Drivers of zoonotic disease risk in the Indian subcontinent: A scoping review

'Community people are the most powerful resources': qualitative critical realist analysis and framework to support co-produced responses to zoonotic disease threats with(in) Nepali communities

BACKGROUND

Co-production between researchers, service providers, and members of affected communities is an old concept renewed by current efforts to decolonise global health, reduce exploitative practices, and develop more sustainable, context-relevant interventions to address global health issues. Working with communities- how ever defined- is central to healthcare improvement but engaging with communities and identifying priorities remains challenging for disease control professionals. Co-production aims to help ensure community members have some control over the design and implementation of any intervention, and greater ownership of processes and outcomes. We aimed to identify what would encourage co-production of activities to prevent potential transmission of zoonoses.

METHODS

In this qualitative study, we (British and Nepali researchers) interviewed 73 participants from six communities across Nepal, with 10 participating in photovoice. We also interviewed 20 healthcare professionals and policymakers, 14 representing human and six representing animal health. We interpreted data using reflexive thematic analysis.

RESULTS

Thirty-nine people in six communities participated in interviews, with another 34 in 5 focus groups. We generated three overarching themes: (i) constrained healthcare-seeking behaviours, (ii) experience of community programmes, and (iii) community priorities and co-production. Community participants, despite strong opinions and desire to participate in disease control interventions, had experienced little or no attempt by intervention organisers to engage them in design, implementation, evaluation, or accountability. Most had no experience of programmes at all. Participants highlighted the significance of working in 'local' languages, respecting religious and cultural realities, relating initiatives to lived experience, and ensuring that local leaders are involved.

CONCLUSIONS

Meaningful co-production requires recognising communities- through legitimate leadership/representation- as expert and equal partners who can 'work alongside' at all stages of any initiative. Implications from this research include the importance of promoting trust in communities through inclusion of influential community members (community health volunteers, traditional medicine practitioners, women's group leaders); the use of indigenous languages; the acceptability of different media for interventions (theatre, drama); and the need to be pragmatic about available resources, to manage the expectations of community members.

Assessing Socioeconomic and Environmental Vulnerability and Awareness of Zoonotic Diseases From a One Health Perspective: A Cross-Sectional Study in a Rural Population in Tamil Nadu, India

BACKGROUND

The interconnection between human, animal, and ecosystem health is crucial, particularly in rural areas, where several socio-economic and environmental risk factors heighten vulnerability to zoonotic diseases. This study aims to assess the vulnerability as well as knowledge and practices concerning zoonosis from a One Health perspective.

METHODOLOGY

A cross-sectional study was carried out in rural areas of Madurai district, Tamil Nadu, from July to December 2024, selected by simple random sampling. The socio-demographic and ecological risk factors, knowledge, attitudes, and practices regarding zoonosis were assessed utilizing a validated semi-structured questionnaire among 408 participants. Microsoft Excel (Microsoft, Redmond, WA, USA) and R programming (version 4.4.3; R Foundation for Statistical Computing, Vienna, Austria) were used for analyzing the data.

RESULTS

The study sample, comprising 238 (58.3%) males, had a mean age of 43.32 years, with 46 (11.3%) being illiterate. Around 134 (32.84%) belonged to the lower middle class, with 50 (12.3%) worked in agriculture, and 118 (28.9%) were unemployed. Around 96 (23.53%) of the population lived in kutcha houses, 151 (37.01%) reported dampness, and 253 (62.01%) reported overcrowding. Environmental issues include mosquito breeding in 279 (68.38%), open drains in 268 (65.69%), stray animals in 308 (75.49%), and rat infestations in 155 (37.99%) of communities. Around 321 (79%) of individuals demonstrated good knowledge, while only 96 (24%) exhibited a positive attitude and 107 (26%) engaged in good practices. We noted a negative attitude and poor practices among 120 (29%) and 170 (42%), respectively. Individuals aged 41 years and older (p=0.02) and pet owners (p=0.01) demonstrated a higher level of knowledge.

CONCLUSIONS

This study emphasizes the importance of addressing vulnerabilities in socially and ecologically disadvantaged populations to prevent zoonotic diseases. It identifies a gap between knowledge and practical application, advocating for behavior change for better rural health outcomes.

Knowledge, attitude, and practice of One Health and zoonotic diseases among multisectoral collaborators in Bhutan: Results from a nationwide survey

The One Health concept is increasingly employed to combat zoonotic diseases. This study assessed the knowledge, attitudes, and practices regarding One Health and zoonotic diseases among key sector professionals to identify gaps and opportunities for enhancing One Health strategies in Bhutan. A cross-sectional, facility-based study was used to conduct a nationwide online questionnaire survey using a validated and pre-tested questionnaire among professionals from the Ministry of Health, the Ministry of Agriculture and Livestock, and universities. Descriptive and summary statistics were calculated. Respondents were categorised into binary groups based on their knowledge, attitude, and practice scores relative to the mean. Multivariable logistic regression analyses were conducted to identify the demographic factors associated with knowledge, attitudes, and practices regarding One Health and zoonotic diseases. The survey achieved a 35% response rate, with 964 responses. The majority of respondents demonstrated above-average knowledge (63%), attitudes (50%), and practices (66%) regarding One Health. Professionals with master's degree or higher (Adjusted Odds Ratio [AOR] = 2.39; 95% Confidence Interval [CI] = 1.16-5.12) were more likely to have above-average knowledge. Regarding zoonotic diseases, approximately half of the respondents had above-average knowledge (51%), attitudes (52%), and two-thirds (66%) had above-average practices. Professionals with mid-level job experience (6-10 years; AOR = 2.13; 95% CI = 1.37-3.30 and 11 to 15 years; AOR = 2.11; 95% CI = 1.31-3.40) were more likely to possess above-average knowledge. Gaps in training, communication, funding, research, and collaborations were identified. Targeted educational interventions, enhanced communication, strengthened collaboration, expanded research, and improved funding are essential for improving One Health approaches and zoonotic disease prevention and control in Bhutan. Our study findings provide valuable insights that can inform global efforts to enhance One Health systems, particularly in regions where resources are limited but disease risks are significant.

A Systematic Review of Zoonotic Disease Prevalence in Sri Lanka (2000-2022)

Background: The burden of zoonotic diseases in developing countries is significantly underestimated, influenced by various factors such as misdiagnosis, underreporting, natural disasters, climate change, resource limitations, rapid unplanned urbanization, poverty, animal migration, travel, ecotourism, and the tropical environmental conditions prevalent in the region. Despite Sri Lanka's provision of a publicly funded free health care system, zoonoses still contribute significantly to the burden of communicable diseases in the country. This study serves as a timely and exhaustive systematic review of zoonoses reported over the past 22 years in Sri Lanka. Materials and Methods: This systematic review adhered to the guidelines provided by the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" (PRISMA) statement. A systematic literature search was conducted between July and September 2022, utilizing the following databases and sources: Google Scholar, PubMed, Cochrane Library, Weekly Epidemiological Reports, and Rabies Statistical Bulletins published by the Ministry of Health, Sri Lanka. Results: From the initial database search, 1,710 articles were identified. After excluding nonzoonotic diseases, duplicated reports, inaccessible articles, and those not meeting the inclusion criteria, 570 reports were evaluated for eligibility. Of these, 91 reports were selected for data extraction, comprising 58 original research articles, 10 case reports, 16 weekly epidemiological reports, and 7 rabies statistical bulletins. Over the study period (2000-2022), 14 parasitic, 7 bacterial, and 7 viral zoonoses have been reported in Sri Lanka. Notably, leptospirosis emerged as the most reported zoonotic disease in the country. Conclusions: In response to these findings, we strongly recommend the implementation of a tailored, country-specific prevention and control program. To achieve this goal effectively, we emphasize the importance of adopting a country-specific "One Health" approach as a comprehensive framework for managing and controlling zoonotic diseases in Sri Lanka.

Smart proteins as a new paradigm for meeting dietary protein sufficiency of India: a critical review on the safety and sustainability of different protein sources

India, a global leader in agriculture, faces sustainability challenges in feeding its population. Although primarily a vegetarian population, the consumption of animal derived proteins has tremendously increased in recent years. Excessive dependency on animal proteins is not environmentally sustainable, necessitating the identification of alternative smart proteins. Smart proteins are environmentally benign and mimic the properties of animal proteins (dairy, egg and meat) and are derived from plant proteins, microbial fermentation, insects and cell culture meat (CCM) processes. This review critically evaluates the technological, safety, and sustainability challenges involved in production of smart proteins and their consumer acceptance from Indian context. Under current circumstances, plant-based proteins are most favorable; however, limited land availability and impending climate change makes them unsustainable in the long run. CCM is unaffordable with high input costs limiting its commercialization in near future. Microbial-derived proteins could be the most sustainable option for future owing to higher productivity and ability to grow on low-cost substrates. A circular economy approach integrating agri-horti waste valorization and C1 substrate synthesis with microbial biomass production offer economic viability. Considering the use of novel additives and processing techniques, evaluation of safety, allergenicity, and bioavailability of smart protein products is necessary before large-scale adoption.

What is the state of the art on traditional medicine interventions for zoonotic diseases in the Indian subcontinent? A scoping review of the peer-reviewed evidence base

BACKGROUND

Traditional medicine (TM) interventions are plausible therapeutic alternatives to conventional medical interventions against emerging and endemic zoonotic diseases, particularly in low-and middle-income countries that may lack resources and infrastructure. Despite the growing popularity in the usage of TM interventions, their clinical safety and effectiveness are still contested within conventional healthcare in many countries.

METHODS

We conducted a scoping review of the peer-reviewed literature that synthesises and maps the evidence on TM interventions for the treatment and prevention of zoonoses on the Indian subcontinent. The region, a global hotspot of biodiversity and emerging infections, is characterised by high prevalence of TM use. Based on the scientific literature (mostly case study research, n=l06 studies), our review (1) maps the scope of the literature, (2) synthesises the evidence on the application of TM interventions for zoonoses, and (3) critically reflects on the state of TM and identifies areas for future research focus.

RESULTS

The evidence synthesis confirmed widespread usage of TM interventions for zoonoses on the subcontinent, with the majority of research reported from India (n=99 studies, 93.4%), followed by Pakistan (n=3 studies, 2.8%), Bangladesh (n=2 studies, 1.9%), and Sri Lanka (n=1, 0.9%). Most of the reviewed studies reported on ethno-medicinal uses of plant species, primarily for treating dengue (n=20 studies), tuberculosis (n=18 studies), Escherichia coli infection (n=16 studies), lymphatic filariasis and cholera (n=9 apiece). However, the evidence on the safety and effectiveness of these reported TM interventions is limited, indicating that these data are rarely collected and/or shared within the peer-reviewed literature.

CONCLUSION

This review thus highlights that, whilst TMs are already being used and could offer more widely accessible interventions against emerging and endemic zoonoses and ectoparasites, there is an urgent need for rigorous clinical testing and validation of the safety and effectiveness of these interventions.

Leptospirosis in India: insights on circulating serovars, research lacunae and proposed strategies to control through one health approach

Leptospirosis is one of the most neglected zoonotic infections of public health concern worldwide and a remerging infection in tropical countries such as India. The infection least explored disease and the epidemiological and other critical data are scarce for the disease rate reported and to control the infection. Leptospirosis as sapronosis is as underrated as the infection itself, and this article aims to explore the significance of this aspect of the disease. The research review aimed at the epidemiological understanding of the infection to control the negative impact of the disease. A mixed review and analysis were carried out to understand the knowledge published on the critical and understudied areas like epidemiology, transmission, diagnosis, treatment, and control of infection. A systematic analysis was carried out to extract information about the reported circulating strains, and research lacunae in India with the published data available in PubMed. The article elaborately discusses crucial inference areas of infection transmission and addresses lacunae in critically unacclaimed areas of infection to control the spread of infection using one health approach (OHA), and strategies to control leptospiral infection are proposed. The article also reviewed how and why Leptospirosis can be best studied and controlled by "One health approach" in India.

Implementation of 'One Health' approach in Kerala state, India - A systematic review

With humans, animals and the environment being as interconnected as they are, the science describing their interactions needs to cut across disciplinary boundaries. Systems research at the interface between the three goes by several names, such as 'Eco-Health' and 'Planetary Health', each with a varied focus, but the concept of 'One Health' (OH) has stood out as the most popular one. COVID-19 has reiterated the importance of OH in response to health challenges. This review aimed to assess the OH approach integration and implementation level in Kerala state, India, in the context of emerging zoonotic diseases. A systematic literature review was conducted by searching for relevant articles with specific keywords across six electronic databases. This involved screening the initial hits for titles and abstracts, then systematic sorting to identify the ones that met the criteria, followed by more thorough scrutiny to finally shortlist the six studies to be included in the review. We found that OH in Kerala has made good progress, as evident from a few recent examples, but has a long way to go with significant challenges. In line with the study's aim, identifying and analysing what is already done, what is missing and what needs to be done can have wider implications for future OH implementation. Relevant threats and opportunities were identified, with lessons for Kerala and India and broader applications.

Assessing and Prioritizing Zoonotic Diseases in Punjab, India: A One Health Approach

Zoonotic diseases have a significant impact on both human and animal health globally. The present study was planned to prioritize the zoonoses in Punjab state of India. To develop a zoonotic disease prioritization scoring system, a comprehensive approach has been taken, including literature review, key person interviews with animal health experts (n = 12) and medical professionals (n = 7), and nine focus group discussions (FGDs) with veterinary academicians, medical professionals, and field veterinary doctors. The scoring system comprises of seven major criteria, each assigned a weightage score (ws): prevalence/incidence of the disease (ws = 0.20), severity of illnesses in humans (ws = 0.18), epidemic potential (ws = 0.16), socio-economic burden (ws = 0.16), availability of effective control and prevention measures (ws = 0.15), inter-sectoral collaborations (ws = 0.1), and bioterrorism potential (ws = 0.05). The finalized scoring system, accompanied by a list of 15 selected zoonotic diseases, was implemented among a group of 23 professionals engaged in zoonoses research (n = 7), animal health (n = 10), and medical health (n = 6) to determine their prioritization. The zoonotic diseases prioritized for the Punjab (India) included, Brucellosis (0.70) > Rabies (0.69) > Anthrax (0.64) > Leptospirosis (0.62) = Toxoplasmosis (0.62) = Highly Pathogenic Avian Influenza (HPAI) (0.62) > Bovine tuberculosis (0.61) > Q fever (0.60) > Cysticercosis (0.59) > Listeriosis (0.58) > Crimean-Congo haemorrhagic fever (CCHF) (0.57) > Japanese encephalitis (0.56) = Echinococcosis (0.56) > Dermatophytosis (0.53) > and Scrub typhus (0.48), respectively. Higher priority is suggested for endemic zoonoses (e.g., brucellosis and rabies) as compared to those with epidemic potential (e.g., CCHF, HPAI etc.) in Punjab. Results of the current study will help in the development of targeted control and prevention strategies for zoonotic diseases in Punjab and other geographical regions facing similar challenges.

Context matters: Leveraging anthropology within one health

Anthropologists develop long-term engagements with communities, animals, and the ecosystems they all share. This approach can provide important context that is necessary for One Health research, which may otherwise overlook the perspectives and lived experiences of community members. This paper presents two case studies that illustrate the importance of leveraging long-term, holistic, engagements with communities in moving the One Health concept forward. The first illustrates the complexity of understanding the health of people and animals within the context of environmental change in South India. The second provides insights into how the conservation of endangered species requires considering the entanglements of people, domestic animals, and the landscapes they share with wildlife in Madagascar. We demonstrate the value of integrating anthropological perspectives within interdisciplinary One Health research and interventions to better understand the complexity of systems.

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One Health research should incorporate anthropologists and/or social scientists.

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Anthropology provides unique approaches to improve One Health research.

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Long-term engagements with communities will improve One Health research.

Strengthening preparedness against global health threats: A paradigm shift based on One Health approaches

The implementation of preparedness strategies to prevent and mitigate the impact of global health threats poses several challenges. It should promptly identify cross-cutting drivers of pandemic threats, assess context-specific risks, engage multiple stakeholders, and translate complex data from multiple sources into accessible information for action. This requires a coordinated, multidisciplinary and multisectoral effort engaging systems that, most of the time, work in isolation.

The One Health (OH) approach promotes the collaboration and communication among different disciplines and sectors, and could be applied across the preparedness phases at national and international level.

We discuss here gaps and needs in preparedness strategies, which can benefit from the OH approach, and a set of actionable recommendations, as shared with the G20–2021 with a dedicated Policy Brief.

The discussion adds to the current debate about OH operationalization and promotes a paradigm shift towards coordinated prevention and preparedness strategies for early assessment and management of global health threats.

"If It Works in People, Why Not Animals?": A Qualitative Investigation of Antibiotic Use in Smallholder Livestock Settings in Rural West Bengal, India

Smallholder farms are the predominant livestock system in India. Animals are often kept in close contact with household members, and access to veterinary services is limited. However, limited research exists on how antibiotics are used in smallholder livestock in India. We investigated antibiotic supply, usage, and their drivers in smallholder livestock production systems, including crossover-use of human and veterinary antibiotics in two rural sites in West Bengal. Qualitative interviews were conducted with key informants (n = 9), livestock keepers (n = 37), and formal and informal antibiotic providers from veterinary and human health sectors (n = 26). Data were analysed thematically and interpreted following a One Health approach. Livestock keepers and providers used antibiotics predominantly for treating individual animals, and for disease prevention in poultry but not for growth promotion. All providers used (highest priority) critically important antimicrobials for human health and engaged in crossover-use of human antibiotic formulations in livestock. Inadequate access to veterinary drugs and services, and a perceived efficacy and ease of dosing of human antibiotics in animals drove crossover-use. Veterinary antibiotics were not used for human health due to their perceived adverse effects. Given the extent of usage of protected antibiotics and crossover-use, interventions at the community level should adopt a One Health approach that considers all antibiotic providers and livestock keepers and prioritizes the development of evidence-based guidelines to promote responsible use of antibiotics in animals.