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US Army public health: one health, one medicine, one team.

One Health is the concept for bringing together health promotion and delivery for humans, animals, and the environment (Figure 1). (1) The One Health concept recognizes that success in one profession such as human health often requires coordination with the other two. Failure to account for these relationships can have disastrous consequences.

Vector-borne disease control is an example of how the 3 disciplines are related. Over one million people die each year from diseases such as malaria, dengue, and yellow fever, which are transmitted by mosquito vectors. (2) When dichlorodiphenyltrichloroethane (DDT) was first identified as an insecticide in 1939, it was lauded as the solution to vector-borne diseases. It was inexpensive and persistent, and over the next few decades, DDT was widely used throughout the world with great success at reducing mosquitoes. For example, the Aedes aegyptii mosquito was eradicated from dozens of countries within the western hemisphere, which in turn led to significant reductions in the number of dengue cases. The vector control programs were so successful that some people soon began asserting that these diseases would be wiped out and no longer threaten the human race. Unfortunately, these assertions failed to recognize the negative impacts of DDT on the environment and animals. Bioaccumulation within the environment (a result of DDT's persistence) was linked to eggshell thinning and decreased reproduction rates in birds of prey. (3) Concern was also voiced that the birds were biosentinels and an early warning to potential human risks, which is supported by recent studies suggestive of possible adverse effects in humans. (4)

The negative animal and environmental effects of DDT eventually led to use restrictions and bans in the United States and many other countries. The bans in turn have been criticized as harmful to humans by increasing exposure to vector-borne diseases leading to increased mortality. (5) These criticisms may be partially responsible for the recent resurgence of DDT use. However, whereas DDT was indiscriminately used during the 1940s and 1950s, its use is more focused today. Perhaps the greatest change in DDT usage (as well as other pesticides) was the shift from widespread agricultural application to targeted indoor residual spraying. Indoor residual spraying takes advantage of the persistent tendencies of DDT to provide inexpensive protection against Anopheles species and other indoor feeding mosquitoes which transmit diseases, (6) while at the same time avoiding bioaccumulation in lakes, streams, and soils that harm the environment, animals, and humans. Used appropriately, such as treating bed nets and rotating insecticides to reduce resistance, indoor residual spraying saves human lives while protecting animal and environmental health.

The One Health Initiative recognizes the importance of an interdisciplinary medical team and "is dedicated to improving the lives of all species--human and animal--through the integration of human medicine, veterinary medicine and environmental science." (7) The One Health Initiative is supported by numerous organizations including the American Medical Association, the American Veterinary Medical Association, and the National Environmental Health Association. Multiple US government agencies, including the Centers for Disease Control and Prevention (CDC), the Department of Agriculture, and the Food and Drug Administration, have recognized the importance of One Health and are working together to improve health promotion cooperation across the 3 health disciplines.

For example, the CDC's Healthy Pets, Healthy People initiative seeks to improve human health through animal health. (8) Over 60% of the diseases affecting humans, and 75% of newly emerging diseases, are zoonotic. (9) Pets are an integral part of many US households and are often considered part of the family. Americans spend countless hours each day walking, grooming, and playing with their pets, and over 60% share their beds with the cat or dog. This close contact facilitates transmission of bacterial, parasitic, and viral infections such as plague, scabies, and rabies. (10) Ensuring pets are healthy and disease free protects human health. Of course, the reverse is also true; healthy people promote healthy pets as diseases can be transmitted from people to pets (zooanthroponosis).

Pet ownership can also be used to improve human health. Pets have been shown to decrease blood pressure, and cholesterol and triglyceride levels, and increase opportunities for exercise and socialization. (11,12) An owner's desire to keep the pets healthy can impact their own behavior. Although obesity is not infectious, canine and feline obesity is associated with owner obesity. While some owners may be unconcerned or unwilling to address their own health, they may be motivated to improve the health of their beloved pets, even if it means making personal changes. Addressing canine obesity in particular is a potential method of improving human health, as exercise (walks, runs or playing in the park) will benefit both the dog and the owner. Similarly, addressing canine nutrition requirements may encourage the owner to examine their own eating habits.

US ARMY PUBLIC HEALTH COMMAND REGION--WEST: PUTTING ONE HEALTH INTO PRACTICE

The One Health initiative is also being implemented within the US military, particularly within the US Army Public Health Command (USAPHC). The USAPHC achieved full operational capability on October 1, 2011 with the mission to "promote health and prevent disease, injury, and disability of Soldiers and military retirees, their Families, and Department of the Army civilian employees; and assure effective execution of full spectrum veterinary service for Army and Department of Defense Veterinary missions." (13,14) The USAPHC distinctive unit insignia includes the One Health triangle representing the triad of human, animal, and environmental health, as well as the motto Una Sanitas, Latin for One Health (Figure 2). The USAPHC internal command publication is entitled "One Health," further evidence of the organization's commitment to the concept.

The Public Health Command provides technical oversight for its broad One Health mission through portfolio management. Functional specialties such as environmental health engineering, epidemiology and disease surveillance, health promotion and wellness, and veterinary services are managed within the Army Institute of Public Health to ensure information is communicated and resources are coordinated effectively. Command and control is subordinated through 5 regional commands (North, South, West, Europe, and Pacific), which are aligned with the regional medical commands (Figure 3). Although this issue focuses on Public Health Command Region-West (PHCR-W) activities, the basic structure, functions, and missions are the same at the other regional commands. The PCHR-W is a multidisciplinary unit with Soldiers and civilians from each of the One Health professions (human, animal, and environment). The disciplines are assigned to divisions, which are aligned with the technical portfolios at the Army Institute of Public Health. This structure and alignment allows for communication and coordination of efforts at all levels.

One area in which USAPHC has a long history of coordinating interdisciplinary health efforts is the human-environment interface. The World Health Organization estimates that environmental hazards account for 25% of the total disease burden worldwide. (15) The environment is associated with communicable and infectious diseases, such as the previously discussed vectorborne diseases, but also noncommunicable diseases such as cancers, respiratory illnesses, and cardiovascular issues. (16) While these environmental hazards can occur naturally, they can just as easily be man-made. In other words, unhealthy human actions lead to unhealthy environments, which in turn lead to unhealthy humans--One Health at its worst. In recognition of the environment-human health connection, PHCR-W activities are directed towards both detecting environmental hazards and preventing them.

An important tool for identifying en vironmental health hazards is the De fense Occupational and Environmental Health Readiness System (DOEHRS). It is a centralized system for storing and managing occupational and environmental health hazard (biological, physical, chemical) data.* Of course, DOERHS is only as good as the samples that are collected and the data which are entered into the system. While PHCR-W personnel have the ability to conduct environmental surveillance and enter the data, they cannot be at every Army installation, including those in deployed environments. Instead, PHCR-W personnel provide training to preventive medicine units on how to conduct environmental surveillance and enter the data into DOEHRS. Over the past several years PHCR-W has provided training to over a dozen garrison and deploying preventive medicine units annually. Each year approximately 200 individuals from Army, Navy, and Marine units have received training on environmental sample collection and data entry. The result is that deployed commanders are given accurate risk assessments for exposed personnel on the ground and recommendations to mitigate health risks, such as the elimination of burn pits. The DOERHS data repository can also be accessed by medical professionals for identification and management of human health concerns resulting from potential environmental exposures during past deployments.

More recently, the formation of USAPHC has led to new One Health collaborations. For example, the merging of Army preventive medicine and veterinary medical assets into a single organization has strengthened food and water safety at Army installations. Traditionally, Army veterinary personnel have been responsible for auditing commercial food and water suppliers and inspecting deliveries through receipt to ensure the subsistence is safe and wholesome. Inspection of food storage, preparation, and serving, as well as ensuring the safety of installation water treatment facilities, is performed by preventive medicine personnel. While these groups have worked well together, there was the potential for information loss during the handover of responsibility. Bringing expertise from both groups together under a single organization improves coordination, assists in the timely identification of issues or problems, and fosters cooperation to develop improved food safety product and measures. One example of this improved collaboration was evident in preparing and staffing the new revision of the Department of Defense (DoD) Tri-Service Food Code. (17)

Vector-borne disease surveillance is another aspect which has benefited from the formation of USAPHC. The Army, as well as the other military services, collects and tests arthropod vectors for pathogens such as Babesia canis, Borrelia burgdorferi, and Rickettsia parkeri, the causative agents for babesiosis, Lyme disease, and tidewater fever, respectively. The arthropods are generally submitted by clinicians following removal from patients or collected as part of environmental surveillance such as tick drags. These surveillance efforts capture 2 of the 3 populations (humans and environment), but they miss the local animal population. Ticks can bite and feed from dogs and cats as easily as humans, especially if pets are not treated with an acaricide, which can lead to infection and diseased pets. One of the ways PCHR-W has improved vector-borne disease surveillance is through coordination of the environmental health, laboratory sciences, and veterinary services divisions to collect, identify, and test ticks collected at installation veterinary clinics throughout the Region. This program not only identifies pets which should be prophylactically treated for infection, but also helps to better quantify the disease transmission risk to other animals, as well as their owners, which in turn shapes future risk mitigation strategies and communications at the installation. The information is also transmitted through the technical portfolio channels and analyzed in conjunction with other surveillance efforts (reportable medical events, for example) to prepare products like the monthly Army Vector-borne Disease Report, (18) available through the USAPHC website* or via e-mail subscription. The monthly report provides a quick snapshot of vector-borne disease activity within the United States as a whole, within the Army active duty and beneficiary medical populations, and environmental surveillance. Eventually, the vector-borne information may be combined with information from veterinary treatment facilities using the newly fielded Remote Online Veterinary Record (ROVR) to further quantify the risk of vector-borne disease transmission at Army installations. The ROVR is the DoD electronic animal health record system for both government and privately-owned animals and can be queried to identify disease trends and outbreaks.

FUTURE DIRECTIONS

One Health will continue to shape USAPHC's efforts to improve Soldier and family readiness through marketing and leveraging of public health in support of larger Army and DoD programs. For example, the DoD's Healthy Base Initiative seeks to improve the health and wellness of service members, families, and civilians through better nutrition. Several DoD installations have recently implemented local farmers markets to improve service members' eating habits by providing healthy alternatives to the traditional fast food options on military installations. However, while these farmers markets may have more nutritious fruits and vegetables in comparison to a burger and extra-large fries, there are health risks. One need look no further than the 2011 Listeria monocytogenes cantaloupe outbreak, with nearly 150 cases in 28 states, for evidence that even fresh fruits and vegetables can be linked to infectious disease transmission. (19) To minimize these risks, USAPHC personnel are developing food sanitation guidance material for consumers and food surveillance inspection programs for farmers markets to ensure food safety supports healthy eating behaviors.

One Health activities also support The Army Surgeon General's Performance Triad. (20) The USAPHC oversees Army Wellness Centers, which provide individual health assessments and information on physical fitness, nutrition, stress management, tobacco cessation, and general wellness to assist individuals in developing and reaching their health goals. (21) The program engages individuals in their "lifespace," their environment, to help them make lifestyle changes, which improve short- and long-term health. These health promotion efforts also extend beyond Army Wellness Centers into all aspects of the USAPHC mission. For example, the veterinary clinic is not a traditional setting for discussing human obesity, yet as previously mentioned, pet owners may be willing to make lifestyle changes for their pet's health that they would not make for their own health. These lifestyle changes are not limited to just nutrition either. Dog runs/walks are an excellent way to encourage owner and pet exercise and multiple veterinary clinics are partnering with their local medical treatment facilities or morale, welfare, and recreation activities to organize and promote these events.

Looking towards the future, the One Health concept will remain a fundamental element of public health. While the structure of USAPHC and its subordinate units will likely undergo significant changes as part of the Army Medical Department reorganization, the public health duty will remain a key component mission of the unit, its successor, and the Army Medical Department. As the world becomes more populated and increasingly interconnected, the interactions between human, animals, and the environment will only increase. The recent introduction of the Chikungunya virus into the western hemisphere and the ongoing outbreak of Ebola in western Africa are 2 examples of outbreaks which are reshaping our thinking. We cannot assume that the way things were will be the way things are in the future. Effectively preparing for and addressing these future health threats requires coordination across all health fields, human, animal, and environment. The 3 fields are inextricably linked and lasting success cannot be achieved unless the medical professions work together--One Health, One Medicine, One Team.

REFERENCES

(1.) King LJ, Anderson LR, Blackmore CG, et al. Executive summary of the AVMA One Health Initiative Task Force report. J Am Vet Med Assoc. 2008; 233(2):259-261.

(2.) World Health Organization. The Health and Environment Linkages Initiative (HELI): Vector-borne disease. 2014. Available at: http://www.who.int/ heli/risks/vectors/vector/en/. Accessed August 10, 2014.

(3.) US Environmental Protection Agency. A Review of Scientific and Economic Aspects of the Decision to Ban Its Use as a Pesticide. Washington, DC: US Environmental Protection Agency. July 1975. EPA-540/1-75-022. Available at: http://www2.epa. gov/aboutepa/ddt-review-scientific-and-economicaspects-decision-ban-its-use-pesticide. Accessed October 31, 2014.

(4.) Rogan WJ, Chen A. Health risks and benefits of bis(4-chlorophenyl)-1,1,1-trichloroethane (DDT). Lancet. 2005; 366(9487):763-773.

(5.) Finkel M. Malaria: stopping a global killer. National Geographic. July 2007. Available at: http://ngm. nationalgeographic.com/2007/07/malaria/finkeltext. Accessed July 20, 2014.

(6.) Walker K. Cost-comparison of DDT and alternative insecticides for malaria control. Med Vet Ento mol. 2000; 14(4):345-354.

(7.) One Health Initiative. Mission Statement. One Health Initiative Website. Available at: http://one healthinitiative.com/mission.php. Accessed July 20, 2014.

(8.) Centers for Disease Control and Prevention. Healthy Pets Healthy People. Available at: http:// www.cdc.gov/healthypets/. Accessed July 20, 2014.

(9.) Taylor LH, Latham SM, Woolhouse ME. Risk factors for human disease emergence. Philos Trans R Soc Lond B Biol Sci. 2001; 356(1411):983-989.

(10.) Chomel BB, Sun B. Zoonoses in the bedroom. Emerg Infect Dis. 2011; 17(2):167-172.

(11.) Anderson WP, Reid CM, Jennings GL. Pet ownership and risk factors for cardiovascular disease. Med J Aust. 1992; 157(5):298-301.

(12.) Beck AM, Meyers NM. Health enhancement and companion animal ownership. Annu Rev Public Health. 1996; 17:247-257.

(13.) Ugalde RM, Resta JJ. The US Army Public Health Command initiative: transforming public health services for the Army. US Army Med Dep J. Apr Jun 2010:4-10.

(14.) US Army Public Health Command. Organization. USAPHC Website. Available at: http://phc.amedd. army.mil/organization/Pages/default.aspx. Accessed July 20, 2014.

(15.) Smith KR, Corvalan CF, Kjellstrom T. How much global ill health is attributable to environmental factors?. Epidemiology. 1999; 10(5):573-584.

(16.) Lim SS, Vos T, Flaxman AD, et al. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. Lancet. 2012; 380(9859):2224-2260.

(17.) TB MED 530/NAVMED P-5010-1/AFMAN 48147_IP: Tri-Service Food Code. Washington, DC: US Dept of the Army; April 30, 2014. Available at: http://www.med.navy.mil/directives/Pub/5010-1. pdf. Accessed October 31, 2014.

(18.) US Army Public Health Command. Army Vectorborne Disease Report. Periodic Publications and Surveillance Reports page, USAPHC Website. Available at: http://phc.amedd.army.mil/whatsnew/ Pages/PeriodicPublications.aspx. Accessed July 20, 2014.

(19.) McCollum JT, Cronquist AB, Silk BJ, et al. Multi state outbreak of listeriosis associated with cantaloupe. N Engl J Med. 2013; 369(10):944-953.

(20.) Horoho PD. A system for health: essential element of national security. US Army Med Dep J. October December 2013:5.

(21.) US Army Public Health Command. Army Wellness Center Services. USAPHC Website. Available at: http://phc.amedd.army.mil/topics/healthyliving/ al/Pages/ArmyWellnessCenters.aspx. Accessed August 26, 2014.

LTC Ronald L. Burke, VC, USA

COL Casmere H. Taylor, MS, USA

* Restricted access: https://doehrswww.apgea.army.mil/doehrs dr/index.jsp

* http://phc.amedd.army.mil

AUTHORS

LTC Burke is the Veterinary Public Health Instructor for the First Year Graduate Veterinary Education Program, Joint Base Lewis-McChord, Washington.

COL Taylor is the Commander, Public Health Command Region--West, Joint Base Lewis McChord, Washington.
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Author:Burke, Ronald L.; Taylor, Casmere H.
Publication:U.S. Army Medical Department Journal
Geographic Code:1USA
Date:Jan 1, 2015
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