1 Introduction

Emerging and re-emerging diseases pose a substantial global health challenge [1]. They cause distinct difficulties to public health systems and can have extensive social, economic, and health consequences [2]. They frequently take public health systems by surprise due to their lack of prior investigation or preparedness [3]. This phenomenon may result in delayed response and cause challenges in effectively managing the spread of the disease. Currently, there is a pressing requirement for a holistic approach [3]. Pandemic preparedness encompasses a variety of measures and methods designed to avoid, identify, respond, and alleviate the consequences of infectious diseases that possess the capacity to induce extensive and severe disruptions to health, society, and the economy [4]. Pandemic preparedness can be decisively strengthened through implementing a comprehensive surveillance and early warning system, as well as conducting timely risk assessments [5, 6].

The concept and practice of "One Health" acknowledges the interdependence and interconnections between the health of humans, animals, and the environment. The need to foster collaboration and integration across many areas, such as human health, animal health, environmental health, and related disciplines, is undervalued so far. Emerging and re-emerging infectious diseases, antimicrobial resistance (AMR), and global health security are important challenges and indispensable perspectives that require attention as well as One Health interventions [7, 8].

The process of identifying and evaluating risk factors from a One Health standpoint entails the acknowledgement of potential hazards to the well-being of humans from animals and the environment, considering their interdependencies [9]. This method considers how modifications or disturbances to one component may affect the others. The potential concerns associated with the confluence of human, animal and environmental domains include the transmission of known zoonotic diseases and the creation of novel pathogens or variations. The management of risk factors for diseases of zoonotic origin requires the use of various resources for meeting the need [10].

The resources in health, as well as all other sectors, are limited, so for judicious and effective use of the resources, prioritisation is needed [11]. Prioritising of diseases has been a common process in Public Health to identify the infectious diseases of importance for human health. Most infectious diseases in humans are zoonotic in origin, evolving from the human and animal interface [12]. Thus, the need arises to involve the human, animal and environmental health sectors in addressing the risk factors by prioritising diseases and risk factors. This collaborative prioritisation will help us to understand the risk factors and diseases of utmost priority and pave a path towards collaborative measures to prevent them. Successful implementation of cross-sectorial collaboration has been the voice and demand of many One Health experts to prevent pandemics [11, 13]. Prioritising risk factors at the human, animal and environmental interface will bring in experts from all the fields under one umbrella and enlighten the risk factors from different perspectives.

Numerous tools are available to prioritise diseases, like One Health Zoonotic Disease Prioritization (OHZDP) [11, 14], but no tool is available to prioritise the risk factors for diseases. So, the One Health Risk and Disease (OHRAD) Prioritisation tool [15] has been prepared to prioritise emerging and epidemic-prone diseases and the related risk factors at the human, animal and environment interface. The tool uses an analytical hierarchical process, and a multi-criteria decision analysis is used to prioritise the risk factors and diseases. This tool has been custom-made for the Indian context and was  used by the stakeholders in  the co-creation workshop. The present study aims to determine diseases and their risk factors in the three western states of Gujarat, Rajasthan and Maharashtra. The three states have been included based on their demography and burden of communicable diseases. Three state-level stakeholder workshops have been conducted in these western states of India to prioritise emerging and epidemic-prone diseases and risk factors.

2 Methods

The state-level co-creation workshops are a part of the One Health System Strengthening in India (OHSSIN) project. The three western states of India, namely Gujarat, Rajasthan, and Maharashtra, were selected  for this project. The three states were selected purposively, considering the presence of the host institute, to determine the feasibility of the implementation. Gujarat is mostly plain land, with the great Rann of Kutch and a vast coast line. Rajasthan is mostly desert land with Aravalli hills and rich wildlife, whereas Maharashtra has a diverse landscape with beaches, hills, and plateaus. Among the three states, Maharashtra has the highest level of urbanization, and Rajasthan is the least urbanised. Similarly, Gujarat state has the highest literacy rate where, as Rajasthan has the lowest literacy rate. All three states face challenges with similar communicable diseases like Dengue, Malaria, and Tuberculosis.

The first objective of the study was to prioritise emerging and epidemic-prone diseases and risk factors through state-level co-creation workshops. The second objective was to strengthen one health task force at the district level. As a part of the first objective, state level co-creation workshops were organised for the states of Gujarat, Rajasthan and Maharashtra. This participatory method prioritises state-specific emerging and epidemic-prone diseases and their risk factors. It followed the OHRAD prioritisation tool prepared by the team for this process. Detailed information on the tool is available in the manuscript of the tool [15].

The prioritisation process involves various steps, including pre-workshop preparation, the workshop day and the post-workshop analysis.

2.1 Pre-workshop preparation

2.1.1 Listing of diseases

A literature search with key terms ‘Emerging diseases’, ‘Infectious diseases’, ‘Outbreaks’, ‘Western India’, ‘India’, ‘Novel diseases’, ‘Gujarat’, ‘Rajasthan’, ‘Maharashtra’ and re-emerging diseases’ on databases like google scholar, PubMed, and Medline has been done to list out the common infectious diseases. An extensive list was prepared, considering scientific publications, journal articles, commentaries, book chapters, and blogs. The final list of diseases was prepared considering the context of the three western states of India: Gujarat, Maharashtra, and Rajasthan. The list was prepared based on the last outbreak of the disease in these three western states of India. Any disease which had an outbreak in the last 15 years was included in the list.

2.1.2 Listing of risk factors

A literature search with key terms ‘disease risks’, ‘Infectious disease risks’, ‘One Health risks’, ‘Western India’, ‘India’, ‘Gujarat’, ‘Rajasthan’, and ‘Maharashtra’ has been done using databases like Google scholar, PubMed and Medline. The search for risk factors was conducted independently of the identified diseases. The journal articles, commentaries, book chapters, as well as blog articles have been thoroughly read to listdown the common risk factors for emerging and epidemic-prone diseases from the context of the three western states of India: Gujarat, Maharashtra, and Rajasthan. An extensive list of risk factors for all the zoonotic or emerging and epidemic-prone diseases was prepared, and upon further deliberation and discussion with the One Health experts, a final list of risk factors was prepared.

2.1.3 Workshop preparation

This pre-workshop preparation process began about three months before the planned workshops. The letters for nominations were sent to the Department of Health and Family Welfare, the Department of Animal Husbandry, and the Department of Forest and Wildlife. The list of the stakeholders was prepared after receiving the nominations. They were invited, and upon confirmation of participation, they were grouped into five heterogeneous groups with equal representation of participants from different sectors, which included medical officers, epidemic officers, staff of integrated disease surveillance program, microbiologists, superintendent of cattle nuisance, veterinary officers, an epidemiologist from the department of animal husbandry, team members of animal disease surveillance, zoo in charge, forest rangers, zoo veterinary officers, assistant conservator of forests, academicians of the human and animal health sectors, One Health experts and researchers.

2.1.4 Tool development

The OHRAD prioritisation tool was prepared using the principles of quantitative and semi-quantitative multi-criteria decision analysis (MCDA) and analytical hierarchical process (AHP). MCDA process includes the decision-making process when multiple criteria are considered for ranking diseases and risks. The tool has four criteria for disease threat, i.e. severity in terms of case fatality rate (CFR), prevalence of the disease seen as number of people infected or disease cases, transmissibility assessed in terms of the ability of the disease to cause an epidemic and the availability of disease prevention and control strategies while the burden of disease for humans and animals were taken as outcome indicator for prioritisation of diseases.

The three likelihood criteria i.e., the scope of exposure assessed as the percentage of the population exposed, frequency of exposure taken as a number of times this population is exposed and existence of a mitigation strategy, while the potential for an outbreak is considered as an impact criterion to prioritise risk factors.

The pre-decided questions from the OHRAD tool that were applied to capture the data on all the criteria for prioritising diseases and risk factors were used in all three workshops.

2.2 Workshop day

The workshop was conducted at Gandhinagar in Gujarat, Jaipur in Rajasthan, and Nagpur in Maharashtra.

2.2.1 Prioritisation of diseases

The following five steps were undertaken during the workshop day. Figure 1 represents the flow chart for the various steps involved in emerging and epidemic-prone disease prioritisation.

Fig. 1.
figure 1

Steps of disease prioritisation

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Step 1: Identification of diseases

The extensive list of emerging and epidemic-prone diseases prepared by the team was shared with the stakeholders, and the stakeholders were asked to indicate eventual diseases of local prevalence that were missing in the list. Finally, a list of 30 state-specific emerging and epidemic-prone diseases to be prioritised during the workshop was selected.

Step 2: Weighing of criteria

The Excel sheet of the OHRAD tool was used, and a semi-qualitative AHP was used to assign weightage for each criterion used to prioritise the diseases: severity in terms of CFR, prevalence of the disease, transmissibility assessed in terms of the ability of the disease to cause an epidemic and presence of disease prevention and control strategies. This step was carried out in groups; each group compared the criteria in pairs and ranked the criteria on a scale of 1 to 9.

Step 3: Disease scoring

The pre-decided questions of the OHRAD tool were used, and the decided emerging and epidemic-prone diseases were scored using a 3-point Likert scale. Each disease was scored on the four pre-decided criteria and the outcome indicator, i.e. disease burden.

Step 4: Disease burden score

Then, the weighted score for each disease was automatically calculated in the automated Excel sheet of the tool.

Step 5: Ranking of the disease

The scores of the each disease obtained in the tool were normalised. Then, these normalised scores were ranked. The final ranking of the diseases was obtained as the top 15 emerging and epidemic-prone diseases for the states of Gujarat, Maharashtra and Rajasthan. The results were further disseminated to all the participants and upon further deliberations, the final list of prioritised diseases for the state was prepared.

2.2.2 Prioritisation of the risk factors

The following five steps were undertaken during the workshop day. Figure 2 represents the flow chart for the various steps involved in risk factor prioritisation.

Fig. 2
figure 2

Steps of risk prioritisation

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Step 1: Identification of risk factors

The extensive list of risk factors for emerging and epidemic-prone diseases prepared by the team was shared with the stakeholders, and the stakeholders were asked to indicate the risk factors that were missing from the list. This list included factors leading to the emerging and epidemic prone diseases like breeding of mosquitoes. Finally, a list of 33 state-specific risk factors for emerging and epidemic-prone diseases to be prioritised during the workshop was selected.

Step 2: Weighing of criteria

The Excel sheet of the OHRAD tool was filled in, and a semi-qualitative AHP was used to assign weightage for each likelihood criterion such as scope of exposure, frequency of exposure and mitigation strategy. This step was carried out in groups; each group compared the criteria in pairs and ranked the criteria on a scale of 1 to 9.

Step 3: Risk factor scoring

The pre-decided questions of the OHRAD tool were used, and the decided risk factors for emerging and epidemic-prone diseases were scored using a 3-point Likert scale. Each risk factor was scored on the three pre-decided likelihood criteria and the impact criteria, i.e. potential for outbreak.

Step 4: Risk impact score

Then, weighted score for each risk factor was automatically calculated in the automated Excel sheet of the tool.

Step 5: Ranking of the risk factors

The scores of the risk factors are obtained in the tool, and were normalised. Then, these normalised scores were ranked and final ranking of the risk factors were obtained. The top 15 risk factors of emerging and epidemic-prone diseases for the states of Gujarat, Maharashtra and Rajasthan were obtained. The results were further disseminated to all the participants, and upon further deliberations, the final list of prioritised risk factors for each state was prepared.

Further details on the prioritisation process of diseases and risk factors are described in the manuscript One Health Risk and Disease (OHRAD): a tool to prioritise the risks for epidemic-prone diseases from One Health perspective [15].

3 Results

3.1 Gujarat workshop

A total of 30 diseases and 33 risk factors were included for prioritisation after a consensus from the stakeholders present in the workshop. The results of the group exercise for weighing of criteria presented in Table 1. The AHP was used for weighing the criteria for disease threats, i.e. severity in terms of CFR, prevalence of the disease, transmissibility assessed in terms of the ability of the disease to cause an epidemic and presence of disease prevention and control strategies. Similarly, weighing of likelihood criteria of risk factor like scope of exposure in terms of the percentage of the population exposed to a particular risk factor, frequency of exposure considered as the number of times the population is exposed, and mitigation strategy for the risk factor was done using the AHP. The results of the group exercise for weighing the criteria are presented in Table 1.

Table 1 Group ranking of the criteria using the AHP from the prioritisation in Gujarat
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Based on the scoring of the listed diseases and risk factors, along with the weightage of each criterion top 15 emerging and epidemic-prone diseases and risk factors were derived for the state of Gujarat. The top 15 risk factors and diseases are presented in Table 2.

Table 2 Top 15 diseases and risk factors prioritised for the state of Gujarat
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3.2 Rajasthan workshop

The results of the group exercise for weighing the criteria for Rajasthan are presented in the Table 3.

Table 3 Group ranking of the criteria using the AHP from the prioritisation in Rajasthan
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The scoring of the listed diseases and risk factors along with the weightage of each criteria derived top 15 emerging and epidemic-prone diseases and risk factors for the state of Rajasthan. The top 15 risk factors and diseases are presented in the Table 4.

Table 4 Top 15 diseases and risk factors prioritised for the state of Rajasthan
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3.3 Maharashtra workshop

The results of the group exercise for weighing the criteria for Maharashtra are presented in the Table 5.

Table 5 Group ranking of the criteria using the AHP from the prioritisation in Maharashtra
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The scoring of the listed diseases and risk factors and the weightage of each criteria derived  top 15 emerging and epidemic-prone diseases and risk factors for the state of Maharashtra. The top 15 risk factors and diseases are presented in the Table 6.

Table 6 Top 15 diseases and risk factors prioritised for the state of Maharashtra
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4 Discussion

4.1 Gujarat workshop

The results obtained through calculations of the weightage of the criteria and the score provided to each criteria by the stakeholders in the OHRAD tool were discussed with the stakeholders and with consensus the disease Covid-19 was removed from the top. The participants argued that the higher ranking of Covid-19 was mainly due to the recent long-term experience of the Covid-19 pandemic. The stigma, social issues as well as issues faced by people from various professions are well documented, so Covid-19 was removed from the list of top 15 emerging and epidemic-prone diseases [16, 17]. The final list of the top 15 prioritised emerging and epidemic-prone diseases and risk factors is presented in Table 7.

Table 7 Final list of top 15 prioritised diseases and risk factors in Gujarat
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Brucellosis was ranked one for emerging and epidemic-prone diseases. The seroprevalence was high in Gujarat among small ruminants [18] as well as humans [19].

The high instances of dog bites, and the recurring outbreaks of avian flu and swine flu has resulted in rabies, avian flu and swine Flu being in the top 10 emerging and epidemic-prone diseases. The recent reporting of glanders among horses and donkeys also put this disease in the top 10. Measles, bovine tuberculosis, dengue, CCHF, salmonellosis, chikungunya, hepatitis E and cholera were listed within the top 15 diseases.

The high number of dengue cases in Ahmedabad in the last year might be the reason for mosquito breeding sites near houses or workplaces being the risk factor in the first place [20].

Thus, the risk factors and diseases prioritised substantiate each other, and the risk factors leading to the diseases are a matter of focus for the state of Gujarat.

4.2 Rajasthan workshop

The prioritised emerging and epidemic-prone diseases and risk factors obtained using the OHRAD tool were disseminated among the stakeholders and a consensus was built for obtaining the final top 15 emerging and epidemic-prone diseases and risk factors for the state of Rajasthan. The top 15 emerging and epidemic-prone diseases and risk factors obtained from the discussion are shown in Table 8.

Table 8 Final list of top 15 prioritised diseases and risk factors in Rajasthan
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The recent Avian flu outbreak in Rajasthan in the year 2021 might be the reason for it being the most prioritised emerging and epidemic-prone disease [21, 22]. Sivachandiran et al. highlighted that 34 outbreaks were reported in various districts of Rajasthan, Gujarat and Uttar Pradesh. The authors have also termed this disease as a ticking bomb [23]. Thus, this might be the reason for the stakeholders to put CCHF at the second place among the top 15 prioritised emerging and epidemic prone diseases. The cumulative seroprevalence of brucellosis among livestock was 3.63%, according to Meena et al. [24]. A report submitted by the Department of Community Medicine, SMS Medical college, Jaipur on the trends of communicable diseases & IDSP reporting for the state of Rajasthan between year 2005–2016 also highlighted the increase in dengue cases by four times since its emergence, and also high numbers of deaths due to dengue. The report also mentioned the increased number of laboratory confirmed cases of scrub typhus between the years 2011 and 2014. The increasing number of cases of swine flu was also pointed at the report. The seasonal increase of cholera cases in Rajasthan along with its recurrent outbreaks was highlighted, too [25].

The above mentioned accounts may be the reasons for the following diseases in Table 8 to be mentioned as top 15 prioritised emerging and epidemic-prone diseases for the state of Rajasthan by the stakeholders. Similarly, the risk factors that could lead to these diseases that were prioritised in Rajasthan were also prioritised as top 15 risk factors for the state of Rajasthan.

4.3 Maharashtra workshop

The Table 9 indicates the top 15 emerging and epidemic-prone diseases prioritised for the state of Maharashtra after thorough deliberations of the stakeholders post prioritisation done using the OHRAD tool.

Table 9 Final list of top 15 prioritised diseases and risks in Maharashtra
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The outbreak of Avian flu in the Vehloli village of Shahpur of Maharashtra in February 2022, resulted in the culling of more than 25,000 birds, might be a reason for stakeholders to place it in the top position during the prioritisation [26, 27]. Between July and September 2022, ten times more swine flu cases were detected in the state of Maharashtra, and the deaths were also very high [28]. Similarly, the number of dengue cases reported in Maharashtra was also very high [29]. The reports on more than 50% of buffalo deaths due to leptospirosis in the Wardha district of Maharashtra had raised concern, and this also might be a reason for this being the fourth prioritised disease for the state of Maharashtra. Similarly, increased cases of food and water-borne diseases, vector-borne diseases and dog bites have raised the alarm in almost all states of the country. Therefore, Table 9 also contains the list of risk factors that lead to the top 15 prioritised diseases.

4.4 All the three workshops

The emerging and epidemic-prone diseases prioritised in Gujarat, Maharashtra, and Rajasthan are state-specific and are synchronised with the published information about various outbreaks and threats. Diseases like avian flu A(H5N1), A(H7N9), and A(H9N2), swine flu A(H1N1), A(H1N2) and A(H3N2), dengue, rabies, leptospirosis, bovine tuberculosis, salmonellosis, chikungunya, soil-transmitted helminths, and brucellosis are 10 diseases prioritised in top 15 diseases in all the three western states of the country. A WHO report on the global disease burden also highlights the high burden of diseases like dengue, avian flu, and chikungunya in India and the burden of soil-transmitted helminths, mainly among children [30, 31]. The diseases like hepatitis E, cholera, CCHF, measles, and scrub typhus were put in top 15 prioritised emerging and epidemic-prone list in more than one western state.

Similarly, risk factors like presence of mosquito breeding sites near houses or workplaces, open defecation, poor hand hygiene, poor personal hygiene, reluctance to follow disease prevention measures and improper carcass disposal were prioritised in all the three states. Mass gatherings or faith-based gatherings, high human and animal density, lack of solid waste management, inadequate vaccination of livestock or pets, presence of wet markets, lack of sanitation facilities, presence of infected animals at homes or farms, animal waste disposal in residential sites, and exposure to pet or livestock were risk factors prioritised in more than one western state. The major prevention strategies for the coronavirus infection applied were social distancing, and maintenance of hand as well as personal hygiene despite evidence for the superior impact of wearing masks.

This prioritisation exercise provides the list of diseases and risk factors that need to be focused on. This will provide evidence to policymakers to decide which diseases or risk factors need to be addressed as a priority in their region for better outcomes. This prioritisation exercise was conducted using a workshop method and hence there is a chance that process is influenced by the participants and their backgrounds, which can introduce bias into risk and disease scoring. To mitigate this, participants were grouped before the workshop to ensure equal representation from different departments in each group.

5 Conclusion

The emerging and epidemic-prone diseases and risk factors that are prioritised give a reflection into the state-specific scenarios and the gravity of the situation. The prioritised risk factors need to be mitigated so that the probability of occurrence of water and food-borne diseases, airborne diseases, diseases due to the touch, diseases due to bite of animals or vector-borne diseases are minimized. This minimization of the chance of occurrence of these diseases may lead to the successful evading of future epidemics. This would significantly decrease the burden of diseases on society as well as on individuals, which makes One Health an extremely worthwhile approach to public and global health.