One-medicine approach hinges on local leadership and participation
Posted March 1, 2008
During an investigation of an outbreak of highly pathogenic avian influenza in their village, a husband and wife from Indonesia provide information using a technique called community participatory mapping. It's an example of the important role of preparedness and response at the local level.
In Indonesia, villagers make a map that provides key epidemiologic information enabling veterinarians to identify the source of highly pathogenic avian influenza—a river along which infected, dead chickens were floating. In Sudan, local veterinarians use Google Earth to find the source of HPAI infection—a truck collecting poultry manure for fertilizing crops.
"One of the essential tools we need for the one-medicine approach is community participatory mapping," said Dr. Gavin Macgregor-Skinner, speaking at the fifth annual One Medicine Symposium hosted by North Carolina state agencies, Dec. 12-13, 2007. Globalization was the symposium theme, but local participation was a focal point.
The Participatory Disease Surveillance program, funded by the U.S. Agency for International Development, trains government veterinary personnel to diagnose HPAI in backyard poultry and teaches villagers to detect and report cases. Dr. Macgregor-Skinner—the USAID pandemic influenza prevention technical team leader—is based in Washington, D.C., and provides technical support to field missions.
Community participatory mapping works, whether in a rural or urban context, he said. This systems-based approach is critical not only with avian influenza but also with other zoonotic and emerging infectious diseases, he said.
North Carolina a leader
In the United States, a national recall last year also underscored the importance of local preparedness and response. Potential botulism contamination had triggered Castleberry Food Company of Augusta, Ga., to issue one of the largest recalls in U.S. history. The recall covered canned chili sauces and meat products for human consumption, and dog food.
North Carolinians responded at "every tier"—even tracking down Boy Scouts who had taken the potentially tainted chili sauce on a camping trip, according to Steve Troxler. He is commissioner of agriculture in North Carolina, a state where agribusiness is a $66 billion a year industry.
Troxler, speaking at the symposium, said, "There are so many examples of the ways that we work together in North Carolina, and I think the reason we have developed such close relationships is the crises that we've had in North Carolina, with so many hurricanes and now the drought.
"The other thing that I think we've learned, even more so recently with the Castleberry recall, was we've got to get down to the local level to get things done. ... We were putting out press releases that there could be botulism in this product and that one nanogram is enough to kill a lot of people, but nobody was really paying attention."
Troxler and Leah Devlin, DDS, MPH, state health director, underscored the vital need to develop relationships and partnerships. Dr. Devlin said it is also important to strengthen statutory language as to how the state veterinarian and the state public health veterinarian work together for better human and animal disease surveillance.
The North Carolina symposium, held in Durham, is one example of the state's proactive approach to one medicine and preparedness. The event was hosted by two state agencies—the Department of Health and Human Services and the Department of Agriculture and Consumer Services.
Dr. Kelly Jeffer of the NCDA&CS, who served on the planning committee, explained why this year's theme was globalization. She told JAVMA, "We're going to be dealing with more issues in agriculture because of globalization. In our program, we brought in the international perspective as well as state experts. Attendees from out-of-state identify with the common themes, even if their issues are not exactly the same as in North Carolina."
Attendance grew by several dozen this year to 361 and ranged from public health and veterinary professionals to industrial hygienists and laboratory personnel.
A holistic approach
Rear Admiral Craig VanderWagen, MD, said, "We don't have (best practices) in the world of preparedness and response. ... We're working on an anecdotal basis." He said that one reason North Carolina is a leader is its focus on developing capable assets.
Dr. VanderWagen spent 25 years as a physician in American Indian country. He is now assistant secretary in the Office of Preparedness and Response, U.S. Department of Health and Human Services. Raised in Zuni country in New Mexico, Rear Adm. VanderWagen grew up in an environment grounded in the earth, so he came to think of the universe in a holistic way. This was important toward his understanding of how disease was playing out. His father, a veterinarian, was later chief of public health in California.
It's important to understand the underpinnings of how people live, he said. In Afghanistan, for example, people live in proximity with their animals. Rear Adm. VanderWagen encouraged the building of partnerships and community capacity, and vigilance by veterinarians and physicians in collaboration with the Centers for Disease Control and Prevention.
"We need to understand the global nature (of preparedness) but (be leaders at community and individual level)," he said.
Trade-related safety risks
Speakers addressed the risks posed by increased foreign trade.
Dr. Corrie Brown, coordinator of international veterinary medicine at the University of Georgia College of Veterinary Medicine, focused on the international political economy and the trade of products or animals carrying infectious agents.
"I like to think we're on the third wave of emerging diseases," Dr. Brown said. The first wave was "brand new and spectacular," the second wave was bioterrorism and new geographic areas, and the third wave is trade-generated.
Dr. Brown noted that countries such as China and India are increasing their gross domestic product and demanding more meat, and it will come from the developing world because those countries are already well-invested in agriculture, are rich in land and labor, and need foreign direct-investment capital. In China in 1983, 16 kg per meat were consumed per person; that is expected to rise to 73 kg per person by 2020.
Expanding risks are involved in importing and producing safe products in a global economy, noted Joseph W. Reardon, director of the Food and Drug Protection Division, NCDA&CS. He said there are as many as 136,000 registered domestic food facilities and 189,000 companies that ship to the United States as registered foreign facilities.
Using the 2007 pet food contamination as a case study, Reardon noted that the inclusion of melamine in vegetable protein is common in China and that according to the chemical manufacturer, cyanuric acid is nontoxic and is added to animal feed there.
"It's not just what's marked 'made in China'—it's the stuff in the stuff," Reardon added. He said that a federal incident command system would have been extremely beneficial. "ICS provides a framework to effectively manage and force-multiply resources. ... By using ICS, North Carolina coordinated the efforts of 1,000-plus personnel statewide in three state agencies and 86 local agencies."
John T. Hoffman, a retired colonel and a senior research fellow at the National Center for Food Protection and Defense, University of Minnesota Center for Animal Health and Food Safety, said that the Chinese take products from many places to a registered facility. "This (melamine) was a very thought-out thing, but it was unsophisticated. ... This tells us we're not prepared for something ... more nefarious," Hoffman said.
Hoffman suggested visiting www.importsafety.gov.
Immigration, travel-related risks
Dr. Nina Marano, chief of the Geographic Medicine and Health Promotion Branch, CDC Division of Global Migration and Quarantine, said that 40 years ago, most international travel was from developed country to developed country. Since then, the volume has climbed and the nature of travel has changed.
Foreign-born U.S. residents visit friends and relatives in their native country, for example. Dr. Marano said there is a mistaken belief among many in that group that they are immune to health threats in their native country.
In addition, about 50,000 U.S. residents study abroad, more seniors travel, and medical tourism—in which people travel to another country for medical, dental, or surgical care—is rapidly growing.
Of 100,000 people who travel in a given month, 50,000 will develop a related health problem, Dr. Marano said. Her take-home message to travelers is personal responsibility in researching their destination, and message to veterinarians—vigilance. The CDC provides an online Travelers' Health area at wwwn.cdc.gov/travel/default.aspx.
Global travel and immigration along with greater availability of CT scans and MRI have contributed to an increase in diagnoses of human cysticercosis in the United States, according to Dr. Katie Kurkjian of the Virginia Department of Health, although it is not a nationally reportable disease.
Cysticercosis, caused by infection with the pork tapeworm Taenia solium, is "zoonotic, treatable, preventable, and potentially eradicable, so it's a perfect disease (to) apply the one-medicine approach," Dr. Kurkjian said. The most common parasite of the CNS, it affects 50 million people and takes two forms—infection with taeniae (adult tapeworms) and with cysticerci (larvae).
"Historically, cysticercosis has been a neglected tropical disease. North Carolina and other states need to be addressing it, because it's in our own backyard," Dr. Kurkjian said.
One medicine in academia, private sector
Dean Warwick Arden of the North Carolina State University College of Veterinary Medicine noted that one medicine extends to academia, saying that the college really takes the concept to heart whether it's in working with a farmer or pet owner. He talked about important partnerships being developed with government agencies and the private sector.
Dr. Thomas M. Edling, director of veterinary medicine for PETCO Animal Supplies, spoke on the exotic pet trade industry.
"This one-medicine approach is something I've been trying to do in the private sector, "Dr. Edling said. "I see my part as trying to help the pet industry in the United States. The pet industry has had a bad rap in the past and probably deserved it. We need to help educate the pet industry and importers, put rules and regulations in place to make sure (we have) healthy animals, and educate the public."
The Pet Industry Joint Advisory Council works with industry associations on risk prevention measures. PETCO aims to use best practices in exotic animal husbandry by educating its store associates. PETCO also has a vendor certification program that requires unannounced annual visits. The company also supports Habitattitude, a national initiative to avert the release of unwanted fish (or aquatic plants) into the environment.
Overviews of national and international defense systems were presented by Dr. Donald L. Noah, Dr. Corrie Brown, and Kamel Senouci, MD, MSc.
Dr. Noah, a U.S. Army colonel, is currently detailed to the U.S. Department of Homeland Security as acting deputy assistant secretary for weapons of mass destruction and biodefense. "My job is to move surveillance and detection to the left (from crisis management to strategic planning)," he said.
Colonel Noah discussed the National Biosurveillance Integration System. "There are many surveillance systems in the United States and the world; they reside at the local, state, and national levels. NBIS was created to integrate these," he said, explaining that if there were a military insult to the United States, there would be a medical component.
Colonel Noah said, "We're still an agrarian nation. Agriculture is the linchpin or the source of America's power. HSPD-9 is important in that regard." The subject of Homeland Security Presidential Directive-9 is "Defense of United States Agriculture and Food." He encourages Americans to read it, as well as "The National Security Strategy of the United States of America"; the latter is accessible at www.whitehouse.gov/nsc/nss.html. Its 25 pages are "entirely readable and wholly enlightening," he said, adding, "You will see the origin of what the U.S. has been doing the last five years. It is very profound."
Drs. Brown and Senouci addressed the international infrastructures for animal health and human health, respectively.
According to the United Nations, Dr. Brown noted, there are about 400 international organizations, with the World Organization for Animal Health (OIE) the largest animal health organization. Dr. Brown said that Dr. Bernard Vallat, OIE director general, is moving the organization forward fast.
She also described the Global Early Warning and Response System, a joint effort of OIE, the U.N. Food and Agriculture Organization, and World Health Organization. The FAO Animal Health Division focuses on certain diseases such as rinderpest.
Dr. Senouci discussed some of the forces that drove WHO member states to adopt the International Health Regulations (2005). Among its provisions, IHR (2005) creates a unique national focal point in each member as well as nonmember country that must be accessible 24-7. These national focal points were added to the WHO National Epidemic Alert and Response System.
Also, IHR (2005) requires disease containment at the source, not just border control, and now covers public health threats of any nature. It provides for adapted responses rather than preset measures. Another innovation is a decision instrument for events detected by a national surveillance system—an algorithm based on four risk assessment criteria. Dr. Senouci described the national core capacities each country is expected to achieve. Countries have from June 2007 to June 2009 to assess their surveillance and response capacity and develop an action plan, and until June 2012 to implement them.
He also described the Global Outbreak Alert and Response Network and the Global Influenza Surveillance Network.
Another symposium theme was the influence of social, economic, and cultural differences on the human-animal relationship, agriculture, and public health.
Dr. David Waltner-Toews said, "In different cultures, we do very similar things with animals, but we do them with different animals. ... We need to pay attention to the roles of animals in different cultures." Dr. Waltner-Toews is a professor in the Department of Population Medicine at the Ontario Veterinary College, University of Guelph.
Certain cultural practices can threaten public health and agriculture. Dr. Waltner-Toews described owners of fighting cocks who suck the mucus and blood from their injured rooster's beak, and potential bettors who first blow into the beak to determine lung capacity. Those who engage in risky practices need to be educated, not regarded as stupid, he said. He employs creative teaching approaches, such as showing young people in disadvantaged areas their feces under a microscope to teach them about parasites.
Referring to the increasing demand for meat in developing countries, he cautioned that if you start changing agriculture, it affects economic health. "You can't simply scale up. If you make changes at one level, it has implications down the line for people's (livelihoods)."
Dr. Waltner-Toews said, "When we go to another culture, we have to understand both what they're doing and what their options are."
North Carolina state public health veterinarian, Dr. Carl Williams, said, "In North Carolina, we have some diseases that are good representations of one medicine." With so much interest in the North Carolina Cooperative Rabies Management Program, he focused on that.
Other speakers talked about the National Bio and Agro-Defense Facility that the U.S. Department of Agriculture plans to build, and nanny laws, which protect society but limit freedom of the individual.
Dr. Devlin, the state health director, said, "We're real pleased other states are starting to hold one-medicine conferences and the (former) American Veterinary Medical Association president has kicked off a one-medicine initiative."
Dr. Roger K. Mahr, who as 2006-2007 AVMA president proposed the current One Health Initiative Task Force, attended and commended the North Carolina one-medicine symposium for clearly identifying issues and bringing together so many entities.