Building a Better System for Outbreak Response, Surveillance, Detection, and Forecasting
In-depth breakout discussions were held to discuss key, feasible goals and steps that can be taken toward improving outbreak preparedness efforts for the future. Organized by topic, breakout groups included response capacities, surveillance and detection mechanisms, and forecasting and predictive innovation. Each group was tasked with identifying short-term goals, long-term goals, and potential actions and relevant institutions involved in achieving these goals. Jonna Mazet, professor and founding executive director of the One Health Institute at University of California, Davis (UC Davis), moderated the breakout room recaps and discussion.
BREAKOUT SESSION HIGHLIGHTS
Kent Kester, vice president and head of translational science and biomarkers at Sanofi Pasteur, moderated the breakout discussion focused response capacities (see Box 7-1). He highlighted short-term goals identified by participants, including addressing areas of improvement that emerged in the coronavirus disease 2019 (COVID-19) pandemic response. Notably, personnel development is needed in professional, governmental, and nonprofit sectors, as well as at the community level, summarized Kester. This involves training for the entire continuum of One Health human resources. Furthermore, an inventory of human resources in the current One Health workforce can aid in identifying gaps and ensuring that all health providers are included. He pointed to insufficient data regarding international spending
on public health capacities and highlighted the need for international monitoring to generate data on this spending. Risk communication also warrants more attention, he added. He emphasized that agriculture is often absent from the conversation and identified this gap as a blind spot in the One Health arena. Despite widespread acknowledgment of the importance of food security, agriculture recedes to the background outside periods of famine and drought, Kester noted. He suggested a midterm goal of mobilizing communities through education and the concept of citizen scientists, as this can expand surveillance and health literacy beyond physicians and veterinarians to encompass a broader segment of society. Remarking that spending is not always reflective of the efficacy of intervention, Kester highlighted a
long-term goal of evaluating interventions with respect to their effectiveness in meeting identified needs. Evaluation data can then be used in a dynamic and continually evolving response process.
Surveillance and Detection Mechanisms
Maureen Lichtveld, dean of the University of Pittsburgh’s Graduate School of Public Health, moderated the breakout discussion on surveillance and detection mechanisms, which focused on the availability and quality of data and their use in decision making (see Box 7-2). She outlined
several goals that participants identified. The first goal is to establish a wide-reaching surveillance system that collects data from disparate silo-driven systems and amasses them into a single global platform. Second, a single, integrated information technology platform could extend beyond single systems and traditional data to create an iterative surveillance system that incorporates data from social media and citizen science input. By creating a system in which data improve in quality while being operationalized locally, local-level public health can become the locus of both decision making and decision implementation. This involves investing time in surveillance systems before an outbreak occurs, rather than waiting until the response phase, said Lichtveld. Third, an opportunity for surveillance innovation exists within low- and middle-income countries, which tend to be less burdened by silo-driven approaches to surveillance and detection than high-income countries. She noted that the breakout group emphasized the importance of communication in integrating participatory surveillance.
Forecasting and Predictive Innovations
Peter Daszak, president at EcoHealth Alliance, moderated the breakout group discussion on forecasting and predictive innovations and outlined three action areas identified (see Box 7-3). First, improvements in data collection and use are needed. A shareable pipeline of real-time genomic data could enable integrating predictive innovations into routine practice. Despite substantial challenges in this area, advances could result in better datasets on human activities. Furthermore, insufficient data on the wildlife trade could be augmented. Low-level collection efforts could result in acceptable data without a public sense of privacy invasion.
Second, education and culture can be used as avenues for strengthening One Health. Education efforts at the primary and secondary levels can help the public understand the value of One Health initiatives and engender support for funding. Moreover, a critical need exists at the postsecondary level for inter-professional education that incorporates data analytics, law, and economics into One Health education, said Daszak. Building centers of interdisciplinary excellence would help address this need. Regarding culture, prioritized values should shift from focusing on per-capita health care spending to valuing health and drivers of health, such as nature, biodiversity, and ecosystem services. Developing a deeper understanding of these factors could increase appreciation for the value of One Health issues, leading to improved global health systems equipped to identify and respond appropriately to first cases and small outbreaks.
Third, predictive approaches should move beyond academia to practical application to achieve impact, said Daszak. Policy makers commonly push back on innovative, predictive approaches, particularly if they lack
confidence in the accuracy of prediction capability and feel comfortable with the status quo. To achieve real change, researchers should improve the ability to quantify risk, work creatively with insufficient or inadequate datasets, and make predictions that are useful to policy makers and agencies in terms of geographic focus or targeted species. If researchers are able to identify ever-higher numbers of microbes, a universal system will be needed to triage by importance. Daszak suggested prioritizing microbes for which prediction capability already exists, such as antimicrobial resistance genes and coronaviruses. Finally, given the growth of wearable and sensor technologies linked to smartphones, these are an underused resource that could increase prediction capability, particularly in regions where new diseases are emerging.
Social Sciences in One Health
Given that greater incorporation of social sciences would benefit One Health, Mazet asked how social scientists can be included in One Health initiatives. Catherine Machalaba, senior policy advisor and senior scientist at EcoHealth Alliance, noted that One Health is context specific, so the context, community, and scale of an initiative will inform which partners may be relevant. Areas that would benefit from the contribution of social science perspectives include behavioral economics and the design of appropriate community-engagement interventions. For example, the PREDICT project’s book, Living Safely with Bats,1 was designed as a visual tool to engage communities about their consumptive practices and exposures and introduce practical solutions. This type of work—involving social scientists, artists, and other professionals outside the major One Health disciplines—could be helpful if introduced on a broader scale.
Olga Jonas, research associate at Harvard University, suggested that efforts should focus on strengthening data collection systems to improve worldwide surveillance, diagnostic, and analytic capacities. She noted that behavior drives the lack of prevention and ultimate costs of outbreaks. Even in wealthy countries, data collection and modeling performed by people who lack sufficient expertise can undermine response efforts and public health as a whole, said Jonas. She remarked that strengthening basic data systems and enabling accurate analysis would encourage constructive public engagement.
Brianna Skinner, senior regulatory veterinarian at the U.S. Food and Drug Administration (FDA), emphasized that social drivers affect all sectors. Human behavior affects the climate, human habitats, the soil used for agriculture, and more. Therefore, FDA is working to diversify One Health personnel beyond biologists, veterinarians, and physicians to create a One Health strategy to help shape public attitudes and behaviors to benefit people, animals, and the environment. FDA is using the One Health concept to address public health issues within its purview; to this end, it has created a One Health steering committee to issue policy, guidance, and standards, said Skinner.
Noting the importance of economic impact on health outcomes and the value of economic drivers for healthy behaviors, Mazet asked about
1 More information about Living Safely with Bats can be found at https://p2.predict.global/living-safely-with-bats-book (accessed April 28, 2021).
the roles of socioeconomics experts, the World Trade Organization (WTO), and the International Monetary Fund (IMF) in One Health efforts. Laura Kahn, research scholar at the Program on Science and Global Security at the Woodrow Wilson School of Public and International Affairs, Princeton University, remarked that behavioral and sociological activities drive pandemics. To address root causes of these behaviors, society needs to reassess the value of nature and natural resources. Presently, a nation’s wealth is typically measured by its gross domestic product (GDP), but this narrow metric only considers a nation’s annual output of products and services. She posited that it should also include factors such as water purity, air clarity, soil condition, health of flora and fauna, and ecosystem diversity—all of which affect food security and population health. Exemplifying this more holistic perspective, a group in China developed the concept of the “gross ecosystem product” to serve as a substitute for GDP (Ouyang et al., 2020). By using such a metric, One Health could contribute data and analysis to supplement the GDP and present a more accurate picture of a nation’s health landscape, said Kahn. Engaging economists and WTO and IMF in this work could increase the value placed on natural resources; this, in turn, might help prevent events that devastate the global economy.
Mainstreaming the One Health Concept
Mazet stated that for approximately four decades, One Health has largely remained an academic concept. Operationalization began when professional organizations implemented One Health approaches, with momentum now emerging within the private sector and pharmaceutical industry. However, because health effects affect everyone, Mazet asked how the concept might become more mainstreamed among taxpayers. Barbara Han, disease ecologist at Cary Institute of Ecosystem Studies, remarked that COVID-19 has provided an opportunity for One Health practitioners to share expertise with the public in an accessible way. She suggested that the public is now less likely to question the relevance of this work than before the pandemic began, when much of them did not understand the value of sequencing viruses to establish a baseline to assess risk. These challenging concepts are easier to comprehend within the pandemic context, as are the costs of failing to invest in virus research, she noted. Han emphasized that the health community needs to stay committed to this message now that people are actively listening.
Andrew Maccabe, chief executive officer at the American Association of Veterinary Medical Colleges, noted the ongoing challenge of breaking down barriers to integrate One Health beyond specialists and scientists. He added that even within one’s own profession, communication can be difficult; hence, effectively communicating with the public can be daunting. Highlighting the National Academy of Medicine’s initiative integrating
humanities and the arts with science, education, and medicine, Maccabe stated that the more engagement artists and people in the humanities have with these topics, the more likely connections about global health will enter the collective consciousness (NASEM, 2018).
Michael Wilkes, professor of internal medicine at UC Davis suggested starting downstream by integrating One Health concepts into the educational system, strengthening health literacy and numeracy to foster public understanding of the interrelationships between humans, animals, agriculture, and the environment. Moreover, in addition to a presence across traditional and social media outlets, Wilkes remarked on the need for greater dissemination of information in communities that have been underserved during the COVID-19 pandemic. He posited that disparities in testing, infection, and vaccination in some communities reflect the health community’s limited ability to communicate and build trust with all communities. He suggested engaging more robustly with stakeholders in these underserved communities.
Mazet recounted discussion earlier in the workshop regarding the incorporation of One Health lessons into grade-school education, similar to the successful recycling curriculum implemented in the past. She recalled an iconic television commercial from the 1970s, in which an Indigenous person was saddened by littering, which had a profound impact on her in instilling the value of not littering. Mazet remarked that One Health needs to create a similar iconic moment. Jonathan Sleeman, director at the U.S. Geological Survey’s National Wildlife Health Center, commented that the COVID-19 pandemic is a transformative moment. The definition of One Health speaks to optimizing outcomes for humans, animals, and the environment; however, defining those optimal outcomes is a question not of science but rather of societal value. He suggested that the One Health community should clearly articulate a core set of values—such as maintaining the integrity of natural ecosystems, preserving biodiversity, and advancing equity and food security—and then educate the public on those values.
Lichtveld stressed that progress in incorporating One Health into the mainstream hinges on the ability to translate data into action at the local level, as well as on investing in local public health infrastructure. The One Health movement should address the root causes of disparities that leave some parents facing decisions such as whether to buy food or an inhaler for their child with asthma. Lichtveld shared a vision wherein One Health engages communities as partners—not as subjects—and creates an environment in which community members act as One Health messengers, rather than government representatives. Furthermore, community participatory strategies can serve to extend the reach of One Health and simultaneously make it better understood. Investing in local public health infrastructure should be integral to One Health efforts, Lichtveld added.
Claire Standley, professor at the Center for Global Health Science and Security at Georgetown University, pointed out that the One Health concept is not new: it has long been routinely practiced by Indigenous societies and people living close to wildlife. These communities can meaningfully contribute to the ongoing dialogue, with One Health practitioners learning from their examples and experience. Kaylee Myhre Errecaborde, policy researcher and veterinarian at the University of Minnesota College of Veterinary Medicine, noted that despite collaborative advantage, collaborative inertia can occur, impeding the process of prioritizing participants to the specific issue at hand. Collaboration requires considerable energy and resources, but prioritizing the participants who are most critical to each conversation or technical activity can help to maximize the impact of collaborative efforts.
Tracey McNamara, professor at the College of Veterinary Medicine at Western University of Health Sciences, highlighted a common misconception that the U.S. Department of Agriculture oversees all national surveillance of zoonotic threats. Efforts to increase public awareness are needed, because the public is largely unaware of the hierarchies involved in One Health surveillance in the United States and the substantial gaps in it. She noted that funding allocation—which often designates all funds to a single agency—can result in conflicts that impede collaboration and progress of One Health surveillance. To limit interagency conflicts, McNamara suggested a concept where each participating agency votes on how funding is allocated. She also emphasized the value of public engagement in advocating for legislative changes. Mazet added that the siloing in the structure of the U.S. government is an additional barrier to collaboration.
Daszak commented on the public’s lack of knowledge about global health concerns. He noted the critical role that popular interest efforts can play in raising awareness of the threat of outbreaks, such as the Outbreak: Epidemics in a Connected World exhibit,2 the film Contagion (Soderbergh, 2011), and a recent episode of Last Week Tonight with John Oliver, “The Next Pandemic” (Pennolino and Werner, 2021). A lack of education about outbreak sources at the middle- and high-school levels has contributed to disbelief that COVID-19 was caused by nature, which, in turn, fuels vaccine hesitancy, said Daszak. He suggested that viruses and public health issues be added to secondary school curricula to leverage the current receptive state of the general public. Furthermore, he stressed that in order to solicit public involvement, scientists should be explicit in highlighting the human role in environmental problems—and, in turn, health concerns—and in creating solutions to these human-made issues. Messaging that appeals to
2 More information about this exhibit can be found at https://naturalhistory.si.edu/exhibits/outbreak-epidemics-connected-world (accessed April 28, 2021).
emotion in connecting humans to the natural environment can be effective in changing behavior, as was the case with the conservation campaigns of the 1960s and 1970s.
Peter Rabinowitz, professor and director of the Center for One Health Research at the University of Washington, echoed the idea that the COVID-19 pandemic is an opportunity for restructuring systems in accordance with One Health principles. In addition, opportunities exist to harness young people’s current enthusiasm for addressing climate change and eradicating institutionalized racism toward expanding the One Health approach. One Health practitioners can capitalize on these opportunities by raising awareness of the connections between One Health, climate change, and the impacts of racism on social determinants of health, said Rabinowitz. John Amuasi emphasized that the One Health movement should extend beyond research and academia to incorporate activism. He added that climate change scientists have been more successful in soliciting public support than have researchers in other areas, which is likely attributable to their engagement with activism. Furthermore, he noted the Black Lives Matter movement has had a greater impact on shifting institutional racism in a relatively short period of time than have research and academic efforts. Given the close ties of racial health disparities and climate change with the One Health approach, activism can serve as an effective vehicle for expanding the One Health platform, said Amuasi.
Ben Beard, deputy division director of the U.S. Centers for Disease Control and Prevention (CDC) Division of Vector-Borne Diseases, suggested that efforts should focus on coordinating systems that are already in place, rather than creating a One Health surveillance system. He pointed out that state governments—not the federal government—are responsible for national surveillance, with the Council of State and Territorial Epidemiologists serving as the governing body and CDC coordinating these efforts. Data-use agreements and concerns around personally identifiable information pose challenges to public health coordination with other agencies, yet this collaboration is necessary and must be strengthened, said Beard. Furthermore, climate change is a pressing concern that requires efforts to expand from disease surveillance to include forecasting. Models can integrate surveillance data and are capable of providing faster responses than traditional surveillance data methods. For example, the public health response to local outbreaks of West Nile virus typically begins as the outbreak is ending. Beard linked this to insufficient forecasting tools and inadequate capacity to convince the public to take prevention steps before an outbreak spreads.
Kahn spoke about the need to include microbial education in grade-school curriculum. As the world is microbial and the human body is largely composed of microbes, people can learn to move more safely in their communities by learning how to prevent the spread of dangerous microbes
between one another, animals, and the environment. Such education efforts could prove helpful in preventing disease outbreaks, said Kahn.
Marc Allard, research microbiologist and senior advisor for genomics at FDA’s Center for Food Safety and Applied Nutrition, stressed the importance of collaborating with state and academic partners, the Department of Health and Human Services, and USDA. Sharing tools and broad communication of standard operating procedures for any stage—be it collecting the isolates, sequencing the isolates, uploading the data, or interpreting the data—empowers partners and fosters communication at the national and international levels. Furthermore, shared protocols and tools enable the establishment of standard, validated methods, enabling efficiency and efficacy, said Smolinski.
Collaborations in Moving Forward
Casey Barton Behravesh, director of the One Health office at CDC, underscored the value of collaboration and identified One Health coordination as a key component in successes achieved during the COVID-19 pandemic. She cited the 2017 collaboration between CDC, the U.S. Department of the Interior, USDA, and multiple other agencies and departments. The collective group developed a list of prioritized zoonotic disease threats in the United States, in which coronaviruses ranked fifth.3 Noting action plans to promote One Health, she highlighted 2021 legislation that directs the federal government to create a national One Health framework to combat the threat of zoonotic diseases, advance emergency preparedness, and establish a formalized One Health coordination mechanism at the federal level.4 Barton Behravesh stated that if passed into law, this legislation will be critically important in fostering interagency collaboration, focusing on shared priorities, and creating a unified framework to demonstrate the needed steps and resources—including a dedicated budget line for One Health activities—to tackle these issues and better serve the collective health goals of the nation.
Mazet remarked that many One Health practitioners have slowly and steadily made inroads in advancing this approach over several decades, but the COVID-19 pandemic has catalyzed momentum toward changing not only the way health problem solving is approached but the very way humans function on Earth. She noted that it is only one of the multiple syndemics—the synergistic interactions between socioecological and
3 More information about this workshop is available at https://www.cdc.gov/onehealth/what-we-do/zoonotic-disease-prioritization/us-workshops.html (accessed May 28, 2021).
4 Advancing Emergency Preparedness Through One Health Act of 2021, S.861, 117th Cong., 1st sess. (March 18, 2021).
biological factors that result in adverse health outcomes—the world is facing. Addressing these syndemics will require pulling together diverse thoughts, experiences, and social contexts to generate new ideas, research, and solutions that are palatable to the global community, said Mazet. She emphasized that One Health has the potential to serve in this capacity, but only if equity, inclusion, and diversity are valued and the voices of people facing the greatest adverse health outcomes are spotlighted. Accomplishing this paradigm shift will require leadership and advocacy in all directions and opening national and disciplinary boundaries, she noted. Finally, Mazet acknowledged that as all things are connected, humans must connect their ideas; no individual or discipline is capable of solving these problems alone.