A Blueprint to Evaluate One Health

The development and validation of the One Health Community Assessment

Interdisciplinary collaborations to address human, animal, and environmental health have been emphasized since the inception of the One Health framework. A quantitative survey instrument was developed to measure perceptions of the impacts of pets on One Health. Using the exploratory sequential mixed methods approach, 20 interviews were conducted with individuals from a racially diverse and low-socioeconomic status community in the U.S. to understand their perceptions of One Health. Data from those interviews informed the development of a Likert scale survey measuring individual perceptions of community, human, pet, and environmental health and welfare, as well as the connections between the domains of the One Health triad (human, animal, and environment). The resulting One Health Community Assessment (OHCA) was administered in two urban and two rural underserved U.S. communities longitudinally (2018-2021) through door-to-door data collection as well as phone, email, and text surveys. Validation of the instrument was completed using data collected in the third and fourth years of the study (n = 654). Factor analysis with orthogonal varimax rotation was used to assess the structure and internal consistency of the OHCA. Five subscales explained 42.4% of the variance in our 92-item instrument: community health (Cronbach's α = 0.897), human health (α = 0.842), pet health (α = 0.899), environmental health (α = 0.789), and connections between domains of One Health (α = 0.762). The OHCA represents the first reliable and validated instrument to measure the impacts of pets on One Health.

A health promotion perspective on One Health

The One Health concept has acquired increasing attention due to the COVID-19 pandemic. We argue for a health promotion perspective that frames One Health in terms of positive health for people, animals, and ecosystems and includes a spiritual-cosmological dimension. This would enhance policy, research, and practice across disciplines and sectors for a more resilient and harmonious planet.

Spatial and temporal distribution of Taenia solium and its risk factors in Uganda

OBJECTIVES

The lack of subnational mapping of the zoonotic cestode Taenia solium in endemic countries presents a major challenge to achieving intensified T. solium control milestones, as outlined in the "World Health Organization neglected tropical disease roadmap by 2030". We conducted a mapping study in Uganda, considered to be endemic, to identify subnational high-risk areas.

METHODS

T. solium prevalence data, adjusted for diagnostic sensitivity and specificity in a Bayesian framework, were identified through a systematic review. Spatial autocorrelation and interpolation techniques were used to transform demographic and health survey cluster-level sanitation and poverty indicators, overlaid onto a pig density map for Uganda into modelled  porcine cysticercosis (PCC) risk maps.

RESULTS

A total of 16 articles (n = 11 PCC and n = 5 human cysticercosis (HCC) and/or human taeniasis) were included in the final analysis. The observed HCC prevalence ranged from 0.01% to 6.0% (confidence interval range: 0.004-11.4%), whereas the adjusted PCC ranged from 0.3 to 93.9% (uncertainty interval range: 0-99.8%). There was substantial variation in the modelled  PCC risk factors and prevalence across Uganda and over time.

CONCLUSION

The high PCC prevalence and moderate HCC exposure estimates indicate the need for urgent implementation of T. solium control efforts in Uganda.

Shiga Toxin-Producing Escherichia coli in Faecal Samples from Wild Ruminants

Wildlife can harbour Shiga toxin-producing Escherichia coli (STEC). In the present study, STEC in faecal samples from red deer (n = 106) and roe deer (n = 95) were characterised. All isolates were non-O157 strains. In red deer, STEC were detected in 17.9% (n = 19) of the isolates, and the eae/stx_2b virulence profile was detected in two isolates (10.5%). One STEC strain harboured stx_1a (5.3%) and eighteen STEC strains harboured stx₂ (94.7%). The most prevalent stx₂ subtypes were stx_2b (n = 12; 66.7%), stx_2a (n = 3; 16.7%), and stx_2g (n = 2; 11.1%). One isolate could not be subtyped (NS) with the applied primers (5.6%). The most widely identified serotypes were O146:H28 (n = 4; 21%), O146:HNM (n = 2; 10.5%), O103:H7 (n = 1; 5.3%), O103:H21 (n = 1; 5.3%), and O45:HNM (n = 1; 5.3%). In roe deer, STEC were detected in 16.8% (n = 16) of the isolates, and the eae/stx_2b virulence profile was detected in one isolate (6.3%). Two STEC strains harboured stx_1a (12.5%), one strain harboured stx_1NS/stx_2b (6.3%), and thirteen strains harboured stx₂ (81.3%). The most common subtypes were stx_2b (n = 8; 61.5%), stx_2g (n = 2; 15.4%), non-typeable subtypes (NS) (n = 2; 15.4%), and stx_2a (n = 1; 7.7%). Serotype O146:H28 (n = 5; 31.3%) was identified. The study demonstrated that the zoonotic potential of STEC strains isolated from wildlife faeces should be monitored in the context of the 'One Health' approach which links human health with animal and environmental health.

How prepared is the world? Identifying weaknesses in existing assessment frameworks for global health security through a One Health approach

The COVID-19 pandemic has exposed faults in the way we assess preparedness and response capacities for public health emergencies. Existing frameworks are limited in scope, and do not sufficiently consider complex social, economic, political, regulatory, and ecological factors. One Health, through its focus on the links among humans, animals, and ecosystems, is a valuable approach through which existing assessment frameworks can be analysed and new ways forward proposed. Although in the past few years advances have been made in assessment tools such as the International Health Regulations Joint External Evaluation, a rapid and radical increase in ambition is required. To sufficiently account for the range of complex systems in which health emergencies occur, assessments should consider how problems are defined across stakeholders and the wider sociopolitical environments in which structures and institutions operate. Current frameworks do little to consider anthropogenic factors in disease emergence or address the full array of health security hazards across the social-ecological system. A complex and interdependent set of challenges threaten human, animal, and ecosystem health, and we cannot afford to overlook important contextual factors, or the determinants of these shared threats. Health security assessment frameworks should therefore ensure that the process undertaken to prioritise and build capacity adheres to core One Health principles and that interventions and outcomes are assessed in terms of added value, trade-offs, and cobenefits across human, animal, and environmental health systems.

Global and regional governance of One Health and implications for global health security

The apparent failure of global health security to prevent or prepare for the COVID-19 pandemic has highlighted the need for closer cooperation between human, animal (domestic and wildlife), and environmental health sectors. However, the many institutions, processes, regulatory frameworks, and legal instruments with direct and indirect roles in the global governance of One Health have led to a fragmented, global, multilateral health security architecture. We explore four challenges: first, the sectoral, professional, and institutional silos and tensions existing between human, animal, and environmental health; second, the challenge that the international legal system, state sovereignty, and existing legal instruments pose for the governance of One Health; third, the power dynamics and asymmetry in power between countries represented in multilateral institutions and their impact on priority setting; and finally, the current financing mechanisms that predominantly focus on response to crises, and the chronic underinvestment for epidemic and emergency prevention, mitigation, and preparedness activities. We illustrate the global and regional dimensions to these four challenges and how they relate to national needs and priorities through three case studies on compulsory licensing, the governance of water resources in the Lake Chad Basin, and the desert locust infestation in east Africa. Finally, we propose 12 recommendations for the global community to address these challenges. Despite its broad and holistic agenda, One Health continues to be dominated by human and domestic animal health experts. Substantial efforts should be made to address the social-ecological drivers of health emergencies including outbreaks of emerging, re-emerging, and endemic infectious diseases. These drivers include climate change, biodiversity loss, and land-use change, and therefore require effective and enforceable legislation, investment, capacity building, and integration of other sectors and professionals beyond health.

Advancing One human-animal-environment Health for global health security: what does the evidence say?

In this Series paper, we review the contributions of One Health approaches (ie, at the human-animal-environment interface) to improve global health security across a range of health hazards and we summarise contemporary evidence of incremental benefits of a One Health approach. We assessed how One Health approaches were reported to the Food and Agricultural Organization of the UN, the World Organisation for Animal Health (WOAH, formerly OIE), and WHO, within the monitoring and assessment frameworks, including WHO International Health Regulations (2005) and WOAH Performance of Veterinary Services. We reviewed One Health theoretical foundations, methods, and case studies. Examples from joint health services and infrastructure, surveillance-response systems, surveillance of antimicrobial resistance, food safety and security, environmental hazards, water and sanitation, and zoonoses control clearly show incremental benefits of One Health approaches. One Health approaches appear to be most effective and sustainable in the prevention, preparedness, and early detection and investigation of evolving risks and hazards; the evidence base for their application is strongest in the control of endemic and neglected tropical diseases. For benefits to be maximised and extended, improved One Health operationalisation is needed by strengthening multisectoral coordination mechanisms at national, regional, and global levels.

One Health evaluation of brucellosis control in Kazakhstan

Brucellosis is one of the main livestock disease risks in Kazakhstan. It's been endemic there since 1930, accounting for over 1300 human cases per annum. The economic loss was 45 million USD in 2015 alone. Since 1952, Kazakhstan has implemented various control strategies with little success. One Health approaches have been suggested to tackle brucellosis, however, there is a lack of evidence for best practices to operationalise One Health in the literature, and methods for implementation are not established. The intention of this study was to introduce the One Health approach during the evaluation phase of the policy cycle. A two-day workshop was organized by the authors to familiarize participants with the evaluation methodology. Twenty-one specialists representing veterinary and public health sector, together with researchers, took part in this study. For two weeks following the workshop, first author conducted individual interviews with workshop participants to obtain individual scorings to assess knowledge integration capacity (One Health-ness). The evaluation results show that there is a lack of knowledge about the perceived damage caused by brucellosis to animal owners and other stakeholders. There is insufficient data available about farmers' practices, interests and motivations, and also data is missing for important transmission processes such as the amount of unsafe dairy consumption. The absence of such data illustrates the extent of the uncertainty to which decision-makers are exposed despite well-elaborated transmission models and supports the importance of co-producing solutions with participatory methods. The results suggest the need for broader involvement of stakeholders. Outputs of this study could help navigate the initial stages of One Health operationalization.

The role of cooking practices in the transmission of the foodborne parasite Taenia solium: A qualitative study in an endemic area of Southern Tanzania

The pork tapeworm Taenia solium is a zoonotic food-borne parasite endemic in many developing countries causing human cysticercosis and taeniosis as well as porcine cysticercosis. It mainly affects the health of rural smallholder pig farmers and their communities, resulting in lower health status, reduced pork quality, and economic loss due to condemnation of pigs or low pricing of pork. This qualitative study aimed to identify key food related practices linked to consumption of pork at village level, of importance for transmission of taeniosis. We used an interpretivist-constructivist paradigm in a multiple case study of exploratory qualitative research design. Data was acquired through guided and probing interviews with 64 pork cooks, and 14 direct observations in four villages in a T. solium endemic area of Mbeya Region in the Southern Highlands of Tanzania. The study showed that the informants were members of communities of practice through their pork cooking practices, one community of practice for the restaurant cooks and one for the home cooks, learning, sharing, and distributing their cooking skills. Furthermore, the analysis showed that the pork cooks generally had some awareness of there being something undesirable in raw pork, but they had very diverse understandings of what it was, or of its potential harm. Major potential transmission points were identified in restaurants and in home kitchens. It appears that the pork cooks act according to socio-cultural and economic factors guiding them in their actions, including pressure from customers in restaurants, the family values of tradition in the home kitchens, and the culturally guided risk perception and appraisal. These practices might generate potential transmission points. Future research on interventions aimed at preventing the spread of T. solium taeniosis should recognise the importance of tradition and culture in risky food practices.

The Promotion and Development of One Health at Swiss TPH and Its Greater Potential

One Health, an integrated health concept, is now an integral part of health research and development. One Health overlaps with other integrated approaches to health such as EcoHealth or Planetary Health, which not only consider the patient or population groups but include them in the social-ecological context. One Health has gained the widest foothold politically, institutionally, and in operational implementation. Increasingly, One Health is becoming part of reporting under the International Health Legislation (IHR 2005). The Swiss Tropical and Public Health Institute (Swiss TPH) has played a part in these developments with one of the first mentions of One Health in the biomedical literature. Here, we summarise the history of ideas and processes that led to the development of One Health research and development at the Swiss TPH, clarify its theoretical and methodological foundations, and explore its larger societal potential as an integrated approach to thinking. The history of ideas and processes leading to the development of One Health research at the Swiss TPH were inspired by far-sighted and open ideas of the directors and heads of departments, without exerting too much influence. They followed the progressing work and supported it with further ideas. These in turn were taken up and further developed by a growing number of individual scientists. These ideas were related to other strands of knowledge from economics, molecular biology, anthropology, sociology, theology, and linguistics. We endeavour to relate Western biomedical forms of knowledge generation with other forms, such as Mayan medicine. One Health, in its present form, has been influenced by African mobile pastoralists’ integrated thinking that have been taken up into Western epistemologies. The intercultural nature of global and regional One Health approaches will inevitably undergo further scrutiny of successful ways fostering inter-epistemic interaction. Now theoretically well grounded, the One Health approach of seeking benefits for all through better and more equitable cooperation can clearly be applied to engagement in solving major societal problems such as social inequality, animal protection and welfare, environmental protection, climate change mitigation, biodiversity conservation, and conflict transformation.

Multi-, Inter-, and Transdisciplinarity within the Public Health Workforce: A Scoping Review to Assess Definitions and Applications of Concepts

In light of the current public health challenges, calls for more inter- and transdisciplinarity in the public health workforce are increasing, particularly to respond to complex and intersecting health challenges, such as those presented by the climate crisis, emerging infectious diseases, or military conflict. Although widely used, it is unclear how the concepts of multi-, inter-, and transdisciplinarity are applied with respect to the public health workforce. We conducted a scoping review and qualitative content analysis to provide an overview of how the concepts of multi-, inter-, and transdisciplinarity are defined and applied in the academic literature about the public health workforce. Of the 1957 records identified, 324 articles were included in the review. Of those, 193, 176, and 53 mentioned the concepts of multi-, inter-, and transdisciplinarity, respectively. Overall, 44 articles provided a definition. Whilst definitions of multidisciplinarity were scarce, definitions of inter- and transdisciplinarity were more common and richer, highlighting the aim of the collaboration and the blurring and dissolution of disciplinary boundaries. A better understanding of the application of multi-, inter-, and transdisciplinarity is an important step to implementing these concepts in practice, including in institutional structures, academic curricula, and approaches in tackling public health challenges.

Perception of poultry veterinarians on the use of antimicrobials and antimicrobial resistance in egg production

This study aimed to describe the perception of veterinarians who work with commercial laying hens in the state of Rio Grande do Sul, Brazil, regarding the use of antibiotics and their possible impacts on animal, human, and environmental health. A descriptive epidemiological study was carried out through face-to-face or web conferencing interviews with the veterinarians that provide technical assistance at commercial laying hen operations. A standardized and structured questionnaire was developed based on the literature and expert opinion, which contained 1 opened and 40 closed questions. Conventional non-probabilistic sampling was used, based on an initial list of 15 veterinarians registered in the Poultry Production Association of Rio Grande do Sul, followed by the snowball technique. The acquisition of 26 contacts of veterinarians was accomplished, and 16 were interviewed. Through the answers obtained it was possible to verify that the interviewees' understanding regarding both the antibiotic resistance impact and the decision-making about the use of antibiotics seem to be linked to their practical experiences. Besides that, according to the veterinarians, farmers can acquire and administer the antimicrobials on their farms. Moreover, both farm storage and administration of lower doses of antibiotics than the recommended one could be contributing factors to resistant bacteria selection. Furthermore, controversially, the professionals believed that resistant bacteria can be transmitted to humans from eggs, but they said that there are no bacteria in eggs. Therefore, the veterinarians´ practices can be improved considering national and international guidelines on antimicrobial resistance to minimize the development of resistance. Finally, it is expected that the present results will contribute to a more complex discussion about antimicrobial resistance, helping to formulate public policies in the egg production industry.

Co-production of knowledge as part of a OneHealth approach to better control zoonotic diseases

There is increased global and national attention on the need for effective strategies to control zoonotic diseases. Quick, effective action is, however, hampered by poor evidence-bases and limited coordination between stakeholders from relevant sectors such as public and animal health, wildlife and forestry sectors at different scales, who may not usually work together. The OneHealth approach recognises the value of cross-sectoral evaluation of human, animal and environmental health questions in an integrated, holistic and transdisciplinary manner to reduce disease impacts and/or mitigate risks. Co-production of knowledge is also widely advocated to improve the quality and acceptability of decision-making across sectors and may be particularly important when it comes to zoonoses. This paper brings together OneHealth and knowledge co-production and reflects on lessons learned for future OneHealth co-production processes by describing a process implemented to understand spill-over and identify disease control and mitigation strategies for a zoonotic disease in Southern India (Kyasanur Forest Disease). The co-production process aimed to develop a joint decision-support tool with stakeholders, and we complemented our approach with a simple retrospective theory of change on researcher expectations of the system-level outcomes of the co-production process. Our results highlight that while co-production in OneHealth is a difficult and resource intensive process, requiring regular iterative adjustments and flexibility, the beneficial outcomes justify its adoption. A key future aim should be to improve and evaluate the degree of inter-sectoral collaboration required to achieve the aims of OneHealth. We conclude by providing guidelines based on our experience to help funders and decision-makers support future co-production processes.

How are large-scale One Health initiatives targeting infectious diseases and antimicrobial resistance evaluated? A scoping review

While One Health initiatives are gaining in popularity, it is unclear if and how they are evaluated when implementation at scale is intended. The main purpose of this scoping review was to describe how One Health initiatives targeting infectious diseases and antimicrobial resistance at a large scale are evaluated. Secondary objectives included identifying the main facilitators and barriers to the implementation and success of these initiatives, and how their impacts were assessed. Twenty-three studies evaluating One Health initiatives were eligible. Most studies included the human (n = 22) and animal (n = 15) sectors; only four included the environment sector. The types of evaluated initiative (non-exclusive) included governance (n = 5), knowledge (n = 6), protection (n = 17), promotion (n = 16), prevention (n = 9), care (n = 8), advocacy (n = 10) and capacity (n = 10). Studies used normative (n = 4) and evaluative (n = 20) approaches to assess the One Health initiatives, the latter including impact (n = 19), implementation (n = 8), and performance (n = 7) analyses. Structural and economic, social, political, communication and coordination-related factors, as well as ontological factors, were identified as both facilitators and barriers for successful One Health initiatives. These results identified a wide range of evaluation methods and indicators used to demonstrate One Health's added values, strengths, and limitations: the inherent complexity of the One Health approach leads to the use of multiple types of evaluation. The strengths and remaining gaps in the evaluation of such initiative highlight the relevance of comprehensive, mixed-method, context-sensitive evaluation frameworks to inform and support the implementation of One Health initiatives by stakeholders in different governance settings.

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Studies evaluating One Health initiatives were scarce.

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Only One Health initiatives related to infectious diseases were evaluated.

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Evaluations were mainly conducted using quantitative approaches.

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Involvement of the community was identified as a major facilitator.

The one health landscape in Sub-Saharan African countries

OBJECTIVES

One Health is transiting from multidisciplinary to transdisciplinary concepts and its viewpoints should move from 'proxy for zoonoses', to include other topics (climate change, nutrition and food safety, policy and planning, welfare and well-being, antimicrobial resistance (AMR), vector-borne diseases, toxicosis and pesticides issues) and thematic fields (social sciences, geography and economics). This work was conducted to map the One Health landscape in Africa.

METHODS

An assessment of existing One Health initiatives in Sub-Saharan African (SSA) countries was conducted among selected stakeholders using a multi-method approach. Strengths, weaknesses, opportunities and threats to One Health initiatives were identified, and their influence, interest and impacts were semi-quantitatively evaluated using literature reviews, questionnaire survey and statistical analysis.

RESULTS

One Health Networks and identified initiatives were spatiotemporally spread across SSA and identified stakeholders were classified into four quadrants. It was observed that imbalance in stakeholders' representations led to hesitation in buying-in into One Health approach by stakeholders who are outside the main networks like stakeholders from the policy, budgeting, geography and sometimes, the environment sectors.

CONCLUSION

Inclusion of theory of change, monitoring and evaluation frameworks, and tools for standardized evaluation of One Health policies are needed for a sustained future of One Health and future engagements should be outputs- and outcomes-driven and not activity-driven. National roadmaps for One Health implementation and institutionalization are necessary, and proofs of concepts in One Health should be validated and scaled-up. Dependence on external funding is unsustainable and must be addressed in the medium to long-term. Necessary policy and legal instruments to support One Health nationally and sub-nationally should be implemented taking cognizance of contemporary issues like urbanization, endemic poverty and other emerging issues. The utilization of current technologies and One Health approach in addressing the ongoing pandemic of COVID-19 and other emerging diseases are desirable. Finally, One Health implementation should be anticipatory and preemptive, and not reactive in containing disease outbreaks, especially those from the animal sources or the environment before the risk of spillover to human.

A Survey on One Health Approach in Colombia and Some Latin American Countries: From a Fragmented Health Organization to an Integrated Health Response to Global Challenges

The “One Health” (OH) approach has been recognized by world health authorities such as FAO/OIE/WHO, advocating for effective, multi-sectoral, and transdisciplinary collaboration. However, there is a lack of published evidence of the awareness of the OH concept in Colombia and other countries in the Latin American Region. In order to explore existing collaboration amongst the animal health, human-public health, environmental health sectors, and to describe the perception, knowledge, and barriers on OH in Colombia and other countries of Latin America, an online questionnaire-based survey was distributed among key professionals representing the three OH pillars (August 2018–August 2020). Overall, 76 key respondents from 13 countries (Colombia, México, Chile, Brazil, Argentina, Bolivia, Costa Rica, Ecuador, Perú, Guatemala, Nicaragua Uruguay, and Venezuela) completed the questionnaire. Respondents worked in institutions of animal (59%), public (20%), human (7%), and environmental health (7%); they mainly belonged to higher academic institutions (59%), followed by ministries (11%), and research organizations (9%). Most participants (92%) were familiar with the OH term and 68% were aware of the formal cooperation among sectors in their countries, mostly on zoonoses; in 46% of the cases, such connections were established in the last 5 years. The main reported limiting factors to intersectorality were the lack of commitment of policy-makers, resources, and budget for OH (38%) and the “siloed approach” of sectors and disciplines (34%). Respondents ranked a median score of 3.0 (1–5 scoring) in how good OH activities are implemented in their countries, and a median score of 2.0 in the citizen awareness on OH as regards their countries. The most important OH issues were identified in vector-borne diseases, rabies, wrong and/or improper use of antimicrobials, emerging viral diseases, food-borne diseases, neglected parasitic diseases, deforestation, and ecosystem fragmentation. Although there is a high-perceived importance on conjoint cooperation, OH implementation, and operationalization remain weak, and the environmental component is not well-integrated. We consider that integration and implementation of the OH Approach can support countries to improve their health policies and health governance as well as to advocate the social, economic, and environmental sustainability of the Region.

A One-Health evaluation of the burden of cystic echinococcosis and its prevention costs: Case study from a hypo-endemic area in Italy

An integrated model, based on a One Health approach, was implemented to estimate the epidemiological and economic outcomes of cystic echinococcosis (CE) in Veneto region, an hypo-endemic area of Northern Italy, and the costs for its prevention. Data and information needed to populate the model were retrieved from published literature, official statistics, expert opinions, or actively searched through data mining (i.e., Hospital and slaughterhouse data), when fundamental data were not available. Human-health and animal-health costs, both public and private, were considered. The overall impact of CE in the study area was estimated in an yearly cost of about 0.5 million €, due to an average of 19.5 human hospitalized cases and about 200 infected animals among cattle and sheep, per year. The human:animal costs ratio was about 8:1. Most of the infected animals were autochthonous, while the identification of an autochthonous source of the infection for the human cases was extremely difficult, and unlikely in most cases. No specific action resulted to be in place for human surveillance, while veterinary surveillance accounted for a yearly cost of about 22,000 €. Sheepherders were found to pay privately an overall amount of around 2000 € for the preventive treatment of their dogs every year, but the applied protocol proved to be sub-optimal. The source of most of the human cases was likely external to the study area, and their economic impact accounts for a cost that is far exceeding that of surveillance and preventive actions in place in the veterinary sector. Although autochthonous human cases appeared to be very rare, the strengthening of preventive actions and surveillance systems can reduce the risk of their increment.

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The study integrated epidemiology and economic aspects in a One Health perspective.

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The research estimates in detail the overall impact of CE in a hypo-endemic region in Italy.

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The study provided data for evidence-based actions to control CE in the study area.

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The investigated case study represents a reproducible model for zoonotic diseases evaluation.

One planet, one health, one future: The environmental perspective

The final goal of the "One Health" is the control of the global health of our planet with a multidisciplinary approach that involves knowledge for different disciplines. In the near future, we could see in the same team veterinarians, doctors, and environmental experts work together to guarantee the health of our planet and one sustainable future for all.

Critical Evaluation of Cross-Sectoral Collaborations to Inform the Implementation of the "One Health" Approach in Guadeloupe

In Guadeloupe, a French overseas territory located in the Eastern Caribbean, infectious and non-infectious diseases, loss of biodiversity, natural disasters and global change threaten the health and well-being of animals, plants, and people. Implementing the “One Health” (OH) approach is crucial to reduce the archipelago's vulnerability to these health threats. However, OH remains underdeveloped in Guadeloupe, hampering efficient and effective intersectoral and transdisciplinary collaborations for disease surveillance and control. A multidisciplinary research group of volunteer researchers working in Guadeloupe, with collective expertise in infectious diseases, undertook a study to identify key attributes for OH operationalization by reviewing past and current local collaborative health initiatives and analyzing how much they mobilized the OH framework. The research group developed and applied an operational OH framework to assess critically collaborative initiatives addressing local health issues. Based on a literature review, a set of 13 opinion-based key criteria was defined. The criteria and associated scoring were measured through semi-directed interviews guided by a questionnaire to critically evaluate four initiatives in animal, human, plant, and environmental health research and epidemiological surveillance. Gaps, levers, and prospects were identified that will help health communities in Guadeloupe envision how to implement the OH approach to better address local health challenges. The methodology is simple, generic, and pragmatic and relies on existing resources. It can be transposed and adapted to other contexts to improve effectiveness and efficiency of OH initiatives, based on lessons-learned of local past or current multi-interdisciplinary and intersectoral initiatives.

One Health Evaluation: A Case Study at the University of Bologna

The level of One Health (OH), or “One Health-ness,” of health interventions has been defined as the capacity to operate according to six dimensions concerning OH operations and OH infrastructures, respectively (thinking, planning, and working; and information sharing, reciprocal learning, and systemic organization). Although health initiatives and research increasingly claim their orientation toward OH, such a capacity is rarely assessed. The objective of this study is to evaluate the One Health-ness of the academic team of the University of Bologna (UNIBO Team) working in the “ELEPHANT” project (Empowering universities' Learning and rEsearch caPacities in the one Health Approach for the maNagement of animals at the wildlife, livestock and human interface in SouTh Africa). This project involves universities, six from South Africa and two from Europe, and aims at embedding OH in research and learning to enable the control of diseases at the human, animal, and environmental interface, and to emphasize the interests of local African communities with wildlife conservation. The methodology adopts the NEOH method, developed in 2018 by the EU-COST Action, “Network for the Evaluation of One Health.” The approach is based on questionnaires delivered to participants, which focus on the six OH dimensions, and then translate answers into quantitative metrics through the OH Index (OHI) and the OH Ratio (OHR). The following two evaluation levels are foreseen: the whole project and the single partner institutions. The evaluations are carried on in parallel, with preliminary, mid-term, and final assessments, to monitor the efficacy of the project actions. The preliminary evaluation of the UNIBO Team resulted in the OHI of 0.23 and the OHR of 1.69 which indicate a low degree of OH-ness and an imbalance between OH operation and OH infrastructure. The UNIBO case study will be the baseline for the evaluation of the other partner institutions involved in the ELEPHANT project. This type of evaluation can support the implementation of OH practices inside a project and underpin the strategies that allow to achieving more effective results. Any improvement in the OH-ness of each single academic team can be also considered as a result of the ELEPHANT project, thus showing its multiplier effect in the context.

System Thinking and Citizen Participation Is Still Missing in One Health Initiatives - Lessons From Fifteen Evaluations

Tackling complex public health challenges requires integrated approaches to health, such as One Health (OH). A key element of these approaches is the integration of knowledge across sectors, disciplines and stakeholders. It is not yet clear which elements of knowledge integration need endorsement to achieve best outcomes. This paper assesses 15 OH initiatives in 16 African, Asian and European countries to identify opportunities to improve knowledge integration and to investigate geographic influences on knowledge integration capacities. Two related evaluation tools, both relying on semi-quantitative questionnaires, were applied to two sets of case studies. In one tool, the questions relate to operations and infrastructure, while the other assigns questions to the three phases of “design,” “implementation,” and “evaluation” of the project life cycle. In both, the question scores are aggregated using medians. For analysis, extreme values were identified to highlight strengths and weaknesses. Seven initiatives were assessed by a single evaluator external to the initiative, and the other eight initiatives were jointly assessed by several internal and external evaluators. The knowledge integration capacity was greatest during the project implementation stage, and lowest during the evaluation stage. The main weaknesses pointing towards concrete potential for improvement were identified to be a lack of consideration of systemic characteristics, missing engagement of external stakeholders and poor bridging of knowledge, amplified by the absence of opportunities to learn and evolve in a collective process. Most users were unfamiliar with the systems approach to evaluation and found the use of the tools challenging, but they appreciated the new perspective and saw benefits in the ensuing reflections. We conclude that systems thinking and associated practises for OH require not only specific education in OH core competencies, but also methodological and institutional measures to endorse broad participation. To facilitate meta-analyses and generic improvement of integrated approaches to health we suggest including knowledge integration processes as elements to report according to the COHERE guidelines.

A qualitative assessment of the context and enabling environment for the control of Taenia solium infections in endemic settings

BACKGROUND

Taenia solium (T. solium), is a zoonotic helminth causing three diseases namely; taeniasis (in humans), neurocysticercosis (NCC, in humans) and porcine cysticercosis (PCC, in pigs) and is one of the major foodborne diseases by burden. The success or failure of control options against this parasite in terms of reduced prevalence or incidence of the diseases may be attributed to the contextual factors which underpin the design, implementation, and evaluation of control programmes.

METHODOLOGY/PRINCIPAL FINDINGS

The study used a mixed method approach combining systematic literature review (SLR) and key informant interviews (KII). The SLR focused on studies which implemented T. solium control programmes and was used to identify the contextual factors and enabling environment relevant to successful inception, planning and implementation of the interventions. The SLR used a protocol pre-registered at the International prospective register of systematic reviews (PROSPERO) number CRD42019138107 and followed PRISMA guidelines on reporting of SLR. To further highlight the importance and interlinkage of these contextual factors, KII were conducted with researchers/implementers of the studies included in the SLR. The SLR identified 41 publications that had considerations of the contextual factors. They were grouped into efficacy (10), effectiveness (28) and scale up or implementation (3) research studies. The identified contextual factors included epidemiological, socioeconomic, cultural, geographical and environmental, service and organizational, historical and financial factors. The enabling environment was mainly defined by policy and strategies supporting T. solium control.

CONCLUSION/SIGNIFICANCE

Failure to consider the contextual factors operating in target study sites was shown to later present challenges in project implementation and evaluation that negatively affected expected outcomes. This study highlights the importance of fully considering the various domains of the context and integrating these explicitly into the plan for implementation and evaluation of control programmes. Explicit reporting of these aspects in the resultant publication is also important to guide future work. The contextual factors highlighted in this study may be useful to guide future research and scale up of disease control programmes and demonstrates the importance of close multi-sectoral collaboration in a One Health approach.

Understanding farmers' and veterinarians' behavior in relation to antimicrobial use and resistance in dairy cattle: A systematic review

To tackle antimicrobial resistance, it is vital that farmers' and veterinarians' antimicrobial use behaviors and attitudes toward resistance are understood so that we can identify how beliefs and motives influence practices. Current literature details qualitative and quantitative research that explores the knowledge, attitudes and perceptions of dairy farmers and veterinarians with respect to antimicrobial resistance and antimicrobial practices, and the reported findings are varied and conflicting. Our objective was to conduct a systematic review to assess the evidence and knowledge gaps in the published literature. We identified articles via database searches of Embase, Medline, PubMed, Scopus, and Web of Science; we limited findings to published articles available in English with no publication year restrictions. Article screening was conducted at 3 levels: title, abstract, and full text. Of the 349 articles identified, 35 were retained for systematic review. Transparency of reporting was assessed for each study using the Consolidated Criteria for Reporting Qualitative Research (COREQ) framework. Quality was assessed using the Critical Appraisal Skills Programme qualitative checklist. Findings relating to dairy farmers' and veterinarians' knowledge, attitudes, and perceptions on antimicrobial resistance and practices were thematically analyzed. The comprehensiveness of reporting was variable: studies reported 5 to 26 of the 32 COREQ checklist items. Five key themes emerged from the data: knowledge and awareness of antimicrobial resistance; factors influencing farmer and veterinarian decision-making; perceived barriers and facilitators to reduced antimicrobial use; perceived responsibility for antimicrobial resistance; and the role of the farmer and veterinarian relationship in reducing antimicrobial use. Awareness of prudent antimicrobial use was not uniform between studies. Many factors influence farmers' and veterinarians' decisions to use antimicrobials, including animal welfare and available resources. The farmer-veterinarian relationship is a potential barrier or facilitator of reduced antimicrobial use, depending on the perceived relationship dynamic. Encouraging collaboration between farmers and veterinarians could lead to shared responsibility for reducing antimicrobial use. This review provided a coherent picture of what is currently known and identified gaps in the current knowledge to inform future behavioral intervention research. Increased knowledge, skill development, resources, engagement, and further research to address the gaps we identified are the main recommendations to effectively overcome barriers, elicit appropriate behavior change, and achieve reduced antimicrobial use in dairy cattle.

A Survey on One Health Perception and Experiences in Europe and Neighboring Areas

A questionnaire survey was promoted under the COST Actions “Network for Evaluation of One Health-NEOH” and “European Network for Neglected Vectors and Vector-Borne Infections-EURNEGVEC”, from June 2016 to April 2017, to collect information on the existence of One Health (OH) collaboration and implementation of OH initiatives in 37 EU COST Countries. The questionnaire was to be answered by key respondents representing the three major OH components: (i). Animal Health; (ii). Human Health/Public Health; (iii). Environmental Health. A target respondent rate of nine respondents/country was aimed for, representing the following categories: (i). ministries; (ii). academia-research; (iii). private sector and NGOs, associations and scientific societies. The questionnaire, composed of 27 questions organized in six sections, was circulated to target respondents by Committee Members of the two COST actions. A total of 171 respondents from 34 countries completed the questionnaire, mainly belonging to academic and research institutions (55.5%), and to Animal Health/Animal Science fields (53.8%). Although the majority (57.9%) declared they had heard about OH, few respondents (10.7%) provided a complete definition. The “human” and “animal” elements prevailed over other key elements of OH definition (ecosystem, intersectoral, transdisciplinary, holistic, collaboration). Overall, 62.6% respondents declared to take part in OH initiatives. Antimicrobial resistance, avian influenza and environmental pollution were cited as the top three OH issues over the past 5 years. Limitations and gaps in intersectoral collaboration included communication and organizational problems resulting in poor networking, differing priorities and a lack of understanding between sectors. Regarding control and monitoring of zoonotic diseases, respondents from different sectors preferentially selected their own directorates/ministries while actually in most countries both Ministry of Health and Ministry of Agriculture are engaged. According to respondents, the level of awareness of OH amongst the general public is limited. Similarly, a dearth of opportunities of collaborations at different institutional and/or professional levels was described. Our survey provided an overview of how respondents in COST countries perceived and experienced OH and current limits to OH implementation. Identifying how initiatives are currently working and knowing the promoting and hindering factors allowed suggesting strategies to promote efficiency and effectiveness of OH implementation in the future.

Wildlife as Sentinels of Antimicrobial Resistance in Germany?

The presence of bacteria carrying antimicrobial resistance (AMR) genes in wildlife is an indicator that resistant bacteria of human or livestock origin are widespread in the environment. In addition, it could represent an additional challenge for human health, since wild animals could act as efficient AMR reservoirs and epidemiological links between human, livestock and natural environments. The aim of this study was to investigate the occurrence and the antibiotic resistance patterns of several bacterial species in certain wild animals in Germany, including wild boars (Sus scrofa), roe deer (Capreolus capreolus) and wild ducks (family Anatidae, subfamily Anatinae) and geese (family Anatidae, subfamily Anserinae). In the framework of the German National Zoonoses Monitoring Program, samples from hunted wild boars, roe deer and wild ducks and geese were collected nationwide in 2016, 2017, and 2019, respectively. Fecal samples were tested for the presence of Salmonella spp. (in wild boars and wild ducks and geese), Campylobacter spp. (in roe deer and wild ducks and geese), Shiga toxin-producing Escherichia (E.) coli (STEC), commensal E. coli and extended-spectrum beta-lactamase- (ESBL) or ampicillinase class C (AmpC) beta-lactamase-producing E. coli (in wild boars, roe deer and wild ducks and geese). In addition, the presence of methicillin-resistant Staphylococcus aureus (MRSA) was investigated in nasal swabs from wild boars. Isolates obtained in the accredited regional state laboratories were submitted to the National Reference Laboratories (NRLs) for confirmation, characterization and phenotypic resistance testing using broth microdilution according to CLSI. AMR was assessed according to epidemiological cut-offs provided by EUCAST. Salmonella spp. were isolated from 13 of 552 (2.4%) tested wild boar fecal samples, but absent in all 101 samples from wild ducks and geese. Nine of the 11 isolates that were submitted to the NRL Salmonella were susceptible to all tested antimicrobial substances. Campylobacter spp. were isolated from four out of 504 (0.8%) roe deer fecal samples, but not from any of the samples from wild ducks and geese. Of the two isolates received in the NRL Campylobacter, neither showed resistance to any of the substances tested. From roe deer, 40.2% of the fecal samples (144 of 358) yielded STEC compared to 6.9% (37 of 536) from wild boars. In wild ducks and geese, no STEC isolates were found. Of 150 STEC isolates received in the NRL (24 from wild boars and 126 from roe deer), only one from each animal species showed resistance. Of the 219 isolates of commensal E. coli from wild boars tested for AMR, 210 were susceptible to all 14 tested substances (95.9%). In roe deer this proportion was even higher (263 of 269, 97.8%), whereas in wild ducks and geese this proportion was lower (41 of 49, 83.7%). Nevertheless, selective isolation of ESBL-/AmpC-producing E. coli yielded 6.5% (36 of 551) positive samples from wild boars, 2.3% (13 of 573) from roe deer and 9.8% (10 of 102) from wild ducks and geese. Among the 25 confirmed ESBL-/AmpC-producing isolates from wild boars, 14 (56.0%) showed resistance up to five classes of substances. This proportion was lower in roe deer (3 of 12, 25%) and higher in wild ducks and geese (7 of 10, 70%). None of the 577 nasal swabs from wild boars yielded MRSA. Results indicate that overall, the prevalence of resistant bacteria from certain wild animals in Germany is low, which may reflect not only the low level of exposure to antimicrobials but also the low level of resistant bacteria in the areas where these animals live and feed. However, despite this low prevalence, the patterns observed in bacteria from the wild animals included in this study are an indicator for specific resistance traits in the environment, including those to highest priority substances such as 3rd generation cephalosporins, fluoroquinolones and colistin. Therefore, also continuous monitoring of the occurrence of such bacteria in wildlife by selective isolation is advisable. Furthermore, the possible role of wildlife as reservoir and disperser of resistant bacteria would need to be assessed, as wild animals, and in particular wild ducks and geese could become spreaders of resistant bacteria given their capacity for long-range movements.

Reflecting on One Health in Action During the COVID-19 Response

The COVID-19 pandemic, a singular disruptive event in recent human history, has required rapid, innovative, coordinated and collaborative approaches to manage and ameliorate its worst impacts. However, the threat remains, and learning from initial efforts may benefit the response management in the future. One Health approaches to managing health challenges through multi-stakeholder engagement are underscored by an enabling environment. Here we describe three case studies from state (New South Wales, Australia), national (Ireland), and international (sub-Saharan Africa) scales which illustrate different aspects of One Health in action in response to the COVID-19 pandemic. In Ireland, a One Health team was assembled to help parameterise complex mathematical and resource models. In New South Wales, state authorities engaged collaboratively with animal health veterinarians and epidemiologists to leverage disease outbreak knowledge, expertise and technical and support structures for application to the COVID-19 emergency. The African One Health University Network linked members from health institutions and universities from eight countries to provide a virtual platform knowledge exchange on COVID-19 to support the response. Themes common to successful experiences included a shared resource base, interdisciplinary engagement, communication network strategies, and looking global to address local need. The One Health approaches used, particularly shared responsibility and knowledge integration, are benefiting the management of this pandemic and future One Health global challenges.

The Prevalence of Salmonella spp. in Two Arctic Fox (Alopex lagopus) Farms in Poland

Simple Summary

Salmonella enterica subsp. enterica derived from poultry meat is the primary cause of Salmonella infection in humans and the second most ubiquitous zoonosis in the European Union after campylobacteriosis. Wildlife animals and livestock can be a reservoir of Salmonella spp., and they can contribute to the persistence of bacteria in the environment. Salmonella spp. pathogens can also be a source of widespread infections in fur-bearing animals, such as foxes (Vulpes vulpes) and mink (Neovison vision). This study analysed the prevalence of Salmonella spp. in two Arctic fox (Alopex lagopus) farms and the correlations between animals that tested positive for Salmonella spp and breeding results. Salmonella Heidelberg, S. Saintpaul, and S. Reading were isolated. All three serotypes are typically isolated from commercial poultry flocks. In this study, Salmonella spp. increased the risk of female infertility, but further research is needed to confirm the results. This is the first report on the prevalence of S. Heidelberg, S. Saintpaul, and S. Reading in an Arctic fox (Alopex lagopus) population.

Abstract

The objective of the study was to determine the occurrence of Salmonella spp. infections in two Arctic fox (Alopex lagopus) farms in Poland, and to analyse the correlations between animals that tested positive for Salmonella spp and breeding results. Faecal samples were taken from 1094 clinically healthy blue foxes from the basic stock of farms A and B. Salmonella spp. were detected in 18.06% (56/310) of the samples collected in farm A and in 15.94% (125/784) of the samples collected in farm B. All isolated strains belonged to S. enterica subsp. enterica serotypes Salmonella Saintpaul (S. Saintpaul), Salmonella Reading (S. Reading), and Salmonella Heidelberg (S. Heidelberg). All three serotypes are typically isolated from commercial poultry flocks. Salmonella spp. infections significantly increased the risk of female infertility, but further research is needed to confirm the results. This is the first report on the prevalence of S. Heidelberg, S. Saintpaul, and S. Reading in faecal samples collected from Arctic fox (Alopex lagopus) farms in Poland.

The state of One Health research across disciplines and sectors - a bibliometric analysis

There is a growing interest in One Health, reflected by the rising number of publications relating to One Health literature, but also through zoonotic disease outbreaks becoming more frequent, such as Ebola, Zika virus and COVID-19.

This paper uses bibliometric analysis to explore the state of One Health in academic literature, to visualise the characteristics and trends within the field through a network analysis of citation patterns and bibliographic links. The analysis focuses on publication trends, co-citation network of scientific journals, co-citation network of authors, and co-occurrence of keywords.

The bibliometric analysis showed an increasing interest for One Health in academic research. However, it revealed some thematic and disciplinary shortcomings, in particular with respect to the inclusion of environmental themes and social science insights pertaining to the implementation of One Health policies. The analysis indicated that there is a need for more applicable approaches to strengthen intersectoral collaboration and knowledge sharing. Silos between the disciplines of human medicine, veterinary medicine and environment still persist. Engaging researchers with different expertise and disciplinary backgrounds will facilitate a more comprehensive perspective where the human-animal-environment interface is not researched as separate entities but as a coherent whole. Further, journals dedicated to One Health or interdisciplinary research provide scholars the possibility to publish multifaceted research. These journals are uniquely positioned to bridge between fields, strengthen interdisciplinary research and create room for social science approaches alongside of medical and natural sciences.

Epidemiologic-economic models and the One Health paradigm: echinococcosis and leishmaniasis, case studies in Veneto region, Northeastern Italy

Epidemiology and health economics have systemic interdependencies. The identification of the economic outcomes of any disease is operated by overlapping its epidemiology with the economic functions of the impacted entities. This communication presents two epidemiologic-economic models designed to evaluate the economic burden of cystic echinococcosis and leishmaniasis in Veneto (Northeastern Italy). Following a One Health approach, the research integrates expertise from different disciplines and institutions and fulfilled its first stage by defining the relevant cost categories and the data collection strategy for the two diseases in the study area. The two models identify the relevant epidemiological factors and the economic outcomes of infections in both animals and humans. The results, visualized in flow charts indicating the types of costs associated with these zoonoses, will guide data collection and the epidemiologic and economic assessment in the next research stages. This experience shows that One Health methods, although still innovative or unusual in many scientific and professional contexts, can be applied by using relatively limited resources and already available professional skills.

Fallow Deer (Dama dama) as a Reservoir of Shiga Toxin-Producing Escherichia coli (STEC)

Shiga toxin-producing Escherichia (E.) coli (STEC) are responsible for the outbreaks of serious diseases in humans. Only a few reports on fallow deer as a reservoir of foodborne pathogens have been published to date. The purpose of this study was to determine the occurrence of STEC strains in the fallow deer population in Poland. In all, 94 fallow deer swabs were tested. Polymerase chain reaction (PCR) was performed to detect the virulence profile of stx1, stx2 and eae or aggR genes, to identify the subtypes of stx1 and stx2 genes and to perform O and H serotyping. STEC and attaching and effacing (AE)-STEC were identified in 13 isolates (13.83%). The most hazardous virulence profile was detected in three strains, namely stx2d serotype O103:HNM, eae/stx1a serotype O26:HNM and eae/stx1a serotype O157:H7. The predominant stx gene was stx2, which was identified in 76.92% of isolates. E. coli O157 was detected in 4/94 (4.26%). Other E. coli serogroups, O26, O103, O111 and O145, were identified in 14/94 fallow deer (14.89%). The present findings suggest that fallow deer are carriers of STEC/AE-STEC that are potentially pathogenic to humans.

Global Crisis Leadership for Disease-Induced Threats: One Health and Urbanisation

The concept of 'One Health' (OH) has gathered momentum among the public health and animal health communities as an important global policy agenda for drawing together these disciplines to inform urban planning and health security policies. OH research, from a risk governance perspective, is generally concerned with identifying preventative programmes that can minimise the threats posed by diseases at the animal-human interface (e.g. Corona virus, Ebola, avian influenza, the Q virus, for example). This article, by drawing on examples of disease threats, discusses the multi-level challenges of establishing OH with a particular focus on urban change. It considers the risks posed by the increasing urbanisation of animal habitats and what this means for achieving OH. The article concludes by discussing why social scientists need to pay greater attention to the concept of OH.

Integrative concepts and practices of health in transdisciplinary social ecology

Increasing recognition of interdependencies of the health of humans, other organisms and ecosystems, and of their importance to socio-ecological systems, necessitates application of integrative concepts such as One Health and EcoHealth. These concepts open new perspectives for research and practice but also generate confusion and divergent opinion, prompting new theories, and call for empirical clarification and evaluation. Through a semi-systematic evaluation of knowledge generation in scientific publications (comprised of literature reviews, conceptual models and analyses of communities of practice), we show how integrative concepts and approaches to health evolve and are adopted. Our findings indicate that while their contexts, goals and rationales vary, integrative concepts of health essentially arise from shared interests in living systems. Despite recent increased attention to ecological and societal aspects of health including broader sustainability issues, the focus remains anthropocentric and oriented towards biomedicine. Practices reflect and in turn transform these concepts, which together with practices also influence ways of integration. Overarching narratives vary between optimism and pessimism towards integrated health and knowledge. We conclude that there is an urgent need for better, coherent and more deeply integrative health concepts, approaches and practices to foster the well-being of humans, other animals and ecosystems. Consideration of these concepts and practices has methodological and political importance, as it will transform thinking and action on both society and nature and specifically can enrich science and practice, expanding their scope and linking them better. Transdisciplinary efforts are crucial to developing such concepts and practices to properly address the multiple facets of health and to achieve their appropriate integration for the socio-ecological systems at stake. We propose the term “transdisciplinary health” to denote the new approaches needed.

EcoHealth and One Health: A theory-focused review in response to calls for convergence

BACKGROUND

EcoHealth and One Health are two major approaches broadly aimed at understanding the links between human, animal, and environment health. There have been increasing calls for convergence between the two. If convergence is desired, greater clarity regarding the underlying theoretical assumptions of both approaches is required. This would also support integrated research to effectively address complex health issues at the human, animal and environment interface. To better understand the areas of overlap and alignment, we systematically compared and contrasted the theoretical assumptions of both approaches.

OBJECTIVES

We aimed to gain a more in-depth understanding of the ontological, epistemological and methodological underpinnings of EcoHealth and One Health in order to identify areas of difference and overlap, and consider the extent to which closer convergence between the two may be possible.

METHODS

We undertook a scoping review of literature about the ontological, epistemological and methodological positions of EcoHealth and One Health, and analyzed these according to Lincoln, Lynham and Guba's paradigm framework.

RESULTS

EcoHealth and One Health are both collaborative, systems-focused approaches at the human, animal, and ecosystem health interface. EcoHealth typically leans towards constructivist-leaning assumptions. Many consider this a necessary aspiration for One Health. However, in practice One Health remains dominated by the veterinary and medical disciplines that emphasize positivist-leaning assumptions.

DISCUSSION

The aspirations of EcoHealth and One Health appear to overlap at the conceptual level, and may well warrant closer convergence. However, further shared discussions about their epistemological and ontological assumptions are needed to reconcile important theoretical differences, and to better guide scopes of practice. Critical realism may be a crucial theoretical meeting point. Systems thinking methods (with critical realist underpinnings), such as system dynamics modelling, are potentially useful methodologies for supporting convergent practice.

Shiga toxin-producing Escherichia coli isolates from red deer (Cervus elaphus), roe deer (Capreolus capreolus) and fallow deer (Dama dama) in Poland

Shiga toxin-producing Escherichia (E.) coli (STEC) pathogens are responsible for the outbreaks of serious diseases in humans, including haemolytic uraemic syndrome (HUS), bloody diarrhoea (BD) and diarrhoea (D), and they pose a significant public health concern. Wild ruminants are an important environmental reservoir of foodborne pathogens that can cause serious illnesses in humans and contaminate fresh products. There is a general scarcity of published data about wildlife as a reservoir of foodborne pathogens in Poland, which is why the potential epidemiological risk associated with red deer, roe deer and fallow deer as reservoirs of STEC/AE-STEC strains was evaluated in this study. The aim of the study was to investigate the prevalence of STEC strains in red deer (Cervus elaphus), roe deer (Capreolus capreolus) and fallow deer (Dama dama) populations in north-eastern Poland, and to evaluate the potential health risk associated with wild ruminants carrying STEC/AE-STEC strains. We examined 252 rectal swabs obtained from 134 roe deer (Capreolus capreolus), 97 red deer (Cervus elaphus) and 21 fallow deer (Dama dama) in north-eastern Poland. The samples were enriched in modified buffered peptone water. Polymerase chain reaction (PCR) assays were conducted to determine the virulence profile of stx1, stx2 and eae or aggR genes, to identify the subtypes of stx1 and stx2 genes, and to perform O and H serotyping. E. coli O157:H7 isolates were detected in the rectal swabs collected from 1/134 roe deer (0.75%) and 4/97 red deer (4.1%), and they were not detected in fallow deer (Dama dama). The remaining E. coli serogroups, namely O26, O103, O111 and O145 that belong to the "top five" non-O157 serogroups, were detected in 15/134 roe deer (11.19%), 18/97 red deer (18.56%) and 2/21 fallow deer (9.52%). STEC/AE-STEC strains were detected in 33 roe deer isolates (24.63%), 21 red deer isolates (21.65%) and 2 fallow deer isolates (9.52%). According to the most recent FAO/WHO report, stx2a and eae genes are the primary virulence traits associated with HUS, and these genes were identified in one roe deer isolate and one red deer isolate. Stx2 was the predominant stx gene, and it was detected in 78.79% of roe deer and in 71.43% of red deer isolates. The results of this study confirmed that red deer and roe deer in north-eastern Poland are carriers of STEC/AE-STEC strains that are potentially pathogenic for humans. This is the first report documenting the virulence of STEC/AE-STEC strains from wild ruminants in Poland.

What makes an effective One Health clinical practitioner? Opinions of Australian One Health experts

Despite agreement that One Health practices facilitate effective management of zoonoses, the pathways to a coordinated and collaborative approach by general medical practitioners (GPs) and veterinarians are hampered by limited understanding of how this can be practically incorporated in routine clinical settings. Data collected during a Delphi survey of Australian One Health ‘experts’ was used to explore opinions and insights into desired knowledge, attitudes and practices of effective One Health clinical practitioners. Five categories were identified as essential for GPs and veterinarians, namely: accurate baseline knowledge of specific zoonoses; a ‘big picture’ understanding of zoonoses; understanding of professional roles within the One Health paradigm; understanding one's own professional limitations; and collaboration and referral improve outcomes. An outline of the roles and responsibilities of GPs and veterinarians as effective One Health clinicians was determined based on the opinions of the expert panel. Educational interventions that foster interprofessional communication and collaboration will be necessary to successfully bring about the cultural change required to achieve effective One Health practice in Australia, and thus expedite improved human, animal and environmental health outcomes.

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Experts identified five essential categories required by general medical practitioners and veterinarians.

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Cross professional collaboration was seen as a hallmark of effective One Health practice.

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Specific roles were identified for GPs and veterinarians with regard to zoonoses management

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Significant cultural change is required to successfully facilitate effective One Health practice at a clinical level

Operationalizing One Health Employing Social-Ecological Systems Theory: Lessons From the Greater Mekong Sub-region

The idea of the interdependency of the health of humans, animals, and ecosystems emerged from the interplay of theory and concepts from medicine, public health and ecology among leading thinkers in these fields during the last century. The rationale for One Health and its focus on the “human, animal, and environmental interface” stems from this legacy and points to transdisciplinary, ecological and complex systems approaches as central to One Health practice. Demonstration of One Health's efficacy, its wider adoption and continual improvement require explicit operational criteria and evaluation metrics on this basis. Social-Ecological Systems Theory with its unique conception of resilience (SESR) currently offers the most well-developed framework for understanding these approaches and development of performance standards. This paper describes operational criteria for One Health developed accordingly, including a protocol currently being tested for vector borne disease interventions. Wider adoption of One Health is most likely to occur as One Health practitioners gain an increasing familiarity with ecological and complex systems concepts in practice employing a transdisciplinary process. Two areas in which this inevitably will be required for significant further progress, and where the beginnings of a foundation for building upon exist, include: (1) Emerging and re-emerging zoonotic diseases, and (2) successful implementation of the United Nations (UN) Sustainable Development Goals (SDGs). The former includes the challenge of stemming the threat of new microbial pathogens, anti-microbial resistant variants of existing pathogens, as well as resurgence of malaria and other recalcitrant diseases. The applicability of SESR in this regard is illustrated with two case examples from the Greater Mekong Subregion, Avian Influenza (H5N1) and Liver Fluke (Opisthorchis viverrini). Each is shown to represent a science and policy challenge suggestive of an avoidable social-ecological system pathology that similarly has challenged sustainable development. Thus, SESR framing arguably is highly applicable to the SDGs, which, to a large extent, require consideration of human-animal-environmental health linkages. Further elaboration of these One Health operational criteria and metrics could contribute to the achievement of many of the SDGs.

Characteristics of One Health surveillance systems: A systematic literature review

The concept of One Health (OH) promotes the decompartmentalisation of human, animal, and ecosystem health for the more efficient and sustainable governance of complex health issues. This means that traditional boundaries between disciplines and sectors must be transgressed and that all relevant stakeholders must be involved in the definition and management of health problems. International efforts have been made to strengthen collaboration across sectors and disciplines and OH surveillance is strongly encouraged at global, national and local-level to efficiently manage hazards involving humans, animals and ecosystems. This concept is intuitively appealing and would suggest the enhanced performance and cost-effectiveness of surveillance systems, as compared to more conventional approaches. Nevertheless, confusion and uncertainty regarding the practical application, outcomes and impacts prevail. We believe that this is due to the lack of a conceptual and methodological framework which would (i) define the characteristics of OH surveillance, and (ii) identify the appropriate mechanisms for inter-sectoral and multi-disciplinary collaboration, to ensure that the surveillance system performs well, with regard to the objective, the context and the health hazard under surveillance. The objective of the study is to define the organisational and functional characteristics of OH surveillance systems, the context in which they are implemented, as well as the influential factors which may obstruct or support their implementation and performance. To achieve this, a systematic literature review of existing OH surveillance systems was conducted using the Prisma guidelines. The selected systems were assessed according to 38 predetermined variables. These allowed the characterisation of their objectives, organisation, functioning, performance and benefits. Data extraction was conducted using a spreadsheet and a database was built using an electronic multiple-choice questionnaire. The literature search identified a total of 1635 records. After the screening phase, 31 references were kept and 22 additional references retrieved from bibliographies were added. From these 53 selected documents, we retrieved 41 different surveillance systems in line with the definition proposed in this study. The analysis of this database enabled the identification of different dimensions and areas of collaboration. Barriers and levers for the implementation of OH surveillance systems were also identified and discussed. Based on our results, we propose a framework to characterise the organisation of collaboration for the governance and operation of an effective OH surveillance system.

Establishing research priorities to improve the One Health efficacy of Australian general practitioners and veterinarians with regard to zoonoses: A modified Delphi survey

While general medical practitioners (GPs) and veterinarians are often the first line responders in the face of a disease outbreak, pathways to improving the One Health efficacy of these clinicians remain unclear. A two-phase modified Delphi survey of professionals with known expertise in One Health (‘expert panel’) was used to 1) identify key knowledge, attitudes and practices (KAPs) of GPs and veterinarians that would be consistent with a One Health approach to zoonoses; and 2) determine priorities for future surveys with Australian GPs and veterinarians to identify important gaps that impede effective diagnosis and management of zoonoses. A list of 13 topics/sub-topics, as well as a list of 25 specific zoonotic diseases/agents emerged from the first phase of the survey. In the second phase the expert panel identified general knowledge of the clinical aspects and epidemiological aspects of zoonoses, as well as risk management practices, as the most important KAPs and research priorities for both GPs and veterinarians. In terms of diseases, the expert panel regarded knowledge of Hendra virus, Q fever, Australian bat lyssavirus (ABLV), anthrax and Brucella suis most important for veterinarians, whilst for GPs, Q fever, gastrointestinal/foodborne diseases, influenza, ABLV and local vector-borne diseases were found to be most important by the expert panel. Some differences were noted in terms of prioritization of topics/sub-topics and diseases/agents according to expert background (veterinary and non-veterinary). The Delphi survey technique enabled efficient collection of data from a diverse range of One Health ‘experts’/specialists and provided clear priorities for proposed future research, and potentially for educational interventions to improve One Health efficacy of clinicians.

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Delphi survey identified research priorities to improve One Health efficacy of clinicians.

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Top priority: GP and veterinarian knowledge of clinical aspects, epidemiology and risk management of zoonoses.

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Top 5 diseases for veterinarians: Hendra, ABLV, Q fever, anthrax and B. suis.

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Top 5 diseases for GPs: Q fever, GI/foodborne diseases, influenza, and local vectorborne diseases.

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Participants with veterinary background prioritised collaboration and referral.

A scoping review on the prevalence of Shiga-toxigenic Escherichia coli in wild animal species

Zoonotic pathogens constitute the major source (60.3%) of emerging infectious diseases. Previous studies have investigated the prevalence of Shiga-toxigenic Escherichia coli (STEC) among wild animal species, but comprehensive data are needed to assess the role that these animals have in the transmission of STEC infections to the human population via faecal contamination of the environment, agri-food or water chain. Due to the nature of these microorganisms in which this human-animal-environment interface plays a relevant role on the disease's dynamics, a "One Health" approach is needed to prevent and control the worldwide spread. The aim of this study was to review the published research on the prevalence of STEC in wildlife. The search was performed using several online databases consisting of three blocks of specific search terms covering pathogen, type of study and population. Two reviewers applied the inclusion and exclusion criteria to screening and eligibility phases. Two hundred and twenty-five abstracts were screened for relevance, and 72 were included for data analysis. Most studies (77.8%) investigated the prevalence of STEC in ruminants and urban birds. Their role in transmitting the pathogen to humans, other animals and the agri-food chain is potentiated by the peculiar biological characteristics in ruminants and improved adaptation of urban birds to urban environments. The popularity of convenience and voluntary response sampling may be due to the lack of human-made boundaries on the wild animal species' habitat and having some samples from hunted-harvested animals. To our knowledge, this is the first comprehensive review on STEC prevalence in wild animal species from studies conducted across the globe. We recommend that future research includes and compares samples from varying origins (i.e., human, animal, environment and food) and applies a "One Health" approach to the emerging challenges that STEC poses to public health.

Application of the NEOH Framework for Self-Evaluation of One Health Elements of a Case-Study on Obesity in European Dogs and Dog-Owners

Obesity is a malnutrition disorder of global concern with increasing prevalence driven by underlying societal, economic and environmental mechanisms leading to changed physical activity patterns, eating behaviors and diet compositions in both humans and in their pet-dogs. A questionnaire-based study was carried out as a joint effort across 11 European countries. It was considered a One Health (OH) initiative between scientists from human and animal health sectors aiming to identify factors associated with obesity in dog owners and their dogs. Expected outcomes of this approach included new insights unachievable by single-sector research initiatives, and hence potentially leading to new cross-sectorial solutions. We performed an internal evaluation among the actors of the obesity initiative using the framework for evaluation developed by the “Network for Evaluation of One Health” (NEOH). It served as a case-study for the NEOH consortium to illustrate the application and provide feedback on the utility of the framework. The evaluation was performed by a subgroup of scientists also involved in the obesity study group, and it consisted of: (1) the definition of the initiative and its context, (2) the description of the theory of change, and (3) the qualitative and quantitative process evaluation of operations and supporting infrastructures scored on a scale from 0 to 1. In the One Health operations, the obesity study initiative scored medium high on OH-thinking (0.5) and OH-planning (0.45), and relatively high on OH-working (0.7). The supporting infrastructure score was high for systemic organization (0.8), but low for sharing (0.45) and learning (0.28). The calculated OH-index was 0.29 (on scale 0 to 1) indicating that the full potential of health integration and collaboration was not exploited in the initiative, and the main issue identified was a lack of stakeholder engagement. The OH-ratio of 1.1 indicated equal focus on operations and supporting infrastructures. Hence, the evaluation identified potentially counterproductive as well as beneficial characteristics, which are further discussed in this paper in relation to the expected outcomes. The NEOH framework for evaluation requires that the evaluators have a good understanding of systems thinking and the mechanisms of the health issue targeted by the initiative.

Brucellosis Control in Malta and Serbia: A One Health Evaluation

Brucellosis, also known as “undulant fever” or “Malta fever”, is a zoonotic infection caused by microorganisms belonging to Brucella, a genus of gram-negative coccobacilli that behave as facultative intracellular pathogens of ruminants, swine and other animals. Brucellosis is a threat to public health, hence identifying the optimal way of preventing disease spread is important. Under certain circumstances, integrated, multidisciplinary “One Health” (OH) initiatives provide added value compared to unidisciplinary or conventional health initiatives. Conceptualizing and conducting evaluations of OH approaches may help facilitate decisions on resource allocation. This article historically describes and compares Malta's 1995–1997 with Serbia's 2004–2006 brucellosis control programmes and quantitatively assesses the extent to which they were compliant with a OH approach. For both case studies, we describe the OH initiative and the system within which it operates. Characteristic OH operations (i.e., thinking, planning, working) and supporting infrastructures (to allow sharing, learning and systemic organization) were evaluated. We scored the different aspects of these programmes, with values ranging from zero to one (1 = strong integration of OH). Malta demonstrated a higher OH index (0.54) and ratio (1.37) than Serbia (0.49 and 1.14 respectively). We conclude that context and timing are key to determining how, when and why a One Health approach should be applied. The adoption of a true OH approach that involved systemic organization, leadership clarity and transdisciplinary communication, collaboration, and co-ordination was essential to Malta's successful eradication of brucellosis after several failed attempts. In contrast, contextual factors in Serbia permitted the successful adoption of a primarily sectorial approach for short term control of brucellosis. However, while a fully-fledged transdisciplinary OH approach was not initially required, it is likely to be key to maintenance of brucellosis control in the medium and long term. Through these two case studies, we demonstrate that One Health initiatives should be applied at the right place, at the right time, with the right people and using the appropriate conditions/infrastructure. Lastly, OH evaluations should include economic assessments to identify optimal of resources in these situations, thereby justifying funding and political support required.

One Health Integration: A Proposed Framework for a Study on Veterinarians and Zoonotic Disease Management in Ghana

In parallel with the recent world-wide promotion of One Health (OH) as a policy concept, a growing body of social science studies has raised questions about how successful OH policies and programs have been in managing some global health issues, such as zoonotic diseases. This paper briefly reviews this literature to clarify its critical perspective. Much of the literature on OH also is focused on health management at an international level and has paid less attention to implementation programs and policies for OH at the national and local levels, especially in low-and-middle-income countries (LMICs). Programs to implement OH often are linked to the concept of “integration”, a notion that lacks a universal definition, but is nonetheless a central tenet and goal in many OH programs. At the local and national levels, strong differences in perspectives about OH among different professions can be major barriers to integration of those professions into OH implementation. Policies based on integration among professions in sectors like animal, human and environmental health can threaten professions’ identities and thus may meet with resistance. Taking into account these criticisms of OH research and implementation, this paper proposes a research framework to probe the dominant social dimensions and power dynamics among professional participants that affect OH implementation programs at the local and national levels in a low-income country. The proposed research focus is the veterinary profession and one aspect of OH in which veterinarians are necessary actors: zoonotic disease management. Results from research framed in this way can have immediate application to the programs under study and can inform more expansive research on the social determinants of successful implementation of OH programs and policies.

Opportunities and challenges to improving antibiotic prescribing practices through a One Health approach: results of a comparative survey of doctors, dentists and veterinarians in Australia

OBJECTIVES

To explore and compare the knowledge, attitudes and experiences of doctors, dentists and veterinarians (as prescribers) in relation to antibiotic use and antibiotic resistance (AbR), and to consider the implications of these for policy-making that support a One Health approach.

DESIGN

A cross-sectional survey conducted online.

SETTING

Doctors, dentists and veterinarians practising in primary, secondary or tertiary care in Australia.

PARTICIPANTS

547 doctors, 380 dentists and 403 veterinarians completed the survey.

MAIN OUTCOME MEASURES

Prescribers' knowledge, attitudes and perceptions of AbR, the extent to which a range of factors are perceived as barriers to appropriate prescribing practices, and perceived helpfulness of potential strategies to improve antibiotic prescribing in practice.

RESULTS

There was substantial agreement across prescriber groups that action on AbR is required by multiple sectors and stakeholders. However, prescribers externalised responsibility to some extent by seeing the roles of others as more important than their own in relation to AbR. There were common and context-specific barriers to optimal prescribing across the prescriber groups. Prescriber groups generally perceived restrictive policies as unhelpful to supporting appropriate prescribing in their practice.

CONCLUSIONS

The results have implications for implementing a One Health approach that involves doctors, dentists and veterinarians as key players to tackling the crisis of AbR. The findings are that (1) prescribers understand and are likely receptive to a One Health policy approach to AbR, (2) policy development should be sensitive to barriers that are specific to individual prescriber groups and (3) the development and introduction of interventions that might be perceived as reducing prescriber autonomy will need to be carefully designed and implemented.

Control of Cattle Ticks and Tick-Borne Diseases by Acaricide in Southern Province of Zambia: A Retrospective Evaluation of Animal Health Measures According to Current One Health Concepts

One health thinking for health interventions is increasingly being used to capture previously unseen stakeholders and impacts across people, animals, and the environment. The Network for One Health Evaluation (NEOH) proposes a systems-based framework to quantitatively assess integration and highlight the added value (theory of change) that this approach will bring to a project. This case study will retrospectively evaluate the pioneering use of a One Health (OH) approach during an international collaboration (satellite project to tackle production losses due to tick-borne disease in cattle in Southern Zambia in late 1980s). The objective of the evaluation is twofold: retrospective evaluation the OH-ness of the satellite project and identification of costs and benefits. Data for evaluation was recovered from publications, project documents, and witness interviews. A mixed qualitative and quantitative evaluation was undertaken. In this case study, a transdisciplinary approach allowed for the identification of a serious public health risk arising from the unexpected reuse of chemical containers by the local public against advice. Should this pioneering project not have been completed then it is assumed this behavior could have had a large impact on public wellbeing and ultimately reduced regional productivity and compromised welfare. From the economic evaluation, the costs of implementing this OH approach, helping to avoid harm, were small in comparison to overall project costs. The overall OH Index was 0.34. The satellite project demonstrated good OH operations by managing to incorporate the input across multiple dimensions but was slightly weaker on OH infrastructures (OH Ratio = 1.20). These quantitative results can be used in the initial validation and benchmarking of this novel framework. Limitations of the evaluation were mainly a lack of data due to the length of time since project completion and a lack of formal monitoring of program impact. In future health strategy development and execution, routine monitoring and evaluation from an OH perspective (by utilizing the framework proposed by NEOH), could prove valuable or used as a tool for retrospective evaluation of existing policies.

A One Health Evaluation of the Southern African Centre for Infectious Disease Surveillance

Rooted in the recognition that emerging infectious diseases occur at the interface of human, animal, and ecosystem health, the Southern African Centre for Infectious Disease Surveillance (SACIDS) initiative aims to promote a trans-sectoral approach to address better infectious disease risk management in five countries of the Southern African Development Community. Nine years after SACIDS’ inception, this study aimed to evaluate the program by applying a One Health (OH) evaluation framework developed by the Network for Evaluation of One Health (NEOH). The evaluation included a description of the context and the initiative, illustration of the theory of change, identification of outputs and outcomes, and assessment of the One Healthness. The latter is the sum of characteristics that defines an integrated approach and includes OH thinking, OH planning, OH working, sharing infrastructure, learning infrastructure, and systemic organization. The protocols made available by NEOH were used to develop data collection protocols and identify the study design. The framework relies on a mixed methods approach by combining a descriptive and qualitative assessment with a semi-quantitative evaluation (scoring). Data for the analysis were gathered during a document review, in group and individual interviews and in an online survey. Operational aspects (i.e., OH thinking, planning, and working) were found to be balanced overall with the highest score in the planning dimension, whereas the infrastructure (learning infrastructure, systemic organization, and sharing infrastructure) was high for the first two dimensions, but low for sharing. The OH index calculated was 0.359, and the OH ratio calculated was 1.495. The program was praised for its great innovative energy in a difficult landscape dominated by poor infrastructure and its ability to create awareness for OH and enthuse people for the concept; training of people and networking. Shortcomings were identified regarding the balance of contributions, funds and activities across member countries in the South, lack of data sharing, unequal allocation of resources, top-down management structures, and limited horizontal collaboration. Despite these challenges, SACIDS is perceived to be an effective agent in tackling infectious diseases in an integrated manner.

One Health-ness Evaluation of Cysticercosis Surveillance Design in Portugal

The increasing occurrence of human cysticercosis, a zoonotic neglected disease, is challenging the traditional prevention and control paradigm and calling for One Health (OH) solutions in industrialized countries. OH solutions for health interventions are increasingly being used to capture expected and unexpected outcomes across people, animals, and the environment. The Network for Evaluation of One Health (NEOH) proposes an evidence-based framework, relying on systems and mixed methods approaches to evaluate the One Health-ness. In this case study, this tool is used to evaluate the design of the Observatory of Taeniasis and Cysticercosis, as an example of intersectorial collaboration for surveillance in Portugal. The OH Initiative (drivers and expected outcomes) and its system (boundaries, aim, dimensions, actors, and stakeholders) were described. The different aspects of this Initiative were scored with values from 0 (=no OH approach) to 1 (=perfect OH approach). The OH index was 0.31. Its OH ratio is 1.98. Overall scores were as follows: OH thinking 0.75; OH planning 0.60; OH working 0.60; OH sharing 0.35; OH learning 0.50; and systemic organization 0.50. Operational levels of the Initiative are the main strengths, indicating a comprehensive multidimensional innovative approach and transdisciplinarity. Critical issues in the supporting infrastructure were observed, related to communication, learning and organizational gaps in the project, with the evaluation being conducted as the project is being designed and implemented. The strengths and weaknesses detected may be used to refine the Initiative. This case study therefore exemplifies and supports OH assessment also for ongoing projects, at design and early implementation stages for guiding and guaranteeing an OH-oriented perspective.

A Systems Approach to Evaluate One Health Initiatives

Challenges calling for integrated approaches to health, such as the One Health (OH) approach, typically arise from the intertwined spheres of humans, animals, and ecosystems constituting their environment. Initiatives addressing such wicked problems commonly consist of complex structures and dynamics. As a result of the EU COST Action (TD 1404) "Network for Evaluation of One Health" (NEOH), we propose an evaluation framework anchored in systems theory to address the intrinsic complexity of OH initiatives and regard them as subsystems of the context within which they operate. Typically, they intend to influence a system with a view to improve human, animal, and environmental health. The NEOH evaluation framework consists of four overarching elements, namely: (1) the definition of the initiative and its context, (2) the description of the theory of change with an assessment of expected and unexpected outcomes, (3) the process evaluation of operational and supporting infrastructures (the "OH-ness"), and (4) an assessment of the association(s) between the process evaluation and the outcomes produced. It relies on a mixed methods approach by combining a descriptive and qualitative assessment with a semi-quantitative scoring for the evaluation of the degree and structural balance of "OH-ness" (summarised in an OH-index and OH-ratio, respectively) and conventional metrics for different outcomes in a multi-criteria-decision-analysis. Here, we focus on the methodology for Elements (1) and (3) including ready-to-use Microsoft Excel spreadsheets for the assessment of the "OH-ness". We also provide an overview of Element (2), and refer to the NEOH handbook for further details, also regarding Element (4) (http://neoh.onehealthglobal.net). The presented approach helps researchers, practitioners, and evaluators to conceptualise and conduct evaluations of integrated approaches to health and facilitates comparison and learning across different OH activities thereby facilitating decisions on resource allocation. The application of the framework has been described in eight case studies in the same Frontiers research topic and provides first data on OH-index and OH-ratio, which is an important step towards their validation and the creation of a dataset for future benchmarking, and to demonstrate under which circumstances OH initiatives provide added value compared to disciplinary or conventional health initiatives.