European Union, External Action
ASIA–EUROPE MEETING
Implementation of the One Health approach
in Asia & Europe
How to set-up a common basis for action and
exchange of experience
PREPARATORY STUDY
September 2011
The Project is financed by
THE EUROPEAN UNION
The Mission was implemented by the
CONSEIL SANTE CONSORTIUM
EUROPEAN UNION
ASIA-EUROPE MEETING
Implementation of the One Health approach in Asia & Europe:
How to set-up a common basis for action and exchange of experience
Framework Contract: EuropeAid / Lot no. 8
Specific Contract ref n°: 2011/266166
PREPARATORY STUDY
September 2011
Name of Experts:
David HALL, Team Leader
Ben COGHLAN, Public Health Specialist
This report has been prepared with financial assistance of the European Union. The views expressed herein
are those of the Consultants and therefore do not necessarily reflect the official position of the European
Union institutions.
For any assistance or information, please contact Conseil Santé Consortium Management Unit
Tel.: +33.1.55.46.92.60  Telefax: +33.1.55.46.92.79  E-mail: lot8@conseilsante.com
Implementation of the One Health approach in Asia and Europe Background document Table of Contents
EXECUTIVE SUMMARY ........................................................................................................ 1
BACKGROUND...................................................................................................................... 3
A)
INTRODUCTION ............................................................................................................. 3
B)
APPROACH TO THE REPORT ........................................................................................... 3
C)
ASSUMPTIONS, LIMITS, CONSTRAINTS TO APPROACH ...................................................... 4
Table 1. Rankinga of One Health themes addressed in ten selected case studies..... 5
D)
THE ONE HEALTH APPROACH – ARE THERE NECESSARY ELEMENTS? .............................. 6
OBJECTIVES OF THE MISSION........................................................................................... 7
RESULTS OF FIRST 3 OBJECTIVES ................................................................................... 8
1. ONE HEALTH INITIATIVES, PROJECTS, AND PROGRAMMES IN EUROPE AND ASIA .............. 8
2. ONE HEALTH ACTORS AND POSSIBLE FOCAL POINTS IN EUROPE AND ASIA ...................... 8
3. PUBLICATIONS AND OTHER DOCUMENTS ON THE ONE HEALTH APPROACH ...................... 8
4. TEN CASE STUDIES ON THE IMPLEMENTATION OF THE ONE HEALTH APPROACH IN EUROPE
AND ASIA .............................................................................................................................. 8
CASE STUDIES ................................................................................................................... 10
CASE STUDY 1: Community Based Avian Influenza Risk Reduction Program ....... 11
CASE STUDY 2: Swiss National Antibiotic Research Programme NRP 49: Antibiotic
Resistance ................................................................................................................ 15
CASE STUDY 3: Communication Influencing Behaviour Change, Vietnam ............. 19
CASE STUDY 4: Chars Livelihoods Programme, Bangladesh ................................. 24
CASE STUDY 5: Controlling Rabies in Bali, Indonesia ............................................ 28
CASE STUDY 6: Healthy Food Market (INSPAI), Indonesia .................................... 32
CASE STUDY 7: Controlling Hydatid Disease, Nepal .............................................. 36
CASE STUDY 8: Controlling Q-fever outbreaks, Netherlands .................................. 40
CASE STUDY 9: Control of food-borne Salmonella in the EU.................................. 44
CASE STUDY 10: The Human Animal Infections and Risk Surveillance (HAIRS)
Group ........................................................................................................................ 48
CONCLUSIONS ................................................................................................................... 52
APPENDIX - PERSONS AND INSTITUTIONS CONSULTED DURING THIS MISSION .... 58
REFERENCES ..................................................................................................................... 60
ANNEX 1: OH INITIATIVES IN ASIA AND EUROPE .......................................................... 61
ANNEX 2: OH STAKEHOLDERS ........................................................................................ 61
ANNEX 3: OH DOCUMENTS AND BIBLIOGRAPHY ......................................................... 61
Implementation of the One Health approach in Asia and Europe Background document Expressions of thanks
The authors gratefully acknowledge the advice, technical input, references, and other
resources shared by the following individuals and organisations:
Animal Health Australia
International Livestock
Research Institute
Bangladesh Agricultural
University
London School of Hygiene and
Tropical Medicine
Centre for International Health,
Burnet Institute, Australia
Mahidol University, Thailand
ASEAN
Chiang Mai University, Thailand
Mekong Basin Disease
Surveillance (MBDS)
Australian Agency for
International Development
National Commission on
Zoonotic Control, Indonesia
CARE Australia
National Institute for Public
Health and the Environment,
The Netherlands
CSIRO, Australia
Department of Agriculture,
Fisheries and Forestry,
Australia
DAI
National Institute of Animal
Science, Vietnam
Royal Veterinary College,
University of London, UK
Directorate General of Livestock
Services, Ministry of Agriculture,
Indonesia
Swiss Tropical Institute
Delegations of the EU in
Indonesia and Thailand
United States Agency for
International Development
(USAID)
Disease Investigation Center,
Denpasar, Indonesia
European Centre for Disease
Prevention and Control
European Commission
European External Action
Service
Food and Agriculture
Organisation (FAO)
Hanoi School of Public Health,
Vietnam
Thai Ministry of Foreign Affairs
University of Calgary, Canada
University of Edinburgh, UK
UN System Influenza
Coordination (UNSIC)
World Bank
World Health Organisation
(WHO)
World Organisation for Animal
Health (OIE)
In particular, the authors are grateful for the time many individuals took to meet with us in
person and to correspond by phone and email in development of this report. The names of
those persons are noted in Appendix 1.
Finally, the authors express their gratitude to Dr Alain Vandersmissen, the Senior
Coordinator of One Health, Emerging Diseases, and Food Security of the European External
Action Service, Asia Department (EEAS), and to Ms Allison Coe-Chirossel of Conseil Santé
for their considerable assistance in coordinating this report. Gratitude is also extended to the
numerous support staff in the offices of Dr Vandersmissen and Ms Coe-Chirossel for their
support.
Executive Summary
Recent global concern for emerging animal diseases and rapidly spreading human diseases
of animal origin has prompted calls for change in the way health-related disciplines prepare
and respond to disease threats. A more harmonized approach to investigating, planning for,
and reacting to emerging infectious disease requires working across disciplines, working
closer with stakeholders, developing capacity, and developing models of regional and global
leadership. This collection of actions, often referred to as the One Health (OH) approach,
aims to improve health and well-being through the mitigation of risks and crises that originate
at the interface between humans, animals, and their various environments. This report
brings together and presents OH case studies and bibliographies in preparation for the
upcoming ASEM conference. It will give participants useful background information on
seminal OH documents, it lists existing OH focal points, and it outlines OH activities currently
being implemented in Europe and Asia. Indirectly, the report will also contribute to the
establishment of a global OH network.
The ten cases presented illustrate a wide range of OH approaches being implemented in
Asia and Europe such as: emergency measures to address serious outbreaks of infectious
disease; community engagement projects to improve disease surveillance and control;
adaptation of animal raising practices to improve livelihoods; communication strategies to
change risky behaviours; and organisational changes to enhance involvement of multiple
sectors. Case studies represent projects or approaches that were well documented,
implemented in Asia or Europe, and at least partly funded by the EU and/or Asian partners.
Leading questions, including those that relate to themes that are not well covered, are posed
at the end of each case study to foster discussion among participants at the upcoming
meeting.
Important themes addressed by the case studies selected were summarized. The factors
transdisciplinarity, prevention of disease, zoonoses, complexity, and community level
responses were common to all case studies and considered highly important in each.
Themes emerging in fewer cases included: improved risk management; education / inservice training; community participation; preparedness and planning. The least addressed
themes overall were: involvement of wildlife / environment sector; barriers to uptake/
adoption of approach; involvement of the private sector; regional networks; roles of main
players; funding; and communications. Although not as well captured by the case studies
chosen, these latter themes nonetheless merit further discussion for the operationalisation of
OH. A further concern of many of the projects examined is the lack of substantive input to
policy formulation, even where project activities lead to successful completion of outputs.
The bibliographies form three comprehensive databases and are presented in Annexes:
1)
OH programs and activities – more than 90 OH initiatives, projects, and
programmes from Europe and Asia, most of which address emerging infectious
disease;
2)
Focal points and key personnel – more than 750 individual names with contact
information of OH actors and practitioners in Asia and Europe, many of whom
could be suitable Focal Points for operationalising OH in these regions;
3)
Key OH documents – more than 250 documents from peer reviewed and grey
literature related to the OH approach.
Information for this report relied on communication with key informants and short field visits
conducted in Bangkok and Jakarta, as well as reviews of peer reviewed and grey literature.
We relied on semi-structured interviews, informal meetings, e-mail, and telephone
conversations to gather key information, verify facts, and solicit input regarding case studies
and recommendations to be included in this report. Input based on discussions at One
Health related conferences also contributed to findings in this document.
Implementation of the One Health approach in Asia and Europe Background document 1 The report presents for consideration and discussion the need to refine what could constitute
necessary (but not necessarily sufficient) elements of the OH approach. Without clearer
boundaries established within disciplinary confines, it seems any and all issues relating to
health could be presented by one discipline or another as valid for addressing with a OH
approach. This seems contrary to the concept of transdisciplinarity because of the
inefficiencies and redundancies it presents, and may well drive away potential health
discipline boundary partners (those individuals, groups, or organisations who participate in
and may be influenced by activities) rather than entice them to consider the novel and
synergistic aspects, encouraging greater support for One Health.
While there are several examples of training in technical matters related to One Health (e.g.,
epidemiology, surveillance, risk assessment), there was little evidence found for genuine
study and training in national or regional inter-institutional collaboration or transdisciplinary
partnership. Examination is needed of the processes that encourage institutions and
transdisciplinary partners to communicate better, willingly collaborate, share information, and
partner in research and application of OH initiatives. In other words, it is not well understood
what work environment, perceived benefits, or other set of stimuli drive health-related
disciplines to make the effort to work better together, other than top-down directives. In
general OH benefits are seen as positive externalities rather than objectives that require
concerted focused effort. Efficient operationalisation of OH will also require better
coordination of the initiatives, projects, and programmes being implemented. There is
considerable duplication of training and activity, and output in the form of documentation for
sharing with others is limited. Establishment of an information sharing network or, as a
preferred approach, more effective synchronisation of existing networks could facilitate
improved coordination of OH related activities.
Some OH leadership effort has begun in the form of developing regional action plans and
striking various committees and working groups. However, output from these regional
activities is very slim. There are numerous suggestions and starting points referenced in this
report from past important workshops and meetings, many of which were partially funded by
and attended by the EU and Asian partners. It would be also be helpful to identify OH
reference persons (e.g., Focal Points) who can be linked in a communication network of
some type in order to share experiences and knowledge on OH. One of the objectives of this
mission was to initiate that process by providing a bibliography of potential Focal Points; it is
hoped that this bibliography may be a valuable catalyst for moving forward OH leadership
plans.
This report also calls for discussion of such leadership development as the basis for regional
governance of OH. This should include a clear roadmap that outlines steps to identifying and
operationalising a OH governance structure, which remains undefined. Institutions and
reference literature are referred to in this report. A proposed short list of themes for
discussion with respect to regional governance includes: technical capacity; education and
training; information sharing; networking and partnerships; logistics; and financing. At time of
writing, a meeting was to be convened of the One Health Global Network Working Group
(formed at the Stone Mountain meetings in 2010) in Atlanta in November 2011 to address
some of these issues. The outcome of the meeting is expected to facilitate development of a
background for OH governance.
Implementation of the One Health approach in Asia and Europe Background document 2 Background
a) Introduction
The emergence of new infectious diseases recognised since the 1970s have been cause for
increasing concern in the health professions, leading to several calls and subsequent
meetings for collaborative action. These calls and meetings which continue in importance
are premised on the concept of One Health. The objectives of the One Health (OH)
approach are to improve health and well-being through the mitigation of risks and crises that
originate at the interface between humans, animals, and their various environments. For that
purpose, a multi-sectoral and collaborative “whole of society” approach to managing health
hazards is encouraged, as a systemic change of perspective in the management of risk.
Three recent international meetings include the “One World, One Health: from ideas to
action” expert consultation in Winnipeg, Canada, March 16-19, 2009 (Public Health Agency
of Canada, 2009), the International Ministerial Conference on Animal and Pandemic
Influenza (IMCAPI) in Hanoi, April 19-21, 2010 (IMCAPI, 2010), and the “Operationalising
‘One Health’” meeting in Stone Mountain, Georgia, May 4-6, 2010 (CDC, 2010). At the
Winnipeg meeting, development of supra-country approaches using multi- and transdisciplinary methods and trans-boundary and regional approaches to ensure an integrated
approach to One Health were recommended. At the IMCAPI conference the European Union
(EU) made an important notification that it was focusing on the way forward with recognition
that the broad approach needed to include the whole of society. At the same meeting, the
significant tripartite declaration of collaboration from the United Nations Food and Agriculture
Organisation (FAO), the World Animal Health Organisation (OIE), and the UN World Health
Organisation (WHO) was announced (FAO-OIE-WHO, 2011) with shared responsibilities
and coordinated global activities to address health risks at the animal-human-ecosystems
interface. While the Winnipeg meeting defined approaches to achieving the One Health
objectives, the Stone Mountain meeting defined specific steps to move the One Health
approach forward. Each of these meetings generated key documents that constitute
essential background reading.
The OH agenda has also been promoted through numerous grey and published literature
reports. Five summary papers are of particular relevance to this report: (1) the Fifth Global
Progress Report (UNSIC and WB, 2010); (2) Cross-Border Cooperation in Animal and
Human Health - EU Regional HPED Programme (Commission, 2011a); (3) the “Outcome
and Impact Assessment of the Global Response to the Avian Influenza Crisis, 2005-2010”
from the EU (Commission, 2010); (4) the “Fourth Consolidated Annual Progress Report on
Activities Implemented under the Central Fund for Influenza Action” (UNDP, 2011); and (5)
“Issues paper: The EU role in global health” (Commission, 2009).
While progress has been made in identifying the need for a One Health approach and
potential activities consistent with such an approach, the ways in which One Health can be
operationalised have yet to be determined. To this objective and in line with the Asia Europe
Meeting (ASEM) process, an ASEM conference is being organised to take in Asia to define a
collective plan of action for OH. The conference is a collaborative effort of ASEM, the
European External Action Service (EEAS) of the EU, the Directorate-General for
Development and Cooperation – EuropeAid of the European Commission, and the
Australian Government. This report will serve as a background document for the conference.
b) Approach to the report
Information in this report relied on several sources. Of primary importance was
communication with key informants which included face-to-face meetings, and
communication by teleconference, telephone, and email. Short field visits were conducted in
Bangkok and Jakarta to meet with key informants (see Appendix 1) to gather key
information, verify facts, and solicit input as to case studies and recommendations to be
Implementation of the One Health approach in Asia and Europe Background document 3 included in this report. Discussions held at One Health related conferences1 attended by the
primary author during the course of preparation of this report also contributed to findings in
this document.
Literature consulted that contributed to this document included peer reviewed publications,
institutional reports and online documents, emails, and news media reports. In particular
instances, internal institutional documents were also sourced. The summary case studies
were generated based on project reports, institutional literature, information available on the
internet (e.g., IGO/NGO websites), personal communication, and personal experience. The
comments and personal visits with key informants were particularly valuable to selecting and
developing the cases.
All the case studies selected demonstrate approaches to managing or addressing a health
problem in a manner consistent with a One Health approach. Case studies represent
projects or approaches that were at least partly funded by the EU and/or Asian partners,
implemented in Asia or Europe, and with adequate documentation to allow write-up.
Selection of the case studies was based on several other additional criteria as well; these
criteria were considered by the authors as important to the One Health philosophy, identified
by key informants, and/or noted in the resources available to the authors. These factors are
listed in Table 1 with a subjective appraisal indicating importance of the factor to the case
study. Note that five themes common to all case studies and considered highly important
(and not listed in Table 1) were transdisciplinarity, prevention of disease, zoonoses,
complexity, and community level responses. Leading questions are included at the end of
the case studies to promote discussion at the upcoming Operationalising One Health
meeting in October 2011, although participants are encouraged to develop their own
questions and reflections on the case studies.
c) Assumptions, limits, constraints to approach
Several assumptions and constraints should be noted for completeness. Key among our
constraints was the very tight time limit for the mission, including the lead time with which to
contact personnel who might inform the report and with whom we might meet while on
mission travel in Asia. While our key informants were extremely helpful in offering their
valuable time at short notice and providing very useful information, a main constraint we
faced was that some key individuals were not available due to vacation or mission travel, or
were no longer occupying a role relevant to our purpose. In several of those cases, email
communication or follow-up by telephone was possible but this does not allow the same
depth of communication.
With respect to the literature searched, the usual conditions apply in that we assumed we
were using the most appropriate sources which included: internet search of science
databases; university based journal search engines; online websites of relevant institutions
(UNDP, EC, CARE); and direct requests for literature from key contacts. Some of the most
recent institutional documentation was not available to us due to confidentiality but in those
cases personal communication was valuable.
In our list of key informants, we assumed we were contacting the best sources of
information; where this was not the case, we assumed we were directed to those individuals
who were most appropriate. It was also assumed that we had identified the most appropriate
persons as current and potential focal points and leaders in One Health in Asia and Europe.
Sources of information included key informants, personal experience and contacts, and
project literature.
1
“International Society for Infectious Diseases – Neglected Tropical Diseases Meeting”, Boston, July 8-10, 2011 and the "One
Health Initiative to Food Safety and Pathogen Threat in Asia Pacific", Chiang Mai, July 21-22, 2011.
Implementation of the One Health approach in Asia and Europe Background document 4 Table 1. Rankinga of One Health themes addressed in ten selected case studies.
One Health theme
Improved risk management
CARE
livelihood
Project
NRP 49
Communication
Chars
livelihood
programme
Rabies
in Bali
Healthy
Food
Markets
Hydatid
control
Q fever
outbreaks
Salmonella
control
HAIRS
group
3
3
2
2
2
3
3
3
3
3
Education / in-service training
3
2
3
3
3
3
3
2
2
1
Community participation
3
1
3
3
3
3
3
1
3
1
Preparedness / planning
3
2
3
3
1
3
1
2
3
3
Communications
2
1
3
3
3
2
3
2
2
3
Culture as a factor in behaviour change
3
2
3
2
2
3
3
1
2
1
Networks
2
3
2
3
2
2
3
1
2
3
Governance: intl., regional, natl. concerns
2
3
1
3
3
1
3
1
3
2
Surveillance
2
3
1
1
3
1
1
3
3
3
Outbreak response
2
3
1
1
3
1
1
3
3
3
Sustainability
3
2
1
3
3
2
3
1
2
1
Access to services
2
2
3
2
2
1
3
1
3
2
Production / distribution systems
1
2
2
3
1
3
3
3
3
1
Research
1
2
2
2
3
1
2
3
2
2
Economic and gender equity
2
1
1
3
1
2
3
1
2
1
Capacity/ training
2
2
2
2
1
3
1
1
2
1
Is there a plan/ roadmap
1
3
2
2
2
1
3
1
1
1
Optimal coordinated efforts
2
3
1
1
2
2
2
1
1
2
Laboratory aspects
1
3
1
1
1
1
1
3
2
3
Involvement of wildlife / envnmt. sector
1
1
1
1
3
1
2
2
1
1
Barriers to uptake/ adoption of approach
2
1
2
1
2
2
1
1
1
1
Involvement of private sector
1
1
1
2
1
1
3
1
1
1
Regional networks
1
2
1
1
2
1
1
1
3
2
Roles of main players
1
2
1
1
2
1
1
1
2
2
Funding
1
1
1
2
3
1
1
1
1
1
a.
Ranked by attention to theme, where 1=low, 2=moderate, 3=high. Note that the themes transdisciplinarity, prevention of disease, zoonoses, complexity, and community level responses
were common to all case studies and ranked as highly important in each. Theme identification was based on a combination of declared project activities, review of project literature, key
informant input, and subjective appraisal by the authors.
Implementation of the One Health approach in Asia and Europe Background document 5 Other constraints and assumptions include the following:

Other relevant OH stakeholders may not have been identified at the outset,
particularly with regard to sectors beyond human and animal health.

In many instances, true OH approaches that declare themselves as such are only
now being applied. This means that there are few complete records of OH
endeavours that have documented impact.

Compilation of the bibliographies relied on searches using key words such as ‘One
Health’ and ‘zoonosis’ and to some extent involves a retrospective OH labelling of
activities. This has implications for the relevance and comprehensiveness of the
bibliographies: post hoc classification of older papers and projects as using a OH
approach could have led to the inclusion of documents that are not relevant, while
more relevant papers and projects that did not use our search terms would have
been missed.

The literature search strategy also omitted examples of operationalising OH that
have not been recorded in the public domain in English language.

The selected cases do not constitute a comprehensive list of relevant OH themes;
rather they reflect topics found to be important to the One Health approach at the
time of writing. Other overarching development themes such as the Millennium
Development Goals will have relevance and there may be other themes not captured
in this document: all should be considered by participants in the conference as
appropriate.
d) The One Health approach – are there necessary elements?
Considerable thought was given to whether or not the report should include some
background discussion around what constitutes a One Health approach without being too
concerned with definitions. While this was not highly constraining on the mission, this
understanding set some margins to the scope of this report. Furthermore, this discussion
has received considerable attention at recent One Health meetings and we felt some
mention is warranted here.
Several institutions and agencies have defined and characterized the centuries old concept
of One Health from broad concepts to more specific definitions (World Conservation Society,
2004; FAO, OIE, UNSIC, UNICEF, WHO, and The World Bank, 2008; Commission, 2011a,
2011b; One Health Initiative, 2011). While definitions differ, it seems that there is general
agreement that rather than an methodology with carefully enumerated components and
steps, One Health is more an approach, a movement, or a philosophy which can guide and
improve strategic control of emerging infectious disease and protect health where and when
such diseases may already be under control. However, some informants questioned whether
any disease impacting on livelihoods or compromising community or individual health might
then be reasonably included under the OH umbrella if that concept is stretched to the limit.
Hog cholera, a severe disease in pigs but not a threat to human health, would thus be a
perfectly valid example of a disease that benefits from a One Health approach. But it is
difficult to accept that a physician, even one working in a rural area struggling with an
outbreak of hog cholera, would come to the same conclusion. The linkages seem too remote
without starting down an all-inclusive slippery slope of conditions and contributing factors
linked to health, hunger, and communities.
Perhaps the key then is to understand that the OH concept does not dictate that all boundary
partners have the same level of engagement, or indeed expect the same benefits from
engaging in a OH approach. Indeed, it is expected that various professional sectors should
Implementation of the One Health approach in Asia and Europe Background document 6 have different levels of engagement in the OH approach by the definition of their roles, just
as the autonomy of various professional sectors must be respected.
Thus, in order for the various actors and institutions to understand and respect their role in a
OH approach as well as that of other partners, it would seem constructive to have some
discussion within professions as to fundamental necessary and sufficient conditions of
engagement in a One Health approach in order to assist in advancing the operationalisation
of OH. We come to some conclusions on this matter at the end of this document based on
the case studies presented, thoughts of key informants during our mission, and our own
discussions during the mission. It is recommended that readers consider these issues
and come to their own conclusions in order to contribute to the ongoing discussion.
Objectives of the mission
This document presents a series of case studies in One Health in Asia and in Europe, as
well as three comprehensive databases covering key One Health documents, focal points
and key personnel, and One Health programmes and activities. Selection of the cases
studied is designed to illustrate key themes that are being addressed in the One Health
approach, and to foster discussion among the participants at the upcoming Operationalising
One Health conference. To this latter objective, leading questions are included at the end of
the case studies, although participants are encouraged to develop their own questions and
reflections on the case studies.
The case studies selected reflect on the broad One Health themes outlined below, identified
by the authors of this report in consultation with key informants. The reader should note that
this is not intended to be a comprehensive list but reflects on themes found to be important
to the One Health approach at this time of writing. Other overarching development themes
such as the Millennium Development Goals should be considered relevant and in
conjunction with this short list.
Description of the study
The global objective of this study is to facilitate the identification by the ASEM conference of
concrete and immediately applicable actions on OH, including the exchange of experiences.
The specific objective of this assignment is to prepare a documentary report with
accompanying OH bibliographies before the conference, in order for it to be used as a
constructive building block by the expected 100 participants. This will, therefore, assist the
different professionals in the development of a OH global network.
Specific objectives of the mission
1) Gather publications and other documents on the One Health approach for
preparation in an annotated bibliography
2) Prepare a database of One Health actors and possible focal points in Europe and
Asia
3) Prepare a list of One Health initiatives, projects, and programmes in Europe and Asia
4) Identify and present ten cases of implementation of the One Health approach in
Europe and Asia
The documents were validated by a short mission to Bangkok and Jakarta. For a list of
persons and institutions visited see Appendix 1.
Implementation of the One Health approach in Asia and Europe Background document 7 Results of first 3 objectives
Results of activities addressing the four specific objectives of this mission are identified and
briefly considered in this section.
1. One Health initiatives, projects, and programmes in Europe and Asia
More than 90 initiatives, projects, and programmes were identified from Europe and Asia
that address One Health in some substantial manner. The references are included in a
spreadsheet, referenced as Annex 1. Many of the initiatives reported are institutional
programmes that broadly address health, including animal and human health. There tends to
be an element in emerging infectious disease in many of the programmes. Particular
attention in terms of activities includes surveillance and response, epidemiology, and
preparedness.
Sources of information included personal communication with key informants, project
documentation, institutional and agency literature (e.g., NGO annual reports), web searches,
university and research institution contacts, and conference and meeting literature.
2. One Health actors and possible focal points in Europe and Asia
More than 750 individual names with contact information were gathered of One Health
actors and practitioners in Asia and Europe, many of whom could be suitable for Focal
Points. The details are reported in a spreadsheet and are referenced as Annex 2.
Sources of information included contact databases shared by key informants, lists of
conference documentation including attendees, website information, and personal contact
information of the authors. There is a bias towards Asian contacts in the database, which
probably reflects the considerably larger contingent of practitioners who identify themselves
as working in a One Health related discipline or activity in Asia rather than in Europe, the
experience of the authors, and the design of the mission.
3. Publications and other documents on the One Health approach
More than 250 documents were gathered and assessed for inclusion in an annotated
bibliography addressing the One Health approach. The references are included in a
spreadsheet, referenced as Annex 3. Sources include peer reviewed and grey literature
(typically institutional publications not appearing in the academic press, which may or may
not be peer reviewed), conference proceedings, website documentation, and literature
contributed from various organisations.
The nature of the content of the literature reported varies widely. Main key words include:
One Health; Ecohealth; Global health; HPAI/ GRAI; transdisciplinary approach to health;
pandemic preparedness; zoonotic disease; One World One Health; and animal and human
health management. This is a short list of key words; many others were used to find relevant
articles. A difficulty encountered during gathering of references was the tendency to stray
from a clearly OH based document to the enormous peripheral health literature that contains
elements pertinent to a OH approach. Readers may find the latter distracting but are
reminded that the definition of OH remains broad and transdisciplinary. What is a key OH
document for one discipline may be seen as not particularly pertinent to another.
4. Ten case studies on the implementation of the One Health approach in Europe and Asia
Ten case studies representing implementation of the OH approach are presented in the
main section of this report. The One Health features of the case studies are summarized in
Table 1. Theme identification was based on a combination of project activities declared by
project officers or in review of project literature, comments from key informants, knowledge
of the activities, and subjective appraisal by the authors.
Implementation of the One Health approach in Asia and Europe Background document 8 The themes transdisciplinarity, prevention of disease, zoonoses, complexity, and community
level responses were common to all case studies and ranked as highly important in each. A
number of slightly less important themes were identified: improved risk management;
education / in-service training; community participation; and preparedness / planning. The
least addressed themes in the ten case studies presented include: involvement of wildlife /
environment sector; barriers to uptake/ adoption of approach; involvement of the private
sector; regional networks; roles of main players; funding; and communications. It is
surprising that wildlife is not more commonly addressed, but this is perhaps considered as a
given component of activities addressing “animals”. Communications and networks are
addressed to a degree in other themes. However, it is disconcerting to note that involvement
of the private sector (e.g., themes to develop market access; working with private industry)
was not more common.
Six case studies are from Asia, and four are from Europe. Other Asian and European cases
were considered (e.g., response to BSE; tuberculosis eradication campaigns) but these are
documented well enough already that it was felt it would be redundant to include them here.
We also draw attention to the successful EU Regional HPED2 Programme, Cross-border
Cooperation in Animal and Human Health (Commission, 2011a). The programme is
investing more than €20 million to fund at least nine projects in Asia from 2009 to 2013
through IGO partners OIE, FAO, and WHO. While the programme did not really fit as a Case
Study (we see it as an EU funding programme rather than a single large OH project in Asia
or Europe), the funded activities of this regional programme in Asia have addressed
numerous OH themes, including improvement of regional capacity in disease diagnosis and
response, strengthening surveillance, and improving community awareness. Readers are
encouraged to learn more about this programme which is strengthening the institutional
capacities of ASEAN and SAARC to control HPEDs and to improve epidemic and pandemic
preparedness in the region.
2
Highly pathogenic and emerging or re-emerging diseases (HPEDs) (Commission, 2011a).
Implementation of the One Health approach in Asia and Europe Background document 9 Case studies
Implementation of the One Health approach in Asia and Europe Background document 10 CASE STUDY 1: Community Based Avian Influenza Risk Reduction Program
Community
Based
Avian Influenza
Risk Reduction
Program
(CBAIRRP)
in four Mekong
countries
Case type:
Program
Case focus:
Highly pathogenic
avian influenza
(HPAI);
Community level
responses
Implementer:
Non-government
organisation:
CARE Australia
through CARE
country offices
Donor:
AusAID
Location:
Cambodia, Lao
PDR, Myanmar,
Viet Nam
Background
Having circulated in southern China and Hong Kong since the late
1990s, highly pathogenic avian influenza viruses (HPAI) of the H5N1
subtype swept through the Mekong sub-region in 2004-05 emerging
as a serious cause of disease in both poultry and humans. With the
support of the international community, governments mounted
expensive awareness raising activities and control measures that in
some cases included large vaccination programs. However, backyard
poultry farmers bore the brunt of the economic impact in Cambodia,
Lao PDR, Myanmar and Viet Nam because mass die offs and culling
of domestic birds threatened livelihoods.
HPAI H5N1 now appears to be endemic in bird and poultry
populations throughout the sub-region with ongoing sporadic
transmission to people. Elimination from domestic bird populations is
expected to take years with persistent threats to the health and
livelihoods of residents.
Against this background, CARE Australia sought AusAID funding to
launch a series of demonstration projects in four Mekong countries
through CARE’s national offices. These projects targeted communities
involved with small-scale backyard poultry raising who remain
vulnerable to HPAI H5N1, and sought to improve community and
institutional capacity for recognition, control and prevention of avian
influenza. CARE developed pilot model projects specific to each
setting to improve community-based surveillance and biosecurity for
backyard farming and wet markets, as well as models to increase
local awareness of HPAI H5N1 and behavior change to reduce the
risk of transmission to birds and people. The combination of the
activities in the four countries was said to constitute a ‘regional’
program.
Period:
April 2007 –
November 2009
Themes:
Community
participation
Interdisciplinary
collaboration
Risk management
Sustainability
Objectives
CARE aimed to strengthen community and institutional capacity to
reduce the risk and mitigate the impact of avian influenza by achieving
the following two outcomes:

Local partners would have successfully piloted models with
CARE support;

Local partners had adopted and were replicating successful
models and approaches beyond the initial project sites.
Activities
CARE designed community level models tailored to community needs
and in light of national, regional and international strategies such as
the Asia-Pacific Strategy for Emerging Diseases and the One World
One Health strategic framework developed by UN agencies and the
Implementation of the One Health approach in Asia and Europe Background document 11 World Bank. The table (next page) lists the models employed in each
country.
A number of models relied on
volunteerism at the village level or
utilised existing volunteer structures and
sought representation of the human and
animal health sectors.
In most but not all cases, rigorous
external assessment of models was
undertaken
which
enabled
the
development of sound monitoring and
evaluation frameworks – an important
aspect when trialling novel models.
Through relations with international
technical agencies, and in some
countries direct links to provincial and
national managers, CARE was able to
transfer community experiences to
national and provincial managers to
support
replication
of
successful
models. Lessons from models were also
shared
across
CARE’s
country
programs.
Impact
Cambodia
Community based surveillance using village
surveillance teams
Demonstration farms for backyard poultry
farmers
Laos
Wet market biosecurity through training
poultry vendors and hygiene installations to
reduce risks throughout the poultry trade
chain
Bio-security improvements in
slaughterhouses
Community Events Based Surveillance using
village volunteer teams
Avian Influenza Communications Package
for villages
Myanmar
Training of Trainers system for community
awareness on avian influenza from central
Myanmar Livestock Breeding and Veterinary
Department to community local extension
workers
Wet markets bio‐security
Biosecurity for backyard poultry using a
confinement model
Viet Nam
Bio‐security
model for poultry and duck
farms
Community Based Surveillance using crosssectoral village collaborators
Behavior change communication model for
villagers
CARE formed volunteer groups in all four countries to provide community level
surveillance. In Laos, the event-based surveillance model appeared to promote speedy
reporting and response of relevant incidents.
In households, slaughterhouses and markets, models were successful in raising
awareness of symptoms of avian influenza in poultry and people, and of personal and
environmental practices that reduce the risk of H5N1 transmission. Local people had an
improved understanding of biosecurity measures to protect backyard poultry.
Some models were able to show that better practices came with improved knowledge.
For instance, poultry sellers involved in a Myanmar model disposed of waste (91%) and
wore aprons (73%) at much higher levels than sellers in markets not covered by the
model (25% for both behaviours). On the other hand, a number of models found that
alterations in behaviours were largely related to household economic interests because
of demonstrated advantages to production and livelihoods rather than education per se:
the confined farming model in Myanmar showed improvements in laying and bird
survival compared with free ranging farming, and demonstration farms in Cambodia and
Viet Nam exhibited increases in incomes.
A number of models have had impact beyond their project sites. For example, the
community event-based surveillance in Laos has been replicated in two districts and
used to inform a nascent national system; Cambodia’s National Committee for Disaster
Management is assessing the potential application of village surveillance teams for
multi-hazard disaster response; and numerous provinces have adopting the bio-security
guidebook developed by CARE Viet Nam.
Implementation of the One Health approach in Asia and Europe Background document 12 Challenges
Challenges documented by CARE include:
 Sustaining behaviour change in the face of declining outbreaks of avian influenza
among poultry
 Requirement for models to prove their (production and economic) worth to local
farmers before adoption
 Economic impediments for farmers to implement bio-secure farming
 Absorptive capacity of volunteers who must manage multiple responsibilities and
understand complex concepts with limited training
 Reliance on sound systems from commune, district and province to provide
ongoing support for community based activities even with high commitment and
ownership evinced by volunteers
 Lack of wider involvement threatening some models e.g. non-poultry traders have
not adopted behaviours in Laos and Myanmar
 Involvement of multiple partners with issues of ownership particularly where
different sectors are involved and where cross-sectoral collaboration has yet to be
institutionalised
 The future of some models, particularly if they are to replicated on a national scale,
is contingent on adequate external funding.
Conclusions
Effectively multiple parallel projects this program allowed for the design and testing of
locally relevant models with sharing of different approaches across the region. The
program set up was appropriate for trialling novel activities. CARE’s experiences drew
attention to:
 Factors important for stimulating lasting culture change especially activities related
to livelihoods;
 The need for political will and sustained resources and support from government to
communities;
 The value of involving different disciplines and agencies; and
 The complexities of crafting effective, efficient, acceptable, and equitable
interventions across the spectrum of risk for a single disease.
The program offers valuable lessons for expansion to address a broader range of
emerging infectious diseases utilising a One Health approach.
Further reading
Contact CARE Australia for further information related to mid-term and endline evaluations.
For a summary of the program see the presentation by:
Ms Jacquelyn Pinat, Regional Program Manager, CARE Australia ‘Pandemic Preparedness as Part of a
Multi-Hazard Approach: CARE’s Community Based Avian and Pandemic Influenza Risk Reduction Models
in the Mekong’. EIDForum of Asia-Pacific Region, 4 November 2010
Available at: http://eidforum.org/index.php/forum/8-2010-meetings
Implementation of the One Health approach in Asia and Europe Background document 13 Acknowledgements
We thank Christina Munzer from CARE Australia for sharing internal documents.
Questions raised by this case study
Observations
Questions
The program was developed to mitigate the impact of HPAI
H5N1, a focus driven by both local and international concerns.
The model-based pilot approach compartmentalized responses to
risks along the backyard poultry production chain not of all of
which were addressed in each country program. Importantly, this
approach allowed determination of the effectiveness of each
particular element, many specific for poultry. On the other hand,
there are indications from assessments of some of the models
that the program may have led to more improvements if a broader
approach had been explicitly adopted (e.g. market wide initiatives
not just poultry specific measures).
Are more ambitious, holistic One Health approaches - that
tackle systems and existing disease problems - preferable
even though they may take longer to design and evaluate
and even though the contribution of individual components
may not be measurable?
The model-based approach allowed for testing of novel activities
adapted to local strategies and communities that also
incorporated elements relevant to international and regional
frameworks.
How can innovation be promoted and sustainability of
effective activities ensured?
Expansion of models relies on acceptance and support at the
national level. Although CARE carefully designed models in light
of national strategies and succeeded in communicating findings to
national managers, model designs and pathways for replication
were not explicitly discussed and established with national
government at the outset.
Piloting models with a view to scaling up necessitates rigorous
evaluation processes. An evaluation of the CARE program noted
the need for technical input into developing useful indicators of
progress. It also highlighted the value of joint evaluations of
models by credible technical agencies and of pooled evaluations
comparing CARE’s models with community-based projects of
other NGOs.
(NB: CARE point out that M&E requirements are likely to be less
onerous when implementing successful models to scale
compared with the rigorous scrutiny required to ascertain if a
model is useful or not.)
Greater involvement of the private sector was not explored
especially for community-based surveillance (e.g. feed suppliers,
private veterinary services, pharmacists, private health services,
traditional healers etc.). This is common to many projects
throughout the region.
Economics was viewed as the primary motivator for many
changes of behaviour, while some behaviours fluctuated with
local perception of the relevance of avian influenza.
Reference to gender dimensions of the risks and impacts of H5N1
was not an explicit component of most of these models.
Strong management and community development skills were
highlighted as a great strength of CARE’s program and may have
contributed to the sound collaborative approaches and the
‘horizontal’ success of this program. On the other hand, internal
and external observers both noted that the program would have
been strengthened with specialized animal and human health
technical inputs.
How can a balance be struck between particular designs
to facilitate evaluation and comprehensive projects that
may make more sense to the way local people do things?
Some diseases merit rapid, specific, vertical responses.
How can single disease programs strengthen generic
disease control programs?
What pathways are available for scaling up successful
community level project pilots?
How can consistency (or relevance) between country-led
designs addressing locally important health problems and
inter-country (or international) priorities be ensured? Does
a broad One Health approach offer common ground for
these different purposes?
Should there be regional standards and M&E frameworks
for documenting community-based projects to facilitate
sharing of lessons throughout the region? How can
lessons from individual projects best be shared across the
region?
Do reviews by technically credible agencies enhance
sustainability?
Do all sections of the community need to be represented
and involved in One Health activities? Will this strengthen
or undermine efforts?
How can behaviour change be established for less
tangible personal / community gains or gains for the public
good rather than the individual?
Should economic and gender equity dimensions be an
essential cross cutting theme of all One Health
approaches?
How relevant are non-technical skillsets to getting One
Health approaches off the ground? Can these be defined
and learnt?
How can these be combined with technical inputs to
develop effective, lasting One Health activities?
Implementation of the One Health approach in Asia and Europe Background document 14 CASE STUDY 2: Swiss National Antibiotic Research Programme NRP 49:
Antibiotic Resistance
Swiss National
Antibiotic
Research
Programme
NRP 49:
Antibiotic
Resistance
Case type:
Establishment of
strategies and
methods for
antibiotic
resistance
monitoring
Case focus:
Antibiotic
resistance;
governance
Implementer:
Multiple including
Università della
Svizzera italiana
Donor:
Swiss Government
Location:
Switzerland
Period:
July 2011 – June
2006
Themes:
Governance
Trans-disciplinary
approach
Coordinated
efforts
Background
The resistance of bacteria to host defenses and to antibiotics is known
to be in constant evolution and requires consistent and regular
management. This requires new strategies developed by multiple
partners from the scientific community. By sharing research
intelligence and resources and by building knowledge together, the
NRP49 team members were able to develop new strategies for
managing the dynamic and changing nature of bacterial resistance.
This work produced recommendations addressed to the political
community at both the scientific and humanistic levels.
Switzerland is among countries where antibiotic resistance is not yet
perceived as an important threat by the population, although
resistance may very well progress should no containment measures
be undertaken. Furthermore, new antibiotics are difficult to develop
from the perspectives of both discovery and economics, and as a
result pharmaceutical companies have conducted little or no research
on new antibacterial drugs.
The World Health Assembly adopted a resolution in 1998 that
recognised the public health importance of antimicrobial resistance,
urging improved surveillance, monitoring of antibiotic usage and
potential resistance, education, and policy development and
implementation.
Objectives
The Swiss National Research Programme "Antibiotic resistance" (NRP
49) was developed to establish scientific strategies and new methods
for resistance monitoring and analysis of antibiotic resistance in
Switzerland. This was at all relevant areas which included: human and
animal populations; agriculture; foodstuffs; and the environment.
The overall goals of NRP 49 were:
1) To produce a situational analysis of the antibiotic resistance
burden in Switzerland and increased knowledge of the
associated risks
2) To establish the scientific basis for initiating appropriate
preventive measures
3) To give insight into the economic, legal and ethical aspects of
antibiotic resistance, and
4) To promote basic research towards developing new antibiotics.
Implementation of the One Health approach in Asia and Europe Background document 15 Activities
Key activities under each area were:
Human medicine and surveillance
 Establishment of SEARCH (Sentinel Surveillance of Antibiotic Resistance in
Switzerland)
 Assemble representative data provided on antibiotic resistance in pathogenic and
commensal human isolates from hospitals and the community throughout
Switzerland; antibiotic consumption data integrated and analysed within the
database
 Develop tools for tracking and characterizing resistance
Veterinary medicine and livestock production
 Develop monitoring strategy for bacterial resistance in livestock
Environment
 Develop new analytical methods to allow accurate and sensitive quantitative
analysis (down to the ng/L range) of the presence and fate of the most important
classes of both human and veterinary antibiotics in the environment.
Impact
Listing again impact under specific area of activities, the following results (and impact in
some cases) were obtained:
Human medicine and surveillance
 Antibiotic consumption and resistance documented in pathogenic and commensal
human isolates from hospitals and the community throughout Switzerland
 In spring 2007, SEARCH linked to European Antimicrobial Resistance Surveillance
System (EARSS)
 Recognition and documentation that overall antibiotic resistance is relatively low in
Switzerland, but that in some geographic regions and in selected patients groups
resistance levels are high. This included a marked trend towards increasing
resistance.
 A fast and reliable tool to genetically characterise the strains, and hence their
epidemiology, was developed and validated. This tool contributed to identifying an
unexpected emergence of community-acquired MRSA in western Switzerland
 Other tools to track resistance genes in gram-positive bacteria were developed and
validated including a tool based on the microchip hybridisation technology
(microarrays) which was used to screen for resistance genes in pathogenic
bacteria
Veterinary medicine and livestock production
 An optimal and cost-effective monitoring strategy to track bacterial resistance in
poultry, pig and cattle production was developed
 Baseline data delivered on the resistance state in food animals in Switzerland; the
resistance state in Swiss livestock was shown to be at favourable levels
 In general, meats produced in Switzerland were lower in Campylobacter when
produced on ”animal friendly” farms or compared to meat produced abroad
 Milk produced during antibiotic treatment for feeding calves and pigs was shown to
result in marked selection for resistant bacterial strains (e.g., enterococci)
Environment
 New analytical methods showed that after their use in livestock, sulphonamides
(SA) reach the soil after manure application in amounts comparable to herbicide
Implementation of the One Health approach in Asia and Europe Background document 16 
application rate and may persist there for several weeks or months; soil is a
reservoir of resistance genes.
Concentrations of SA and other antibiotics in water bodies are generally very low.
Challenges
A major constraint to continued monitoring and activities related to antibiotic resistance
is funding. Although a primary recommendation of the programme was to establish the
Swiss National Antibiotic Resistance Centre (NARC), we could find no evidence that
such a centre was established. Switzerland does however participate in the EU funded
European Surveillance of Antimicrobial Consumption Project, and this work was
instrumental in promoting this participation.
While there were no data showing the impact of low levels of antibiotics in water on the
development of resistance, an association was shown between antibiotic concentrations
in hospital wastewater and antibiotic susceptibility of some waterborne bacteria (e.g.,
Aeromonas). This finding was a concern and follow-up study was recommended.
While much of the parallel activities focused on related health disciplines including
human and veterinary medicine, it was not clear that a coordinating mechanism was
established to share data and to conduct any sort of meta-analysis of joint data sets
across health and food safety related disciplines. This was in fact one of the
recommendations: that the sentinel activities of the NARC (if it were established) should
integrate the veterinary data in order to provide better advice.
As a One Health study, there were elements of this study that are clearly important to a
One Health approach in monitoring antimicrobial resistance (inclusion of several health
related disciplines, identification of food safety as important to the study, efforts to
include community knowledge, recognition of the environment as a highly important
component of the interrelated activities leading to resistance). Nevertheless, the study
may also be one of the weaker examples presented in this document of genuinely
integrating the transdisciplinary elements of the study.
Further to this study, there are now efforts to a more harmonized approach to
antimicrobial resistance susceptibility testing of human, food, and animal isolates (e.g.,
joint scientific of the ECDC, EFSA, and EMEA). The challenge continues to improve
methods of transdisciplinary data gathering and analysis, surveillance, and management
to prevent, identify, and respond to antimicrobial resistance.
Conclusions
The Swiss NRP 49 (Antibiotic Resistance) contributed to understanding antibiotic
resistance in Switzerland using, if not fully transdisciplinary, at least a multidisciplinary
approach that included concern for environmental elements of the problem. Most of the
defined objectives were fulfilled and the programme initiated activities that have
developed to wider participation in other European projects and programmes monitoring
and responding to antimicrobial resistance.
The programme also found that awareness and knowledge about antibiotics and
antibiotic resistance was not very high among the Swiss population, and that information
sources in Switzerland were clearly unsatisfactory and inaccurate. In this regard,
scientific efforts are not sufficient in a One Health approach to identifying problems;
management must include information and education with guidelines for change.
Implementation of the One Health approach in Asia and Europe Background document 17 Further reading
Fall
08
Swiss National Science Foundation. 2007. National Research Programme NRP 49: Antibiotic
Resistance. Final Report.
Joint scientific report of ECDC, EFSA and EMEA on meticillin resistant Staphylococcus aureus
(MRSA) in livestock, companion animals and food. EFSA-Q-2009-00612 (EFSA Scientific Report
(2009) 301, 1-10) and EMEA/CVMP/SAGAM/62464/2009.
Questions raised by this case study
Observations
Questions
True transdisciplinary approaches bring together multiple
disciplines and members of the (affected) community. In this
example the linkages were not as strong as in other case studies
presented. Nonetheless, there at least was inclusion of sectors
that might otherwise have been neglected (e.g., environment).
A role of the private sector was not clear in this programme. The
pharmaceutical industry has a vested interest in monitoring and
responding to antimicrobial resistance, from regulatory affairs to
consumption to monitoring food safety.
How can inclusion of civil society be achieved in a
programme of this type and at what levels (national,
provincial district/city)?
Can this structure allow for equal inputs from various
disciplines?
How might the private sector be represented in this
programme?
In what context should the governance of policies and
programmes include the private sector (which is an
essential partner)?
The focus of the programme does not deliberately target food
safety or livestock products. And yet, the veterinary and food
safety popular press tends to implicate livestock as a major
contributor to antimicrobial resistance.
Should the use of antimicrobials in the livestock sector
have played a more prominent role in this study? How did
the Swiss authorities integrate the recommendations of
this research with the wider approach in Europe?
This case study raises the idea of targeting research to aid
decision making including planning policy. Arguably, this is a
neglected aspect of research related to emerging diseases
(including antimicrobial resistance) but of critical importance when
bringing a wide range of stakeholders together.
How can policy research be promoted? And will this
advance the One Health approach?
Implementation of the One Health approach in Asia and Europe Background document 18 CASE STUDY 3: Communication Influencing Behaviour Change, Vietnam
Use of
Communication
to Influence
Behaviour
Change
Related to
H5N1, Vietnam
Case type:
Programme
Case focus:
Preparedness,
livelihoods,
community
participation
Implementer:
Multiple including
Government of
Vietnam, UN
agencies, and
multiple partners
Donor:
Multiple including
European
Commission and
EU countries
Location:
Vietnam
Period:
2005 to 2010
Themes:
Communication
Culture as a factor
in behaviour
change
Training and
education
Community
participation
Background
In response to the outbreak of avian and human influenza in Vietnam
that began in late 2003, the Government of Vietnam together with
national agencies and international partners including several
agencies of the United Nations jointly agreed to implement and
support a single overall framework. This framework was called the
Integrated National Operational Programme for Avian and Human
Influenza (OPI), 2006-2010, also known colloquially as the “Green
Book”. These institutions also agreed to promote effective
coordination of different activities within this overall programme
through the Partnership for Avian and Human Influenza (PAHI). The
joint initiative between these institutions has become known as the
“Joint Programme” or the Joint Government of Vietnam and United
Nations Programme to Fight Highly Pathogenic Avian Influenza in
Vietnam. The OPI includes three major parts: I. Enhanced
Coordination Activities; II. HPAI Control and Eradication in the
Agricultural Sector; and III. Influenza Prevention and Pandemic
Preparedness in the Health Sector. All three parts include components
on public awareness and behavioral change, driven in part by
communications activities. The Joint Program has been discussed and
evaluated in numerous publications; this case study examines the
communications component which has not be widely discussed or
evaluated.
Initially, some collaboration existed across agencies with regards to a
communication strategy, although by 2005 there was no formal
coordinating and communication mechanism across Ministries or
among implementing agencies. This led to some overlap of resources,
inconsistent messages leading to confusion among the audience,
unnecessary competition for the audience’s time and attention, and
potential for low impact as result of technically incorrect information
(OPI, 2005). Also, monitoring and evaluation of the activities required
improvement and capacity of Government agencies and mass media
needed strengthening.
An Information, Education, and Communication (IEC) working group
of government and UN agencies’ staff was established in 2005 with
the goal to achieve greater impact through harmonization of the efforts
of all implementing partners under an over-arching communication
strategy with a common set of objectives and core messages (“One
campaign – many sectors”). The IEC was to focus on providing a
better rationale for activities through investigative work, monitoring,
and evaluation, and to build capacity in the mass media and
government agencies implementing the HPAI control and pandemic
communication plans.
Implementation of the One Health approach in Asia and Europe Background document 19 As well, public awareness and behaviour change was directed at the agricultural and the
health sectors. Under the OPI, the health sector will take the lead on promoting
behaviors associated with: (a) timely reporting of human diseases; (b) improved
personal hygiene and food safety; (c) compliance with medical regulations; and (d)
improved containment response if human-to human transmission occurs. The primary
target audience is the general public who will be reached through different channels
such as health workers, mass organisations, and the school network.
As a One Health case study, communications in Vietnam to influence behaviour change
related to HPAI is interesting because it represents a discipline not often thought of by
non-experts in a health management campaign, although it is a vital element of a One
Health approach.
Objective
The main objectives of this One Health case study in communications in Vietnam were:
1) reduce mortality and morbidity from HPAI in Vietnam
2) develop awareness and knowledge that HPAI is preventable
3) reduce animal-to-animal and animal-to-human transmission of HPAI
4) increase adoption of behaviors that contribute to taking preventive measures
against HPAI, both in the agriculture and in the health sectors
Activities
According to the OPI, the health sector will take the lead on promoting behaviors
associated with:
a) timely reporting of human diseases;
b) improved personal hygiene and food safety;
c) compliance with medical regulations; and
d) improved containment response if human-to human transmission occurs.
The primary target audience is the general public who is reached through different
channels such as health workers, mass organisations, and the school network.
According to the OPI, the agricultural sector will take the lead on promoting behaviors
associated with:
a) timely reporting of animal diseases;
b) improved bio-security in poultry farming; and
c) safer poultry handling practices in slaughtering, transport and marketing.
The primary target audiences of the agricultural sector include backyard, semicommercial, and semi-industrial poultry farmers, traders, and marketers.
Although early results of the communications work are not available, the outcome
indicators developed for agriculture are:
 50% of target audience able to list at least 80% of recommended preventive
measures
 50% of target audience saying that AI animal-to-animal transmission is
preventable
 50% of target audience practicing at least 60% of recommended preventive
measures
Implementation of the One Health approach in Asia and Europe Background document 20 Similarly, the outcome indicators for the health sector are:
 50% of target audience able to list at least 80% of recommended preventive
measures
 50% of target audience saying that AI animal-to-human transmission is
preventable
 50% of target audience practicing at least 60% of recommended preventive
measures
 50% of target audience able to list at least 80% of recommended preventive
measures
 50% of target audience prepared to take preventive measures
 50% of target audience practicing minimum 60% of recommended preventive
measures
Numerous parties were involved in developing and implementing the communications
section of the OPI in Vietnam. These include the lead Government of Vietnam
institutions and UN agencies: the Ministry of Agriculture and Rural Development; the
Ministry of Health; FAO; UNICEF; UNDP; and WHO. The Vietnam Women’s Union
(VMU) played a key role in implementing the communications section through a training
of trainers approach; the VMU number over 13 million members in 64 provinces. As well,
the Vietnam Poultry Association (VIPA) and the Vietnam Feed Association helped
educate poultry farmers.
Impact
Preliminary results are available by examining some of the field projects implemented in
Vietnam. These results follow:
 The Vietnam Women’s Union had trained 3,833 district and commune women in
24 provinces by September 2007; in turn, these women trained more than 88,000
other women farmers
 By early 2008, VIPA had trained more than 2,125 farmers in four provinces, who
in turn communicated HPAI prevention messages to family, friends, and
neighbors raising poultry
 Both the VWU and VIPA continue training and trainees continue to communicate
messages to other contacts.
The EU has been a major donor to Vietnam’s fight against HPAI. In a recent evaluation
report conducted by HTSPE Limited (Outcome and Impact Assessment of the Global
Response to the Avian Influenza Crisis: Final Report - August 2010), general
conclusions were reached that:
 UNICEF has taken a lead role in strengthening countries’ capacity in
communication and social mobilisation
 Increased knowledge has not necessarily translated into effective behaviour
change (this has been reported elsewhere informally)
 Low levels of bio-secure farming and disease reporting were recorded (informal
results indicate reporting may be higher than average for Vietnam)
 Factors discouraging reporting were:
o low risk perception;
o fear of the economic consequences of reporting;
o lack of clear information about follow-up actions;
o actual post-reporting experiences; and
o strong distrust of authorities.
Implementation of the One Health approach in Asia and Europe Background document 21 


The current set of behaviour change messages, which are technically sound, are
perceived as imperatives and often lack relevance for the target group.
In future, messages and training programmes should be designed by working
groups composed of technical and social scientists and based on social, cultural,
political and environmental values and contexts of the target group.
The GRAI has improved outbreak/pandemic communication strategies and
systems, and particularly a better harmonization of outbreak protection messages
and dissemination strategies among partners and actors.
Specific results are available for hand washing (targeting reduction of diarrheal diseases
in children), from a report presented by Nguyen in Dhaka, 2010 (Nga Kim Nguyen,
Designing Evidence-based Communications Programs to Promote Handwashing with
Soap in Vietnam, South Asia Hygiene Practitioners’ Workshop, Dhaka Bangladesh,
February 2010):
 The program has reached over 1.8 million people in the first phase, with a target
of 30 million to be reached in phase II.
o over 1.8 million people have been reached through communications
activities via health workers and Vietnam Women’s Union members
 there has been significant demand from other donor and government programs
for integration of handwashing with soap messages into their water and sanitation
programs
Challenges
Without pre-existing behaviour knowledge, it is difficult in terms of monitoring and
evaluation to evaluate the impact a communications program can have on rates of
infection. Nevertheless, it seems clear that increasing knowledge through
communication activities is not sufficient to elicit behaviour change, although it may be a
necessary condition in many communities.
Conclusions
This Case Study demonstrates a participatory approach across institutions to work
together in understanding and addressing a particularly complex problem, with strong
involvement of the community. The education component is clearly important, but it also
demonstrates that even with transfer of information, behaviour change does not
necessarily happen. The knowledge transfer, adoption, and behaviour change literature
is rich with examples of this with recommendations based on past experience to which
the reader is referred.
One of the most important lessons coming from this case study is that change of
behaviour associated with health outcomes can be slow to happen. This portion of the
UNJP is one of the more complex and challenging dimensions of the programme.
Activities continue with cross institutional participation, community involvement, and
transdisciplinary efforts.
For further information
Government of Vietnam Ministry of Agriculture and Rural Development
www.agroviet.gov.vn
Government of Vietnam Ministry of Health
www.moh.gov.vn
UNICEF
www.unicef.org
Implementation of the One Health approach in Asia and Europe Background document 22 The Partnership on Avian and Human Pandemic Influenza
www.avianinfluenza.org.vn/index.php
AED
avianflu.aed.org
GRAI evaluation report 2010
HTSPE Limited. Outcome and Impact Assessment of the Global Response to the Avian Influenza Crisis. Final
Report. August 2010.
Questions raised by this case study
Observations
Questions
The IEC was to focus on providing a better rationale for activities
through investigative work, monitoring, and evaluation, and to
build capacity in the mass media and government agencies
implementing the HPAI control and pandemic communication
plans.
As well, public awareness and behaviour change was directed at
the agricultural and the health sectors.
The GoV-UNJP relies on alliances with non-traditional health
disciplines for success in achieving its objectives related to
behaviour change.
Two of the factors discouraging reporting were fear of the
economic consequences of reporting and strong distrust of
authorities.
How could a arrangement such as the IEC work closely
with communities to encourage community leadership in
communication?
If directorship of such activity is placed within government
ministries, what roadblocks or catalysts to progress are
created?
Where can the private sector be a partner in nontraditional health discipline leadership?
What benefits can be drawn from the private sector in
such arrangements that are not possibly from the public
sector?
How could the public sector instil confidence in producers
to report diseased birds? What difficulties does this
present for policy formulation and implementation,
particularly where outbreaks may be unexpected and
sudden?
In a programme that is heavily reliant on community
participation, does distrust of authorities translate into
failure?
The GoV-UNJP is a national programme targeting national,
provincial, and community levels of action. Leadership comes
from government, international agencies, NGOs, and community
groups. Careful coordination of such a widely reaching
programme is highly challenging.
In a programme such as the GoV-UNJP, what are there
benefits and risks to transfer of responsibility of activities
to lower level institutions/ partners? Does this compromise
a governance model led by national government?
Implementation of the One Health approach in Asia and Europe Background document 23 CASE STUDY 4: Chars Livelihoods Programme, Bangladesh
Chars
livelihoods
programme
Case type:
Programme
Case focus:
Livelihoods,
community
participation,
economic
empowerment
Implementer:
Multiple local
partners including
NGOs
Donor:
UK government
(DFID) and
AusAID
Location:
Bangladesh
Period:
2004 to current
Themes:
Community
participation
Health governance
Disease ecology
Small enterprise
development /
market access
Background
The Jamuna River island region of Bangladesh is home to
approximately 3.5 million Bangladeshis, many of them under extreme
poverty. The Char Livelihoods Programme (CLP) in this region directly
targets the 55,000 poorest households living on island chars, small
islands of sandy land that is at risk of severe flooding during the rainy
season. The core beneficiary households, home to about 220,000
people, receive a transfer of investment capital worth about USD300.
The households also enroll in a development input and training
package that includes social, livelihood, and market development
components. Home improvements include raising the homestead
plinth above the highest known local flood level, as well as
construction of a sanitary latrine and access to clean drinking water.
The CLP has complete Phase I (2001-2004) and is now in Phase II of
the programme.
The risk of emerging infectious disease is present at higher than
normal levels in the CLP region for several reasons. Firstly, due
primarily to low education levels, sanitation and hygiene has not been
well understood by many villagers leading to risky practices including
lack of a sanitary latrine. Secondly, livestock are often kept within
households at night to prevent theft and predation. This practice
increases human exposure to harmful bacteria and other
microorganisms. Thirdly, poor access to health care for animals and
humans has meant low levels of protective immunity to disease or
post-exposure care, resulting in increased morbidity and mortality as
well as economic losses. And finally, recurring flooding and poor
environmental management leads to rapidly increased levels of
coliform bacteria and vibriosis, further exposing residents to harmful
pathogens. Many of these risks are reduced with CLP activities.
There are several interesting dimensions of the CLP that make it an
appealing One Health case study. Only one of the main components
of the CLP directly targets improved access to health, although all
seven components address developing capacity for improved health
care for humans and livestock. The main components of the CLP are:
Asset Building and Livelihoods; Providing Infrastructure; Encouraging
Social Development; Offering Social Protection; Promoting Enterprise;
Innovation, Monitoring, and Learning; and Improving Access to Health
and Education. Through these components, benefits are extended
from 55,000 core beneficiary households to an estimated one million
people.
As a One Health case study, the CLP uses an integrated approach
drawing on cross-disciplinary skills beyond core health disciplines,
works closely with communities to develop health infrastructure
capacity, concerns itself with the interaction of animals, humans, and
the environment, and addresses fundamental processes of emerging
Implementation of the One Health approach in Asia and Europe Background document 24 disease, not just specific diseases already present in a community. Finally, the CLP has
made a concerted effort to ensure decision makers were those living and working in
targeted communities in order to increase sustainability of interventions.
Objective
The main objectives of the CLP are to:
1) reduce extreme poverty
2) decrease environmental vulnerability
3) enhance economic opportunities
4) improve social well-being
Activities
The CLP is a large and ambitious programme. Among the dozens of programme
activities, several are highlighted here that illustrate the One Health dimension of the
programme. The nature of these activities, which for the most part do not directly target
health results, demonstrate how a project or programme can indirectly have strong
influence on health outcomes by targeting change in key areas (for example,
encouraging social development) that impact on health.
1) Asset building: use of asset transfer to invest in an income-generating asset
helps secure household income which can be used for health interventions (e.g.,
purchase of health services or supplies)
2) Providing infrastructure: raising households above the flood plane, ensuring
access to safe drinking water, and provision of a latrine reduce risk of infectious
disease transmission
3) Encouraging social development: developing a community based women’s
group, for example, increases villagers’ knowledge, skills, and capacity to
cooperate with others in their community. This strengthens household
sustainability, and develops a sense of control and responsibility. Specific
structured learning sessions also take place, and this includes sessions on health
and the environment (e.g., cleanliness of the homestead, using sanitary latrines,
and healthcare for adolescents).
4) Offering social protection: CLP core beneficiaries develop a strong sense of
community self-reliance, but are still highly vulnerable to crises such as food
insecurity. Under such circumstances, participants have access to other forms of
short-term social protection (safety nets), such as temporary food transfers.
Safety nets are important to preventing crisis situations under which diseases can
proliferate, with devastating results.
5) Promoting enterprise: access to services and markets is severely restricted for
char dwellers for numerous reasons. The CLP core beneficiaries benefit from
developing livestock markets, for example, and parallel activities such as poultry
breeding, dairy management, and microfinance. Such activities promote private
enterprise including provision of household needs and health inputs for humans
and animals.
6) Innovation, Monitoring, and Learning: Lessons learned by the CLP are shared
with any interested parties and are freely available from the CLP website and
team. As well, CLP and its beneficiaries continue to learn from other programmes
including donors and poverty reduction organisations.
7) Improving Access to Health and Education: Although all seven of the major CLP
activity areas benefit health outcomes, only one specifically addresses access to
Implementation of the One Health approach in Asia and Europe Background document 25 human health care. There are two major activity areas under this activity theme: i)
the Primary Healthcare and Family Planning Project (PHC-FP) which provides
low-cost healthcare services to the chars, and ii) the CLP Learning Centres: NonFormal Primary Education which provides education for children.
The CLP addresses other key elements across its main activity groups including
fostering a participatory approach to solutions, socioeconomic and cultural factors
contributing to poverty, and gender and economic equity issues. The major partner and
donor for this initiative is the UK Department for International Development (DFID).
Other partners and donors include the Australian Agency for International Development
(AusAID) and numerous implementing local partners including RDRS Bangladesh, Gana
Unnayan Kendra (GUK), SKS Foundation, Mahideb Jubu Samaj Kallayan Samity
(MJSKS), and AKOTA.
Impact
Impact of the CLP has been monitored using a number of variables (indicators) reported
on the programme website. A sampling is reported here, based on data from CLP
reports. From the first phase of the programme, the percentage of households reporting
no infection at baseline was 46.9% in June 2010; this increased to 83.3% in April 2011.
Other indicators linked to health outcomes showing improvement include hand washing
behaviour,
Average daily per caput income at baseline was 21.8 Bangladeshi taka (about USD
0.30). In April 2011, the average income increased more than 112% to 46.39 taka.
Household income spend on non-food increased nearly 100%, while the proportion of
income spent on food reduced from 62% to 30%.
Training and access to primary health care includes para-medical and para-veterinary
services based initially on a service for voucher system. Use of these services has
increased as well as indication of willingness to pay for such services.
Challenges
While short to intermediate-term social protection measures can be provided by external
donors, longer term measures are generally regarded as a service provided by
government. This can be a challenge in low income, densely populated countries such
as Bangladesh where provision of government services are already in extreme demand.
Working with local government can help to address this, although cultural barriers still
exist (e.g., issues relating to land ownership, access to mainland markets).
Networking can always improve, and in the Chars Districts this has been noted by some
external reports. For example, improved networking with government, NGO, and private
health service providers in the Char Districts. Similarly, networking with veterinary care
providers is constrained by availability of highly trained personnel and access to (for
example) laboratory or epidemiologic services.
Other challenges include: meeting high demand for training in many areas including
livestock management; home small enterprise skills training; sustainability concerns
regarding provision of community health care workers; and development of broader
formalized microfinance programs (e.g., participation in PKSF micro-finance) based on
the limited client base on the islands.
Conclusions
Implementation of the One Health approach in Asia and Europe Background document 26 The success thus far of the large and ambitious Char Livelihoods Programme is even
more remarkable considering that the main unit targeted in terms of activities is the
household, although enrolment of the community is clearly essential. Without
intentionally delivering a programme that was built around One Health foundations, it is
clear that many of the approaches rely on a One Health philosophy. By addressing the
health of animals, humans, and the environment while ensuring economically viable
options for households that develop community based decision processes contains
many of the elements one would wish to see in a successful One Health strategy.
External evaluation of the CLP had observed that success in many community level
parameters (e.g., reduction of infection rates, increased household income, improved
literacy rates, more participation in childhood education, and better access to markets)
does not translate into higher level policy dialogue and formulation. Nor does it generate
research activities that can lead to conclusions regarding change that can be adapted,
transferred, or upscaled in other settings. Other criticisms were that the CLP was
attempting to do too much of a general nature. The latter observations seem to be
unfounded, although there still remains concern that little real policy formulation has
occurred at the national level as a result of the CLP.
Questions raised by this case study
Observations
Questions
A general concern of community based approaches to
development is the lack of impact it may have on policy
development at a wider/ larger scale.
What activities and agents would be necessary to ensure
health policy dialogue and formulation happens? Is this a
necessary outcome of community based development
programmes?
The CLP has assisted communities to develop access to markets,
which in turn has generated income that can be used for
household consumables, health inputs, and education.
How can development of market opportunities contribute
to a One Health approach, particularly where poverty and
lack of access to services are barriers to health
outcomes?
A key element contributing to the success of the CLP has been
guidance of communities to make their own project decisions.
This has been partnered with access to health services through a
credit system, helping establish understanding for the value of
services delivered.
Suggest what key factors can assist in fostering
community leadership managing health decisions. Where
delivery of health services is managed by the public
sector, can development of a market based system for
community outputs (e.g., agricultural goods) link to access
of those services? Does this suggest a governance model
for One Health in developing countries?
For further information:
Chars Livelihoods Programme
www.clp-bangladesh.org
UK Department for International Development (DFID)
www.dfid.gov.uk/Where-we-work/Asia-South/Bangladesh
Australian Agency for International Development (AusAID)
www.ausaid.gov.au
Implementation of the One Health approach in Asia and Europe Background document 27 CASE STUDY 5: Controlling Rabies in Bali, Indonesia
Background
Controlling
rabies in the
island of Bali
Case type:
Programme
Case focus:
Disease control
Implementer:
Multiple including
Government of
Bali and local
partners
Donor:
Multiple including
EU and several
charitable
organisations
Location:
Bali, Indonesia
Period:
2008 to current
Themes:
Community
participation
Surveillance
Outbreak
response
Health governance
Research
Bali, Indonesia, an island that is home to more than 300,000 dogs and
4 million people, was rabies free until November 2008 when a human
rabies case of canine origin was diagnosed. As of June 2011, more
than 125 human deaths caused by rabies have been reported; more
than 40,000 dog bites have occurred. In any habitat, the complex
relationship between dogs, humans, and their environment makes
rabies
eradication
difficult
without
consideration
of
the
interrelationships of these and other factors. Thus, an ecohealth
approach was proposed and is being developed and applied to control
and hopefully eradicate rabies in Bali.
Initially the cases were isolated to the southern peninsula of the
island, but rabies cases began to appear elsewhere on the island
within a year. The approach to controlling the outbreak has changed
considerably since it began. At first the approach was to cull dogs by
shooting or baiting with strychnine, matched with selective
vaccination. There was little involvement with community partners or
NGOs to develop an approach acceptable to all stakeholders, partly
because of the urgency of the situation. Nevertheless, pressure was
brought from local villagers as well as international NGOs to stop the
killing of dogs and to instead use a broad vaccination strategy, which
is the current approach. While selective culling of stray dogs
continues, other techniques including broad vaccination have been
established as part of a more acceptable approach by the community.
A number of partnerships are developing in this One Health approach
to rabies control. Some were easy alliances to generate, others have
been more complicated. The nature of relationships always changes,
but three elements seem to be required in controlling rabies in Bali:
community participation, technical expertise, and clear governance.
The Provincial Government of Bali vows to have Bali rabies free by
2013.
Objectives:
The main objectives of the One Health approach to controlling rabies
in Bali are to:
1. Bring the epidemic under control and eventually eliminate rabies
from the island
2. Develop awareness of rabies as a health threat to all mammals
including humans
3. Develop a sustainable approach to rabies control by
understanding the complexity of the rabies epidemic
4. Promote community partnerships in health management
5. Generate a sustainable participatory approach to disease
surveillance and response.
Implementation of the One Health approach in Asia and Europe Background document 28 Activities
The ecohealth approach being developed and applied in Bali will focus on the following
key elements in order to develop an optimal strategy for controlling, possibly eradicating,
and if so preventing re-emergence of the fatal disease in Bali:
1. Participatory approach to understanding complex host/human/environment
interactions contributing to the rabies epidemic
2. Socioeconomic and cultural factors contributing to maintaining the disease
3. Gender and economic equity issues
4. Inter- and trans-disciplinarity approach to control/ eradication, and
5. Sustainability issues
This will include continuation and expansion of educational and communication
initiatives to educate residents and visitors about rabies, including prevention and postexposure measures.
Key agents in Bali responding to the rabies epidemic from initial cases have been the
Provincial Government of Bali, animal welfare organisations including the Bali Animal
Welfare Association (BAWA), Yudisthira Animal Welfare, and Indonesian Animal
Welfare, the World Society for the Protection of Animals (WSPA). Funding support was
provided by the Australian government and the International Fund for Animal Welfare.
BAWA founding director Janice Girardi states that 210,000 dogs have been vaccinated
in 4126 villages across Bali. A second stage of the provincial-wide vaccination campaign
began in March 2011.
Other partners assisting with the ecohealth research in this One Health initiative include
the Center for Indonesian Veterinary Analytical Studies (CIVAS), the Disease
Investigation Center of Denpasar (DIC), the International Livestock Research Institute
(ILRI), and Veterinarians without Borders/Vétérinaires sans Frontières–Canada
(WVB/VSF). Numerous boundary partners are also involved in developing the ecohealth
strategy.
Recently, the Food and Agriculture Organisation of the United Nations (FAO) confirmed
that it has begun to mobilize a major training initiative in Bali to develop a participatory
disease surveillance and response program which will initially be directed at controlling
rabies. The project will address other zoonotic diseases as activities are widened.
Funding for this major initiative comes from the EU, and is consistent with the broader
FAO/OIE/WHO tripartite concept note titled “The FAO/OIE/WHO Collaboration - Sharing
responsibilities and coordinating global activities to address health risks at the animalhuman-ecosystems interfaces.”
Impact
As of June 2011, the Bali government claimed about 294,000 dogs have been
vaccinated, believed to be about two-thirds of the island dog population, and to have
killed about 81,130, approximately 18%. It is possible that up to 70% of the dogs on the
island may have been vaccinated for rabies at least once in the last two years. Better
knowledge of the dog ecology and populations on the island would make these numbers
more amenable to validation from an epidemiologic standpoint, but there’s no question
the number of dogs vaccinated during this response is extraordinary.
There has been social impact as well; residents have a better understanding of the
causes of rabies, measures to prevent infection, and post-exposure treatment. As well,
dog owners are now keen to have their animals vaccinated to protect both canine and
human life.
Implementation of the One Health approach in Asia and Europe Background document 29 Challenges
From an epidemiologic point of view, the mechanisms of maintenance of rabies in Bali
are still being understood. There is lack of detailed knowledge of canine ecology on the
island and the role of culture in maintaining the disease is well articulated. As well, the
degree to which wildlife such as monkeys or other domestic species maintain the rabies
virus needs investigating – although it is thought the simian population does not harbour
the virus, a detailed sero-survey has not been conducted to establish this.
The question of governance has arisen in several contexts including responsibilities and
authority, public goods, distribution of resources, role of communities in decision making,
and right of access. The model of governance in terms of who (or what institution) is
responsible for controlling rabies and how can authority for control be managed in a way
that includes communities in a sustainable manner is still being developed. This is a
fascinating example of operationalising One Health in a complex situation with many
stakeholders and in which governance is still developing.
In a similar light, the nature of the working relationships between the community,
government leaders, NGOs, and researchers and how that relationship can be nurtured
is a challenge. Some of these relationships are strong; others have yet to develop to the
satisfaction of all parties. Without strong alliances in which all stakeholders play a clear
role, there is increased risk of failure.
Because of the nature of the rabies campaign in Bali (capturing and release, mobilizing
teams, the vaccine itself) this is a costly program. While subsidization continues, plans
for continuing the campaign seem viable, but without this it is questionable how the
community and Government of Bali could continue the programme.
Conclusions
The epidemic emergence of rabies in Bali has been controlled by dog control and
vaccination, community engagement, and public education. A wider view of the
complexity of the problem and potential approaches to controlling and eradicating rabies
is advocated using a combination of participatory methods, both quantitative and
qualitative, addressing the interrelationships between the island's animals, humans, and
their environment.
A major One Health lesson learned from the coordinated response to the rabies
outbreak in Bali has been that it can be particularly difficult to bring different actors
together in a unified transdisciplinary approach when: a) community preferences are not
clear, understood, or well respected; b) designation for activity leadership is not well
defined; c) disease ecology is assumed to similar to that of different ecozones; d) control
efforts are not sustainable. Despite these challenges, the rabies control efforts are
moving in a positive direction which recently includes a strong increase in international
support.
Useful sources of further information
Provincial Government of Bali
www.baliprov.go.id
Indonesian Center for Agriculture Socio Economic and Policy Studies
pse.litbang.deptan.go.id/eng/
The Center for Indonesian Veterinary Analytical Studies
www.civas.net
UN Food and Agriculture Organisation
www.fao.org
Implementation of the One Health approach in Asia and Europe Background document 30 International Livestock Research Institute
www.ilri.org
Bali Animal Welfare Association
www.bawabali.com
Veterinarians without Borders/Vétérinaires sans Frontières–Canada (WVB/VSF).
www.vwb-vsf.ca
World Society for the Protection of Animals
www.wspa.org.uk
Questions raised by this case study
Observations
Questions
In some ways the rabies epidemic in Bali came as a surprise; the
island that had no history of the disease prior to 2008.
How should a One Health approach to surveillance align
with other health disciplines to prevent disease from
occurring in areas free from zoonotic disease? Is control
of zoonotic diseases the responsibility of veterinary public
health officers?
Coordinating stakeholders in a One Health approach assumes
many things are in place: leadership; policy; agreement on
strategy and tactics; understanding of the problem; sustainable
solutions, etc.
Who should be responsible for coordinating a One Health
approach when the community is the primary benefactor?
How can government representatives from local to
national levels participate in a One Health response while
assisting communities to play a key role? Is a top down
approach useful in am epidemic situation case such as
rabies in Bali?
Rabies control and eradication relies on participation from dog
owners and other people working with domestic animals and
wildlife. Communication is thus a critical part of a control and
eradication campaign.
Considering level of stakeholders (village, provincial,
national, regional) and types of partners (academic,
community, government), what are the options for
developing a One Health education programme to prevent
disease from emerging? How might this be different from
programmes that respond to outbreaks/ epidemics?
The interactions of gender and culture may play an issue in rabies
disease ecology in Bali. For example, it is typically men who leave
shore to fish and with them they may take a dog, often for cultural
reasons.
How does the interaction of gender and culture influence
patterns of emerging infectious disease, and how can
knowledge of such interaction inform One Health
strategies for controlling EIDs?
Implementation of the One Health approach in Asia and Europe Background document 31 CASE STUDY 6: Healthy Food Market (INSPAI), Indonesia
Implementation
of the National
Strategic Plan
for Avian
Influenza
Project
(INSPAI): Pilot
of health food
markets,
Indonesia
Case type:
Food production
and trade
systems: markets
Health promotion
Case focus:
Avian influenza
H5N1 and
foodborne
diseases; Public
markets
Implementer:
Ministry of Health
World Health
Organisation
National
Committee for
Avian and
Pandemic
Influenza
Donor:
European
Commission
Location:
Indonesia
Period:
2010 - 2011
Themes:
Culture change
Coordinated
efforts
Sustainability Background
The Implementation of the National Strategic Plan for Avian Influenza
(INSPAI) Project (2007-2011) aims to improve Indonesian capacity to
respond to avian influenza H5N1 through strengthened case
management and surveillance, development of healthy food markets,
improved risk communication, and better understanding of H5N1
transmission. These measures are also intended to improve national
capacity to respond to other diseases of pandemic potential. The
European Union funds the World Health Organisation (WHO) to
support the Indonesian Ministry of Health in implementing the project.
A 2008-09 qualitative study found low awareness of avian influenza at
the community level with limited application of standard personal
protective measures and improper handling of sick and dead poultry.
Some 40% of human cases in 2010 were directly linked to confirmed
or highly suspicious cases of H5N1 in poultry. Food markets were not
only considered to be important nodes for the transmission of avian
influenza, but also key sites for promoting changes of behaviour that
would have health benefits beyond those related to H5N1.
The Healthy Food Market (HFM) component of the project brings
together a range of local stakeholders with technical support from the
Ministry of Health (food safety and communications) and WHO
(environmental health). Ten sites throughout Indonesia were selected
as pilot sites [Sumatra (2), Java (5), Kalimantan (1), Bali (1), Nusa
Tengarra Barat (1)] with a view for wider replication if the pilots were
judged to be successful.
The design of the HFM component follows the framework of the
Ottawa Charter for Health Promotion and embeds elements of the
One Health approach: there is action to guide and promote local policy
related to markets that involves a variety of local stakeholders
including community representatives; supportive environments are
created to facilitate change including modifications to market
infrastructure that seek to reduce the risks associated with the humananimal-environment interface of the market; there is strategic
community level action using local resources; the skills of local
stakeholders to manage and promote change are developed; and
there is a strong focus on cross-sectoral collaboration to prevent
illness and promote health.
Objectives
The HFM component had the following objectives:
1. To improve the capacity of local stakeholders to develop and
maintain healthy food markets in pilot sites;
2. To effectively and efficiently manage the HFM project
implementation and monitor its impact;
3. To improve public awareness in preventing and controlling the
spread of avian influenza and foodborne diseases
Implementation of the One Health approach in Asia and Europe Background document 32 These objectives were conceived in consideration of practical elements to advance
replication of the pilots:
 The National Committee for nationwide market improvement had been formed
under the Ministry of Trade with a specific initial budget line for improvement of
125 markets;
 The Ministry of Health is a partner agency supporting the National Committee
and a key partner in the piloting of healthy food markets;
 All guidelines and manuals were made available to government for nationwide
replication with clear steps for implementation.
Activities
The HFM component of the INSPAI project consisted of the following elements:
 Coordination activities –annual work plans were developed in pilot areas with
district and municipality stakeholders from a range of sectors including personnel
from trade, agriculture, water, environment and health offices, market
management, local development and planning agency, public works, nongovernment organisations (Danamon Care Foundation), and market
representatives. In some cases, specialist advice was sought from technical
agencies (FAO, Avian Influenza Control Unit of the Ministry of Agriculture)
 Capacity building and training activities – training on the management of healthy
food markets was provided for district and municipality officers and participants
from the market sector (operators, vendor associations, healthy market task
force). Participatory risk assessment and risk management training was given to
30 cadres of market facilitators to empower vendors to conduct risk identification
and market planning.
 Activities to improve market infrastructure - priority needs and minimum
standards for provision of water, latrines, waste management systems,
equipment and hand washing facilities and health services were identified. Minor
construction was undertaken and supplies provided (food safety kits, hygiene and
sanitation supplies) to improve the hygienic conditions of the pilot markets.
 Awareness raising and promotion of hygienic practices - in collaboration with the
Indonesian Community Radio Network (JRKI), vendors and market workers were
trained to operate radios and function as a steering committee to guide radio
productions. Radios were installed and better market hygiene and safety
practices were promoted on air during market hours. Print health promotion
materials were also developed and disseminated, and the local media was
involved in further promotion of HFM activities through articles in local papers.
Impact
HFM claims that local people at different levels are now more aware of the need for
market restructuring to address avian influenza and reduce food borne diseases. This
has been achieved through the distribution in pilot markets of 30,000 flyers, 10,000
booklets, 5,000 pocket books, 1,000 posters and 240 signboards. In addition, 14 audio
public service announcements have been aired in market communities and market
based health hygiene and sanitation concerns are raised on a daily basis. A video
instruction manual on community empowerment in preventing avian influenza and
pandemic influenza has also been developed.
Stakeholders in the pilot sites are now demanding community activities to improve
market cleaning and manage risks, and are independently proposing minor
constructions to control risk factors related to poor hygiene and sanitation, improper
drainage, and waste management. In some sites, both central and local governments
Implementation of the One Health approach in Asia and Europe Background document 33 are seeking (non-health sector) funds to continue with HFM activities. For example, the
Ministry of Trade provides assistance to many sites through special allocation funds from
Trade and Market Services; the Public Works sector has provided bins for solid waste
and construction of a wastewater treatment plant; and the local agricultural service has
constructed a special stall for fish and meat vendors in one site.
Challenges
Documented challenges relate more to administration of the project than difficulties in
realising desired impacts. Over 30% of the budget was not spent during the project
period. Changes to the organisation structure, terms of reference and staffing of the
Ministry of Health affected timely implementation and dispersal of funds. In addition,
WHO underwent a major restructuring during the project, which at one point led to a
funding freeze for three months. The management of mixed government and external
donor funds also posed challenges to ministry staff.
Conclusions
This project is a good demonstration of how a broad approach to prevent disease
emergence can lead to support from multiple sectors, many of whom have historically
been left out of planning interventions to address human and animal health concerns.
The community was put at the centre of the project design and a comprehensive
approach to health promotion appears to have facilitated lasting positive changes.
Further reading
Implementation of the National Strategic Plan for Avian Influenza (INSPAI). Annual Progress Report
Year 2010. World Health Organisation, Indonesia Country Office. February 2011.
The Ottawa Charter for Health Promotion
http://www.who.int/healthpromotion/conferences/previous/ottawa/en/
Acknowledgements
We thank Dr Graham Tallis from the Indonesia Country Office of the World Health
Organisation for providing details of this project.
Implementation of the One Health approach in Asia and Europe Background document 34 Questions raised by this case study
Observations
Questions
Although the HFM component of the INSPAI project is not
explicitly described as using the Ottawa Charter for Health
Promotion framework, it clearly incorporates the core elements of
this framework, which has synergies with the One Health
approach.
While research into understanding the transmission dynamics of
H5N1 was part of the larger INSPAI project, operational research
was not a formal part of the Healthy Food Markets component.
Similarly, the measures of success of the project were not well
reported with the exception of the sound collaborative, transdisciplinary approach achieved in each of the pilot sites.
A key strength of the HFM design was the longer-term view for
how the pilots could be replicated in other sites. This included
consideration of financing, as well as recording the practical steps
required for implementation of different elements of the project.
How can One Health elements be incorporated into other
useful public health frameworks? Could this offer a
practical method of promoting One Health within the
human health sector?
How important is it to document the effectiveness,
efficiency and acceptance of new One Health projects?
Do economic measures of success become more
important given the involvement of sectors beyond human
and animal health?
Are other sectors willing to spend parts of their budget on
activities for the public good?
How can advanced support be gained for the scale up of
projects that have demonstrated their worth? Whose
support is needed?
With its decentralised system of government and great
cultural diversity, does Indonesia offer any lessons for
how successful projects can be promoted within the
region?
Implementation of the One Health approach in Asia and Europe Background document 35 CASE STUDY 7: Controlling Hydatid Disease, Nepal
Background
Controlling
Hydatid
Disease in the
Kathmandu
Valley, Nepal
Case type:
Programme
Case focus:
Disease control,
community
development,
ecohealth
Implementer:
Local community
organisations and
partners
Donor:
IDRC and local
funding sources
Location:
Nepal
Period:
1998 to 2006
Themes:
Community
participation
Health governance
Disease ecology
Small enterprise /
market access
The city of Kathmandu, Nepal has grown rapidly in the last three
decades from roughly 235,000 in 1981, 420,000 in 1991, 671,000 in
2001, to just over 1 million people in 2011. The major driver of
population growth has been economic migration as people search for
services and economic opportunity in the main urban area of the
country. With this extraordinary growth of population came demand
for food including livestock products. The Participatory Action
Research (PAR) projects on Urban Ecosystem Approaches to
Health, conducted between 1998 to 2006 in Kathmandu, examined
the impact of this rapid urbanization, the related health
consequences, and possible interventions.
This case study reports on a problem that developed as a result of
the interaction of several factors including: high demand for cattle
products, primarily meat; socio-economic and cultural factors; urban
geography of Kathmandu; interaction of humans, animals (cattle and
dogs), and environment; and initial lack of empowerment of
community members to implement a solution. The demand for meat
led to cattle slaughter on the banks of the Bishnumati and Bagmati
rivers in the city, within which developed a complex hierarchy of
stakeholders including slaughterers, street cleaners, butcher shop
owners, squatters who lived along the river, and dogs. The cattle
carried a tapeworm (Echinococcus granulosus) that would infect
scavenging dogs, the dogs would defecate in the slaughter area
perpetuating the cycle of infection, and humans would be infected as
end hosts from ingesting cattle products (or to a lesser extent from
contaminated water). If untreated, the infection in humans results in
hydatid disease with cyst development in numerous organs including
the brain which can be fatal. As well as the health hazards to
humans, the river banks areas rapidly became highly polluted and a
nuisance to Kathmandu residents.
The PAR projects embarked on a prolonged ecosystem approach to
health management (or the “ecohealth approach”) to solve the
problem. While purists will debate whether or not an ecohealth
approach is the same as a One Health approach, allow that for this
case study an ecohealth approach is a One Health approach in that
it: engages transdisciplinarity; involves a participatory approach;
addresses gender and economic equity; recognizes complexity of
the problem; and is concerned with sustainability. All these features
are seen in a One Health approach which seeks to understand the
relationships and interdependence of causal disease factors.
Objectives
The main objectives of this One Health case study in Kathmandu
were:
1. Assist communities to define and describe the socioecological systems in which people live and work;
Implementation of the One Health approach in Asia and Europe Background document 36 2. Identify stakeholders’ problems and needs relative to ecosystem health of the
river system;
3. Implement feasible and sustainable solutions to the identified health problems
(human, canine, ecological, economic); and
4. Develop a monitoring and evaluation approach to health for the river system of
Kathmandu.
Activities
The ecohealth approach developed in Kathmandu was implemented over more than
seven years and had numerous activities. Major activities reported here focused on
reducing the parasite burden included the following:
1) Understanding of stakeholder problems and needs: this included not only
identifying stakeholder groups and their problems and demands, but also
understanding the complex cultural relations between the various groups, their
roles and responsibilities in society, and the lines of accepted authority between
them.
2) Waste management: slaughter waste was a causal factor in human hydatid
disease but developing a community based solution to the waste management
problem would require recognition of the costs of waste disposal.
3) Establish rights: the rights of some stakeholders in the community were not well
understood while others had high degree of control of access to resources.
Establishing rights meant also developing representatives to who could meet
and discuss options.
4) Governance: Along with understanding rights (and social responsibilities) came
the matter of governance of the problem, including developing and enforcing
local standards of procedure to address access to clean water, housing,
butchering, slaughter waste, dog control, and sale of meat.
5) Changing slaughter facilities and practices: new rules needed to be established
regarding who slaughtered animals, where, what was done with the waste, and
how this could be regulated by the community.
6) Improve environmental hygiene: cleaning up the river beds required knowledge
from other activities, particularly 1) and 3). Improving environmental hygiene
would need to include water quality as well as making the river beds acceptable
to residents of Kathmandu.
7) Increased public awareness: community and wider public awareness needed to
be addressed in order to put pressure on all stakeholders to find a solution
acceptable to the community.
8) Better management of street dogs: as a vector of disease, dogs were seen as
unclean and a nuisance. But they also acted as watch dogs and were
companions to some community members. Management of dogs required
understanding the role of dogs in the community and possible solutions that did
not simply eliminate the dogs.
Numerous parties were involved in the complex relations in this community, and
activities 1) and 3) above resulted in identification of at least the following: Kathmandu
City (KMC), Department of Drinking Water Supply Corporation (DDWSC), Ward
Committees and chairs, Local Clubs, Ward Clinics, Schools, local NGOs (Lumanthi and
ENAPHC), representatives of butchers, street sweepers, street vendors, hotel owners,
business owners and squatters. Other stakeholders who play a significant role include:
Implementation of the One Health approach in Asia and Europe Background document 37 meat sellers, tea shop owners, local clubs, local clinics, teachers, and a local trust
(GUTHI).
Impact
This participatory approach to understanding complex host/human/environment
interactions resulted in several changes in the community, although it took a decade for
the changes to slowly take place. Results that led to a sustainable community based
solution included: 1) developing a systemic description of the urban socio-ecological
system including identification of stakeholders, major concerns, and needs; 2)
stakeholder-specific action plans with roles and obligations for each community member;
3) development of ecosystem health indicators; and 4) implementation of collective
action plans for improving the situation.
Ultimately, the local government banned open slaughtering practices and they were
moved to inside closed courtyards. Discharging of waste of all types into the river is now
prohibited. Community education is conducted including health education and
awareness training. Numerous stakeholder associations have been formed to represent
various groups (e.g., The Nepal Butchers' Association, Nepal Meat Marketing
Association), and squatters have been moved to low-cost housing. A livestock marketing
centre developed where butchers can buy and slaughter livestock.
A major impact claimed of the urban ecosystem health project has been the reduction of
disease in Kathmandu although quantifying this has been a challenge. Certainly, the
river bed is now remarkably transformed in appearance and public gardens have
developed where carcass waste used to sit.
Finally, the research generated was used to influence policy in Nepal, resulting in a new
Animal Slaughtering and Meat Inspection Act, modifications of the Nepal Food Act,
modifications of the Infectious Disease and Public Act, revision of the Kathmandu valley
housing plan, and revision of the Nepal Drinking Water and Sewerage Plan.
Challenges
Population growth continues in Kathmandu and high demand for livestock products has
resulted in the construction of slaughterhouses outside the city. Managing supply and
demand of livestock products has been a challenge and lack of funds to build new
modern equipped slaughterhouses threaten to return communities to the former open
slaughter system. Maintaining control of the city’s canine population is still an issue,
partly because of the loose ownership of dogs that are hard to capture for (e.g.) rabies
vaccination and tagging.
The complex issue of community based governance of the health problems in
Kathmandu remains a challenge as costs of controlling the risks rise with increasing
population pressure.
Conclusions
This case study illustrates the extended length of time it can take for sustainable change
to occur. Although the study began as an epidemiology focused research, it became
clear that understanding of behaviour and the complexity of roles of various actors was
as important to understanding the hydatid disease ecology in Kathmandu Valley. This
included a process of empowerment of some key stakeholders that did not threaten
others in the social and economic hierarchy. This is also a good example of communities
working to identify changes to meet ecohealth goals that benefit their community.
Implementation of the One Health approach in Asia and Europe Background document 38 Without addressing concern for the needs of all groups of community members, any
solution proposed would be unstable.
Education, recognition for gender and socioeconomic equity, and concern for a cleaner
and healthier physical environment were catalysts for change. Of particular importance
was the role of clean water and waste management, two factors often associated with
health outcomes.
Finally, policy formulation was influenced by a need for change leading to dialogue and
trial solutions managed by community members. In a One Health approach, this lesson
is particularly valuable where policy is expected to lead to sustainable changes.
For further information
Joshi, D.D. and M. Sharma. An Urban Ecosystem Health Approach To Make A Cleaner City And Better Health In
Kathmandu, Nepal. Paper presented at the World Congress of Public Health, August 18-26, 2006, Brazil.
Neudoerffer, R. Cynthia, D. Waltner-Toews, J. Kay, D.D. Joshi, M.S. Tamang. 2005. A diagrammatic approach to
understanding complex eco-social interactions in Kathmandu, Nepal. Ecology and Society 10 (2):12.
National Zoonoses and Food Hygiene Research Centre (NZFHRC), Kathmandu, Nepal
www.nzfhrc.org.np
International Development Research Centre
www.idrc.org
Questions raised by this case study
Observations
Questions
There were many researchable themes that came out of this
study, including options for improving decision making that could
inform policy formulation and implementation.
Collaboration across disciplines and stakeholders was critical to
achieve a sustainable One Health solution in this case. Key to
collaboration was recognition of the complexity of social and
economic relations.
Waste management and respect for market hygiene resulted in
changes that were beneficial to the environment in Kathmandu
Valley.
What elements of an ecosystems approach to health
management make it particularly challenging for policy
makers charged with formulating preventive health policy?
Where are the opportunities for communities to be brought
into this process?
What are the possible models of collaboration – across
disciplines and between stakeholders – and what are the
advantages and drawbacks of each?
How is health compromised when there is inequitable
distribution of authority and community resources? When
and how can stakeholder associations help in this regard?
Without date that demonstrate quantitative impact and
validate recommendations for change, advocating
changes that benefit environmental health can be
challenging. How can social sciences work with ecological
sciences in this regard?
Implementation of the One Health approach in Asia and Europe Background document 39 CASE STUDY 8: Controlling Q-fever outbreaks, Netherlands
Controlling
Q-fever
outbreaks,
Netherlands
Case type:
National response
Case focus:
Disease
investigation and
control,
Epidemiology
Implementer:
Multiple
Donor:
Multiple
Netherlands
agencies
Location:
Netherlands
Period:
2007 to current
Themes:
Surveillance
Outbreak
response
Risk management
Research
Disease ecology
This case study of Q Fever represents consistency with the new EU
animal health strategy which strives to focus on all issues linked to
animal health, including public health, research, and sustainable
development as well as recognizing the importance of preventative
measures such as vaccination, disease surveillance, and emergency
preparedness. In addition, it recognizes reliance on cross-sector
support and cooperation.
Background
Since 2007, the Netherlands has been working to contain the largest
outbreak ever reported of Q fever, a highly infectious zoonotic
bacterial disease caused by Coxiella burnetii. More than 4,000
confirmed cases and eleven deaths have occurred since the outbreak
began. The source of the organism may be infected dairy products
from sheep, goats, or cattle; the bacterium can also be inhaled as an
aerosol. Clinical signs in humans and animals include general
malaise, joint ache, diarrhea, and fever, rarely progressing to
pneumonia. The organism can cause similar clinical signs in
ruminants as well as abortion in sheep. Treatment with antibiotics is
highly effective, and preventive vaccines are available.
In order to slow the spread of the disease, in 2009 the Dutch
government began a mandatory vaccination program of goats,
although the volume of vaccine required was not sufficient for the
whole country. At this point, the Dutch government slaughtered over
50,000 goats and restricted breeding and movement of sheep. The
slaughter has been highly controversial for several technical reasons,
including the fact that the vaccination program we well underway.
Nevertheless, human health authorities have noted the organism is
behaving somewhat differently in the Netherlands, infecting humans at
greater rates than expected, and there is concern that many of the risk
factors in the current outbreak are not identified. Previous studies
have shown risk factors in humans to be living close to a ruminant
farm that had been infected, smoking, and contact with manure, hay,
and straw.
Current studies to understand better the risk factors, nature of the
organism, and ecology of the disease involve researchers from
veterinary and human medicine, agriculture, public health,
behaviorists,
economists,
policy
formulators,
and
social
anthropologists. The inter-disciplinary approach is necessary due to
the highly unusual infection rate, unidentified risk factors, and concern
that the prevalence may be getting worse despite aggressive culling
and vaccination measures.
Veterinary and public health scientists around the world are monitoring
the outbreak in the Netherlands waiting to learn more about patterns
Implementation of the One Health approach in Asia and Europe Background document 40 of spread and the possibility of an emerging disease threat. This case
study examines current research investigating the outbreak.
Objectives
The main objectives of this One Health case study in the Netherlands are:
1. Identify risk factors associated with the unusual infection rate of the Q fever
outbreak
2. Identify and describe the agrarian socio-ecological systems in which people who
become infected live and work;
3. Understand the etiology of the disease as it presents itself in the Netherlands and
any unusual recognize features
4. Implement feasible and sustainable solutions to the identified health problems
(human, canine, ecological, economic); and
5. Develop a monitoring and evaluation approach to health for the river system of
Kathmandu.
Activities:
There are numerous research themes (activities) currently being investigated that will
inform the above objectives. Prominent among them are the following:
1. Identification of risk factors associated with the unusual infection rate of the Q
fever outbreak in the Netherlands
2. Identification and description of the agrarian socio-ecological systems in which
people who become infected live and work;
3. Understanding of the etiology of Q fever as it presents itself in the Netherlands
and recognition of any unusual features
4. Examination of the possible role of rats as a reservoir of Coxiella burnetii
5. Possibility of shedding of Coxiella burnetti post vaccination
6. Appropriate animal health policy measures to support stamping out in the face of
an outbreak of Q fever
7. Characteristics of agricultural enterprises that are associated with increased
prevalence of
8. Awareness of Q fever and the impact on health seeking behaviour
Numerous parties were involved in the Q fever cases and research, including
physicians, veterinarians, public health workers, agriculturalists, and environmentalists.
Government agencies including the Ministry of Health, Welfare and Sport, the Ministry of
Agriculture, Nature and Food Quality, the Centre for Infectious Disease Control, and the
National Institute for Public Health and the Environment also partnered to investigate the
Q fever outbreaks.
Impact
Transdisciplinary research is producing results that are helping to unraveling the unusual
features of the Q fever outbreak in the Netherlands. Veterinary and agricultural
researchers are learning of the farm characteristics that are associated with the
outbreaks. Animal behaviorists and microbiologists are studying the role of the rat in
maintaining the disease and if so, how one can respond to this reservoir host. Biologists
and medical researchers are investigating appropriate vaccination strategies for high risk
groups. One of the more remarkable findings is that vaccine-derived C. burnetii DNA can
be detected in the milk of dairy goat up to nine days post vaccination, which in turn has
Implementation of the One Health approach in Asia and Europe Background document 41 strong policy and economic implications in the face of a mandatory blanket vaccination
strategy. Most recently, environmental research suggests that vegetation and soil
moisture are factors in the transmission of C. burnetii from infected farms to humans;
reduced dust results in reduced dispersion of the bacteria. These findings have
implications for identifying the appropriate agro-ecological characteristics suitable for
biosecure small ruminant dairy farms.
The impact on the approach to research due to the peculiarities of the presentation of
the disease (e.g., higher than expected prevalence, absence of human cases around
some goat farms with high infection rates, the role of rats in maintaining the disease) has
been significant. In this regard, a One Health philosophy has been applied to
researching the problem. This has been evident in the transdisciplinarity of research
teams, choice of questions with respect to interaction of animals, humans, and the
environment, examination of the role of wildlife, recognition of the complexity of the
problem, and suggesting what the policy implications of research findings might be for
farming communities.
What may be noteworthy is whether much of the trans-disciplinary research is a product
of necessity or was a pre-existing relationship. If the latter is the case, what was the
compelling reason(s) for putting such a team together.
Challenges
There are numerous questions still unanswered in the Q fever outbreaks in the
Netherlands. While some environmental factors seem relevant in the transmission of C.
burnetii to humans, the complete epidemiology is still unclear. The need for a One
Health approach in this problem is unambiguous: transdisciplinary knowledge and
cooperation is needed in animal, human, environmental health, behavioural factors, and
the role of communication and education.
Conclusions
In the Q fever investigations the One Health approach thus far has been helpful in
unravelling some of the etiology of the outbreaks. While still under investigation,
transdisciplinarity has been useful to identify and understand contributing factors to the
outbreaks, and to help recognize that the standard model of Q fever evident in the past
does not seem to be apparent with the current outbreaks.
Working with farming communities and exploring the environmental factors of the
outbreaks also have contributed to understanding better the epidemiology of the
outbreaks. These are critical elements of a One Health approach, without which the
whole complex picture would be missing fundamental linkages.
For further information:
Corné H.W. Klaassen, Marrigje H. Nabuurs-Franssen, Jeroen J.H.C. Tilburg, Maurice A.W.M. Hamans, and
Alphons M. Horrevorts. Multigenotype Q Fever Outbreak, the Netherlands. Letter. Emerging Infectious Diseases.
Volume 15, Number 4–April 2009.
Hoek, Wim van der, Johannes Hunink, Piet Vellema and Peter Droogers. 2011. Q fever in The Netherlands: the
role of local environmental conditions. Int J Env Health Res. 11:1–11, iFirst article.
Mirjam H.A. Hermans, C. (Ronald) J.J. Huijsmans, Jeroen J.A. Schellekens, Paul H.M. Savelkoul,and Peter C.
Wever. Coxiella burnetii DNA in goat milk after vaccination with Coxevac®. Vaccine. 29:2653-2656.
Reusken, Chantal , Rozemarijn van der Plaatsa, Marieke Opsteegha, Arnout de Bruina and Arno Swarta
Coxiella burnetii (Q fever) in Rattus norvegicus and Rattus rattus at livestock farms and urban locations in the
Netherlands; could Rattus spp. represent reservoirs for (re)introduction? Prev. Vet. Med. V.101:1-2:124-130.
Implementation of the One Health approach in Asia and Europe Background document 42 Veenstra, T., B.E. Snijders, B. Schimmer, A. Rietveld, S. Van Dam, P.M. Schneeberger, F. Dijkstra, M.A. Van
Der Sande, and W. Van Der Hoek. 2011. Risk Factors for Q fever in the Netherlands. WebmedCentral. Infectious
Diseases. 2011:2(7):WMC002006.
Netherlands battles to contain Q fever outbreak. Feb 23, 2011. Homeland Security Newswire.
Questions raised by this case study
Observations
Questions
The Netherlands has an extensive and well respected history of
research and application in zoonotic disease. Much of it can be
considered at least in part a One Health philosophy in that it
bridges disciplinary boundaries and takes into account economic
equity.
Are there compelling necessary and sufficient elements of
a One Health philosophy, beyond transdisciplinarity, that
make it a highly recommendable approach to zoonotic
disease control?
Lessons learned in the transdisciplinary approach in the
Netherlands could benefit other countries and regions facing
established disease outbreaks that exhibit unconventional
epidemiologic patterns.
What platforms exist for the sharing of information –
including case studies – where a One Health approach is
possible or applied? How can such forums be supported
and maintained in order that knowledge be transferred to
countries and regions wishing to move forward with
operationalising One Health?
An integrated or transdisciplinary approach to disease
investigation requires leadership and coordination across
agencies, programmes, and individuals in order for results to be
delivered in a manner that generates possible solutions with
broad application. Without such coordination, highly focused
solutions may be generated that address specific elements of the
problem, but possibly miss wider precipitating factors. This was
the case for H5N1 in Asia and the SARS epidemic.
Well defined leadership, coordination, and monitoring of a
disease investigation are characteristics of good
governance of public health resources. If a One Health
approach is to be operationalised at national, regional,
and international levels, how might the various candidate
institutions and agents communicate, come to agreement
on activities, and develop monitoring mechanisms for
outbreak preparedness, prevention, response, and
recovery?
Implementation of the One Health approach in Asia and Europe Background document 43 CASE STUDY 9: Control of food-borne Salmonella in the EU
Background
Control of foodborne
Salmonella in
the EU
Case type:
Disease control
Case focus:
Regulatory
provisions to
support control of
disease
Implementer:
European
Parliament and
Member Countries
Donor:
European
Commission
Location:
Europe
Community
Period:
2003 to Current
Themes:
Governance
Surveillance and
monitoring
Risk management
Transdisciplinarity
According to the European Centre for Disease Prevention and Control
(ECDC) and the European Food Safety Authority (EFSA), in 2007
Salmonella in the EU was reported to have caused 151,995 cases of
salmonellosis in the 27 EU Member States. This included 3,131 foodborne outbreaks (64.5% of the total number of food-borne outbreaks
of known origin) affecting 22,705 victims, of whom 14% were
hospitalised and 23 died. These figures are more alarming considering
that the number of human cases is seriously underestimated and
underreported.
In order to improve control of communicable diseases the EC has
prepared a number of directives and regulations. Chief among them is
Regulation (EC) No 2160/2003 of the European Parliament and of the
Council of 17 November 2003, directed to the control of Salmonella
and other specified food-borne zoonotic agents, and Directive
2003/99/EC addressing the monitoring of zoonoses and zoonotic
agents. As well, Commission Decision 2000/96/EC and Decision No
2119/98/EC effectively outline mandatory surveillance of salmonellosis
in humans. Directive 2003/99/EC ensures that zoonoses, zoonotic
agents, and their antimicrobial resistance are properly monitored; as
well, food-borne outbreaks must receive proper epidemiological
investigation. This results from monitoring of food, animals, and feed
which must be submitted electronically to the EFSA.
As a result of these and other regulatory provisions, there has been a
50% decline in the number of reported human cases of salmonellosis
in the EU since 2004 (192,703 cases in 2004 to 103,400 cases in
2009). This case study represents the comprehensive One Health
approach used in the EU to control Salmonella addressing humans,
feed, foodstuffs, animals, and consumer information.
Objectives
The major objectives of this comprehensive approach to controlling a
communicable zoonosis are:

Reduce exposure of humans and animals to Salmonella,
thereby reducing cases of salmonellosis in the EU

Improve reporting methods and data collection of monitoring
food, feed, and animals in EU Member States

Improve investigation of food-borne disease

Ensure food safety along the food chain

Control Salmonella resistance to antibiotics

Build capacity in monitoring and control of zoonotic disease,
particularly food-borne pathogens including Salmonella
Implementation of the One Health approach in Asia and Europe Background document 44 Activities
The following activities, with particular reference to Regulations and Directives, have
contributed to above objectives of the comprehensive EU control of Salmonella.
1. Monitoring of Salmonella





The Commission Decisions noted in the Background section have outlined
mandatory surveillance of salmonellosis in humans
Directive 2003/99/EC also addresses monitoring in feed, foodstuffs, and
animals of zoonoses, zoonotic agents, and their antimicrobial resistance
Results from monitoring food, animals, and feed in EU Member States are
submitted electronically to the EFSA
Harmonization of monitoring for Salmonella by common sampling protocols and
analytical methods
Other activities include investigation of food-borne outbreaks including
development of tools and recommendations to improve investigations, and
development of a Community Reference Laboratory for Salmonella
2. Control of Salmonella in feed
 Regulation (EC) No 1774/2002 stipulates that processed animal proteins must
comply with particular criterion addressing health rules concerning animal byproducts not intended for human consumption
 Vegetable feed materials including soybean meal and rapeseed meal area also
a possible source of Salmonella; Regulation (EC) No 183/2005 stipulates
requirements for feed hygiene, including a HACCP system, to contribute to
prevention or limiting Salmonella contamination during transport, storage and
processing of feed materials
3. Control of Salmonella in animal populations
 Regulation (EC) No 2160/2003 moves towards establishing European
Community targets for the reduction of Salmonella in pig and poultry
populations
 Activities have included data collection on prevalence of Salmonella and
analysis of risk factors towards development of control programmes
 National control programmes
 Other activities supported by EU Regulations and Decisions have included
establishing targets for reduced levels of Salmonella in animal populations,
restricting importation of eggs and poultry, marketing restrictions, and economic
impact analysis of restrictions
4. Control of Salmonella in foodstuffs
 Regulations (EC) No 852/2004 and No 853/2004 ensure food safety along the
food chain by implementing procedures based on HACCP and good hygiene
practice, hygiene rules for food of animal origin, and implementation of those
rules
 Regulation (EC) No 2073/2005 lays down food safety criteria to be complied
with by food business operators and for 18 groups of foodstuffs which define
the acceptability of foodstuffs placed on the market.
5. Other activities to control food-borne Salmonella
 A number of other Regulations address resistance to antibiotics against
Salmonella, including restrictions on the use of antibiotics in animal populations
to control Salmonella, laboratory activities and networking, and linkages with
EU and other international (OIE, Codex alimentarius) authorities addressing
food safety and medicines in humans and animals
Implementation of the One Health approach in Asia and Europe Background document 45 



Training sessions were conducted addressing monitoring and control of
zoonoses with particular attention to good hygiene practices
Salmonella control programmes may co-financed by the Community based on
Council Decision 90/424/EEC of 26 June 1990. Total Community funding of
€29,935,000 was allocated to Salmonella control for 2008; 19 Member States
have received Community financial support for implementing control
programmes
Guides to good hygiene practice were developed in conjunction with
stakeholders representing livestock producers, wholesalers, and processors
Numerous research initiatives targeting Salmonella and anti-microbial
resistance have been launched and supported by the Commission including
prevention and control of food-borne zoonoses.
Impact
The use of Regulations and Directives to influence and guide actions intended to reduce
the incidence of food-borne infections from Salmonella in the EU appears to have had
significant impact. The number of reported human cases of salmonellosis has declined
50% since 2004, and for most animal species and production systems reduction targets
have been set. Training activities have been conducted and Member Countries have
willingly participated in activating guidelines. As well, data sharing and laboratory
networking has increased, and adoption of food safety guidelines has resulted in
changes in the food chain from production systems to retail procedures.
Challenges
Several challenges have been identified by the Commission to improve the control of
Salmonella in the EU, including:
 Increased research in estimation of the prevalence of human salmonellosis and
comparison of prevalence between Member States
 Improved harmonisation of sampling plans and analytical methods related to food
safety, risk assessment, and control programmes
 Special considerations continue for some Member Countries indicating some
need for capacity building in areas including laboratory testing standards,
sampling, and adoption of risk management measures such as HACCP
 Increased provision of training to the competent authorities in the Member States
and third countries
 Convince greater numbers of EU stakeholder organisations to actively participate
 Continue to provide financial support to the Member States.
Conclusions
By using a strong governance mechanism identified and communicated through
Directives and Regulations, European Member Countries have reduced the incidence of
food-borne illness due to Salmonella. This is a powerful example of the use of a
governance mechanism to guide and influence more desirable stakeholder behaviour
the outcome of which may contribute to reduction of a widespread zoonotic disease
problem. In terms of One Health elements, apart from obviously addressing zoonosis
and prevention of disease, the EU approach to control of Salmonella addresses multidisciplinarity, recognition of complexity of the problem, governance, and community
engagement. One area of weakness may be the lack of clear transdisciplinarity at many
levels – it is not clear that there is wide joint involvement of multiple health related
Implementation of the One Health approach in Asia and Europe Background document 46 disciplines working closely together (as opposed to working in parallel towards a
common goal).
Further reading
European Commission. Communication from the Commission to the European Parliament and to the
Council with Regard to the State of Play on the Control of Food-borne Salmonella in the EU. Brussels,
May 29, 2009. Available at: http://ec.europa.eu/food/food/biosafety/salmonella/index_en.htm
The Community Summary Report on Trends and Sources of Zoonoses and Zoonotic Agents in the
European Union in 2007 (The EFSA Journal (2009) 223).
Scientific Opinion of the Panel on Biological Hazards on a quantitative microbiological risk
assessment on Salmonella in meat: Source attribution for human salmonellosis from meat. The EFSA
Journal (2008), 625, 1-32.
Questions raised by this case study
Observations
Questions
Governance includes definition of expectations, granting of
authority, and regulation of the processes, policies, and laws
affecting those same multifaceted institutions.
What advantages might the European Commission have
compared to other regional governing institutions in terms
of developing Regulations and Directives to reduce
salmonellosis or other zoonotic disease?
The Directives and Regulations of the European Parliament
presented cover a wide degree of activities and embrace a broad
scope of stakeholders from human and veterinary health to food
production to communications.
Is there greater need for promotion and advocacy of the
Directives and Regulations of the European Parliament or
of the principles of a One Health approach in general?
Does this suggest enforcement or moral suasion is a
better tool for encouraging participation in a wide regional
food safety control program?
Do One Health training courses that address food safety
concerns (e.g., reduction of Salmonella in
slaughterhouses) need to include technical elements? If
so, which are important skills common to multiple
disciplines?
Transdisciplinarity is one of the core tenants of an ecohealth
approach and arguably the One Health approach as well.
What modules emerge as the product of a
transdisciplinary approach? How can this be incorporated
into a curriculum?
Is One Health more about ways of working together rather
than sharing common technical skills? How can this be
best taught? What competencies are needed?
Implementation of the One Health approach in Asia and Europe Background document 47 CASE STUDY 10: The Human Animal Infections and Risk Surveillance (HAIRS) Group
The HAIRS
Group
Case type:
Disease
surveillance;
Information
sharing &
coordination
Case focus:
Surveillance to
identify emerging
and potentially
zoonotic infections
Implementer:
More than ten
agencies,
departments, and
directorates in the
UK
Donor:
UK Government
Location:
UK
Period:
2004 to current
Themes:
Transdisciplinarity
Zoonotic disease
Surveillance
Background
The Human Animal Infections and Risk Surveillance (HAIRS) Group
was established in 2004. It is group dedicated to horizon scanning to
identify emerging and potentially zoonotic infections which may pose a
threat to public health in the UK. At least ten different agencies and
departments are coordinated in the group which meets monthly to
identify and assess infections – particularly zoonotic infections – with
potential for interspecies transfer.
Institutional members of the group include:

Health Protection Agency (HPA)

Department for Environment, Food and Rural Affairs (Defra)

Veterinary Laboratories Agency (VLA) (from 2011 merged with Animal
Health and known as ‘Animal Health and Veterinary Laboratories
Agency’ (AHVLA))

Food Standards Agency (FSA)

Animal Health (from 2011 known as AHVLA, as above)

Health Protection Scotland (HPS)

The Scottish Government, Veterinary Division Rural Directorate

National Public Health Service for Wales (PH Wales)

Department of Health, and

Public Health Agency, Northern Ireland
The HAIRS group’s activities cover England, Wales, Scotland, and
Northern Ireland. Horizon scanning involves systematic examination of
formal and informal reports on infectious incidents in animal and
human populations globally. A wide range of sources of information
are scanned, including informal news reports and bulletins, early
warning communications, surveillance data and peer-reviewed
scientific literature. Potential hazards are identified including new or
unusual syndromes or infections in animals and are brought to the
group for discussion and assessment. The trans-disciplinary approach
used by the HAIRS group reinforces objective and scientific
assessment of potential threats.
Infections thought to be of potential significance by the HAIRS group
are included in a monthly publication ("Infectious Disease Surveillance
and Monitoring System for Animal and Human Health: Summary of
notable events/incidents of public health significance") which is
circulated to a range of colleagues working in human and animal
health. The publication is also made available to the public online.
Implementation of the One Health approach in Asia and Europe Background document 48 Objectives
The major objectives of the HAIRS group are:
 Identify and communicate emerging and potentially zoonotic infections which may
pose a threat to public health in the UK
 Increase transdisciplinarity of agencies and other institutions working in the UK
addressing infectious disease.
Activities
HAIRS group activities are directed under four major categories and include: hazard
identification; risk assessment; risk management; and risk communication. Further
details of activities are as follows:
1. Hazard identification

Identify and review zoonotic or potentially zoonotic/interspecies infectious
incidents, as noted above

If the incident discussed falls within the remit of another group, the HAIRS group
ensures the relevant group is aware and considering the event.
2. Risk assessment

Following identification, the group discusses the risk of interspecies transfer and
threat to animal or human public health

Assessment and actions are outlined in a procedure involving various levels of
decision making and action

Incidents of urgent public health significance result in rapid convening of the
group, discussion of implications, and informing of the relevant agencies.
3. Risk management

Based on the risk assessment outcome, the HAIRS group may act as risk
managers (e.g., low risk issues) or refer issues to other groups for risk
management action (e.g., potential threats to public health).
4. Risk communication
 The HAIRS group contributes to the monthly Infectious Disease Surveillance and
Monitoring System for Animal and Human Health: Summary of notable
events/incidents of public health significance
 The group may also inform other agencies and prepares and communicates any
conclusions and recommendations of expert qualitative risk assessments
conducted by the group.
Further details outlining activities of the HAIRS group are available in the annual reports
and on the HAIRS website noted below.
Impact
Impact of the HAIRS group has been documented by the group in annual reports.
Primary impact has been early identification of organisms that could be of concern for
human health, such as Toxocara vitularum (identified in 2007 in beef cattle in Wales),
which allowed early monitoring and the possibility of early response to public health
threats. Other interesting examples include: observation of increase in Fasciola hepatica
(2007) and identification of association of the hepatic parasite with illegal importation of a
leaf from Africa used for its stimulant properties; Q fever in the Netherlands (2010), with
Implementation of the One Health approach in Asia and Europe Background document 49 the conclusion that risk of a similar rapid increase in Q fever outbreaks in the UK was
highly unlikely; and bovine neonatal pancytopenia (BNP), a fatal haemorrhagic
syndrome in calves that appeared across Europe in 2009. The latter case prompted
HAIRS to contact the appropriate preventative authorities with consideration of possible
causes and possible routes of infection. Specifically, discussion led the HAIRS group to
note that it was important to understand vaccine mechanisms that may have led to
disease, and whether a similar mechanism might be seen in humans. Investigations
continue.
Challenges
Challenges facing the HAIRS group are not well articulated and time did not permit
identification of any challenges prior to completion of this report. We conclude however
that the challenges might not be much different than other transdisciplinary health
related groups, including the following:
 Agreement on procedures and protocols for risk assessment and other techniques
 Prioritization when multiple risks are identified under limited time or other constraints
 Availability of appropriate expertise to conduct risk assessments
 Establishing agreement where differences of professional opinion may exist
 Coming to conclusion on presence of a hazard and level of public health risk where
limited evidence is published (but anecdotal evidence may suggest otherwise)
 Identification of incidents of an emerging animal disease may rely on virological and
microbiological criteria that are insufficient to capture the true zoonotic potential of
the disease
Conclusions
The HAIRS group is a particularly clear example of a One Health approach to
surveillance for emerging infectious diseases. The transdisciplinary approach used by
the group allows for shared expertise and experience in a regular forum addressing
infectious – and often zoonotic – disease. Communication is recognized as key in
containing potentially emerging diseases. The HAIRS group has also developed a clear
process for risk assessment which is documented in their reports, and can serve as a
model for risk assessors and managers elsewhere.
Further reading
Health Protection Agency. 2010. Human Animal Infections and Risk Surveillance 2010 report. August
2011. London, UK.
Health Protection Agency. 2010. Human Animal Infections and Risk Surveillance 2010 report. August
2011. London, UK.
Implementation of the One Health approach in Asia and Europe Background document 50 Questions raised by this case study
Observations
Questions
The HAIRS group embraces the concept of transdisciplinarity in
surveillance of emerging diseases. The group relies on “horizon
scanning” which involves systematic scanning of potential threats,
opportunities, and developments including those at the margins.
The HAIRS group relies on the active participation of members
from at least ten health-related agencies and departments that
meet one a month.
The HAIRS group initiative is an example of the benefits from
cooperative efforts to tackle communicable diseases of potential
harm to humans. A broader range of wider threats to wildlife or to
ecosystems are not yet monitored through a similar group.
How can transdisciplinarity be put to full use when
information or data are limited? Are new techniques
required in surveillance activities in a One Health
approach?
How can One Health roles and responsibilities be
institutionalised such that networks and One Health
activities don’t collapse if particular staff are lost?
Are network studies of use in determining how to best
structure networks and identify key focal points?
What lessons can be translated from the One Health
activities of the HAIRS group to be applied in other
networks (existing or not) to address a wider range of
threats?
Implementation of the One Health approach in Asia and Europe Background document 51 Conclusions
Based on readings of the One Health literature referred to in this report it is fair to
conclude that the mitigation of health risks generated from the complex intersection of
animals, humans, and the environments in which they live requires understanding and
training that no single discipline or skill by itself can provide. Improved understanding of
the epidemiology of emerging infectious diseases demands a transdisciplinary approach,
truly sustainable solutions require recognition of gender and economic equity, and
inclusion of communities in EID preparedness and response is now considered essential
for success. Although the “next steps” to operationalising One Health were outlined in a
general manner at the Stone Mountain meetings, in Asia and much of Europe, a clear
road map for moving from principals to operations remains undefined. This report should
be seen as a stimulus for discussion and planning at the ASEM conference and beyond
to help push that process forward.
The ten case studies presented and assessed in this report provide a number of useful
lessons and conclusions, pose questions for discussion, and illustrate some of the
concerns and challenges of a One Health approach.
Necessary and sufficient conditions of a One Health approach
The Case Studies were chosen for this report because, among other criteria presented
in the Introduction, they present as highly important at least four of the broad,
overarching themes that One Health addresses including:
1) Complexity of health problems necessitates a transdisciplinary approach
2) Zoonotic health risks are mitigated
3) Interventions result in improved wellbeing of humans, animals, and/or the
environment, and
4) Communities are involved in developing responses to health problems.
These four themes are found in each of the case studies and from this study surface as
the dominant characteristics of a One Health approach. This is also consistent with
comments received from most of the key informants who contributed to this mission.
These themes are thus presented for the ASEM conference participants to consider as
necessary (but not necessarily sufficient) elements of a One Health approach.
Participants would do well to consider what is missing or should be removed from this
list. We do feel an accepted generalized understanding of One Health needs to be
established or, as noted in the Introduction, any health response that addresses
economic compromise could be considered a One Health response. The latter would
trivialize the One Health philosophy, not sharpen it, resulting in inefficient, not
synergistic, collaboration. This same call for a clarified (but not necessarily rigidly
defined) description of what constitutes One Health has been noted by several other
studies and meetings referenced in this document, including the important 1st
International One Health Congress (Melbourne, February 2011).
Other One Health themes considered important based on the case studies (reported in
Table 1) include education or training of in-service personnel, preparedness and
planning, communications, culture as a factor in behaviour change, local or national
networks, and governance. Laboratory aspects, capacity, research, and development of
a roadmap were not highly ranked themes. Surprisingly, regional networks, involvement
of the private sector, funding for One Health which would influence sustainability, and
involvement of wildlife did not appear to be important themes with the exception of
rabies in Bali.
Implementation of the One Health approach in Asia and Europe Background document 52 We note that these rankings are highly subjective and influenced by case choice.
Nevertheless, identifying potential characteristics of a One Health approach help the
practitioner address the questions why is a One Health approach applicable and what
might it bring to the case that other standard approaches could not. Both of these
questions are important if limited health resources are to be used efficiently, and if
transdisciplinary partners and communities are to be convinced of the benefits of a One
Health approach over others.
Initiatives, Projects, and Programmes
There is no shortage of initiatives that reference One Health (Annex 1). Many of these
address technical perspectives including training in fundamental One Health or
ecohealth knowledge, advanced training in particular aspects of epidemiology and public
health including prevention and response, and development of capacity in diagnostics
and surveillance. The level of technical training targets a wide range of audience from
support staff to advanced technicians and academics. In essence, these activities
address strengthening of capacity in health technologies. While One Health cannot
operationalize without advanced technical training, there is nothing particularly unique
from a One Health perspective about this capacity building (nor does there need to be).
However, much less evidence was found for genuine study and training in national or
regional inter-institutional collaboration or transdisciplinary partnership that addresses
how institutions and transdisciplinary partners can communicate, collaborate, share
information, and partner in research and application of One Health initiatives. While
several projects or programmes mention building collaborative efforts, in general this is
an expected outcome of bringing different stakeholders together for joint training of one
type or another. While increased communication may be an outcome, without a specific
road map and action plan, this is unlikely to emerge on a regional basis. In contrast, at
the national level there has been progress in understanding and developing interinstitutional collaboration or transdisciplinary partnership – this has been referred to in
the UNJP case study.
Operationalisation of One Health will require better coordination of the initiatives,
projects, and programmes being implemented. There is considerable duplication of
training and activity, and output in the form of documentation for sharing with others is
limited. Establishment of a regional coordinating mechanism could facilitate improved
coordination of One Health related activities. Notably missing from the various initiatives
is active partnering involvement of the mid to large scale private sector (i.e., the
corporate sector). Without this level of partnership in joint activities there is a risk that
health activities including policy formulation may develop independently in the private
and non-private sectors, leading to technical barriers to access of health services. We
note that there is corporate recognition and statements of support for the One Health
approach, although we are not aware of active roles by the corporate sector in a One
Health project pr programme that includes institutions at the level of government, NGO,
IGO, or community. Research and policy development activities can assist in developing
a level of consultation and joint action by bringing these partners together in areas of
mutual interest.
There has been leadership effort from ASEAN to develop regional action plans, which
started in 2009 (ASEAN Plus Three Workshop on Animal and Human Health
Collaboration for Emerging and Neglected Zoonotic Diseases, February 3-5, 2009,
Vientiane, Lao PDR). It was noted by delegates at an ASEAN workshop in Lao PDR that
there was need for and agreement to move towards stronger collaboration between the
health sectors. An action plan was to be presented to the 31st ASEAN Ministers’
Implementation of the One Health approach in Asia and Europe Background document 53 Meeting on Agriculture and Forestry in 2009 and the 10th ASEAN Health Ministers
Meeting in 2010. While there is evidence that specific plans for particular activities has
been discussed (e.g., information sharing related to national dengue fever programmes,
and the ASEAN HPAI Taskforce roadmap activities for regional coordination), we could
not find evidence of a broad action plan or blueprint to move the general concept of
collaboration between health sectors forward. This was to be presented for support at
the ASEAN Plus Three Emerging Infectious Diseases Programme Completion Meeting
in June 2010, for inclusion in the Senior Officials Meeting on Health Development
(SOMHD) Plan for 2010-2015, based on the ASEAN Socio-Cultural Community (ASCC)
Blueprint. As well, the ASEAN Economic Community (AEC) Blueprint, adopted by
ASEAN Leaders at the 13th ASEAN Summit on November 20, 2007, provides a
roadmap and timetable to establish the AEC by 2015.
Health of humans, animals, and the environment are addressed in the ASEAN
blueprints, although they are presented under compartmentalized and separable calls for
action, rather than cross-disciplinary or integrated themes. Nowhere in the ASEAN
blueprints is there clear address of One Health, although ASEAN activities are moving in
this direction (e.g., the ASEAN Coordinating Centre for Animal Health and Zoonoses
(ACCAHZ) is clearly intent on addressing zoonoses under a One Health agenda). Since
November 2008 there has existed an ASEAN Secretariat Working Group for One Health
which is tasked with development of crisis management arrangements and protocols
and a “Long-Term Plan for One Health”. As well, in October 2010 at the 32nd Meeting of
the ASEAN Minsters on Agriculture and Forestry, ASEAN Ministers did declare their
commitment to “advance the One Health approach and support existing collaborative
frameworks on animal and public health governance at global, regional and national
levels to address vulnerabilities associated with zoonotic diseases”3. This included
reference to the ASEAN Plus Three Joint Recommendations and Work Plan on Animal
and Human Health Collaboration (a record of the latter document could not be located
for reference). Finally, the ASEAN HPAI Taskforce has had some success in assisting
countries to develop multi-sectoral strategies to control avian influenza led by livestock
and public health sectors.
Overall, these developments to 2010 appeared promising. It would be highly valuable to
operationalising One Health in Asia if the status of these initiatives were updated to
embrace the One Health philosophy, and awareness and promotion of the One Health
related activities of ASEAN be supported in Asia. Valuable lessons are no doubt also
available from activities in the SAARC countries and in China, Japan, and South Korea
(the latter being ASEAN Plus Three countries), all of which are very important partners in
operationalising One Health in Asia. Much less information regarding One Health
engagement in those countries was available to the authors of this report, and thus the
limited reporting, other than the references made in the Case Studies.
Mention is made again of the EU’s regional HPED regional programme in Asia, launched
in December 2009, and the first regional OH programme in Asia. The overall objective of
the programme is to strengthen the institutional capacities of ASEAN and SAARC and
their secretariats to control HPEDs and to improve epidemic and pandemic
preparedness in the region. The programme, scheduled to continue to December 2013,
addresses some of the above mentioned objectives including promoting efficiency of
resource utilization in the region and outcomes will be communicated as the programme
continues.
3
ASEAN, 2010.
Implementation of the One Health approach in Asia and Europe Background document 54 One Health actors and focal points
Considerable individual capacity exists in knowledge of One Health and experience at
training sessions and workshops. It is less clear when and how this capacity has been
translated into actions and experience. This is likely to be due in part to existence of
opportunity as well as willingness of institutions to adopt a One Health approach. This
report will not make recommendations as to individuals well placed to lead One Health;
there are many such persons and this should be the call of institutions that are and will
be operationalising One Health. However, there are some patterns we see as
developing that merit attention.

It would be of benefit to countries interested in operationalising One Health if
the growing number of persons with skills and practical experience in One
Health – those who can serve as Focal Points, such as have been identified by
this mission – could be identified and agree to contribute in a communication
network of some type in order to share experiences and knowledge. Such
knowledge and experience sharing networks4 have been quite successful in
assisting to develop other initiatives and development approaches.

If activities to operationalize One Health are to be led by Focal Points and One
Health actors in the region of interest, it would be helpful to lay out the linkages
between Focal Points, key actors, and those partners (individuals to agencies)
on or with whom the Focal Points and actors expect to find opportunity for
influence leading to change. In other words, the task of clearly identifying at an
early stage who is leading, who is advising, and who will benefit in what way
from which partnerships seems obvious but is not often clear when reviewing
project literature. Posing these questions to persons in the database (Annex 2)
may provide valuable lessons in this regard.

Persons attending training and workshop sessions tend to be mid-level or lower
in terms of institutional hierarchy; this is a sensible investment in human capital
if such persons are able to use their new skills in agencies managed typically
be more senior individuals

To develop capacity in One Health, it may be more productive to identify and
train core teams of actors in a series of One Health events, including
application of newly developed skills, rather than bringing different individuals to
different workshops. The majority of actors and focal points identified are not
part of core teams that we know of, having attended training where
opportunities arise. The value of this time honoured approach to training (i.e.,
train as many attendees over time as possible) is questioned in terms of
developing regional capacity in One Health.

With the growing number of initiatives in Asia involving One Health, those that
require Focal Points are perhaps too quick to rely on individuals already known
to agencies, and with credentials that clearly align with One Health principals.
While this is understandable, it has also resulted in some of the same
individuals taking on the role of Focal Points across several projects, diluting
the likelihood of time being made available to accomplish objectives.
Lessons learned from the selected Case Studies
The Case Studies chosen reveal One Health themes presented elsewhere in this report
(e.g., Table 1) and valuable lessons, summarized at the end of each Case Study and not
repeated here. With regard to operationalisation of One Health, some important general
conclusions can be drawn regarding challenges.
4
For a good example visit the Outcome Mapping Learning Community website: www.outcomemapping.ca
Implementation of the One Health approach in Asia and Europe Background document 55 Communication and behaviour change are recognized as essential if health outcomes
are to be achieved, but in the absence of a present or impending health crisis threat
(e.g., HPAI) convincing communities to maintain vigilance will be difficult. A One Health
approach will have to address this concern in developing educational strategies related
to prevention and preparedness.
Stakeholders who partner with agencies to embrace a One Health approach, particularly
livestock producers, are likely to request evidence of positive economic impact resulting
from change. While intuitively sensible, this can be difficult evidence to provide when
outcomes are hypothesized, or when the benefits are prevention of negative outcomes
rather than tangible benefits such as reduced days to market.
Coordination is a key feature of several of the Case Studies, indicating the concern for
appropriate leadership and programme management to facilitate desired health
outcomes. This underscores the importance of developing healthy alliances and
partnerships across agencies and institutions, key element of successful
transdisciplinarity, to help lead coordinated efforts when they are needed. It is better to
work at developing such relationships well before they are needed, as most of the Case
Studies illustrate, than to try and force them under urgent circumstances.
A separate issue regarding coordination at a regional scale is the apparent need for
greater coordination of programmes and activities between countries and institutions
working at a regional level. This is recognized and acted on at the level of, for example,
UN and ASEAN institutions, but there are still substantial gaps in coordinating regional
activities of NGO and country level agencies working at the regional level.
Input to policy formulation and implementation is another important feature of many of
the Case Studies. A concern of many of the projects examined is the lack of substantive
input to policy formulation, even where project activities lead to successful completion of
outputs. Part of the problem is lack of knowledge or lack of strategy to engage with
policymakers. Other problems cited include lack of time, funds, or community interest in
engaging with the policy process. In the experience of the authors, the latter is rarely the
real issue but may represent lack of confidence that engagement will have influence,
and thus be of benefit to the community.
Public awareness also plays an important role in many of the Case Studies. Where
communities participated in change there was first appreciation of the complexity of the
roles of community members, and understanding of the risks to animal, human, and
environmental health. Where knowledge transfer is to influence behaviour change, these
lessons indicate awareness is critical.
Governance of One Health
It is useful to reflect on the differences between coordination, referred to earlier in this
section, and governance. Coordination refers to the planning, organisation, and
implementation of the different components and activities of a multifaceted association of
units or bodies in order to achieve effective performance. Governance refers to the
definition of expectations, granting of authority, leadership and guidance, and regulation
of the processes, policies, and laws affecting those same multifaceted institutions or
bodies. In other words, while governance steers institutions and societies towards a
goal, coordination ensures travel along the road map indicating how to get there.
Governance and coordination need to exist in the growing complexity of the One Health
picture in Asia. The reasons for clearer coordination have been outlined above. The
need for governance exists with respect to regional authority, decision-making, and
accountability. Much of the groundwork for developing a governance structure lies in the
Implementation of the One Health approach in Asia and Europe Background document 56 recommendations and other output from the series of One Health meetings (New Delhi,
2007; Sharm El Sheikh, 2008; Winnipeg, 2009; Hanoi, 2010; Stone Mountain, USA,
2010; and Melbourne, 2011) as well as collaborative consultation documents from the
EU, UN, and donor agencies. One of the important and relevant conclusions of these
meetings with regard to governance of OH is that the OH concept cannot be owned but
must be shared across governing agents. A clear roadmap that outlines steps to
identifying and operationalising a governance structure remains undefined. The
upcoming meeting of the OH Global Network Working Group in Atlanta is likely to make
a significant contribution to this.
There are a number of institutions that could be involved in the process of developing a
governance structure for One Health, including relevant ASEAN departments, SAARC
areas of cooperation, regional coordinating organisations, UN agencies, OIE, the donor
community, and national representatives of community interest groups. As the leading
regional institutions representing the development interests of South and Southeast
Asia, SAARC and ASEAN may be in the best position to lead a One Health governing
structure for Asia forward. Steps in the process have begun with development of a
Regional Coordination Mechanism, still in its early days, and likely to be established as
part of the ASEAN and SAARC frameworks. PRC China, Japan, and South Korea would
of course need to be included as part of this grouping (and are already members of the
ASEAN Plus Three grouping addressing EIDs).
A proposed short list of themes for discussion with respect to regional governance
includes:
 Technical capacity
 Education and training
 Information sharing
 Networking and partnerships
 Logistics, and
 Financing
It may be of value to include a process for prioritization of One Health activities at both
regional and national levels, and develop a One Health readiness checklist against
which countries can gauge stages of engagement and suggest areas of need for
improvement.
Discussions regarding governance of any matter at the regional level is going to be a
sensitive issue. However, without moving governance of One Health forward, it will
remain at advanced stages of discussion with some good examples, but no regional
inertia.
Finally, for an example of developing wider technical governance and leadership in the
region, it is worth noting the example of the linkages of ASEAN and SAARC Regional
Support Units (RSU) with FAO/OIE GF-TADs, which aim to strengthen regional policy
and legislation as well as regional cooperation and disease response capacity through
sustained coordination and partnership with stakeholders in ASEAN and SAARC
countries5. The RSUs also have begun to establish a regional epidemiology network
(REN) for animal and human diseases, and a regional laboratory network (RLN) to share
training, expertise, reagents, facilities and information.
5
At least for ASEAN, these are also three of the intended output components of the European Union’s Regional Cooperation
Programme on Highly Pathogenic Emerging Diseases (HPEDs) in Asia.
Implementation of the One Health approach in Asia and Europe Background document 57 Appendix - Persons and institutions consulted during this mission
Individual
Royce Escolar
Daniel Schar
Sudarat Damrongwatanapokin
Pattamaporn Kittayapong
Stan Fenwick
Subash Morzaria
Filip De Loof
Andrew Davis
Wantanee Kalpravidh
Bruce Wilcox
Ronello Abila
Annu Lehtinen
Pornchai Danvivathana
Moe Ko Oo
Manoj Potapohn
Suwit Chotinun
Fred Unger
Edhie S. Rahmat
Graham Tallis
Solomon Benigno
Suriyan Vitchitlekarn
Bambang Heryanto
Emil Agustiono
Marcia Soumokil
Iwan Willyanto
Anak Agung Gde Putra
Jeff Gilbert
Dinh Xuan Tung
Hung Nguyen Viet
MG Shah Alam
Shankar Raha
Position
Regional Program Manager
Regional EID Manager
Regional Animal Health Advisor
Assoc. Professor
Technical Director
Regional Manager, ECTAD
Attaché
Programme Coordinator, OIE-IDENTIFY
Regional Coordinator, ECTAD-RAP
Senior Advisor
Sub-Regional Representative
Regional Representative
Deputy Director General, ASEAN Affairs
MBDS Coordinator
Dir., Econ. & Business Forecasting Ctr.
Lecturer
Veterinary epidemiologist
Project Officer
Medical Officer
Project Manager
ADR
Influenza Specialist
Secretary
Program Manager
Animal Health Consultant
Senior Investigator
Project Coordinator, Emerging Zoonoses
Researcher
Researcher
Professor
Professor
Organisation
AusAID
USAID
USAID
Mahidol University
EPT-RESPOND, DAI
FAO
Delegation of the EU
OIE
FAO
Mahidol University
OIE
UNSIC
Thai Ministry of Foreign Affairs
MBDS
Chiang Mai University
Fac. Vet. Medicine, Chiang Mai Univ.
ILRI
Delegation of the EU
WHO
ASEAN
ASEAN
USAID
Natl. Commission on Zoonotic Control
Burnet office
Disease Investigation Center
ILRI
National Institute of Animal Science
Hanoi School of Public Health
Fac. Vet. Med., Bangladesh Agr. Univ.
Fac. Agr. Econ., Bangladesh Agr. Univ.
Implementation of the One Health approach in Asia and Europe Background document Location
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Bangkok, Thailand
Nonthaburi, Thailand
Chiang Mai, Thailand
Chiang Mai, Thailand
Chiang Mai, Thailand
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Jakarta, Indonesia
Denpasar, Indonesia
Vientiane, Lao PDR
Hanoi, Vietnam
Hanoi, Vietnam
Mymensingh, Bangladesh
Mymensingh, Bangladesh
58 Individual
Jim Scudamore
Sue Welburn
Anne Okello
Jonathan Rushton
Dirk Pfeiffer
Richard Coker
Wim van der Hoek
Elise Dieleman
Jakob Zinsstag
Esther Schelling
John MacKenzie
Martyn Jeggo
Peter Black
Mike Nunn
John Edwards
Christine Munzer
Jessica Appert
Quynh Le Ba
Position
Professor
Professor & Director of Global Health Acad.
Ph.D. student
Senior Lecturer
Professor
Professor (based in Bangkok)
Project leader respiratory infections
Consultant
Professor, Faculty of Health Sciences
Director, Australian Animal Health Lab.
Principal Research Scientist
Principal Scientist – Animal
Emeritus Professor
Program Manager
Researcher
Organisation
School of Veterinary Science
Centre for Infectious Disease
Royal Veterinary College
Royal Veterinary College
London School Hygiene & Trop. Med.
National Institute for Public Health and the Envt.
Swiss Tropical and Public Health Institute
Swiss Tropical and Public Health Institute
Curtin University
CSIRO, Australia
Department of Agriculture, Fisheries & Forestry
Department of Agriculture, Fisheries & Forestry
School of Veterinary and Biomedical Sciences
CARE Australia
Center for Animal Health and Food Safety
Fac. Vet. Medicine, Univ. of Calgary
Implementation of the One Health approach in Asia and Europe Background document Location
University of Liverpool, UK
University of Edinburgh, UK
University of Edinburgh, UK
University of London, UK
University of London, UK
University of London, UK
Netherlands
Netherlands
Switzerland
Switzerland
Perth/ Melbourne, Australia
Geelong, Australia
Canberra, Australia
Canberra, Australia
Murdoch Univ., Australia
Canberra, Australia
Univ. of Minnesota, USA
Calgary, Canada
59 References
ASEAN. 2010. ASEAN Ministerial Statement On “ASEAN Cooperation On Animal Health
and Zoonoses: Avian Influenza and Beyond”. At the Thirty Second Meeting of the ASEAN
Ministers On Agriculture and Forestry (32nd AMAF.) Phnom Penh, October 23, 2010.
Cook, R.A., W.B. Karesh, and S.A. Osofsky. 2004. Comments from Conference Summary
One World, One Health: Building Interdisciplinary Bridges to Health in a Globalized World.
September 29th 2004, Rockefeller University. Wildlife Conservation Society, New York.
European Commission, 2009. Issues paper: The EU role in global health. The European
Commission, Brussels.
European Commission. 2010. Outcome and Impact Assessment of the Global Response to
the Avian Influenza Crisis, 2005-2010. Funded by The European Union, and implemented by
HTSPE Limited, London.
European Commission, 2011a. Cross-Border Cooperation in Animal and Human Health - EU
Regional HPED Programme. Directorate-General for Development and Cooperation –
EuropeAid, Brussels.
European Commission. 2011b. HPED Networking Event. Linking the actors of the EU-Asia
Regional One Health Programme. Bangkok, 18-19 January 2011. The European
Commission, Brussels.
FAO, OIE, UNSIC, UNICEF, WHO, and The World Bank. 2008. Contributing to OWOH – A
Strategic Framework for Reducing Risks at the Animal-Human-Ecosystems Interface.
Consultation Document UNSIC, FAO, WHO, UNICEF, OIE, WB.) Oct 14, 2008
UNDP, 2011. The Fourth Consolidated Annual Progress Report on Activities Implemented
under the Central Fund for Influenza Action. UNDP, New York.
UNSIC and World Bank. 2010. Animal and Pandemic Influenza: A Framework for Sustaining
Momentum. Fifth Global Progress Report. July 2010. UN System Influenza Coordination
(UNSIC) and The World Bank, 2010.
"One Health Initiative - One World One Medicine One Health." One Health Initiative - One
World One Medicine One Health. Web. July 12, 2011.
<http://www.onehealthinitiative.com/about.php>.
Implementation of the One Health approach in Asia and Europe Background document 60 Annex 1: OH Initiatives in Asia and Europe
See separate attachment
Annex 2: OH Stakeholders
See separate attachment
Annex 3: OH Documents and Bibliography
See separate attachment
Implementation of the One Health approach in Asia and Europe Background document 61