The one health movement—the global interdisciplinary effort encompassing human and animal health and the environment—has generated substantial discussion in the past decade.1 However, translating this increased interest into action is challenging,2 and real-world applications incorporating one health strategies are needed to illustrate how the one health concept can be translated into practical programs.3 In 2010, the Veterinary Public Health Program (VPH) within the Los Angeles County Department of Public Health launched the 2020 Healthy Pets Healthy Families (HPHF) initiative as a way to put one health into action. A central theme was to educate people about how keeping pets healthy is important for their own and their family's health.
The AVMA One Health Initiative Task Force emphasized the need for collaboration among individuals in the human, animal, and environmental health fields.4 Los Angeles County represents an ideal region for such interprofessional partnerships, with a population of approximately 10 million residents,5 40% of adults owning pets,6 more than 400 veterinary practices, 28 animal control agencies, a strong public health department, and multiple universities (including one veterinary college, two medical schools, and six schools with public health curricula).
In organizing the HPHF initiative, we sought to adapt the model used in Healthy People, a US Department of Health and Human Services initiative that started with the 1979 Surgeon General's Report “Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention.”7 This data-driven, nationwide program identifies human health improvement priorities for each decade and has directed efforts for human health improvement on a national scale. Healthy People 2020 is the fourth and most current iteration. It was developed in two phases through a collaborative process involving federal agencies, private individuals, and other organizations. The first phase identified the mission, vision, and goals. The second phase selected objectives to fulfill those goals. Each objective was associated with a reliable data source, baseline measure, health target to be reached by the year 2020, and evidence-based resources for improving health. Implementation was based on the MAP-IT (Mobilize, Assess, Plan, Implement, and Track) framework, which creates a path to plan and evaluate each step, from building a coalition to developing and executing interventions.8 This MAP-IT framework was adapted for use in creating and developing the HPHF initiative (Appendix 1).
The Los Angeles County Healthy Pets Health Families Initiative
The vision for the HPHF initiative was to create a local one health coalition that would use animal health metrics to improve both pet and human health while developing an evidence base to identify the most effective interventions. The coalition objectives were to identify and prioritize areas where human and pet health intersected in Los Angeles County, set goals to be reached by the year 2020, develop interventions, and generate data-driven reports for the community on progress toward achieving those goals. In keeping with the Healthy People framework, the coalition set out to identify or, if necessary, create sources of ongoing animal health data collection that could be monitored to track progress toward obtaining measurable objectives. The initiative was implemented with currently available resources, although there was an understanding that outside support could be sought if needed for future interventions.
Identifying focus areas and stakeholders—To begin the process, the VPH developed an initial list of priority animal-related concerns (focus areas) and identified potential local partners with an interest in each focus area (stakeholders). Some of the focus areas, such as zoonoses, represented situations where human health is directly affected by animal health. Others, such as obesity and secondhand smoke, were incorporated in the HPHF initiative because they are threats to the health of both humans and their pets. Important aspects of pet preventative health care were also included as focus areas because preventative health care can protect not only pet health but also health of the family. Overall, seven focus areas were identified: bite prevention, disaster preparedness, obesity, secondhand smoke, pet neutering, vaccine-preventable diseases in pets, and zoonotic diseases and parasite prevention.
In 2011, VPH staff held meetings with potential stakeholders to explain the overall goals of the project, discuss the current state of local pet health, and solicit interest in joining the initiative. The first HPHF coalition meeting was held in 2012. Attendees included private veterinarians, physicians, animal control agency staff, public health professionals, environmental health specialists, vector management professionals, university professors, animal behaviorists, members of the public, and representatives of nonprofit organizations. Engaging a diverse group of stakeholders was considered key to gaining local support and resources for the HPHF initiative.
Data gathering—Data collection was an early priority of the HPHF initiative. No standardized animal disease surveillance measures and only limited data sources on health in companion animal populations were identified. Still, Los Angeles County had more data on companion animal infectious disease than most jurisdictions owing to local ordinances established in 1926 requiring reporting of infectious diseases in animals. As the county urbanized, these ordinances were rarely used until VPH reestablished surveillance for animal diseases after the anthrax attacks in 2001. Veterinary clinics and animal shelters were first notified of the renewed reporting requirement in 2002. In 2007, a list of priority diseases for reporting was created and distributed. Since then, data on a variety of infectious diseases had been collected. These data proved crucial because zoonoses seen in veterinary practices are not always reportable conditions in human medicine. For example, Onchocerca lupi infection in dogs, but not in humans, is reportable in Los Angeles County. Data on canine cases of onchocerciasis demonstrated that this zoonotic parasite is present locally and that humans may therefore be at risk of exposure. Similarly, pets with leptospirosis or plague can serve as sentinels for human illness. Monitoring, tracking, and recording infectious disease trends in veterinary clinics were considered necessary to build an evidence-based understanding of local animal pathogen prevalence.
On the other hand, unlike infectious diseases, there were no local data sources for noninfectious animal diseases such as obesity. Thus, VPH elected to gather information on noninfectious animal diseases through various pet owner surveys. These surveys were developed in cooperation with epidemiologists from other public health programs to ensure the data collected would be consistent and repeatable and compatible with data obtained for similar measures of human health. The first survey was an online assessment of pet owners' knowledge, attitudes, and practices related to the seven focus areas. With the help of students, volunteers, and staff, similar surveys were administered in-person at animal shelters, dog parks, and veterinary clinics throughout the county. Additional surveys addressing specific focus areas were also developed, including two on pet obesity and one on vaccine-preventable diseases. All surveys were evaluated by Los Angeles County's Institutional Review Board and deemed exempt from formal review.
Additional existing data sources were identified for use in conjunction with the HPHF initiative. Animal control agencies maintain licensing information on all dogs impounded in shelters, and all animal bites to people in Los Angeles County are reportable to VPH. These additional data sources were essential tools for assessing the health of Los Angeles County residents and their pets.
Identifying objectives and goals—During the initial phase of the HPHF initiative, the coalition's attention was focused on identifying objectives for each focus area. To ensure objectives were measurable and relevant to the community, members were guided by an HPHF-specific model (Appendix 2), with final objectives chosen through group discussion, prioritization, and consensus.9 The quantitative nature of the data collected (eg, number of disease cases or number of specific responses to a survey) enabled the coalition to set measurable goals for the year 2020. Consistent with Healthy People, the HPHF initiative decided to aim for a 10% improvement in most of the objectives for the initial decade (Figure 1).
Selected objectives of the Los Angeles County Healthy Pets Healthy People initiative within each of the seven identified focus areas.
Citation: Journal of the American Veterinary Medical Association 247, 2; 10.2460/javma.247.2.143
Planning and implementing interventions—Local data revealed that community education would be a critical part of all interventions. For example, surveys indicated that obesity is a problem in the pet population but that many dog owners appeared to be unaware of what a healthy dog weight is and that many dogs did not receive regular exercise. In other cases, disease surveillance data revealed geographic clusters where intervention efforts could be focused for greatest effect. For example, cases of parvovirus reported to VPH were mapped to reveal areas where dogs were likely not receiving basic preventive veterinary care (Figure 2). Further review of these data showed that canine parvovirus clustered in areas of higher economic hardship.10
Distribution of canine parvovirus cases in Los Angeles county during 2008 through 2014.
Citation: Journal of the American Veterinary Medical Association 247, 2; 10.2460/javma.247.2.143
Subcommittees for each focus area then began discussing and implementing interventions. An important aspect of the HPHF initiative was to connect special needs populations with existing resources in the community. For example, the geographic distribution of canine parvovirus cases was shared with local animal control agencies; these agencies were subsequently able to organize a series of free vaccination clinics within two ZIP codes most affected by the virus.
Interventions related to other focus areas included development of a toolkit for starting dog-friendly neighborhood walking groups,11 with the ultimate intent being to address obesity and associated chronic diseases by increasing daily exercise of people and their pets to the recommended 150 min/wk.12 As an extra benefit, members would be introduced to one health messages developed by the coalition, and neighbors would get to know each other, increasing community resilience during disasters.
Current developments—The HPHF coalition meets quarterly to discuss current work done by partners. At each meeting, one member presents details of a local project, while other partners share updates on their work and discuss strategies for improving human and animal health in each focus area.
Coalition meetings also encourage members to collaborate on joint projects. One of these joint projects was creation of an HPHF Community Report that describes the initiative in detail, including background on each focus area and proposed interventions, and highlights the measurable goals for the next decade.13 The report is intended to raise awareness and build support in the community by introducing community members to the concepts of one health. It also aims to be a resource informing key policy makers and potential grantors about the importance of one health and opportunities for community health impact. Other joint projects of the coalition included developing a brochure for pet owners and media messages for HPHF partners. The brochure was created to supplement the report, providing an overview of each of the seven focus areas, and is distributed through veterinary clinics and animal shelters and at health fairs. Targeted media messages for all focus areas were created to allow coalition members to deliver consistent messages when discussing HPHF topics with the public.
The quarterly coalition meetings provide a platform for networking, enhancing existing partnerships, and improving cooperation between governmental and nongovernmental agencies. For example, one coalition meeting brought together public health officials, vector control agency staff, animal control officers, private veterinarians, and others to discuss an increase in the number of cases of flea-borne typhus in people in Los Angeles County. This led to the creation of an inter-agency Emerging Zoonoses and Vector-borne Disease work group, which meets quarterly to review animal and human health data related to those diseases and promote multidisciplinary prevention strategies. In addition, the local veterinary association board members participated in targeted outreach to veterinary clinics to encourage practitioners to report animal diseases and support coalition efforts. Their efforts have helped strengthen working relationships between public health officials and veterinary practices.
Replicating the HPHF Model
The Los Angeles County HPHF initiative provides a model that we believe can be replicated by animal and human health leaders in any community. By combining HPHF members' resources, long-lasting change may be accomplished with a limited budget.
One of the most important strategies of the HPHF initiative involved surveillance of zoonoses in animals and sharing those data with public health authorities.3,14 Los Angeles County's laws allowed VPH to gather these data, but the same procedures may not be possible in other jurisdictions without similar laws. However, disease tracking can be done in other ways. For example, it may be possible to have local veterinary practices share data on local cases of disease, so long as data are collected in a way that minimizes work for the practices and preserves patient and client privacy.
As a result of the Affordable Care Act, hospitals are now required to conduct community assessments if they wish to receive federal funds. A one health coalition could partner with a local hospital to incorporate measures of pet health that could impact human health in their assessment, as they develop community programs for conditions such as obesity.
Although there is no one way to create and maintain a local one health initiative, we believe the HPHF initiative approach can be used elsewhere to operationalize one health at a local level. One health coalitions can serve as an important avenue for preventive medicine messages to reach the public, enhance the role of veterinary practitioners in the community, and deepen the veterinarian-client-patient relationship. Local and state veterinary associations may be ideally positioned to launch similar initiatives in their own communities. In our experience, the most important elements for building a successful one health coalition may be organization, motivation, and dedication.
References
1. Zinsstag J, Schelling E, Waltner-Toews D, et al. From “one medicine” to “one health” and systemic approaches to health and well-being. Prev Vet Med 2011; 101: 148–156.
2. Lee K, Brumme ZL. Operationalizing the one health approach: the global governance challenges. Health Policy Plan 2013; 28: 778–785.
3. Zinsstag J, Shcelling E, Bonfoh B, et al. Towards a “one health” research and application tool box. Vet Ital 2009; 45: 121–133.
4. 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: 259–261.
5. Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Key indicators of health by service planning area; March 2013. Available at: publichealth.lacounty.gov/ha/docs/kir_2013_finals.pdf. Accessed Jun 20, 2014.
6. Los Angeles County Department of Public Health. 2007 Los Angeles County Health Survey. Available at: www.publichealth.lacounty.gov/ha/hasurveyintro.htm. Accessed Jun 20, 2014.
7. Department of Health, Education, and Welfare. Healthy people: the surgeon general's report on health promotion and disease prevention, 1979. Available at: profiles.nlm.nih.gov/ps/access/NNBBGK.pdf. Accessed Jun 20, 2014.
8. Healthy People 2020. Implementing Healthy People 2020. Available at: www.healthypeople.gov/2020/implement/mapit.aspx. Accessed Jun 20, 2014.
9. Guzenhauser JD, Smith KN, Fielding JE. Quality improvement brief: priority-setting in public health. Los Angeles: County of Los Angeles Department of Public Health, 2010.
10. Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology. Premature deaths from heart disease and stroke in Los Angeles County: a cities and community health report, January 2006. Available at: lapublichealth.org/epi/docs/CHR_CVH.pdf. Accessed on Jun 20, 2014.
11. Los Angeles County Department of Public Health, Veterinary Public Health Program. Walking group toolkit. Available at: publichealth.lacounty.gov/vet/docs/Walking_Toolkit_042514.htm. Accessed Jun 20, 2014.
12. CDC. How much physical activity do adults need. Available at: www.cdc.gov/physicalactivity/everyone/guidelines/adults.html. Accessed May 14, 2014.
13. Ehnert K, Beeler E, Coelho L, et al. Healthy Pets, Healthy Families Initiative. Available at: publichealth.lacounty.gov/vet/docs/2014HPHFCommunityReport.pdf. Accessed Jun 20, 2014.
14. King LJ, Marano N, Hughes JM. New partnership between animal health services and public health agencies. Rev Sci Tech Off Int Epiz 2004; 23: 717–726.
Appendix 1
Modified MAP-IT framework for developing local one health initiatives.
| Category | Description |
|---|---|
| Mobilize | Develop a community coalition |
| Assess | Gather data and set local animal health goals |
| Plan | Identify best interventions |
| Implement | Jointly implement programs and campaigns |
| Track | Monitor impact and progress |
Appendix 2
Selection criteria used to develop animal health objectives within the Los Angeles County Healthy Pets Healthy People initiative.
| Criterion | Description |
|---|---|
| Understandable | The objective should be important and understandable to a broad audience |
| Prevention-centric | The objective should be prevention-oriented |
| Useful | The objective should be useful and reflect issues of national importance |
| Measurable | The objective must be measurable and supported by local data |
| Impactful | The objective should have an impact on the community, including humans and animals |
| Evidence-based | The objective must be supported by the best available scientific evidence |
| Supported | The objective should be supported by a specific agency willing to provide needed data to monitor progress and provide direction for interventions |
