Table 1.

Characteristics of the studies that used one or more components of One Health in Q fever prevention and control.

Study and Location	Study Type	One Health	Observed and/or Expected Outcomes	Comments
[16] South Africa	Cross-sectional	Practiced
		▪Risk factor survey among farmers, herders and veterinary staff	▪Q fever included in the differential diagnosis of febrile illnesses	▪Diagnostic challenges related to febrile illnesses identified
		▪Human serology	▪Positive Q fever serology demonstrated	▪Small sample size and non-random selection of participants limit generalizability of the results
		Recommended
		▪Education and training related to zoonosis for human health and veterinary practitioners	▪Educated clients for better disease prevention
[17] Europe/Belgium	Systematic review	Practiced
		▪ Risk factors reviewed: ▪ Occupational factors e.g. farmers, abattoir workers ▪ Husbandry factors e.g. goat farming ▪ Environmental factors e.g. infected livestock transportation	▪One Health is a model for Q fever control addressing complex interactions between the reviewed factors	▪One Health focus was drawn from the Netherlands experience, which may fail to appreciate the subtleties of Q fever epidemiology that determine possible control options in other countries
		Recommended
		▪Q fever monitoring in high incidence countries	▪Promote optimum health of humans, animals and environment
		▪Collaboration across disciplines
[18] Côte d’Ivoire	Cross-sectional	Practiced
		▪Risk factor survey in rural farming communities	▪Positive Q fever serology at the farm and community level	▪No association between animal abortions and Q fever seropositivity contradicting findings in other studies e.g. Netherlands’ outbreak
		▪Human and animal serology
		Recommended
		▪Educate community about zoonosis by combining public health and animal health	▪Reduced human exposures to Q fever
[19] Africa/Tanzania	Review	Recommended
		▪Global zoonosis surveillance system	▪Impromptu response to endemic zoonosis	▪Stakeholders meet, interact, share experiences and embark on agreed upon decisions
		▪Strengthen national core capacities	▪Coordinated response to future disease threats
		▪Interventions targeted at Q fever source e.g. livestock vaccination	▪Reduction of animal abortions and human Q fever cases
		▪Community trust, engagement and collaboration	▪Less fragmentation, less inequalities for sustainable development
[20] Spain	Cross-sectional	Practiced
		▪Wild and domestic ruminant serology	▪Positive C. burnetii antibodies in wild and domestic ruminants ▪First evidence of antibodies in European wildcats	▪Inclusion of human serology would have provided a strong One Health practice and helped further understanding of Q fever epidemiology in Spain
		Recommended
		▪Multidisciplinary studies required	▪C. burnetii epidemiology at human-livestock-wildlife interface will be better understood
[21] Kenya	Cross-sectional	Practiced
		▪Risk factor survey among randomly selected households	▪C. burnetii exposure was heterogeneous	▪Studying only cattle limits extrapolation of results to settings such as the Netherlands where small ruminants are the main reservoir ▪Without full explanation of socio-cultural factors, it is premature to conclude certain ethnic groups had increased exposure risks
		▪Human and cattle serology	▪Cattle brought from livestock markets had highest seroprevalence
		▪Spatial correlation of cattle and human seropositive samples	▪Human and cattle seroprevalence was not associated
		Recommended
		▪Livestock markets be targeted for Q fever control interventions (e.g. animal serology and vaccination)	▪Reduction of C. burnetii shedding in previously exposed animals
[22] Netherlands	Ecological correlation	Practiced
		▪Netherlands’ outbreak analyzed Q fever notification data, farm data and climate data	▪Q fever notification was correlated with environmental conditions, e.g. wind current and humidity	▪An estimated 8% of Q fever cases was notified in 2009 outbreak. This, in part limited the authors' conclusion of the causal associations between human notifications and environmental predictors
		Recommended
		▪Ecological research on outbreak associated data	▪Spatially planned farming
[23] Kenya	Cross-sectional	Practiced
		▪Knowledge, attitude and practices survey among medical, veterinary and wildlife workers, and farmers	▪Q fever knowledge was low among most participants (94% human health providers had little or no knowledge)	▪How stakeholders’ knowledge contributes to a One Health collaboration, and why this multi-sectoral approach is important is not discussed
		Recommended
		▪Provide healthcare professionals updated Q fever knowledge	▪Effective control of Q fever
		▪Strengthen multi-sectoral collaboration
		▪Community sensitization	▪Help community members prevent Q fever
[24] Australia	Outbreak investigation	Practiced
		▪Multidisciplinary epidemiological investigation and animal serology	▪Comprehensive risk assessment techniques and consensus control measures developed ▪Workers protected by HEPA* filters ▪Goats identified as likely source of the outbreak ▪Controlled human cases without source control	▪Key similarities with the Dutch outbreak include outbreak source, both occurred at goat farm; use of human vaccination; and application of a One Health approach. Differences include magnitude of the outbreaks, livestock vaccination was not used in the Australian outbreak because of manufacturing biosecurity concerns
		▪Skin and serological testing for workers, subsequent vaccination	▪Could not prevent infections in workers’ family members
		▪PCR testing of aborted materials, vaginal swabs, environmental samples	▪Ongoing farm environmental contamination due to intensive breeding and milking goats demonstrated
		▪General measures e.g. biohazard sign erection	▪Presumably these public health measures controlled the outbreak
		▪Site surveillance launched
		▪Health education
		▪Management of farm environment e.g. manure management
		Recommended
		▪Mandatory vaccination for all occupational contacts	▪Prevent acute Q fever cases
		▪Further research to identify possible interstate introduction of Q fever	▪Traditionally held views that interstate importation of C. burnetii to Victoria may be established
		▪Validation of IFA	▪Livestock and wildlife prevalence of C. burnetii could be established
		▪Livestock vaccination	▪Reduced environmental shedding
[25] Netherlands	Ecological correlation	Practiced
		▪Q fever notification data, veterinary and farm data analyzed	▪Largest goat farm had abortion waves, bulk tank milk and almost all samples positive for C. burnetii – considered as the most likely source	▪Largest goat farm caused a smaller outbreak in 2008, with a larger community outbreak following year ▪Public health and veterinary health professionals should work together on an alert mechanism to identify any potential human Q fever outbreaks ahead of time
		▪Largest farm visited, and farmers interviewed on risk factors	▪Several unsafe farm practices related to manure and removal of birth products
		▪Atmospheric dispersion model used	▪Likely period of infection and airborne propagation shown
		Recommended
		▪Consider farms with history of C. burnetii infection as potential source of human outbreaks	▪These could guide future Q fever control strategies
		▪Use meteorological forecast data
[26] Africa/Tanzania	Feature/Review	Recommended
		▪Syndromic surveillance and targeted collection of diagnostic materials e.g. aborted products	▪Better linking etiology and epidemiology of C. burnetii in humans and animals ▪Early detection of possible human outbreaks ▪Identification of key intervention points ▪Cost-effective interventions	▪One Health approach provides a holistic management perspective in a cost-effective fashion and is most viable option to minimize misdiagnosis, assess zoonotic impacts and utilize disease control methods
		▪Improved communication across sectors	▪Early diagnosis, prompt treatment and better control strategies
		▪Regional data on Q fever burden is essential	▪Q fever becomes a global disease control priority
[27] Lao People’s Democratic Republic (Laos)	Review	Practiced
		▪Summarized 8 pig associated zoonoses, their risks and impacts	▪Misdiagnosis and underreporting were common	▪Focusing only on pigs led the scope of wide range of zoonotic reservoirs remained unexplored. Inclusion of a range of reservoirs could have offered a stronger case scenario of advocating for a One Health approach ▪Unique aspect is emphasizing socio-cultural determinants of zoonoses
		Recommended
		▪Improved diagnostic approaches	▪Reduced diagnostic errors and improved notification
		▪Strengthen disease surveillance systems
		▪Interdisciplinary collaboration and research	▪Designing socially and culturally appropriate control methods
[28] Africa/Chad	Conference proceedings/Review	Practiced
		▪ Summarized “One Health” studies among mobile farmers ▪ Linked human and animal health studies ▪ Summarized human and animal intervention (e.g. vaccination) studies ▪ Combined human and animal serological studies	▪Livestock vaccination coverage higher than human vaccination in farming communities ▪Better access to care for mobile farmers and their families ▪Camel breeding associated with human C. burnetii seropositivity	▪One Health programs were shown to be efficient (e.g. joint vaccination) and acceptable (e.g. health assessment using mobile phone). Public health and veterinary interventions which are coordinated, accessible, resource saving and based on community needs are successful
		Recommended
		▪Integrated zoonotic surveillance using cell phone for mobile farmers to be established	▪Demographic and disease surveillance and control methods for mobile populations
		▪Social and anthropological studies	▪Social and cultural complexities of zoonotic infections will be understood
[29] USA	Outbreak investigation	Practiced
		▪Multidisciplinary outbreak investigation by veterinarians, public health nurses, medical doctors, epidemiologists and Q fever and reference diagnostic laboratories	▪Extent and epidemiology of this outbreak was determined	▪A good example of applying One Health approach to Q fever ▪Personal communications were established with principal author, detail information sourced and incorporated ▪Moreover, this conference abstract was published in a slightly different way in 2016 as cited in reference [30]
		▪Risk factor survey and human serology	▪Livestock contact had strong association with Q fever
		▪Ruminants’ milk, vaginal swab, placenta, manure and environmental samples were tested	▪Goat and cattle samples were positive for C. burnetii ▪Birthing areas had highest concentration of C. burnetii
		Recommended
		▪Health education and change in farm practices	▪Prevent future C. burnetii transmission ▪Reduce lost productivity and ensure better livelihoods
[31] Netherlands	Review	Recommended
		▪Dispute between human health providers and veterinarians be dissolved	▪Better Q fever control through agreed measures	▪Communication gap between human and animal health sectors was identified in an outbreak investigation, although it was believed that both sectors were working together. One Health as a method of bridging that gap needs practical interactions rather than written words ▪Only goat as reservoir was discussed without considering other species e.g. sheep and cattle
		▪Better diagnostic methods	▪Improved Q fever notifications
		▪Livestock vaccination	▪Reduced human exposure through prevention of animal abortions
[32] USA	Review	Practiced
		▪Multidisciplinary diagnostic facilities	▪Sample testing from a range of sources	▪Local, state and federal levels involving public and private partnerships that combine human, animal and ecological sectors helps minimize resource exhaustion in control of zoonotic diseases
		▪Quick result production
		▪Less communication pitfalls among stakeholders	▪Stewardship and collaborations
		▪Public-private partnerships	▪Coordinated local responses against diseases and threats
		▪Joint investigation of Q fever cases
		▪Human and animal serology	▪Positive Q fever serology demonstrated
		Recommended
		▪Vector borne disease control requires human, animal and vector surveillance	▪Shared resources and expertise ▪Animals and humans are protected

* HEPA: High-efficiency particulate arrestance; IFA: Immunofluorescence assay.