AAVMC /APTR One Health Case Studies

One Health is the collaborative effort of multiple disciplines – working locally, nationally, and globally – to attain optimal health for people, animals and our environment. The One Health initiative focuses attention on the importance of the connections between human health, animal health, and ecosystem health. The recent Ebola virus outbreak, along with the growing recognition of the importance of antimicrobial resistance, a spectrum of emerging and re-emerging diseases, as well as the positive benefits of human-animal interactions, is bringing One Health concepts to the attention of health professions educators.

The One Health Interprofessional Education Initiative seeks to integrate One Health concepts into the degree programs of health professions students through the case study method of instruction. To accomplish this goal the Association of American Veterinary Medical Colleges (AAVMC) convened a Working Group in collaboration with the Association for Prevention Teaching and Research (APTR) and the Healthy People Curriculum Task Force (HPCTF). 15 case studies were selected for publication, and they are listed below.

One Health Interprofessional Education Webinar

APTR and AAVMC are pleased to present the One Health Interprofessional Education Webinar, which highlights four case studies available for use by instructors from a variety of health professions. Emerging infectious disease threats, as well as growing awareness about the dangers of antimicrobial resistance and the positive benefits of human-animal interactions are bringing One Health concepts to the attention of many educators in the health professions.

Case Studies

A Veteran and His Dog

Erin Brewer, Erika Rost, Gigi Davidson, Kelly L. Scolaro, Rebecca Cozart, Gene Hobbs, Carol Durham, Benny Joyner

Worldwide, carbon monoxide (CO) poisoning is the leading cause of toxicological deaths in humans, accounting for 20,000 emergency room visits and 400 deaths every year.1,2 CO poisoning outbreaks are linked to gas leaks and usage of alternative sources of heat or power such as charcoal burners and gasoline powered generators. Indoor usage of these energy sources puts humans and animals at risk for poisoning from the colorless, odorless gas. In humans, symptoms of CO poisoning are non-specific and are usually described as "flu-like" which can make diagnosis, especially in the winter, difficult. In dogs symptoms of CO poisoning can present as excessive sleepiness or lethargy, nausea, vomiting, cough, and uncoordinated movements/gait.When CO levels become too high both humans and dogs can lapse into coma then death.

Our proposal is a role-play scenario using a standardized patient and a dog . The patient, a 50-year-old veteran, Robert Santiago, uses a service dog, Siri, for PTSD. Mr. Santiago has not been able to pay his electric bill and has been using a charcoal grill on his screened porch. Mr. Santiago presents to the "VA team" (medical, nursing, pharmacy, veterinary students) for a follow-up on his PTSD/depression and to refill his anti-depressant, sertraline. He complains to the team about being tired and nauseous for a few weeks. In the course of the visit Mr. Santiago mentions that Siri has been sleeping a lot and is not eating well. He is worried she is depressed and asks the team for help.

Bordetella Infections in Cystic Fibrosis Patients
Jared Gillingham and Robert Burlage

In a recent study of people with cystic fibrosis (which affects the lungs significantly) it was discovered that many were infected with the microorganism Bordetella bronchiseptica. This pathogen causes kennel cough in dogs but only rarely causes disease in humans. It is a reasonable causality hypothesis that the patients became infected from household pets, perhaps a companion animal. While the patients did not appear to be ill because of the infection, the presence of bacteria in the lungs may be a predisposing risk factor in pneumonias caused by other pathogens. Cystic fibrosis patients suffer acutely from pneumonias, and any contributing factor would be significant. An animal vaccine for the Bordetella pathogen is available and will limit exposure to humans.

The purpose of this case study is to demonstrate the link between human and animal health, even when the outcome in humans is indirectly associated with illness. It also shows the interconnectedness of health professionals such as veterinarians and physicians, nurses and pharmacists in obtaining relevant information about their patients' greater environment, such as the vaccination status of pets or the presence of other health issues in the household. Building a holistic concept of the patient environment may reveal unexpected risk factors. This case study is designed as an interactive forensic investigation, with data introduced gradually to challenge the students as they evaluate risk factors and causality from the new information. The best fit for the case is in the epidemiology/public health course in the 3rd professional year.

Staphylococcus pseudintermedius: Look What the Dog Dragged In?
Carey-Ann Burnham and Brian Lubbers

A 36 year old man fractured his left humerus in a bicycling accident. Several weeks later, he presented to his physician with drainage from a sinus tract at the site of the fracture. A culture was performed on the exudate and Staphylococcus pseudintermedius was recovered from the specimen.

Although S. pseudintermedius can be a member of the oral, nasal and skin flora of healthy dogs it is also the leading cause of skin and soft tissue infections in dogs. The true incidence of S. pseudintermedius infection in humans is unknown, but is likely underestimated. This is attributed to the fact that the traditional methods used in human clinical microbiology laboratories would be likely to misidentify these isolates as Staphylococcus aureus. With the introduction of Matrix Assisted Laser Desorption Ionization Time-of-Flight Mass Spectrometry (MALDI-TOF MS) as a diagnostic tool, it is becoming clear that S. pseudintermedius is indeed a cause of human infections. This is clinically significant as the methodologies to predict beta-lactam susceptibility differ for S. aureus and S. pseudintermedius.

We will use this scenario to introduce concepts in microorganism identification in human and veterinary microbiology laboratories, mechanisms of methicillin resistance, and methods to detect this resistance in the laboratory. We will contrast traditional microbiological methods with MALDI-TOF MS, and emphasize how this is informing new biological insights. In addition, we will discuss approaches to S. aureus and S. pseudintermedius in pets and in humans, and the benefits and potential limitations of decolonization as a preventative measure.
Abstract | Student Materials| Request Facilitator Materials

Care of Immunocompromised Individuals: The Role of Companion Animals in Mental Health
Stephen Cole and Shelley Rankin

Unfortunately, the diagnosis of HIV/AIDS often carries social discrimination and misunderstanding. For many HIV/AIDS patients their pets are the only individual in their life that their relationship does not change with once a diagnosis is made. This case study will focus on the mental health benefits that pets play in the lives of immunocompromised individuals and weigh them with the health risks that they may present. Participants will play the role of both physician and veterinarian during this exercise. Through playing both roles, regardless of the participants training, they will be able to see the critical role these professions play in preventing zoonotic disease transmission. Collaborative discussions will elucidate the ways to minimize risk for the patient such as hygiene, behavior and veterinary care of the animal. This will morph into a discussion of mental health being an integral part of human health and, therefore, a critical pillar within One Health.
Abstract | Pre-Reading | Student Materials | Request Facilitator Materials

Lead Poisoning
Stephen Cole, Shelley Rankin and Peter Rabinowitz

Based on an actual case that I saw while on senior rotations in vet school, this case study will focus on the collaborative roles that veterinarians and physicians play in protecting One Health. A poultry veterinarian for the state diagnostic lab receives 4 dead pigeons for necropsy and further work up. The pigeons belong to the client's 10-year-old daughter who takes care of them and races them. She keeps them in an old shed on the property. The autopsy is unremarkable, but toxicology reports show incredibly high lead levels. After testing the shed it is found to have lead paint. Recommendations by veterinarians and physicians will be covered (testing of family members, guidance on decontamination etc.). There will also be discussion of other examples of animals as sentinels for human health. This case will be compared to the 2010 outbreak of lead poisoning in Northern Nigeria where the death of waterfowl lead officials to determine the cause of illness and death of hundreds of children. This case study analyzes and tests One Health skills and competencies as they are needed on microscopic (a single family and four pigeons) and macroscopic (a quarter of the children in villages in Northern Nigeria) levels.

Pet Ownership
Robert Ellis and Carrie Ellis

This interactive case study will educate health professional learners on many aspects of human-animal interactions through a problem based learning format. It will be easily adaptable to other formats that may better fit an institution's curriculum. Topics will include benefits and risks of human-animal interaction and pet ownership, issues related to special populations such as children and immunocompromised individuals, prevention and treatment of animal bites, and prevention of common zoonotic infections. This case study will empower learners to educate the community they serve to improve the health of both humans and animals. The case will begin with parents of a child presenting to a health professional inquiring about the benefits and risks of pet ownership. After some discussion, it is found out that the child underwent a bone marrow transplant for leukemia 8 months earlier. Learners will explore issues of risks and benefits of pet ownership in different situations. The family elects to get a dog and subsequently presents to the health professional to advise on minimizing health risks. The learners will explore issues related to minimizing health risks in human-animal interactions including prevention of common zoonotic diseases and animal bites. Six months later, the dog gets tangled in wire while running through a field and suffers multiple lacerations. While freeing the dog, the dad sustains a bite wound to the hand. The learners will explore issues related to animal bites including initial treatment and triage, definitive treatment, risk of infection, issues related to rabies, and applicable laws and regulations.

Abstract | Student Materials | Risks and Benefits | Zoonotic Infections | Animal Bites | Cat Scratch Disease | Dog Bite | Leptospirosis in Dogs and Cats | Toxoplasmosis: An Important Message for Cat Owners | Worms (Toxocariasis) | Toxocariasis Fact Sheet | infections | Request Facilitator Materials

Q Fever in the Suburbs: Zoonotic Disease Outbreak Tabletop Training Exercise
Armando Hoet, Joanne Midla, Jeanette O'Quin, Jason Stull

Efforts to prevent and control the spread of emerging/re-emerging zoonotic diseases require a coordinated interdisciplinary response by public health professionals. We propose the development of a participative zoonotic disease outbreak tabletop exercise. The realistic scenario will focus on a zoonotic outbreak (Q Fever) affecting a suburban community. Due to the classification of this biological agent as Category-B, as well as its potential agricultural origin and multiple transmission pathways (aerosol, foodborne, waterborne, direct contact), an outbreak of this disease in the community must involve multiple agencies and professionals. Therefore, as the scenario develops, participants will engage in group discussion and decision-making opportunities designed to simulate a multiagency response. Through this exercise it is expected for students to learn about the role of their chosen profession in a zoonotic outbreak as well as the roles of other professions including public health, human and animal health, environmental health, law enforcement and emergency management. In recent years, we have successfully created similar types of scenarios (e.g. AI, Rabies, Tuberculosis) in collaboration with a multidisciplinary panel (DVMs, MDs, nurses, EMS, epidemiologists) from different public health and agricultural/veterinary agencies as well as academia. Using those scenarios, over 600 public health officials as well as veterinary and graduate students have been trained. The critical reviews from such audiences will be used to further develop the Q-Fever case to target the needs of professionally and geographically diverse health students. The completed interactive exercise will have two distinct formats: one for small groups (workshop style), and one for large classes (conference style).

Brucella suis: A Re-emerging Pathogen at the Human, Livestock, and Wildlife Interface.
Suzanne Kennedy-Stoskopf, Glen Almond, Chris DePerno, Gregory Gray, April Kedrowicz, Danielle Stanek, Chris Woods, and Asher Wright

The rapid expansion of feral swine in the US, the increased demand for free-range pork in niche markets, and the non-specific clinical signs of brucellosis, a re-emerging zoonotic disease in the US form the pieces of this simulated, jigsaw case study illustrating disease challenges at the human, livestock, and wildlife interface. Brucella suis was eliminated from large, commercial swine operations, but is endemic in certain feral swine populations posing a risk to free-range, domestic pigs and hunters. Ideally, this inter-professional teaching case would involve medical, veterinary, public health, and graduate students in wildlife management/conservation biology to develop the three major components of the puzzle. 1) Human: Recognize the diversity of clinical signs associated with brucellosis, diagnosis, exposure routes, and treatment of a father and son with a small family farm and how best to prevent additional cases. 2) Livestock: Recognize diversity of clinical signs of brucellosis in domestic swine, diagnosis, and management strategies. 3) Wildlife: Management of feral swine, an invasive species that has adverse impacts on the environment including destruction of agricultural crops but also is hunted as non-regulated game; includes surveillance for Brucella suis, influenza, pseudorabies, and classical swine fever. This case study can also be developed for problem based learning for respective student populations with summaries of components outside their disciplines. The ultimate goal is for students to discuss and develop effective lines of communication between physicians, veterinarians, public health workers, and wildlife managers to share information early about potential health problems that impact people and animals.
Abstract | Student Materials | Human Case Scenario | Livestock Case Scenario | Wildlife Case Scenario | Request Facilitator Materials

Of Dogs and Men: Methicillin-resistant Staphylococcus aureus
Brian Lubbers and Carey-Ann Burnham

"A healthy, adult male presents to the primary care professional for a routine MRSA (methicillin-resistant Staphylococcus aureus) screen. The doctor obtains a swab from the perineal area by gently lifting the patient's tail…..yes, tail. The patient is Rusty, a 6 year-old, Golden Retriever, whose family is experiencing recurrent MRSA episodes."

In 2013, the Centers for Disease Control and Prevention listed methicillin-resistant Staphylococcus aureus as a Serious Antibiotic Resistance Threat in the United States. Although MRSA was traditionally considered a nosocomial pathogen, community-associated infection, especially skin and soft tissue infection, is increasingly common. In addition, strain types that were traditionally considered "community associated" are becoming the predominant strain types in many medical centers. In addition to skin and soft tissue infections, MRSA may colonize individuals completely asymptomatically, or cause invasive disease such as blood stream infection, pneumonia, and bone and joint infections. Using a directed case study approach, the proposed case will utilize the above fictional scenario to enhance student understanding of the basic microbiology / mechanisms of resistance for MRSA, potential diagnostic measures, and epidemiological challenges associated with MRSA. The interplay of this organism between companion animals and humans, and infection prevention measures will be discussed, in light of current scientific literature, with emphasis on the interaction that is needed between human and veterinary medical professionals in resolving recurrent household MRSA infections.

Human-Animal Interaction
Jean Prast, Ellen Herlache, Andrea Frederick, Meghan Baruth, and Lucy Mercier

The proposed evolving case study will address the Human-Animal Interaction component of the One Health Educational Framework. The case study will involve an interprofessional team consisting of nursing, occupational therapy, social work, health sciences, and veterinary medicine professionals. The interprofessional team will address the development, implementation, and evaluation of programs involving both residential and visiting animals at a skilled nursing facility.

The case study will require participants to address the following core components:
  • Completion of a SWOT analysis to identify potential benefits and barriers to successful implementation of the program
  • Development of a budget and plan for financial sustainability of the program
  • Development of outcome measures for evaluating program success
  • Identification of roles and responsibilities of all team members
  • Development of policies and procedures to ensure the safety of the animals, clients, and facility
  • Development of procedures for determining if and how individual residents would participate in the program once it has been implemented
  • Development of procedures for the prevention of zoonotic diseases
  • Protocols for ensuring animal suitability, health, and well-being
  • Risk management plan for the programs
  • Procedures for the evaluation and management of volunteers and staff associated with the animal-assisted activities and therapy program
Abstract | Student Materials | Request Facilitator Materials

Chagas Disease: Connections Between Humans, Animals and the Ecosystem
Ashley Saunders, Sarah Hamer, Rachel Curtis, Trevor Tenney, and Jodi Korich

Chagas disease is an infectious disease caused by the parasite Trypanosoma cruzi and transmitted by the kissing bug (triatomine insects). It is a well-known disease affecting humans and animals in South America and is an emerging disease with zoonotic potential that is under recognized in the United States. This case study of a dog diagnosed in the United States aims to leverage technology to enhance students' knowledge and understanding of Chagas disease including the clinical presentation and cardiac manifestations in dogs, when to consider testing for infectious diseases, kissing bug vector ecology and epidemiology, and client education including animal and human health aspects and vector management. The case highlights the One Health initiative to focus attention on the importance of connections between humans, animals and the ecosystem. A web-based case study allows learners to make a series of clinical decisions as they follow a real case from diagnosis through treatment using instructional video lectures and other useful reference materials in an interactive and media rich format.

More Than Just Companions: The Role of Animal Assisted Therapy In Prevention, Health, and Wellness
Leslie Stewart, Heidi McKinley, and Jennifer Gess

This case study addresses the human-animal interaction component of the One Health Framework and will equip students in the health professions with the knowledge necessary to analyze the potential health benefits of animal assisted therapy (AAT) and to understand the interdisciplinary application of AAT interventions to prevent and treat a wide range of healthcare concerns.

In this case study, the director of a fictional integrative healthcare hospital is considering incorporating AAT services because of the potential benefits to healthcare, physical therapy, occupational therapy, psychiatric, and mental health patients. The hospital director hires a team of experts in AAT to serve as consultants. Students assume the role of members of the expert consulting team and, using a jigsaw technique, explain and explore the potential advantages, applications, and ethical considerations associated with incorporating AAT into healthcare and human services treatment settings.

Animals, Humans and the Environment in the Epidemiology of Chikungunyavirus
Renee Prater, Teresa R. Johnson, Alexis M. Stoner, Matthew D. Cannon, Nammalwar Sriranganathan

Because Chikungunyavirus is an emerging infectious disease with a complex relationship between humans, animals, and the environment, it is a critical One-Health topic. Chikungunyavirus is a single-stranded RNA alphavirus (family Togaviridae), spread through Aedes mosquitoes that causes acute-onset fever, maculopapular rash and severe polyarthralgia. People at increased risk include newborns, elderly, and patients with cardiovascular/metabolic disease. Chikungunyavirus likely originated in the 1700s but was first recognized in Tanzania in 1952, and has become endemic throughout Africa, Europe, and Asia. However in 2013, the disease emerged in St. Martin and quickly spread through the Caribbean into North/Central/South America, and as of April 2015, there have been over 1.4 million reported cases in the Caribbean, Latin America, and the southern US. This case study will require students to use critical thinking, epidemiologic principles, and diagnostic skills to understand the role of environment, vectors, animal and human carriers, and the importance of prevention in disease control, based on these factors: 1) Chikungunyavirus causes large outbreaks with high attack rates that are interdependent upon infected vectors, animals, and humans; 2) while the disease typically follows a sylvatic lifecycle (mosquitoes and asymptomatic animal reservoirs: monkeys, birds, cattle, rodents) with humans as accidental hosts, the virus is now spread through urban human-mosquito-human, or mother-child transmission, as virus persists in joint macrophages and spleen, and 3) environmental management (screens, insect repellents, clothing, standing water) may reduce disease transmission. Given the lack of vaccines and specific treatments other than symptomatic care, the case study will focus on prevention.
Abstract | Student Materials | Chikungunya PPT | Request Facilitator Materials

When Nature Strikes! An Unusual Infection in a Child from New Orleans, LA
Susanne Straif-Bourgeois, Julio Figueroa, Joseph Taboada, and David Baker

A four-year-old boy is admitted to a hospital with a history of sudden onset of headache, right arm pain and emesis. He has sickle cell disease and so receives an extensive medical evaluation. The boy has not travelled outside the US. He has an unremarkable pathogen exposure history, including no pets at home and no history of raw seafood consumption. However, the family acknowledges that the home is infested with rodents. The child's symptoms worsen and on day 5 the patient is diagnosed with eosinophilic meningitis, suggestive of parasitic infection. Public Health officials and School of Veterinary Medicine faculty are consulted to identify a potential causative agent for this yet unconfirmed infection. On day 12 serological test results are positive for Baylisascaris procyonis, the raccoon roundworm. Despite an unusual full recovery from the eosinophilic meningitis, the interdisciplinary team consisting of physicians, veterinarians and infectious disease epidemiologists, is faced with a wide range of questions and concerns from the City Health Department and the media. The Mayor of New Orleans requests a public hearing to address the concerns of his constituents and tasks the team to develop a feasible and sustainable plan to control and prevent the spread of this potentially deadly parasite in New Orleans. Students from the different disciplines will assume their respective roles and work together to develop a control plan. The case study is based on the first confirmed case of Baylisascaris procyonis meningitis in Louisiana.

The Pathomechanics of Degenerative Joint Disease: A One Health Comparative Case Study Approach
Elizabeth Uhl and Michelle Osborn

The most common disease affecting man and animals is degenerative joint disease (DJD, osteoarthritis). Pathomechanical forces are induced by how an individual structurally interacts with its environment and directly cause joint injury. Therapeutics based upon identification of the sources of mechanical stress are critically needed as treatments focused only on controlling pain and tissue pathology mostly fail to prevent disease progression. Static postural analysis (SPA) is a well-established technique requiring no specialized equipment that can be used to identify the pathomechanical causes of joint pain and damage. It is a physics-based functional anatomical approach that can also explain why a particular joint is painful even when lesions are not visible. To perform SPA, free-body diagrams are used to analyze the normal and pathomechanical forces and torques acting on an individual in various static and freeze action postures. For this case study, comparative SPA analyses of the common forms of DJD in humans, horses and dogs will be performed. 2D models will be used to highlight vulnerabilities that are both shared and unique between humans and animals. This type of functional analysis illustrates why a patient has DJD, and can be used by practitioners to educate clients and formulate individualized therapies. The comparative approach emphasizes that the causal relationship between pathomechanical forces and DJD is based upon the same principles across species, allows a better understanding of the shared susceptibility to a very common disease and facilitates the transfer of therapeutic approaches between human and veterinary medicine.

One Health Educational Framework for Health Professional Students

The One Health Educational Framework is designed as a structure for the education of all health professions students to understand the relationship between human health, animal health, and ecosystem health. The framework consists of the following components:
  • Microbiologic influences on health and disease
    • Internal exposure e.g. microbiome and potential impact on health and disease
    • Antimicrobial resistance and mechanisms by which antimicrobial resistance occurs
    • Emergence of new diseases and mechanisms by which previously unknown diseases occur by crossing species boundaries, such as HIV/AIDS, SARS, Ebola virus
    • Long standing and re-emergent diseases, such as West Nile virus, rabies virus, animal-origin novel influenza viruses, Dengue fever, Chikungunya viruses, zoonotic tuberculosis
  • Environmental health
    • External exposures including air, food, and water, and the influence of the built and natural environment on health and disease impact of humans on the ecosystem and the potential to produce disease as well as control disease
    • Globalization and its impacts on health and disease
    • Long term ecosystem changes including climate change and impacts on weather patterns and vector epidemiology, ocean and habitat alterations, deforestation, and desertification
  • Human-animal interaction
    • Animal assisted therapy and service animals
    • Health benefits associated with interaction with animals
    • Animal-centered industries
For each of the components of the framework, health professions students should have the necessary knowledge to describe and the necessary skills to analyze:
  • Mechanisms for potential production of human and/or animal disease
  • The options for prevention to avoid occurrence of animal and human diseases
  • The options for early detection and actions to avoid spread of animal and human diseases
  • The options to address health problems once disease is established in a population including interprofessional actions involving the health care and public health systems
  • Impact on human health and responses to illness
  • Areas for ongoing study and potential application of One Health principles