One Health – an interdisciplinary approach in combating emerging diseases

Hung Nguyen-Viet1, Delia Grace2, Jakob Zinsstag3

1Hanoi School of Public Health 2International Livestock Research Institute 3Swiss Tropical and Public Health Institute

Kuala Lumpur, Malaysia, 20-21 August 2013

• Studies the health and well-being impacts of development factors using integrative approaches of Ecohealth/One Health with special focus on South East Asia with link to similar issues of Africa.

• Focus on the link between health and agriculture, infectious and zoonotic diseases, chemical pollution, food safety and nutrition, from lab to the field.

Ecosystem Health / One Health

Food Safety

Health Impact Assessment

Main research themes

Outline

• Disease situation at global level and new

approaches needed

• One Health: history, application, case studies

• Regional initiative of One Health

• Integrated approach and way forward

DISEASE SITUATION AT

GLOBAL LEVEL

Context

4

Emerging Infectious Diseases

1. Diseases that have recently increased in incidence or in geographic or host range – e.g., tuberculosis, cholera, malaria, dengue fever, Japanese encephalitis, West Nile fever, and yellow fever.

2. Diseases caused by new variants assigned to known pathogens – e.g., HIV, new strains of influenza virus, and SARS, drug resistant strains of bacteria, Nipah virus, Ebola virus, hantavirus pulmonary syndrome, and avian influenza virus.

3. Bacteria newly resistant to antibiotics, notably the multiple antimicrobial resistant strains – e.g., MRSA, and E. coli O157

Infectious Disease Emergence at Global level

Jones et al. – Nature - 2008

from

wildlife

from

non-

wildlife

drug-

resistance

vector-

borne

29.08.2013 7

Infectious Disease Emergence at Global level

Morens et al., Nature 430, 242-249 (2004)

Challenges

75% of all new, emerging, or reemerging diseases

affecting humans at the beginning of the 21st century have

originated in animals.

Global impact of new emergent diseases include

HIV/AIDS, severe acute respiratory syndrome (SARS),

H5N1 avian influenza, and the pandemic 2009 H1N1

influenza virus

Serious public health, economic, and development

concerns

Needs of updates

• West USA & west Europe hotspots

• Last decade: S America & SE Asia

• Unlucky 13 zoonoses sicken 2.4

billion people, kill 2.2 million people

and affect more than 1 in 7 livestock

each year

Greatest burden of endemic zoonoses falls on one billion poor livestock keepers

Top Zoonoses (multiple burdens) • Assessed 56 zoonoses from 6 listings:

responsible 2.7 billion cases, 2.5 million deaths

• “Unlucky 13” responsible for 2.2 billion illnesses and 2.4 million deaths

– All 13 have a wildlife interface

– 9 have a major impact on livestock

– All 13 amenable to on-farm intervention

Priority zoonoses

0

20000

40000

60000

80000

100000

120000

140000

Deaths - annual

0

200000

400000

600000

800000

1000000

1200000

1400000

1600000

1800000

2000000

Top 13zoonoses

Next 43

12

0

20

40

60

80

100

Rich Poor

Infectious disease

• 40% disease is infectious

• one twentieth total from animals

• one fortieth total burden is

zoonotic

• ..one twentieth with under-

reporting

• 4% disease is infectious

• one two hundredth total disease

from animals (zoonotic or

emerged)

• one thousandth of the total

disease burden zoonotic

The burden of animal associated disease is

borne by the poor

Rich countries Poor countries

Grace et al., 2012

Important factors leading to the emergence of infectious diseases

• Overpopulation and urbanization

• Population movement and animal trade

• Water and sanitation

• Agriculture and changing land use

• Livestock production

• Climate

• Drug resistance

Coker et al. Emerging infectious diseases in southeast Asia: regional challenges to control. Lancet. 377. 2011

HIV, TB, malaria

Other infectious

Mat//peri/nutritional

CVD

Cancers

Other NCD

Road traffic accidents

Other unintentional

Intentional injuries

0

5

10

15

20

25

30

2004 2015 2030 2004 2015 2030 2004 2015 2030

Dea

ths

(mill

ion

s)

High-income countries

Middle-income countries

Low-income countries

Mortality: global projection, 2004-2030

Priority 3: Communicable diseases

0

10

20

30

40

50

60

70

80 “The big three”

Neglected tropical diseases

(NTDs)

Burden of communicable diseases

Burd

en (

million D

ALYs)

Hotez et al. (2006) PLoS Medicine

29.08.2013 16

MORAN ET AL., PLoS MEDICINE; THE GLOBAL BURDEN OF DISEASE: 2004 UPDATE (WHO)

HISTORY, APPLICATION, CASE

STUDIES

One Health:

17

History of One Health and integrative thinking in medicine 19th to 20st century

• Human medicine in the medieval European universities, Claude Bourgelat, first veterinary school in Lyon (1762) heavily criticized wanting human clinical training for the veterinary curriculum

• 19th Century: Strong interest in comparative medicine: “Between animal and human medicine there is no dividing line – nor should there be. The object is different, but the experience obtained constitutes the basis of all medicine”. Rudolf Virchow (1821-1902) coined the term “zoonosis”

• In the 20th century both medicines became increasingly specialised, separating themselves into multiple sub-disciplines

The “One Medicine” by Calvin Schwabe‘s has its origins in his work with pastoralists in Sudan in the 1960s

• «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 C. (1964, 1984 3rd Edition): Veterinary Medicine and Human Health. Williams and Wilkins, Baltimore

“One medicine” as a General Medicine

Schwabe C. (1964, 1984 3rd Edition): Veterinary Medicine and Human Health. Williams and Wilkins, Baltimore

“One Health”– Addresses Zoonotic Dieases

Robert Virchow (1821-1902) : “…between animal and human medicine there is no dividing line” (Kahn et al., 2007).

The American Veterinary Medicine Association defines One Health as “the collaborative effort of multiple disciplines-working locally, nationally, and globally – to attain optimal health for people, animals and our environment.”

Calvin Schwabe (1927-2006): veterinary epidemiologist and parasitologist, described and promoted One Medicine and proposed a unified human and veterinary approach to zoonoses in his 1964 book Veterinary Medicine and Human Health.

19th century 20th century

...encourages the collaborative efforts of

multiple disciplines working locally, nationally, and globally, to attain optimal health for people, animals, and our environment

…endorsed by FAO, OIE and WHO...

http://www.cdc.gov/onehealth

One Health approach

CDC STONE MOUTAIN meeting

Davos, 2.2012

PMAC Bangkok 1.2013

“One Health” can be defined as the added value in

terms of lives of animals and humans saved, financial

savings and improved ecosystem services from a

closer cooperation of human and animal health as

compared to single sector approaches.

Zinsstag et al. (2012) Onderstepoort J Vet Res. 2012 Jun 20;79(2):E1-5. doi: 10.4102/ojvr.v79i2.492.

From theoretical to operational definition

Benefits of One Health • Improving animal and human health globally

collaboration among all the health sciences

• Meeting new global challenges through

collaboration

veterinary medicine, human medicine,

environmental and social sciences, wildlife and

public health

• Developing centres of excellence for education

and training

veterinary medicine, human medicine, and public

health One Health Initiative Task Force: Final Report, July 15, 2008

29. August 2013 Präsentationstitel 26

Weekly human exposure (blue) and rabid dogs (red) in N’Djaména

0

1

2

3

4

5

6

1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58

weeks as of Jan. 1st 2000

Rab

ied

do

gs / E

xp

osed

hu

man

s

I

Y

One Health and Rabies control in N‘Djaména

29. August 2013 27

Statistical relationship of human exposures – dog rabies

2 human exposures / rabid dog

-2

0

2

4

6

8

10

12

14

-1 0 1 1 2 2 3 3 4

Rabid Dogs

Exp

osed

Hu

man

s

29. August 2013 Präsentationstitel 28

29. August 2013 Präsentationstitel 29

Comparative profitability of rabies control in N‘Djaména Zinsstag et al. (2009) PNAS 106(35):14996-5001

Human vaccination alone

Dog and human vaccination

29. August 2013 Präsentationstitel 30

Existing textbook knowledge of brucellosis transmission

B. mellitensis B. abortus

Sheep

Goat

Dog

Human Milk

Cattle

Others

Cattle Cattle

Milk,

Cheese

31

Mixed teams assessing human and animal health

29. August 2013 Präsentationstitel 32

Synoptic view of benefits and costs of animal brucellosis mass vaccination in Mongolia

Distribution of Benefits

0

5000000

10000000

15000000

20000000

25000000

30000000

Intervention

cost

Public

health

benefits

Private

health

benefits

Household

income

loss

Total Health

Benefits

Agricultural

Benefits

Total

Societal

Benefits

Sector

US

$

Agent Orange and dioxin

One Health: beyond zoonoses and apply NCDs?

76.9 millions litres of herbicides (including 49.3 millions litres of AO with

366 kg dioxin) were sprayed during the Operation Ranch Hand (1961-

1971)(Stellman 2003). Currently there are 28 dioxin hot spots in

Vietnam, in which seven of them are very severe.

Agent Orange and dioxin: Current exposure pathways

One Health is useful here – integrated management of food chain of environment - animal /plant – human

REGIONAL INITIATIVES

One Health

38

• INDOHUN

• SEAOHUN

• VOHUN

•MYOHUN

SEAOHUN Core Universities

Hanoi School of Public Health

Chiang Mai University

Mahidol University

Universiti Kebangsaan Malaysia

Institut Pertanian Bogor

Universitas Indonesia

Universitas Gadjah Mada

Universiti Putra Malaysia

Hanoi Medical University

Hanoi University of Agriculture

4 countries/10 universities/14 faculties

South East Asia Universities One Health Network Inaugural Meeting in Bngkok, Thailand 24-26 May 2011

Vision A South East Asia One Health University Network fostering

sustainable trans-disciplinary capacity building to respond to emerging and re-emerging infectious and zoonotic diseases

Mission

To leverage the training, education, and research capacities of the university network to build the skills, knowledge and attitude base

for One Health leaders

SEAOHUN Vision and Mission

SEAOHUN Objectives

1.To promote and advance the One Health approach for control of emerging and re-emerging infectious and zoonotic diseases

2.To improve the competencies of One Health professionals

3.To build a One Health evidence base through research activity

4. To build cadres of trained professionals to be One Health current and future leaders

VIETNAM ONE HEALTH

UNIVERSITY NETWORK

(VOHUN)

Hanoi (Network Secretariat): • Hanoi School of Public Health • Hanoi Medical University • Hanoi University of Agriculture

Thai Nguyen University: • College of Medicine • College of Agriculture

& Forestry

Thai Binh University of

Medicine

Hai Phong Medical

University

Bac Giang Agriculture and Forestry University

Nam Dinh University of

Nursing

Hue University: • College of Medicine and Pharmacy • College of Agriculture and Forestry

Dak Lak: Tay Nguyen University, Faculty of Medicine and Pharmacy

Can Tho •University of Medicine & Pharmacy •University of agriculture

Hochiminh City: • HCMC Medicine and Pharmacy University; • HCMC University of Agriculture &-Forestry

15 UNIVERSITIES/FACULTIES (NOVEMBER 2011)

Capacities, strengths and weaknesses

Main research gaps:

1. Disease trends, risk,

burden, prioritisation

2. Epidemiology of

zoonoses

3. Qualitative and economic

methods

4. Molecular epidemiology Grace et al. 2010, Ecohealth

Disease prioritization

1 Avian Influenza

2 Rabies

3 Leptospirosis

….

Remark:

Classification was not well reflected by

disease burden caused by zoonosis

Impact of media attention, funding

availability, donor perspective…

INTEGRATED APPROACH AND WAY

FORWARD

48

Similar concepts

• Ecosystem approach to health (IDRC) – Ecohealth – Considers human health is closely linked to animal and

environmental health in a socio-ecological interactions • Veterinary Public Health (VPH)

– Veterinary public health is defined as the contribution of veterinary science to public health

• Agro-ecosystem Health (OVC and others)

• Extension of health concept to whole ecosystem

– Evolution from « one medicine » to « one health »

Six principles of Ecohealth (Charron, 2012)

• Systems Thinking

• Transdisciplinary Research

• Participation

• Sustainability

• Gender and Social Equity

• Knowledge to Action http://www.idrc.ca/EN/Resources/Publications/Pages/IDRCBookDetails.aspx?PublicationID=1051

Integrative approaches

51

Human health Human

health

One Medicine

Societies, cultures,

Economies, institutions,

Policies

Agroecosystem health

Animal

Health .livestock

.CA

.wildlife

V P H.

EcoHealth

ONE HEALTH

Incentives

Values

Preferences

Culture

Ignorance

Governance

Rule-breaking

One Health / Ecohealth =Transdisciplinarity = Integrative

Integrated research (interdisciplinary and trans-disciplinary research) uses system thinking to generate new knowledge and competences by combining principles, theory and methods of difference

One Health research and application comprise practices of emerging disease prevention and control to mintage the risk of complete ecosystem.

Transdisciplinary research (TD research)

Integrates the social and natural sciences in a common approach (interdisciplinarity), and simultaneously…

includes non-academic knowledge systems

Nat. Sci. Discipline 1

Tech. Sci. Discipline 2

Econ. Sci. Discipline 3

Soc. Sci. Discipline n

One Health

Non-academic actors

Definitions

Adapted from Herweg et al. (2011)

When do we need Transdisciplinarity?

Herweg et al. (2010)

Summary

• Disease situation at global level is complex

– then new approaches needed: One Health

• One Health: Integrative approach, great benefit

– but needs more validation by case studies at practical level

• Current initiatives for One Health

– Need of capacity building in SEA

• System thinking and integrated approach

– Trans-disciplinarity, inter-sectoral collaboration, working together

Acknowledgements

• Bruce Wilcox, Dirk Pfeiffer

• David Waltner-Toews, Guelph University

• Marcel Tanner, Esther Shelling

• Tran Thi Tuyet Hanh, Le Vu Anh

• Dr Stan Fenick, RESPOND

Thank you for your attention!

Emerging Pandemic Threats Program

PREDICT • RESPOND • PREVENT • IDENTIFY

One Health – an interdisciplinary approach in combating emerging diseases

Hung Nguyen-Viet1, Delia Grace2, Jakob Zinsstag3

1Hanoi School of Public Health 2International Livestock Research Institute 3Swiss Tropical and Public Health Institute

Kuala Lumpua, 20-21 August 2013