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R E V I E W Open Access
Implementing One Health approaches to
confront emerging and re-emerging
zoonotic disease threats: lessons from
Terra R. Kelly
, Catherine Machalaba
, William B. Karesh
, Paulina Zielinska Crook
, Kirsten Gilardi
, Julius Nziza
Marcela M. Uhart
, Erika Alandia Robles
, Karen Saylors
, Damien O. Joly
, Corina Monagin
Prime Mulembakani Mangombo
, Placide Mbala Kingebeni
, Rudovick Kazwala
, David Wolking
, Woutrina Smith
PREDICT Consortium and Jonna A. K. Mazet
Recurring outbreaks of emerging and re-emerging zoonoses, such as Ebola virus disease, avian influenza, and
Nipah virus, serve as a reminder that the health of humans, animals, and the environment are interconnected
and that early response to emerging zoonotic pathogens requires a coordinated, interdisciplinary, cross-
sectoral approach. As our world becomes increasingly connected, emerging diseases pose a greater threat,
requiring coordination at local, regional, and global levels. One Health is a multisectoral, transdisciplinary, and
collaborative approach promoted to more effectively address these complex health threats. Despite strong
advocacy for One Health, challenges for practical implementation remain. Here we discuss the value of the
One Health approach for addressing global health challenges. We also share strategies applied to achieve
successful outcomes through the USAID Emerging Pandemic Threats Program PREDICT project, which serve as
useful case studies for implementing One Health approaches. Lastly, we explore methods for promoting more
formal One Health implementation to capitalize on the added value of shared knowledge and leveraged
Keywords: Emerging infectious diseases, Global health, One Health, Zoonotic diseases
Zoonoses lead to millions of deaths annually; the eco-
nomic losses from a single outbreak can amount to bil-
lions of dollars [1,2]. Recurring outbreaks of emerging
and re-emerging zoonotic infectious diseases, such as
Ebola virus disease (EVD), severe acute respiratory syn-
drome (SARS), avian influenza (e.g. H5N1, H7N9), and
Nipah virus disease underscore the need to consider the
interconnections among the health of humans, animals,
and the environment in disease prevention and control
measures. As trade and travel facilitate greater access
and connections across the world, these zoonoses pose
significant and growing global health threats.
Lessons learned from these disease outbreaks highlight
the need to shift to a more integrated, holistic, and pro-
active paradigm, such as can be achieved using the One
Health approach. One Health considers the linkages
among the health of humans, animals, plants, and their
shared environment. As such, the approach allows for a
deeper understanding and ability to address the complex
eco-social determinants of health and to more effectively
and efficiently tackle threats through coordination across
disciplines and sectors. One Health approaches are in-
creasingly recognized for their value in addressing emer-
ging infectious disease (EID) threats, as the majority of
EIDs arise from wild animal reservoirs in biodiverse
© The Author(s). 2020 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: email@example.com
One Health Institute, University of California, Davis, CA, USA
Full list of author information is available at the end of the article
Kelly et al. One Health Outlook (2020) 2:1
landscapes experiencing strong anthropogenic pressures,
including human population growth, land use change,
and natural resource extraction .
At a global level, there is broad support for the con-
cept, which has led to the establishment of several One
Health initiatives around the world, including designated
divisions within U.S. federal agencies (e.g., in the U.S.
the National Park Service One Health Initiative, Centers
for Disease Control and Prevention One Health Office,
and U.S. Department of Agriculture One Health Coord-
ination Center), interagency working groups and na-
tional multisectoral coordination mechanisms (such as
Bangladesh’s One Health Secretariat and Liberia’s One
Health Coordination Platform) [4–6], international One
Health networks and consortia (e.g., the FAO/OIE/
WHO Tripartite collaboration, One Health Workforce,
One Health Alliance of South Asia, Southeast Asia One
Health University Network, One Health Central and
Eastern Africa) and One Health designated degree and
training programs [7–12]. Furthermore, nearly 50 coun-
tries have signed on to the Global Health Security
Agenda (GHSA), which was launched in 2014 to bring
countries together to promote One Health approaches
and strengthen capacities to prevent, detect, and respond
to disease threats .
Despite this broad support, implementing One Health
approaches in practice still proves challenging. For in-
stance, most countries lack formal mechanisms for co-
ordination and integration of activities across the human
health, agricultural, and environmental sectors, which
are traditionally based in separate ministries or govern-
ment agencies with different mandates on activities and
spending [4,14]. As a result, practical applications of
One Health approaches have largely been ad-hoc [4,15],
resulting in delayed or incomplete prevention and con-
trol measures. There is also a need for formal standard-
ized analyses showing the added benefits of One Health
over conventional approaches in disease prevention and
control [14,16]. A growing body of research, including
studies revealing the financial benefits of One Health in-
vestments in addressing emerging zoonoses, is building
the evidence base for One Health [17,18]. However,
additional case studies and formal assessments demon-
strating the social, health, and economic benefits are
needed to garner broader high-level support by decision
In 2009, the US Agency for International Development
(USAID) launched the Emerging Pandemic Threats
(EPT) Program’s PREDICT Project. PREDICT utilizes a
One Health approach focused on early detection and re-
sponse to potentially zoonotic viral threats at their
source ideally before they emerge in people . PRE-
DICT’s efforts have focused on strengthening zoonotic
virus surveillance and laboratory capacity in “hotspots”
for EIDs. The project provided a platform for breaking
down barriers through development of cross-sectoral
surveillance and laboratory networks with open sharing
of data, coordination on disease outbreak response, and
contributions to extant or new national One Health plat-
forms. PREDICT’s efforts to operationalize One Health
in collaboration with government and university part-
ners provide valuable examples and evidence for the im-
portance of One Health approaches in addressing
complex health challenges. Here we discuss the value of
One Health for addressing complex health threats at the
human-animal-environment interface and current hur-
dles for implementing One Health. We also share ap-
proaches used by PREDICT to achieve successful
outcomes, which serve as useful case studies for applying
the One Health approach.
Value of the One Health approach
The One Health approach builds on existing capacities
but is novel in bringing disciplines and sectors together
to provide broader health benefits. Increasing cross-
sectoral coordination can help promote science-based
decision making; reduce unnecessary duplication among
the sectors responsible for the health of humans, ani-
mals, and the environment; and more effectively address
outside factors influencing disease burdens [2,18].
Comparative medicine has long been acknowledged
for its benefits in scientific research, and One Health ex-
pands comparative medicine’s scope to surveillance in
animals and the environment for early detection and
better understanding of threats to mitigate risk and im-
pacts. For example, great ape die-offs associated with
Ebola virus have often been detected prior to outbreaks
in humans, providing a potential predictive value that
can help prevent human cases if paired with risk mitiga-
tion measures, such as hunter avoidance of carcasses
. Weather conditions have also been used to forecast
Rift Valley fever and other outbreaks and can inform
vaccination and mosquito control campaigns to reduce
health and economic consequences of disease epidemics
. Integrated human, animal, and environmental sur-
veillance can likewise elucidate pathways of pathogen
sharing and inform development of more comprehensive
solutions that emphasize prevention at the source.
The onset of encephalitis cases in people and birds
that were ultimately linked to the emergence of West
Nile virus in the U.S. in 1999 left public health author-
ities challenged with identifying its origin. Critical
insight into the cause of disease was gained from the
veterinary community investigating associated wild bird
mortalities. Currently, sentinel surveillance in mosquitos,
birds, and horses is used routinely to monitor risk to hu-
man health and trigger preventive measures. Parts of
North America and Western Europe have also made a
Kelly et al. One Health Outlook (2020) 2:1 Page 2 of 7
concerted effort to control rabies using a One Health ap-
proach. While effective rabies control efforts have re-
quired substantial investments, they have yielded high
public health benefits, with canine vaccination widely
considered the most cost-effective strategy [22–24]. The
successful control of rabies in dogs through vaccination
has then allowed for a targeted approach to managing
wildlife reservoirs. Baseline surveillance data has enabled
managers to monitor risk and target control efforts in
these populations, as seen in response to the rise of rac-
An economic optimization projection suggested that
investing in a One Health approach through mitiga-
tion of pandemic threats versus business-as-usual
adaptation could yield a savings of over $300 billion
globally over the next century . Similarly, a World
Bank analysis suggested that upfront investments of
$3.4 billion per year globally in One Health capacity
through improved veterinary and public health ser-
vices could avoid over $30 billion in zoonotic disease
response annually worldwide .
While these scenarios reflect value for global public
good, countries are also increasingly endorsing health
security as a national priority given the potential for
rapid disease spread via trade and travel networks.
This necessitates improved prevention and control of
both endemic and emerging disease risks within and
beyond a nation’s borders. Climate and other eco-
logical changes are resulting in shifts in geographic
ranges of species and their pathogens with a wide
range of associated ongoing and novel health threats
–ranging from vector-borne and zoonotic diseases to
impacts on food safety and security. For example, the
spread of Zika virus and CDC’s request to the U.S.
government for $1.8 billion to respond demonstrate
the need for One Health approaches to implement
preventive measures prior to the emergence of novel
Case studies: One Health contributions toward
more efficient and effective response to emerging
zoonotic disease threats
Over the past decade, PREDICT partnered with foreign
governments, universities, and other organizations to ad-
vance One Health initiatives . In collaboration with
local partners, the PREDICT project strengthened
capacity for viral surveillance at high-risk animal-human
interfaces. Also, when requested by host country govern-
ment partners, PREDICT provided support during dis-
ease outbreaks by incorporating animal sampling into
investigations, expanding laboratory analyses to look for
novel viruses, and promoting the growth of a trained
One Health workforce.
Rapid outbreak response and containment
During the widespread EVD outbreak in West Africa in
2014, the Democratic Republic of Congo (DRC) experi-
enced its own separate and unique Ebola virus disease
outbreak. Unlike West Africa, DRC has a long history of
Ebola outbreaks and substantial capacity for response,
due in part to a long-running partnership between l’In-
stitut National de Recherche Biomédicale (INRB), the
national infectious disease reference laboratory, and
other partners like PREDICT. Many experts from the
Viral Hemorrhagic Fever Unit of the INRB were
deployed in West Africa when the outbreak in DRC oc-
curred. As a result, PREDICT was requested to support
laboratory testing. Suspect cases were sampled, speci-
mens were shipped to the PREDICT laboratory at INRB
for analyses, and Ebola virus was detected within 1 day
of receiving the specimens. Importantly, the strain of
Ebola virus detected was distinct from the strain causing
the West Africa epidemic, ruling out linkages between
the two outbreaks. Following the prompt testing and
pathogen identification, the DRC government was able
to access the affected area and respond rapidly with con-
tact tracing, dispatching a mobile laboratory, and quar-
antining suspected cases, leading to swift containment
with only 66 cases reported over the two-month dur-
ation of this outbreak.
The PREDICT team was also able to assist with collec-
tion of wildlife samples from the outbreak area. Contact
tracing later identified the likely source of the outbreak
as an infected wild animal that had been found dead and
butchered for food. This information was key to identify-
ing high-risk practices to target for disease prevention.
The rapid response and field investigations informing on
prevention measures illustrate what is achievable when
an in-country One Health workforce is trained,
employed, and ready to act. Such prevention arguably
becomes even more important when country capacity to
rapidly respond to outbreaks is lacking, especially in fra-
gile areas of high vulnerability to both disease threats
and their impacts (e.g. resulting from weak governance
structures). The impacts of the on-going EVD outbreak
in DRC, which began in Kivu DRC in August 2018,
highlight the challenge of responding to a disease out-
break in a remote location where access and control ef-
forts have been substantially impeded by violence and
insurgency. These reinforce the need for continued cap-
acity strengthening and integration of sectors at national
and sub-national levels, tailored to the local risk context
and stakeholders to promote relevance, sustainability,
Prevention of human disease outbreaks
Currently, response to outbreaks around the world is
highly reactive, with control measures employed once an
Kelly et al. One Health Outlook (2020) 2:1 Page 3 of 7
outbreak in humans has been detected. PREDICT activ-
ities in Bolivia demonstrated that monitoring for zoo-
notic viruses in wild animals can be a valuable early
detection tool for preventing disease outbreaks, particu-
larly in landscapes undergoing substantial alteration,
such as deforestation, where breakdown of natural bar-
riers leads to increased contact between wildlife and
Yellow fever (YF) is a zoonotic viral hemorrhagic dis-
ease  that is perpetuated in a transmission cycle in-
volving mosquitos and non-human primate hosts.
Because New World primate hosts are especially suscep-
tible to YFV infection, acute clusters of mortality in
these populations can signal YFV activity and alert au-
thorities to increased risk of human infection, thereby
serving as an early warning system.
In 2012, staff at a wildlife sanctuary in Bolivia, who
had received training in wildlife disease surveillance
through PREDICT, discovered six dead howler monkeys
(Alouatta sara) near the park. In collaboration with the
sanctuary, PREDICT investigated the mortality event.
Post-mortem examinations and diagnostic testing per-
formed at the University of San Andres’Institute of Mo-
lecular Biology and Biotechnology, PREDICT’s partner
laboratory in Bolivia, indicated infection by a flavivirus,
the family of viruses to which YFV belongs. PREDICT
partners reported the results to the Ministry of Health,
while conducting further laboratory analyses to confirm
that infection was caused by YFV. The Ministry of
Health, Pan-American Health Organization, and PRE-
DICT conducted a joint risk assessment followed by a
prompt cross-sectoral, coordinated response in the af-
fected area. The response included preventive YF human
vaccination, public education and outreach, and mos-
quito control to reduce risk of infection.
Although YF outbreaks had never been documented in
Bolivian primates, authorities were able to implement
preventive measures in the surrounding area within 1
week of detection of the mortality event. No human
cases of YF were subsequently reported, suggesting the
value of early warning systems for increased zoonotic
disease risk, local pathogen detection capacity, effective
collaboration channels across sectors, and prompt im-
plementation of public health measures for preventing
pathogen spillover from animals into people.
Systematic coordinated data sharing and national One
PREDICT worked with foreign government partners to
establish a systematic One Health approach to commu-
nicating findings stemming from disease surveillance.
The process involved sharing laboratory results with des-
ignated points of contact in the ministries representing
public health, livestock/agriculture, and wildlife, which
facilitated discussions on coordinated solutions. It also
established open communication channels that enabled
more rapid coordinated responses to disease outbreaks.
In Rwanda and Tanzania, this collaborative approach
was the impetus for PREDICT’s involvement in the de-
velopment of national One Health platforms in the
In Rwanda, PREDICT-trained personnel served on the
Government of Rwanda’s One Health Steering Commit-
tee. The committee, which is made up by representatives
from the animal and human health and environmental
sectors, applied “a participatory and consensus building
process”to develop an integrative framework for solving
problems at the animal-human-environmental interface
. As part of the committee, PREDICT team members
aided in the development of a One Health Strategic Plan
in 2015 . The plan references commitments to en-
hance cross-sectoral collaboration and increase One
Health workforce capacity in Rwanda. It outlines an im-
plementation strategy covering organizational structure
and pooling and mobilizing resources . The Steering
Committee oversees the plan, including prioritization of
resource allocations, and coordinates the technical as-
pects of the strategy, which are integrated into the an-
nual action plans of the implementing partners. If
successfully operationalized, Rwanda’s One Health Stra-
tegic Plan will lead to more efficient and timely re-
sponses to disease threats .
For example, following the avian influenza (AI) out-
break in neighboring Uganda in 2017, the Rwanda Agri-
culture Board, in collaboration with representatives from
the National One Health Steering Committee, conducted
a field investigation of an avian mortality event in
Rwanda. In the process of their investigation, they con-
ducted public sensitization around AI risk through infor-
mal community meetings and radio broadcast. Although
AI was not confirmed in Rwanda, the collaborative ef-
forts initiated by the committee raised critical awareness
and led to improvements in Rwanda’s National Contin-
gency Plan against AI highlighting the benefits of this
plan to improving preparedness.
Alongside Rwanda, Tanzania also launched its One
Health Strategic Plan in 2015. This plan laid the ground-
work for multi-sectoral coordination and established a
One Health Coordination Unit overseen by a One
Health Steering Committee, comprised of secretaries of
participating ministries and supported by five technical
working groups. Tanzania was the first country to
undergo a self-assessment using the World Health
Organization (WHO) Joint External Evaluation (JEE)
tool, which is a voluntary, collaborative process to assess
a country’s capacity to prevent, detect, and rapidly re-
spond to public health threats . PREDICT represen-
tatives served in one of the technical working groups
Kelly et al. One Health Outlook (2020) 2:1 Page 4 of 7
using the tool to evaluate strengths, gaps, and priority
actions for enhancing national health security. The as-
sessment was instrumental for encouraging cross-
sectoral communication and identifying activities in
which ministry partners could work together to combat
disease threats. The process paved the way for develop-
ing the Tanzania National Action Plan for Health Secur-
ity, which addresses gaps identified by the evaluation. As
a culmination of these efforts, Tanzania formally
launched the first national One Health Platform and
One Health Strategic Plan in 2018 .
The way forward: implementing One Health
While mechanisms for operationalizing One Health are
variable across contexts, case studies demonstrating suc-
cessful One Health outcomes can provide valuable
insight for implementing approaches elsewhere. These
can be leveraged as countries work toward multisectoral
coordination platforms with more sustainable ap-
proaches to One Health (such as through the establish-
ment of the Zoonotic Disease Unit in Kenya ). These
platforms often have high political will, with oversight
and support at prime minister or presidential levels
which promote country ownership and sustained atten-
tion and across sectors. Over the past 5 years, the GHSA
has been instrumental in creating an enabling environ-
ment and political will for strengthening global and na-
tional health securities through a One Health approach.
JEEs conducted in several countries around the world
have revealed weaknesses in coordination across health
sectors prompting the recommendation to develop na-
tional One Health platforms. To work towards this goal,
the World Bank, USAID EPT program, and United Na-
tions organization partners have compiled resources to as-
sist countries with formalizing a One Health strategy,
including tools for capacity assessments, resource map-
ping and prioritization, and One Health systems improve-
ment [24,31–37]. These tools aid in identifying where
investments in One Health approaches and leveraged re-
sources could fill gaps, avoid unnecessary overlap, and re-
sult in more holistic, preventive approaches . In
allocating resources, it is beneficial to conduct formal
standardized assessments to evaluate how best to optimize
investments to ensure added value gained by integrating
efforts across health sectors [32,33]. For example, One
Health approaches have yielded higher returns on invest-
ments through joint human-animal disease surveillance
and prevention and control measures, including vaccin-
ation campaigns [18,19,34]. Cross-sectoral exercises to
assess risk and economic impacts of zoonoses have also
brought stakeholders to the table to facilitate more sys-
tematic collaboration and communication and to identify
opportunities of mutual benefit [18,35,36]. Leveraging
the One Health approach to ensure the wider risk context
and relevant sectors, especially at sub-national levels, can
help boost countries’abilities to prepare for a suite of
current and evolving threats.
Finally, it is critical to continue to raise awareness of
One Health and foster leaders who are uniquely skilled
to work across disciplines and sectors. Around the
world, universities are progressively incorporating One
Health education into their curricula, including desig-
nated degree programs. These programs need to be de-
veloped around a set of core competencies with an
emphasis on practical skill-building  to provide stu-
dents with the knowledge and experience necessary to
address complex health threats.
While there is increasing commitment to One Health
across the world, implementing One Health approaches
in practice still proves challenging. Development of na-
tional One Health platforms and policies are critical for
improving coordination and integration of activities and
programs across sectors. In many countries, the GHSA
has provided a platform for coordination and served as
the impetus to initiate One Health strategic plans and to
develop national One Health policies. In addition, sup-
port from international organizations, such as the World
Bank, USAID (EPT Program), and UN partners has
aided several countries in designing and implementing
One Health strategies and in strengthening national One
Health systems [18,19]. While some programmatic ac-
tivities may not be feasible in the absence of external
funding, one route for sustainability is the application of
low-cost coordination systems that have been tested and
validated, including routine inter-ministry meetings to
share disease surveillance results and discuss coordi-
nated mitigation efforts. Country investments in human
and animal health systems, including through develop-
ment loans, illustrate the value that countries place on
enhancing capacity for disease preparedness. Further,
there is a need to continue to bring attention to the
value of One Health approaches and to invest in training
a workforce of One Health leaders who have the skills to
think critically and work collaboratively across sectors.
AI: Avian Influenza; CDC: Centers for Disease Control and Prevention;
DRC: Democratic Republic of Congo; EID: Emerging Infectious Disease;
EPT: Emerging Pandemic Threats; EVD: Ebola Virus Disease; GHSA: Global
Health Security Agenda; INRB: l’Institut National de Recherche Biomédicale;
JEE: Joint External Evaluation; UN: United Nations; USAID: US Agency for
International Development; WHO: World Health Organization; YF: Yellow
This work was made possible by the generous support of the American
people through the USAID. The contents are the responsibility of the
PREDICT authors and do not necessarily reflect the views of USAID or the
U.S. Government. We thank the governments and partners in PREDICT
Kelly et al. One Health Outlook (2020) 2:1 Page 5 of 7
TRK, CM, WBK, PZC, and JM conceived the study and were major
contributors in writing the manuscript. KG and JN led the PREDICT project’s
activities in Rwanda and contributed to the writing of the manuscript. MMU
and EAR led the PREDICT project’s activities in Bolivia and contributed to the
writing of the manuscript. KS, DOJ, CM, PMM, and PMK led the PREDICT
project’s activities in the DRC and contributed to the writing of the
manuscript. RK, DW, JM, and WS led the project’s activities in Tanzania and
contributed to the writing of the manuscript. The PREDICT Consortium is a
consortium of researchers who have made substantial contributions to the
design and implementation of the PREDICT project. All authors read and
approved the final manuscript.
This work was made possible by the generous support of the American
people through the USAID. The USAID did not play a role in conceiving or
writing this manuscript.
Availability of data and materials
Ethics approval and consent to participate
Consent for publication
The authors declare that they have no competing interests.
One Health Institute, University of California, Davis, CA, USA.
Alliance, New York, NY, USA.
Gorilla Doctors, Mountain Gorilla Veterinary
Project and Karen C. Drayer Wildlife Health Center, University of California,
Davis, CA, USA.
Bolivian Network of Primatology, La Paz, Bolivia.
San Francisco, CA, USA.
Sokoine University of Agriculture, Morogoro,
Received: 24 May 2019 Accepted: 13 December 2019
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