately than

1.4 Challenges to Implementation of Clinical

One Health Approaches

While many of the clinical One Health opportunities outlined above may seemself-evident and commonsense, there are a number of challenges and barriers totheir implementation These include the historical professional segregationbetween human and animal health professionals that continues into the present.Veterinarians and their human health care colleagues rarely encounter each otherduring medical education and training Once in practice, there are no routinevenues on either the local, national, or international level for inter-professionalcontact and information sharing

On a daily practical level, it is challenging for a physician to directly contact aveterinarian about a patient, or a veterinarian to contact a physician regarding a client

or animal There are not established guidelines or protocols for such sional communication and perceived barriers toward issues of information sharingand medical record documentation While health departments can serve as conduitsfor sharing information that is relevant to both human health care providers andveterinarians, this is often restricted to reportable diseases or established epidemics,and may lose the richness of the data contained in the clinical encounters that can lead

inter-profes-to the recognition of novel syndromes and disease emergence events

In addition to the absence of protocols for cross referrals of patients and clientsbetween human and animal health clinicians, there are issues of reimbursement.While an immunocompromised patient who has animal contact may benefit from aconsultation with a veterinarian regarding reduction of zoonotic disease risk, there

is no mechanism for the veterinarian’s time and effort to be reimbursed by thepatient’s health insurance under current health care payment structures This lack

of reimbursement can be a major deterrent to such activities In the occupational

health arena, cost is also a barrier for providing enhanced preventive services toanimal workers, since this cost is assumed by the employer, and many farms, zoos,and animal clinics have narrow profit margins and are not accustomed to settingaside funding for worker occupational health services.

A related obstacle is the lack of time allotted for many clinical encounters thatmakes it more difficult for human health care providers to inquire about non-traditional issues such as animal contact during routine visits, or for veterinarians

to step out of their usual practice patterns to initiate contact with a physician.Since the One Health approach considers environmental health as central toaddressing emerging infectious disease threats, a major obstacle to the incorporation

of One Health principles is the lack of human and animal health clinicians’ training orawareness regarding environmental health assessment and interventions A basicunderstanding of patients’ access to and quality of food, air, and water may provideclues to potential ongoing risks for infectious disease exposure For example, havingdiagnosed a case of leptospirosis in a dog, there is often no further investigation toidentify potential sources of contaminated water and communicate this informationappropriately to prevent other animal or human infection Similarly, private wellwater is often not tested for enteric bacteria beyond when the well was constructed, asmany people are not aware of the need for ongoing testing While it is currentlyunlikely that human and veterinary clinicians recommend well water testing andprovide such information from the local health department, by doing so could provethe impetus to assess home water quality

1.5 Overcoming Challenges to Clinical One Health

Overcoming the challenges to incorporating One Health principles into clinicalpractice will require a multi-level approach, including training on specific com-petencies, intervention effectiveness research, and policy change These devel-opments are interdependent and could best proceed in tandem

A critical need is for training opportunities for ‘‘One Health Clinical ists’’ among the human health and animal health professional workforce Thistraining would stress a number of core competencies, including:

Special-• Ability to diagnose and treat zoonotic diseases

• Ability to do preventive care interventions for individual patients

• Ability to provide occupational health services for animal workers

• Ability to recognize sentinel cases

• Ability to report cases to public heath and clinical colleagues

• Ability to assess environmental factors driving infectious disease risk and work

on environmental health interventions

A goal of the training programs is to achieve competency in these areas, andcertification in such competencies could lead to enhanced career opportunities forsuch clinicians

26 P Rabinowitz and L Conti

In addition to training, there is a need to develop pilot protocols for cooperationand communication between animal and human health clinicians, and to researchthe clinical effectiveness of such protocols Examples of such research couldinclude early detection of emerging infections, reduction of opportunistic infec-tions in immunocompromised individuals due to reduction of animal contact risks,and the use of a ‘‘One Health team’’ approach to reducing environmental healthrisks in communities where water contamination with pathogens from both humanand animal sources is driving transmission of diarrheal diseases If the One Healthapproach can be linked to improved disease outcomes in either or both humans andanimals, such evidence can help to drive policy changes, including changes inreimbursement schemes.

A number of policy changes could lead to lasting improvements in clinicians’ability to practice along a One Health model These changes could involvereimbursement for preventive services by veterinarians to benefit human health,occupational health policies that encourage occupational health services for animalworkers, and incentives for competency training in One Health

Box

Practical Applications: Human and animal health professionals working onthe front lines of clinical practice can play an important role recognizing,informing, and managing a wide range of health issues involving overlapsbetween human and animal health

• Human health histories should include questions about patients’ tions with animals given the pet ownership’s beneficial health impacts andpossible health risks

interac-• Human and animal health clinicians can provide counseling to theirpatients about animal contact-risk factors

– This includes recognition of high risk scenarios (high risk pets and/orpersons at increased infection risk)

– Special precautions are required for significantly immunocompromisedpatients to minimize risk of infection

– Patients should be counseled about the risks of particular habits of petownership such as kissing or sleeping with pets

• Human and animal health clinicians can share information about sentinelcases in order to detect environmental changes driving disease emergence

• Veterinarians can assist with appropriate animal selection, healthscreening, and animal health maintenance

• Human health clinicians and veterinarians can collaborate to preventoccupational transmission of zoonotic diseases between animals andanimal workers

Adams LG, Khare S, Lawhon SD, Rossetti CA, Lewin HA, Lipton MS, Turse JE, Wylie DC, Bai Y, Drake KL (2011) Enhancing the role of veterinary vaccines reducing zoonotic diseases of humans: Linking systems biology with vaccine development Vaccine 29(41):7197–7206 Adjemian JZ, Krebs J, Mandel E, McQuiston J (2009) Spatial clustering by disease severity among reported Rocky Mountain spotted fever cases in the United States, 2001–2005 Am J Trop Med Hyg 80(1):72–77

Australian Companion Animal Council (2010) Contribution of the pet care industry to the australian economy, 7th edn http://www.acac.org.au/pdf/ACAC%20Report%200810_sm.pdf Accessed 4 March 2012

Barker SB, Dawson KS (1998) The effects of animal-assisted therapy on anxiety ratings of hospitalized psychiatric patients Psychiatr Serv 49:797–801

Batson K, McCabe BW, Baun MM et al (1997) The effect of a therapy dog on socialization and physiological indicators of stress in persons diagnosed with Alzheimer’s disease In: Wilson

CC, Turner DC (eds) Companion animals in health Sage, Thousand Oaks

Beck A (2000) The use of animals to benefit humans, animal-assisted therapy In: Fine AH (ed) The handbook on animal assisted therapy: theoretical foundations and guidelines for practice Academic Press, San Diego

CDC (2005) Fatal rat-bite fever—Florida and Washington, 2003 MMWR 53:1198–1202 CDC (2012a) Ticks: geographic distribution http://www.cdc.gov/ticks/geographic_distribution.html Accessed 17 May 2012

CDC (2012b) Update: influenza A (H3N2)v transmission and guidelines—five states, 2011 MMWR 60(51):1741–1744

Chua KB (2010) Risk factors, prevention and communication strategy during Nipah virus outbreak in Malaysia Malays J Pathol 32(2):75–80

Chomel BB, Sun B (2012) Zoonoses in the bedroom Emerg Infect Dis 17(2):167–172 Review Cohen SP (2002) Can pets function as family members? West J Nurs Res 24:621–638 Cole K, Gawlinski A (1995) Animal assisted therapy in the intensive care unit Res Util 30:529–536 Companion Animal Parasite Council (2012) Recommendations http://www.capcvet.org/capc- recommendations Accessed 4 March 2012

Dembicki D, Anderson J (1996) Pet ownership may be a factor in improved health of the elderly.

Kahn LH (2006) Confronting zoonoses, linking human and veterinary medicine EID 12(4):556–561 Kimura R, Hayashi Y, Takeuchi T, Shimizu M, Iwata M, Tanahashi J et al (2004) Pasteurella multocida septicemia caused by close contact with a domestic cat: case report and literature review J Infect Chemother 10:250–252

Klotz SA, Ianas V, Elliott SP (2011) Cat-scratch disease Am Fam Physician 83(2):152–155 Kravetz JD, Federman DG (2005) Prevention of toxoplasmosis in pregnancy: knowledge of risk factors Infect Dis Obstet Gynecol 13(3):161–165

Martin F, Farnum J (2002) Animal-assisted therapy for children with pervasive developmental disorders West J Nurs Res 24:657–670

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McGibbon NH, Andrade CK, Widener G et al (1998) Effect of an equine movement therapy program on gait, energy expenditure, and motor function in children with spastic cerebral palsy: a pilot study Dev Med Child Neurol 40:754–762

Paddock CD, Brenner O, Vaid C, Boyd DB, Berg JM, Joseph RJ, Zaki SR, Childs JE (2002) Short report: concurrent Rocky Mountain spotted fever in a dog and its owner Am J Trop Med Hyg 66(2):197–199

Rabinowitz PM, Conti LA (eds) (2009) Human-animal medicine: clinical approaches to zoonoses, toxicants and other shared health risks Elsevier/Mosby, St Louis

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The Historical, Present, and Future Role

of Veterinarians in One Health

Samantha E J Gibbs and E Paul J Gibbs

result of the increased emergence of zoonotic infectious diseases over the pastdecade The subsequent impacts of these diseases on human, livestock, andwildlife health, as well as the economic effects, have given international healthorganizations and national governments a greater appreciation of the importance ofcollaborative efforts in solving health problems The One Health concept is notnew, but under its umbrella, a new generation of veterinarians, physicians, ecol-ogists, biologists, and social scientists is shaping the concept in novel ways Thishas led to increased support for One Health initiatives to control disease byinternational agencies, national governments, and nongovernmental organizations

as well as a growing emphasis on One Health concepts in training the veterinaryworkforce Veterinary schools are reorganizing veterinary education to betterteach students the precepts of One Health This chapter explores the evolution andapplication of the One Health concept from the perspective of the veterinarian Theveterinary profession is positioned to be a strong advocate and leader of OneHealth Veterinarians have a long history of involvement with One Health activ-ities, and this involvement has adjusted and shifted with the changing needs ofsociety A new area of work for veterinarians is ecosystem health, which isbecoming more relevant as a result of the impact that the ever-increasing humanpopulation is having on the environment that supports them

S E J Gibbs ( &)

Division of Migratory Bird Management, Avian Health and Disease Program,

U.S Fish and Wildlife Service, 12302 Beech Forest Road,

 Springer-Verlag Berlin Heidelberg 2013

Published Online: 22 August 2012

1 Introduction 32

2 The History and Different Perspectives of One Health 33

3 The Historical Role of the Veterinary Profession in One Health and a Profile

of the Profession Today 35

4 Applying the One Health Concept: Veterinary Contributions 38 4.1 Responding to Emerging Disease Outbreaks Caused by Zoonotic Agents 38 4.2 Prevention of Known Zoonotic Diseases 39 4.3 Pathogen Discovery of Potential Zoonotic Agents 40

5 The Dangers of Neglecting the One Health Concept: An Argument for Strong

Veterinary Leadership 40

6 The Education of Veterinarians in One Health 42 6.1 Education of Veterinarians Already in the Workforce 43 6.2 Education of Students in Veterinary School 44

7 Conclusions 45 References 45

1 Introduction

In the first decade of the new millennium, there was global angst (some may usethe word panic) associated with pandemics of Severe Acute Respiratory Disease(SARS), Avian Influenza H5N1, and other emerging zoonotic diseases Anxietylevels rose even though the human mortality associated with these pandemicspaled in comparison to the Spanish Influenza of nearly a century earlier Thesepandemics drew attention to the interconnection between humans and the etio-logical source of the pandemics in animal reservoirs; they spurred the imple-mentation of the global control of such diseases by multidisciplinary teamsapplying the principles of ‘‘One Health’’ Practitioners of One Health strive togenerate far-reaching impacts on global health, food security, and poverty alle-viation (particularly in developing countries) through interdisciplinary science andintegrated control of disease

The current One Health initiative is little more than 5 years old and is tioning from concept and rhetoric into policy and action Drawing the analogy ofthe germinating seed, One Health is still a tender shoot If historians are going toreflect positively on One Health, it is axiomatic that the veterinary profession oftoday, and into the future, must be well trained in the precepts of One Health, be astrong advocate of multidisciplinary approaches to solving the complex challenges

transi-of One Health, and provide decisive leadership The response transi-of the veterinaryprofession in meeting the precepts of One Health is also a litmus test for the future

of the profession

2 The History and Different Perspectives of One Health

The One Health concept is not new, though it has been rebranded several times Itsorigin lies in comparative medicine, the idea that there is no line between humansand animals when it comes to health and disease When founding the first veter-inary school in Lyon, France in 1761, Claude Bourgelat emphasized the impor-

William Osler, and John McFaydean carried the concept forward by incorporatingveterinary perspectives into human health care through their respective work incomparative medicine, veterinary pathology, microbiology, and veterinary and

Karl Meyer, Calvin Schwabe, and James Steele maintained this inclusive approach

and Steele used the term ‘‘One World, One Medicine, One Health’’ to refer to their

nineteenth and twentieth centuries was the ecologists and environmental healthexperts While the pioneers of the One Health concept recognized that environ-mental factors played a crucial role in the well-being of humans and animals, thevalue of environmental health for the benefit of the ecosystem itself was notemphasized

In 2004, in part influenced by a series of themed conferences that began in 1999and organized by the Society for Tropical Veterinary Medicine under the banner of

‘‘Working together to promote global health’’, the Wildlife Conservation Society(WCS) organized a conference on One World-One Health and extended the OneHealth concept to include ecosystem health The WCS listed 12 recommendationsfor establishing a more holistic approach to preventing epidemic/epizootic diseaseand for maintaining ecosystem integrity for the benefit of humans, their domes-

known as the Manhattan Principles in recognition that the meeting was hosted bythe Rockefeller University in New York

One Health has become a twenty-first century exhortation to action by manyindividuals and organizations Many have their own definition, but the commonthread is collaboration on a global scale among multiple disciplines to ensure thehealth of humans, domestic animals, and the ecosystem (including wildlife) in the

The One Health Initiative Taskforce Report from the American VeterinaryMedical Association (AVMA) defines One Health as the ‘‘collaborative effort ofmultiple disciplines working locally, nationally, and globally to attain optimal

Union (EU) has adopted the following definition: ‘‘The improvement of health andwell-being through (i) the prevention of risks and the mitigation of effects of crisesthat originate at the interface between humans, animals and their various

Veterinarians in One Health 33