This study to finalize a list of priority zoonotic diseases for India through a participatory action research approach followed the Good Reporting of a Mixed Methods Study guidelines [26]. A mixed methods approach was necessary to incorporate both the qualitative and quantitative components adopted before, during, and after the 3-day national multistakeholder workshop (Figure 1). Discussions involved 50 experts in zoonotic diseases (Figure 1) from institutions including the Ministry of Fisheries, Animal Husbandry, and Dairying; the Ministry of Agriculture and Farmers’ Welfare; the Ministry of Environment, Forest, and Climate Change; the Ministry of Health and Family Welfare; state governments; private agencies; and national and international organizations (Textbox 1).

The US CDC’s OHZDP process [20] was modified for country-specific requirements and used for this prioritization. The modified prioritization process was completed using the following 6-step sequence of methods.

Experts were identified by first determining stakeholder organizations. A stakeholder was any organization, institution, network, or group involved in activities pertaining to zoonotic diseases at the national or international level. Initially, a formal communication was sent to state health departments, the Department of Animal Husbandry (Ministry of Fisheries, Animal Husbandry, and Dairying), the Department of Wildlife (Ministry of Environment, Forest, and Climate Change), state medical colleges, the Indian Council of Agricultural Research (Ministry of Agriculture and Farmers’ Welfare), the Indian Council of Medical Research (Ministry of Health and Family Welfare), veterinary universities, and international agencies in India to nominate or identify experts from these sectors at the provincial and federal level. Experts from these agencies were identified for participation in the workshop and were categorized as voters (n=33), advisors (n=10), and facilitators (n=7). In total, participation spanned seven major sectors. Doctors from clinical and diagnostic sectors constituted the largest group of experts (16, 32%), followed by veterinarians (12, 24%). Representatives from national-level public health institutions comprised 7 (14%) of participants, while state government officials and wildlife sector experts accounted for 5 (10%). International agencies represented 8 (16%) of the experts, and 2 (4%) were from the environment and food safety sector. The roles and responsibilities of each of these categories were as follows:

Three rounds of preworkshop online discussions were held to acquaint the voting members, advisors, and facilitators with the steps, process, and expected outcomes of the workshop. During these discussions, a list of 40 potential priority zoonoses was developed through a focused literature review and discussions (Textbox 2). The literature review included reports available under government health programs; peer-reviewed publications indexed on PubMed, Google Scholar, The BMJ, and Public Library of Science; and unpublished work on zoonoses from universities, research institutes and information created by government agencies and national programs such as the IDSP with publication dates from January 2000 to January 2020 (using the search terms “zoonotic disease” OR “zoonoses” OR “infectious disease” AND “India”).

Before the workshop, the advisors and facilitators and most of the voting members identified in step 1 debated the criteria to be included, the supporting questions and responses, and the scores until consensus was achieved. Through this process, 5 criteria, along with categorical questions that would enable weighting and ranking for prioritization of zoonotic diseases, were decided upon. Prioritization documents produced by other countries were used as a reference. The discussion was led by the NCDC. The 5 criteria that were developed were the severity of the disease in humans, the economic burden of the disease, pandemic or epidemic potential, potential of transmission, and capacity for prevention and control in humans and the animal health sector. These criteria were presented at the workshop for discussion and ultimately used during the prioritization process (Table 1).

A 3-day national multistakeholder zoonotic disease prioritization workshop was held in Jaipur, Rajasthan, from February 10 to 12, 2020. This workshop included the 50 facilitators, advisors, and voting members described previously, all experts in the fields of epidemiology, microbiology, parasitology, public health, veterinary public health, environmental health, and international health (Textbox 1). The day 1 agenda included the finalization of the weightage and ranking of criteria, the day 2 agenda included the finalization of zoonotic disease rankings, and the day 3 agenda included a workshop summary and action plan (Figure 1).

On the first day of the workshop, the participants familiarized themselves with AHP, which was used to rank criteria and develop a weighted score for each criterion using the OHZDP tool [12].

All the workshop participants were initially divided into 6 sector-specific groups of 6 to 7 participants, a modification of the CDC OHZDP methods. These groups ranked the 5 criteria finalized in step 2 to generate 6 sets of criteria rankings. The OHZDP tool was then used to compute the average ranking from the 6 groups’ inputs and generate the final rankings and criteria weights.

The voters, advisors, and facilitators were then reorganized into 6 heterogenous groups of representative stakeholders. Each group included a moderator from the US CDC (India) or the American Society for Microbiology. Each of these groups was provided with a list of 40 zoonotic diseases and a questionnaire to facilitate the scoring of each categorical question. They were also provided with references for each criterion identified from the literature review. Question scores were then entered into the OHZDP tool to calculate final scores for each zoonotic disease, normalize these scores, and generate the final ranking for each of the 40 listed diseases. The OHZDP process incorporated decision tree analysis to calculate the final weighted score by multiplying the weights of each criterion with the score assigned to each question. A consistency ratio of 0.1 or less was considered satisfactory [28]. We used a Microsoft Excel–based program for AHP to rank the criteria and calculate the consistency ratio by conducting pairwise comparisons of the criteria. For diseases for which participants felt that available data were too limited for scoring to be conducted, ranks were given using simple decision rules based on heuristic knowledge of the existing capacity of health care systems, vaccination, and infrastructure in India. Ranks given using simple decision rules were confirmed through expert consensus within the groups. While this qualitative method had certain limitations in terms of its subjectivity, this was partially overcome by averaging the ranks from the 6 groups and using the best available quantitative and qualitative data for expert consensus ranking.

Sensitivity analysis was conducted to test the validity of the prioritization results based on the impact of input variables (weighted criteria and scoring of individual zoonotic diseases). In the first stage of sensitivity analysis, the 5 criteria were given an equal weight of 1 each to obtain normalized scores. In the next stage, scores for each of the zoonotic diseases were obtained by sequentially removing each of the 5 criteria. The Pearson correlation was used to assess the relationship between normalized scores and the adjusted scores used to assess the impact of criteria weightage and their contribution to disease prioritization ranks. The Pearson correlation coefficient was considered significant at P<.05. The analysis was conducted in the Stata software (version 15.1; StataCorp).

The workshop concluded with a discussion on a road map for the prevention and control of identified priority zoonotic diseases, as well as overall areas for improvement, including the development of a national One Health action plan and robust linkages across all sectors.

This workshop did not require ethics approval or written informed consent because it did not involve research on human participants as defined by institutional and national regulations, and only anonymized aggregate data are reported. Participating experts did not receive any financial or other material compensation for attending the workshop.

The methodology followed a modified OHZDP process to accommodate India’s context, ensuring inclusivity of stakeholders and harmonization with the existing surveillance and health system structures. The first modification was the selection of criteria before the workshop. The criteria, their responses, and associated scores were finalized 2 days before the workshop through a videoconference led by the NCDC. This ensured smooth workshop progression but limited input from all stakeholders. However, presenting the criteria during the workshop mitigated this limitation, and the ranking process proceeded without further suggestions. The second modification involved sector-specific grouping for criteria ranking. To manage the large number of voting members, they were divided into 6 sector-specific groups. Each group discussed and ranked the criteria, and the results were aggregated for AHP analysis. This modification promoted informed discussions, minimized score variation, and ensured a consistency ratio below the acceptable threshold of 0.1, confirming the process’s integrity. The use of AHP to assign weights and rank criteria provided a transparent, semiquantitative framework that allowed participants to incorporate both quantitative data and expert judgment. Sensitivity analysis validated the robustness of the prioritization as minimal variations were observed in the ranking of the top 10 diseases despite changes in criteria weights. This finding underscores the consistency and reliability of the process and affirms that the prioritization outcomes were not unduly influenced by any single criterion.

Two criteria—severity of the illness in humans and capacity for prevention and control in humans and the animal health sector—received the highest weights, reflecting participants’ emphasis on public health impact and feasibility of intervention. Diseases such as zoonotic influenza, anthrax, and Japanese encephalitis were ranked highly, consistent with their historical and epidemiological relevance to India. These results align with findings from similar OHZDP exercises in other countries, including Bhutan and Uganda, where disease severity and prevention capacity were also key determinants [29,30]. Previous efforts at the local level [25] identified rabies, brucellosis, avian influenza (H5N1), influenza A (H1N1), and CCHF as the highest priority. That list closely resembles the results of this national-level workshop with the exception of avian influenza, which was not included in this workshop.

This prioritization exercise also revealed the utility of combining evidence-based scoring with expert consensus to address data limitations that often constrain disease prioritization in low- and middle-income countries.

The outcomes of this study have direct programmatic implications. The prioritized list serves as a strategic foundation for strengthening surveillance, laboratory capacity, and intersectoral coordination for zoonotic diseases in India. Furthermore, these findings can inform the development of state-level prioritization exercises and One Health action plans, thereby supporting the operationalization of the National One Health Programme for Prevention and Control of Zoonoses.

Limitations of the prioritization process include potential underreporting of certain zoonotic diseases and gaps in data availability, which may have influenced expert scoring. However, these were mitigated through an extensive literature review and expert consensus. Despite these limitations, the structured use of AHP, high consistency ratios, and minimal rank variation in sensitivity analysis together demonstrate the robustness of the findings.

In summary, this study not only identifies the zoonotic diseases of highest national concern but also demonstrates the applicability and adaptability of the OHZDP process in a complex and diverse health system such as India’s. The results provide an evidence-based foundation for future multisectoral action, capacity building, and surveillance system strengthening in alignment with India’s One Health vision. Through the conduct of this prioritization workshop, India has demonstrated its commitment to One Health through interministerial collaboration and a multidisciplinary, multisectoral approach to prioritization, demonstrating “functionality with bridges and fluidity” [31] in action.

Zoonotic influenza (zoonotic influenza A viruses) was the highest-ranked zoonosis in this workshop. Overcoming the programmatic silos that currently exist within different government agencies and institutions will be a major challenge in operationalizing One Health in India; however, this workshop demonstrated that such coordination is possible. This prioritization conducted at the national level has the potential to catalyze such efforts at the state and local levels across India by fostering the communication, collaboration, cooperation, and coordination necessary to make meaningful progress. Given the diversity in geography and prevalence of communicable diseases in different parts of India, states may be interested in taking up similar exercises to further streamline their needs and resource use. State action plans developed under the guidance of the National One Health Programme for Prevention and Control of Zoonoses will help states achieve the One Health goals outlined by the National One Health Programme for Prevention and Control of Zoonoses.