Viewpoint

After 2 years of the COVID-19 pandemic, translating

One Health into action is urgent
Thierry Lefrançois*, Denis Malvy*, Laetitia Atlani-Duault, Daniel Benamouzig, Pierre-Louis Druais, Yazdan Yazdanpanah, Jean-François Delfraissy,
Bruno Lina

Introduction the emergence of infectious diseases need to be filled to Lancet 2023; 401: 789–94
The world is coping with the health, societal, and allow the identification and rapid control of zoonotic risks Published Online
economic consequences of more than 2 years of the before their introduction in humans. Optimum October 24, 2022
https://doi.org/10.1016/
COVID-19 pandemic. Emerging diseases caused by new preparedness will depend on strategies and plans prepared
S0140-6736(22)01840-2
pathogens, or re-emerging infectious diseases, appear jointly by scientists, decision makers, and all stakeholders
*Contributed equally
regularly and their frequency is increasing.1,2 Several involved in surveillance and early warning. The pandemic
CIRAD, DirBIOS, Department of
research papers3–5 have shown that the cost of preventing high­lighted both the interdependence of human health, Biological Systems,
an infectious disease is much lower than the cost of animal health, and environmental health and the need for Montpellier, France
managing one, especially at a global level. A change in an interdisciplinary vision to produce fundamental and (Prof T Lefrançois DVM, PhD);
health-care framework is needed to improve pandemic comprehensive scientific and epidemiological knowledge. Department of Infectious and
Tropical Diseases, University
prevention, which will require a global understanding of A strategic One Health8,9 approach that fulfils this vision is Hospital Pellegrin, Bordeaux,
disease emergence and an integrated One Health only feasible with a comprehensive and multisectoral France (Prof D Malvy MD);
approach. The environmental, social, economic, ethical, approach. However, despite some successful examples in National Institute for Health
and Medical Research (INSERM)
and political factors that characterise a social ecosystem Rwanda10 and Senegal, the vision for a One Health
UMR 1219, Research Institute
and influence the emergence of zoonoses should be approach is still not shared by all, often poorly structured, for Sustainable Development
considered to control these emergences. and not operational. (IRD) EMR 271, Bordeaux
COVID-19 has exposed the disconnection between Population Health Research
Centre, University of Bordeaux,
governmental promotion of the One Health approach in An efficient One Health surveillance system is needed
Bordeaux, France (Prof D Malvy);
international arenas (eg, political conferences) and the The goal of the One Health strategy is to prevent and Université Paris Cité, IRD, Ceped,
reality outside of government spaces—with the absence control the emergence, re-emergence, or dissemination Paris, France
of an efficient, comprehensive One Health surveillance of zoonotic pathogens;11,12 it includes surveillance in (Prof L Atlani-Duault PhD);
Mailman School of Public
system that could have been in place from the start of the animal reservoirs, deciphering factors facilitating emer­
Health, Columbia University,
pandemic. As members of France’s COVID-19 Scientific gence,13 and actions for disease control. New York, NY, USA
Council appointed in March, 2020, to support govern­ In an optimum One Health approach, because (Prof L Atlani-Duault); Sciences
mental efforts in managing the COVID-19 pandemic, we southeast Asian bat species harbour corona­ viruses Po, National Centre for Scientific
Research, Paris, France
had to contend with this negative reality. Based on our similar to SARS-CoV-2, coronavirus surveillance14 should
(Prof D Benamouzig PhD);
experience, we propose an ambitious roadmap to prevent have been triggered with regular biobanking from High Authority of Health,
and mitigate future pandemic crises, including real-life reservoirs, surveillance of transmission to potentially Saint-Denis La Plaine, France
implemen­tation of intersectoral activities and processes. susceptible animals or to humans in contact with those (Prof P-L Druais MD);
ANRS Maladies Infectieuses
Our strategy will require a new, worldwide, One Health animals, and an analysis of the environmental factors Emergentes, Inserm,
vision that includes ambitious national and international favouring transmission (ie, analysis of ecosystems and Paris, France
initiatives, and One Health education and training. factors associated with carriage; figure). Action could (Prof Y Yazdanpanah MD); Comité
then have been taken to control the risk of spillover or Consultatif National d’Ethique,
National Ethical Consultative
Lessons learnt from the pandemic transmission to humans with reduced contact between Committee for Life Sciences and
The pandemic is a One Health issue animals and modified or resilient ecosystems reducing Health, Paris, France
As with around 75% of listed emerging human diseases, the risk of transmission. The cost of such a mechanism (Prof J-F Delfraissy MD); HCL,
COVID-19 is most probably a zoonosis caused by a would have to be considered with the potential medium Institut des Agents Infectieux,
Centre National de Référence de
coronavirus from an animal reservoir (figure). Zoonotic or long-term benefits arising from its use. In addition, virus des infections respiratoires
coronaviruses can spread to humans, as observed in the the data generated, and the genetic resources collected (dont la grippe), Hôpital de la
past (OC43 in the 19th century, SARS-CoV in 2003, and would have to be shared and used beyond national, or Croix Rousse, Lyon, France
MERS-CoV in 2011), and during the COVID-19 pandemic.6,7 even regional, public health strategies. (Prof B Lina MD); CIRI, Centre
International de Recherche en
The absence of an efficient early warning system and early Control of zoonotic diseases requires an understanding Infectiologie (Team VirPath),
collaboration between stakeholders, and the knowledge of all factors that allow pathogens to cross the species Inserm U1111, Université de
gap regarding the overall process of SARS-CoV-2 adap­ barrier. In addition to modified ecosystems and virus Lyon, Lyon, France (Prof B Lina)
tation to new hosts, had two consequences: unknown molecular evolution that can trigger cross-species Correspondence to:
knowledge of the exact mechanisms or factors involved in transmission, biological surveillance should also include Dr Thierry Lefrançois, CIRAD,
DirBIOS, Department of
virus emergence and adaptation steps, and speculation how host responses influence the evolution of viruses, to Biological Systems, Montpellier
without scientific basis about the origin of the virus behind help identify relevant evolutionary drivers responsible 34398, France
the pandemic. If crises similar to the COVID-19 pandemic for changes that bring the virus to the point of thierry.lefrancois@cirad.fr
are to be avoided in the future, these knowledge gaps about transmissibility to humans.

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particularly in mustelid mammals,15 and in deer and

hamsters.16,17 As of September, 2022, the human
Global changes, climatic SARS-CoV-2 virus has been detected in 25 animal
changes, land use changes, species in 36 countries,18 and the figures are increasing.
loss of biodiversity,
deforestation During reverse zoonosis, viruses might accumulate
mutations leading to changes in different genes, with
the potential acquisition of severity and (or) immunity
escape factors. The omicron (B.1.1.529) variant is
speculated to have possibly emerged after reverse
zoonosis (figure).19 This understanding of potential
evolutionary processes through reverse virus zoonosis
and their consequences is part of the One Health
strategy that needs to be addressed for each emergence
Spillover
(eg, monkeypox virus; appendix p 2).

Reverse zoonosis Developing an ambitious roadmap for each step

of a pandemic crisis
New variants Going beyond past and current One Health projects and
strategic plans
Global diffusion Much is being done to develop One Health approaches.
More than just a concept, One Health is a strategy long
used in research and surveillance in many zoonosis
New variants
projects, mostly implemented in specific areas known to
Interhuman be places of emergence and re-emergence (eg, for Ebola
transmission virus, MERS-CoV, avian influenza virus, Nipah virus,
vector diseases, and rabies), or regionally by setting up
Figure: Transmission of zoonotic diseases One Health surveillance networks (eg, One Health
Stages involved in a pandemic crisis, from the initial circulation of pathogens within wild fauna and the natural Indian Ocean, or Sega One Health). Some large
environment, to the global dissemination after large-scale human-to-human transmission. Anthropological
factors lead to changes in pathogen circulation and to increased contacts with new animal species, including multiregional projects (eg, Predict20) have implemented
domestic ones, which can induce spillover, with possible transmission to humans. The COVID-19 pandemic large-scale virus surveillance in the environment.
highlights the risk of reverse zoonoses, due to intensive circulation of SARS-CoV-2 in humans, transmission to new Beyond these research initiatives, true political
animal species, and circulation within some that have proven to be highly susceptible (hamsters, minks, and wild- awareness has emerged worldwide, with some symbolic
tailed deer), with possible transmission of a mutated virus to humans. New variants can also emerge from
circulation within humans. declarations, including those from the Group of 7 (G7)
Summit (June 4, 2021) and G20 (Sept 5–6, 2021) Summit
See Online for appendix Even 2 and a half years after the start of the pandemic, health ministers. The COVID-19 pandemic has also
For more on the G20 the COVID-19 emergence process remains unexplained. prompted some institutional One Health strategies. A
declarations see https://www. However, a comprehensive holistic One Health pro­ One Health High Level Expert Panel was created in
salute.gov.it/portale
gramme would have provided data on virus ecology, May, 2021, with responsibility for gathering, analysing,
rapportiInternazionali/dettaglio
ContenutiRapportiInternazionali evolution, mechanisms involved in the acquisition of passing on, and giving greater visibility to the scientific
.jsp?lingua=english&id=5478& virulence factors (including furin or polybasic cleavage information available on the links between human,
area=rapporti&menu=vuoto sites), and adaptive molecular traits. Surveillance would animal, and environmental health. The aim of the panel
also have facilitated control and preventive measures, was to assist policy makers and international organisa­
such as appropriate farming processes and prevention tions in preventing and responding to future health
with restricted culling strategies. crises. The panel published a new inclusive definition
An optimised surveillance system capable of of One Health, encouraging intersectoral, but also inter­
providing early and robust data on a new pathogen will disciplinary and multistakeholder approaches.21,22 Several
rely on three factors: (1) virus surveillance and detection One Health operationalisation plans have also been
in wildlife ecosystems; (2) identification of potential developed, such as the One Health Joint Plan of Action
inter­mediate hosts (in wildlife and livestock) and developed by the Quadripartite Agreement, working
factors favouring transmission (including adaptive together for the health of humans, animals, plants and
processes); and (3) early detection of asymptomatic or the environment,23 and the One Health operational
symptomatic infections in exposed humans. framework proposed by The World Bank.24
However, although declarations and action plans
The risks of reverse transmissions between humans and provided by each stakeholder in their own sector are a
animals prerequisite for any change, they are not enough. The
As with other zoonotic pathogens, SARS-CoV-2 is human health sector and agencies are well funded, but
capable of reverse infection (reverse zoonosis), they are not experienced or equipped for the One Health

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concept to take an intersectoral approach. Conversely, event of detection, these initiatives should be rapidly
this global understanding is more advanced in the reinforced, with the surveillance upgraded to provide all
ecology and animal health sectors, although One Health relevant data for risk assessment and management.
activities are poorly funded and mostly theoretical. This action plan can be facilitated by increased
These funding and commitment hurdles need to be collaboration between the reference laboratories of health
addressed to increase our capacity to respond to and agriculture ministries via joint funding or dual
epidemics and pandemics. trusteeship. This joint effort would simplify the rapid
We consider that action plans should incorporate a mobilisation and early response of animal health and
solid long-term research programme rather than merely human health experts at the start of any health crisis.
providing short-lived epidemiological data from a Reference laboratories with holistic expertise in real-life
One Health surveillance system outsourced to high- surveillance activities (eg, surveillance of emerging
income countries. Concrete and sustained surveillance zoonotic infectious diseases or syndromic surveillance),
and prevention actions are needed on all scales, together such as the current World Organisation for Animal
with education, training, and behavioural changes. These Health collaborative centres, could also be established.
ambitious research projects need to be developed with all Embedded national or regional surveillance platforms
the stakeholders required for a One Health action could be set up with high-level diagnostic, sequencing,
plan to be taken into account, including local pathogen discovery, and surveillance capabilities.
communities. Surveillance and prevention actions should Emergence surveillance gaps at the human health or
be embedded in national plans with national stakeholders, animal health interface need to be identified, with a
not as external or international studies. Local empower­ redefinition of monitoring and management responsi­
ment is a prerequisite for programme implementation on bilities. For example, pathogens or diseases with a public
a national and regional scale. health impact can circulate on livestock farms or in
arthropod vectors without being the direct responsibility
Targeted health prevention means developing resilient of a Ministry of Agriculture because they are not categor­
socioecological systems ised, including swine flu virus infection, surveillance of
This objective entails some knowledge prerequisites, H5N8 avian influenza virus in humans, or the circulation
notably an understanding of the associations between of Crimean–Congo haemorrhagic fever in animals.
biodiversity, agriculture, food, and health; the concept of A One Health inter-ministerial scientific platform, with
interdisciplinary data sharing; and the development of governance at the highest political level in each country,
comprehensive indicators, including some from the could identify, analyse, and update major local risks
human sciences. With such common and shared involving emerging pathogens in the environment, in
knowledge in advance of an emerging risk, economically animals, or in humans, and could share that information
viable and accepted socioecological systems can be with all stakeholders and develop control strategies.
jointly constructed with characteristics that are
detrimental to long-term disease emergence, offering Predefined One Health structures and task forces should
increased resilience to health crises. drive crisis management and use all diagnostic and
Levers and monitoring systems could be deployed control capabilities
locally, with support from national and supranational A rapid decision-making process with robust institu­
bodies. Environ­mental intelli­gence sites (ie, sentinel sites) tionalised support is essential to ensure that rapid
and operational monitor­ing of prevention initiatives (ie, responses agreed by different socioeconomic actors and
living laboratories) can help to build socioecological political decision makers are implemented. Priority should
systems that respect mandatory specifications for environ­ be given to developing an operational alert–decision
mental and health management. This approach will model, using a scientific basis and a multidiscip­
require combined environmental and ecology research linary evaluation that includes the social sciences (eg,
programmes, incorporating stake­holders responsible for anthropology, sociology, health geography, and economics).
the health of a territory, based on a predefined policy and The early reporting of atypical and severe clinical
identification of a risk for emerging diseases. presentations without any known causes (including
impor­­ted diseases) requires hospital resources, ranging
Preparedness and early detection should structure from infectious disease specialists, infection control
One Health action plans specialists, and micro­biologists, to resuscitation experts.
A list of pathogens to be monitored should be jointly In addition, rapid and innovative disease information
decided and updated regularly by all the stakeholders reporting, with feedback on case monitoring to a large
involved in public health surveillance. Corresponding community, will ease the diagnostic process.
indicators and innovative tools combining surveillance From the early days of an emergence, administrative
and alert should then be developed, and research and regulatory hurdles will have to be removed to
programmes addressing the relevant emergence and mobilise all relevant laboratory resources, regardless of
transmission issues should be implemented. In the their affiliation (eg, veterinary laboratories), to allow

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diagnostics and research. Multisectoral laboratories will including WHO, need to evolve to cope with the global
need to work together for sample handling and sharing challenges raised by global health and One Health. The
of materials, results, and techniques. effort needs to be focused on major emergence zones
Field collaborations developed between hospital, animal and be developed on a regional scale to have a global
health, and wildlife or environmental professionals, and effect. Specific areas of Africa and southeast Asia are the
between institutional surveillance and research platforms, epicentres of emerging and epidemic-prone infectious
will include using common platforms for laboratory diseases. Recognised hotspots or evolving zones for
testing, metagenomics, sequencing, and all relevant diag­ emergence need to be identified, listed, and published
nostic techniques. on the basis of factors such as agricultural or human
Implementing these operational recommendations at infringement into wildlife habitats, increasingly
each stage of a pandemic will require strong political will intensified livestock or poultry systems, live animal
in each country to overcome the usual sectoral work, markets, poor biosecurity, and the emergence of
habits, and rules. Active local and international com­muni­ megacities with poor hygiene and infection prevention
ties, together with civil society mobilisation, could thus management systems.
become a game changer, as observed for climate change. In addition, implementing One Health approaches
with countries less advanced in health management will
Inspiring new perspectives for a worldwide health need to be supported by sustained twinning programmes
vision (ie, collaborations between advanced, recognised
Improving surveillance and prevention by reinforcing laboratories and less advanced laboratories to improve
both upstream and operational research their capacities) to improve diagnostics, sequencing,
Research programmes should rely on multidisciplinary, surveillance, and public health capacities (appendix p 2).
multisectoral, and multiprofessional international On a regional scale, neighbouring countries share the
projects, with a focus on novel approaches to enviro­n­ same risks and the same socio­ economic and political
mental and ecological genomics (eg, open-minded constraints; regional One Health strategies34,35 are needed
detection of pathogens circulating in reservoirs and to develop shared expertise, laboratories, and platforms,
vectors and molecular identification of viruses with especially in countries with poor resources. The existing
zoonotic potential),25,26 modelling, artificial intelligence, One Health regional health networks need to be further
and social science studies. developed, with a focus on pandemic prevention and
Such combined research approaches will accelerate preparedness, which means solving the major issues
control and prevention with the acquisition of basic related to animal diseases and natural disasters that affect
knowledge in a coordinated manner, including on origins food sustainability and security, and population resilience.
and adaptation mechanisms; strengthen sustained Regardless of the scale, a sustained political will and
infrastructures and networks, allowing the coordinated understanding of the One Health approach is necessary
collection of data for modelling and implementing a and should be modelled by leader countries with a long-
response strategy; and boost innovative public health term view, together with international organisations,
strategies, or early development of innovative counter­ and not only at the start of a crisis. A long-term plan
measures (eg, diagnostics, vaccines, therapies, or beha­v­ means long-term financial guarantees provided by
ioural recommendations), to mitigate the effect of international communities from different mechanisms,
emerging epidemic events. including funding from The World Bank.
International operational research initiatives, such as
PREZODE,27 are thus needed to implement robust One Ensuring adequate education and training for One
Health programmes, surveillance programmes, and Health
networks worldwide, with support from all the necessary Implementing One Health and global health concepts
stake­holders. Ambitious research projects targeting will take time to produce operational effects. Training
large-scale surveillance in the environment will need initiatives are needed to abolish boundaries between
collab­oration that focuses on bottom-up co-construction, sectors.36
local empowerment, and meaningful interactions For all One Health professions (veterinarians,
between research and decision making. Projects will clinicians, pharmacists, biologists, and ecologists), the
have to consider the Nagoya Protocol.28 Overcoming jointly constructed concept should be included in the
hurdles related to this protocol will require international curriculum of each discipline in its initial training. This
collaboration and mutual trust and will have to be common training should be widely available, based on
endorsed by policy makers.29–31 teaching modules involving multidisciplinary expertise
and combining public health; human and social
Developing a worldwide comprehensive and united sciences; the health of populations; territories and the
vision of health environment; and research. Consistent education across
Diseases inherent to globalisation cannot be controlled One Health professions would subsequently improve
on a single-country basis.32,33 International institutions, collaboration between professionals.

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One Health awareness campaigns and continuous 5 Intergovernmental Science-Policy Platform on Biodiversity and
training for decision makers, teachers, and members of Ecosystem Services. Workshop report on biodiversity and
pandemics. Bonn, Germany: Intergovernmental Science Policy
civil society will lead to a population-based shared culture. Platform on Biodiversity and Ecosystem Services, 2020.
Awareness education should be provided early in the 6 Pekar, JE, Magee A, Parker E, et al. The molecular epidemiology of
school curriculum to support early behavioural changes, multiple zoonotic origins of SARS-CoV-2. Science 2022;
377: 960–66.
as observed for global warming. Specific training will 7 Worobey M, Levy JI, Serrano LM, et al. The Huanan seafood market
develop cross-curricular skills needed to understand in Wuhan was the early epicenter of the COVID-19 pandemic.
the One Health concept, such as complex thinking, Science 2022. 377: 951–59.
8 Osterhaus ADME, Vanlangendonck C, Barbeschi M, et al. Make
systems thinking, and suitability for multidisciplinary science evolve into a One Health approach to improve health and
collaboration capacity. security: a white paper. One Health Outlook 2020; 2: 6.
9 Zinsstag J, Schelling E, Waltner-Toews D, Whittaker MA, Tanner M,
A change in health-care framework is needed coordinateurs. One health, une seule santé. Théorie et pratique des
approches intégrées de la santé. Versailles, France: Éditions Quae,
Health continues to be largely viewed through the 2020.
restricted lens of human diseases. WHO clearly defines 10 Nyatanyi T, Wilkes M, McDermott H, et al. Implementing For more on the WHO
health as being “a state of complete physical, mental and One Health as an integrated approach to health in Rwanda. Constitution see https://www.
BMJ Glob Health 2017; 2: e000121. who.int/about/governance/
social wellbeing and not merely the absence of disease or 11 de Garine-Wichatitsky M, Binot A, Morand S, et al. Will the constitution
infirmity”. Environmental protection, animal health, and COVID-19 crisis trigger a One Health coming-of-age?
the sustainable health of a territory are not part of this Lancet Planet Health 2020; 4: e377–78.
12 Gibbs EP. The evolution of One Health: a decade of progress and
definition. challenges for the future. Vet Rec 2014; 174: 85–91.
For a holistic vision of health, we need to rethink how 13 Taylor LH, Latham SM, Woolhouse ME. Risk factors for human
we approach the One Health concept by effectively inte­ disease emergence. Philos Trans R Soc Lond B Biol Sci 2001;
356: 983–89.
grating the environment into its implementation, thereby
14 Delaune D, Hul V, Karlsson EA, et al. A novel SARS-CoV-2 related
gaining an overall idea of the health of all living coronavirus in bats from Cambodia. Nat Commun 2021; 12: 6563.
organisms in a given ecosystem. 15 Goraichuk IV, Arefiev V, Stegniy BT, Gerilovych AP. Zoonotic and
The One Health concept goes beyond preventing health reverse zoonotic transmissibility of SARS-CoV-2. Virus Res 2021;
302: 198473.
crises and is closely linked to a holistic vision of health and
16 Pickering B, Lung O, Maguire F, et al. Highly divergent white-tailed
to the associations between health, environmental quality, deer SARS-CoV-2 with potential deer-to-human transmission.
climate, food and agriculture, and biodiversity. Studies in bioRxiv 2022; published online May 24. https://doi.
org/10.1101/2022.02.22.481551 (preprint).
2022,37,38 and older, but nonetheless important studies,1,39–41
17 Yen HL, Sit THC, Brackman CJ, et al. Transmission of SARS-CoV-2
have shown and reinforced the association between delta variant (AY.127) from pet hamsters to humans, leading to
climate change, biodiversity crises, and emerging zoonotic onward human-to-human transmission: a case study. Lancet 2022;
399: 1070–78.
diseases. One Health comprises the challenges grasped by
18 World Organisation for Animal Health. SARS-CoV-2 in animals—
all and shared by all societal objectives. The One Health situation report 13. 2022. https://www.woah.org/en/document/sars-
objectives need to be addressed at a global level to fulfil the cov-2-in-animals-situation-report-16/ (accessed Oct 15, 2022).
Sustainable Development Goals, together with global 19 Wei C, Shan KJ, Wang W, Zhang S, Huan Q, Qian W. Evidence for
a mouse origin of the SARS-CoV-2 omicron variant.
empowerment. J Genet Genomics 2021; 48: 1111–21.
Contributors 20 PREDICT Consortium. Advancing global health security at the
All authors contributed to the writing of the manuscript (original draft, frontiers of disease emergence. Davis, CA: One Health Institute,
review, and editing). TL, DM, BL, and J-FD were involved in the University of California, Davis, 2020.
conceptualisation and supervision. TL, DM, and BL designed the figure. 21 WHO. Tripartite and UNEP support OHHLEP’s definition of
“One Health”. Joint tripartite (FAO, OIE, WHO) and UNEP
Declaration of interests statement. 2021. https://www.who.int/news/item/01-12-2021-
All authors are members of the French COVID-19 Scientific Council. tripartite-and-unep-support-ohhlep-s-definition-of-one-health
J-FD is the President of the Council. (accessed Oct 15, 2022).
22 Adisasmito WB, Almuhairi S, Behravesh CB, et al. One Health:
Acknowledgments
a new definition for a sustainable and healthy future. PLoS Pathog
We thank all members of the French COVID-19 Scientific Council for
2022; 18: e1010537.
their contribution to the advice on One Health published on
23 World Organisation for Animal Health. One Health joint plan of
Feb 8, 2022, on the French Ministry of Health website. We thank
action. Working together for the health of humans, animals, plants,
Patricia Doucet and Delphine Guard-Lavastre (CIRAD) for the figure and the environment. https://www.woah.org/app/uploads/2022/04/
illustration. oh-joint-plan-of-action-summary.pdf (accessed Oct 15, 2022).
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