Bridging policy and practice: implementation of emerging infectious disease risk assessment in China from a One Health perspective

Abstract

Background

Risk assessment of emerging infectious diseases (EIDs) enables the early identification of potential threats and informs timely public health responses. A One Health perspective may enhance its comprehensiveness by integrating human, animal, and environmental factors. However, current understanding of the policy implementation of EID risk assessment in China remains limited. This study examines the implementation of related policies in China to identify gaps between policy design and practice from a One Health perspective.

Methods

Semi-structured interviews were performed in Hainan Province and Jiangxi Province during March and June in 2024. Purposive sampling was used to recruit stakeholders from human, animal, environment, and other administrative sectors. All interviews were conducted in Chinese with each lasting 40−60 min. Grounded theory methodology was used to guide thematic analysis. Open coding and axial coding were conducted to allow themes and subthemes from the data.

Results

A total of 54 experts from human (25.9%), animal (24.1%), environment (22.2%) and other (27.8%) sectors participated in the interview. Overall, China advanced risk assessment of EIDs across multiple dimensions, including governance system, cross-sectoral coordination, technology, workforce capacity, and financial investment. The results revealed barriers in implementing of risk assessment, including: (1) minimal surveillance of unknown diseases, (2) minimal surveillance of aquatic and wild animals, (3) insufficient staffing size and weak professional competence, and (4) inadequate cross-sectoral collaboration. It is recommended to improve legal provisions concerning sector responsibilities, develop a minimum data set to facilitate cross-sectoral collaboration, enhance work force capacity through training, and strengthen scientific research cooperation between academic communities and sectors.

Conclusion

Persistent gaps in the local implementation of policies on EID risk assessment in China were identified. The findings highlighted the need to strengthen risk surveillance and facilitate data sharing across multiple sectors from One Health perspective, which may contribute to China's capacities to cope with EIDs.

Graphical abstract

1. Introduction

Emerging infectious diseases (EIDs) are those that either appear and infect human beings for the first time, or are previously known diseases experiencing a marked increase in incidence [1,2]. The onset of EIDs is driven by a complex interplay of factors, including climate change [3], rapid urbanization [4], and interspecies transmission caused by intensified interface interactions among wildlife, livestock, and human populations [5,6]. In recent years, there has been a marked global increase in EIDs, posing a serious threat to global public health. This challenge is further amplified by the inherent complexity and uncertainty of EID triggers, consequential impacts, and responses, which impede the effective prevention and control of EIDs [7]. In practice, such uncertainty may initially manifest as disease events of unknown etiology, including abnormal health signals or unexplained case clusters, referred to here as unknown diseases.

Timely and effective risk assessment plays a pivotal role in EID prevention and control. By systematically evaluating the likelihood and potential consequences of transmission events, it enables early detection of potential threats and informs appropriate control strategies for mitigating outbreak risks [8,9]. Traditional risk assessment of EIDs is often confined to a single sector or to either the human or animal interface, with insufficient consideration of broader environmental and meteorological drivers. This represents an important limitation, as these factors may substantially influence the emergence and transmission dynamics of infectious diseases. For example, temperature, rainfall, and humidity can influence pathogen survival, vector abundance and distribution, and patterns of human–animal–environment interaction [10]. These limitations are particularly important for EIDs, whose emergence is often shaped by interacting human, animal, and environmental determinants. The One Health approach provides an integrated framework to address this complexity by applying systems thinking at the human–animal–environment interface and incorporating natural, economic, and social determinants into risk assessment [[11], [12], [13], [14]].

China is facing a greater risk of EIDs due to the rapidly developing animal industry [15] and meteorological factors [16]. Building on the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic, China has continued to enhance its framework of laws, regulations, and technical guidelines to address the vulnerabilities of EID prevention and control. Meanwhile, a series of policies and technical documents were issued to support the standardization of EID risk assessment, including explicit clarification of core principles, operational procedures, methodologies, sectoral responsibilities, and cross-sectoral collaboration from a One Health perspective [9]. This policy orientation is broadly consistent with the international guidance provided in the Joint Risk Assessment Operational Tool (JRA OT), in which risk assessment serves as the core process, accompanied by consideration of management options, communication needs, and related recommendations. According to the national guideline Measures for the Management of Infectious Disease Epidemic Risk Assessment (Trial) issued by the National Administration of Disease Prevention and Control in 2023, the process of EID risk assessment comprises four components: risk identification, risk analysis, risk characterization, and risk management recommendations. However, despite continued progress in policy development and implementation in China, systematic understanding remains limited regarding how these policy requirements are implemented across sectors and administrative levels, and how far practice aligns with policy expectations. A comprehensive understanding of policy implementation progress is essential to identify gaps between policy design and practice, thereby clarifying key enablers for advancing the One Health–originated risk assessment of EIDs.

This study examined the practical implementation of policies for EID risk assessment across national, provincial, municipal, and county levels in China. Barriers to real-world implementation were identified to help bridge the gaps between policy design and practice. From a One Health perspective, the study provides evidence to inform more actionable implementation strategies and strengthen China’s preparedness for future public health emergencies.

2. Methods

2.1. Study setting

This study adopted a qualitative approach, following the Consolidated Criteria for Reporting Qualitative Research (COREQ) Checklist. Semi-structured interviews were performed between March and June in 2024. Hainan Province and Jiangxi Province were selected as case study sites based on their complementary risk profiles and distinct regional characteristics. Hainan Province, located in the tropical zone, features a hot and humid climate inviting the transmission of mosquito-borne diseases. The booming tourism and ongoing development of the free trade port have collectively raised regional imported infectious disease risks. As Hainan has integrated One Health concept into public health strategies, it could help explore One Health governance experience to provide references for regions facing mosquito-borne and imported infectious diseases [17]. In contrast, Jiangxi is a typical inland province situated along the East Asian–Australasian Flyway, characterized by intensive livestock–wildlife interactions around Poyang Lake. This unique ecological context places the province at elevated risk of zoonotic disease emergence, such as avian influenza [18,19]. It was selected to provide actionable insights for optimizing One Health strategies in inland regions with higher risk of zoonosis. The combination of the two provinces might ensure the generalizability and representativeness of the research findings.

2.2. Study framework

The outline of semi-structured interview was developed through an iterative process based on the study objectives, a review of relevant national policy documents, and the analytical domains of the Consolidated Framework for Implementation Research (CFIR) and the Interactive Policy Model (IPM) (Fig. 1). CFIR is the most widely used determinant framework for identifying barriers and facilitators to implementation, which provides a systematic theoretical structure grounded in five core dimensions: intervention characteristics, inner setting, outer settings, process, and characteristics of individuals [20]. In contrast, the IPM emphasizes the dynamic, evolutionary nature of implementation processes, thereby addressing CFIR’s relative limitation in capturing procedural dynamics [21]. Integrating the two frameworks allows for a comprehensive analysis of interview while simultaneously enhancing focus on practice. A pilot interview was performed to refine the preliminary interview outline.

Fig. 1.

Conceptual framework of this study. Abbreviations: CFIR, Consolidated Framework for Implementation Research; IPM, Interactive Policy Model.

The outline was designed to elicit participants’ perspectives on the implementation of policies related to EID risk assessment from a One Health perspective. The interview covered five topics: policy awareness and institutional arrangements, departmental roles and responsibilities, implementation processes and analytical methods, capacity building, and implementation barriers (Table 1).

Table 1.

Overview of the semi-structured interview outline.

No.	Question	CFIR	IPM
1	Could you briefly describe your department and its main responsibilities in relation to infectious disease prevention and control?	–	Additional stakeholders
2	Does your department carry out risk assessment for emerging infectious diseases? If so, under what circumstances are these typically conducted?	Assessment characteristics	Additional stakeholders
3	Are there specific policies in China governing the risk assessment of emerging infectious diseases? If so, what are their main components?	Outer setting	–
4	Which diseases are classified as emerging infectious diseases, and which of these are currently the main focus of risk assessment in China?	–	Purpose and scope
5	What types of data are primarily used in the risk assessment of emerging infectious diseases in China, and how accessible are these data in practice?	Inner setting	Fit and effectiveness
6	What methods are currently employed in China for the risk assessment of emerging infectious diseases?	Process	–
7	Why are quantitative methods used less frequently than qualitative methods in the risk assessment?	Assessment characteristics	–
8	What criteria are used in practice to classify the results of infectious disease risk assessment?	Process	–
9	Does your department collaborate with other departments during the risk assessment? How is relevant information communicated across departments?	–	Additional stakeholders
10	What is the current information reporting process after an infectious disease outbreak is detected in China?	–	Additional stakeholders
11	What is the current emergency response mechanism following the detection of an infectious disease in China?	–	Sustainability
12	How is your organization staffed for the risk assessment of emerging infectious diseases?	Characteristics of individuals	Characteristic
13	In your view, what are the current difficulties and challenges in the risk assessment of emerging infectious disease outbreaks?	–	Determinants

Note: "–" indicates that the interview question did not correspond to/align with the content presented in the conceptual framework. Abbreviations: CFIR, Consolidated Framework for Implementation Research; IPM, Interactive Policy Model.

2.3. Participant recruitment

Purposive sampling was employed to recruit participants at national, provincial, municipal, and county levels. Interview sectors were firstly identified covering human health, animal health, environmental, and other relevant sectors. In this study, other relevant sectors refer to those beyond the human, animal, and environmental domains that provide administrative, regulatory, or operational support for EID risk assessment. Then, invitations to participate were subsequently issued to these sectors, with each nominating appropriate representatives for the interviews. Participants were selected according to criteria as follows: (1) possessing a professional background in either human, animal, environmental health, or other related disciplines; (2) having core practical experience in infectious disease prevention and control; (3) representing diverse geographical regions (Hainan Province and Jiangxi Province); and (4) demonstrating voluntary commitment to study participation and the ability to guarantee sufficient availability for field investigations. In order to gain more information on the practice of risk assessment, personnel with frontline experience were prioritized. The sample size was determined based on the principle of information saturation. Participant recruitment and data collection ended when no new information emerged from iterative data analysis, following deliberation by the research team.

To facilitate interpretation of the findings, all interviewees were assigned standardized identifiers. References such as “HK-A-1” follow a standardized format: the first element denotes the abbreviation of the city where the interviewee was based, derived from the initial letters of the local city name; the second indicates the category of the affiliated institution (A, animal sector; H, human sector; E, environmental sector; O, other relevant sectors); and the final number represents the interview order.

2.4. Data collection

Semi-structured interviews were conducted in two formats: individual interviews with experts and group interviews in which multiple frontline staff participated in the same interview session. Interviews were conducted face-to-face, with each session lasting 40–60 min and being fully audio-recorded. The interviews followed a progressive structure. Each interview began with a broad and familiar question about the participant’s department and its main responsibilities in relation to infectious disease prevention and control. The discussion then moved to more specific topics related to EID risk assessment, with follow-up probes used to explore participants’ experiences and perceptions in greater depth. To maximize protection of participants from potential social pressures, an anonymization protocol was implemented. Specifically, the collection of demographic information (e.g., name, age, gender, institutional affiliation) was excluded from the interview design. This approach ensured the non-identifiability of individual participants, thereby mitigating response bias and participation-related pressures that might otherwise arise from hierarchical relationships or institutional affiliations. All interviewers completed standardized training in qualitative research methods before the study, which covered core interviewing techniques, strict adherence to the interview protocol, and pertinent ethical considerations to ensure methodological consistency across all data collection sessions. Upon completion of the interviews, all audio recordings were transcribed verbatim by the research team to generate a complete set of written transcripts. A second researcher then independently verified these transcripts to ensure accuracy and fidelity.

2.5. Data analysis

All interview transcripts were imported into NVivo software (version 15.0.0) for systematic coding. Grounded theory methodology was used to inform the coding process and thematic analysis. In line with this approach, coding was conducted without preconceived assumptions, with insights generated inductively from the interview data. A bottom-up analytical process was adopted, in which subthemes were identified through open coding, and related codes were subsequently integrated through axial coding to formulate the main themes. To ensure consistency, two researchers (T.Y.L. and N.Q.) firstly selected five identical interview transcripts to familiarize themselves with the data, discuss strategies for identifying initial concepts, and reach consensus on the coding rationale. They then coded the remaining transcripts independently, compared their coding results, resolved discrepancies through discussion, and jointly developed a unified codebook (Table S1). The recommendations were derived from the qualitative findings through an iterative synthesis of the major policy–practice gaps, together with the barriers shaping implementation, informed by the study’s analytical framework.

2.6. Ethics

This study was approved by the Ethics Committee of School of Public Health, Shanghai Jiao Tong University School of Medicine (SJUPN-2024-036-KS1). Following confirmation that all participants fully understood the study objectives, written informed consent was obtained from each individual prior to the interviews, in accordance with the Declaration of Helsinki. Participants were informed that their participation was voluntary, and they could withdraw at any time without penalty.

3. Results

3.1. Overview

A total of 29 semi-structured interviews were conducted with 54 experts, including 22 individual interviews and seven group interviews (Table S2). The participants comprised 14 (25.9%) human health specialists affiliated with institutions such as centers for disease control and prevention and hospitals, 13 (24.1%) animal health specialists from entities such as animal disease control centers, 12 (22.2%) environmental health specialists representing sectors such as forestry departments, and 15 (27.8%) professionals from other relevant fields, including customs authorities and public security bureaus. In terms of administrative level, 5 (9.3%) participants were from national-level institutions, 7 (13.0%) from provincial-level institutions, 32 (59.2%) from municipal-level institutions, 9 (16.7%) from county-level institutions, and 1 (1.8%) from a district-level institution.

There were five themes derived through coding: governance system, duty, implementation process, capacity building, and innovation (Fig. 2). Representative interview quotations for each theme and subtheme were summarized in Table 2, providing supporting evidence for the findings reported below.

Fig. 2.

Five themes identified by coding.

Table 2.

Example quotes about the five themes generated through coding.

Theme	Frequency	Sub-theme	Frequency	Example quotes
Governance system	22	Overarching policies on risk assessment	10	Relevant documents on national risk assessment have clearly stipulated that national risk assessment shall be conducted on a weekly basis; municipal-level assessments are required by provincial authorities to be carried out monthly, and county-level assessments on a quarterly basis. (NC-E-43) Establish a regulation for multi-sector coordination, seeking corresponding solutions through institutional mechanisms. (SR-O-51)
		Operational guideline	6	Operational guidelines have been developed to detail the specific operational procedures at each stage of implementation. (HK-O-2)
		Development of collaboration platform	6	Establish an integrated grassroots surveillance and reporting network for the collaboration between human and veterinary medicine. (ON-A-47)
Duty	123	Responsibilities of each sector	38	If there is an abnormality, we can only report to the agriculture department. It has a special reporting system. (YX-A-34) Our work focuses on the human dimension. Taking brucellosis as an example, we conduct investigations and management of human cases, and carry out special screening for occupationally exposed populations such as sheep farmers. (HK-H-6)
		Cross-sectoral collaboration	69	While official notifications and documents are issued for information dissemination, daily communication is primarily conducted via phone calls and WeChat. (YX-H-37) Relevant sectors will notify us upon detection of the case, and we will promptly conduct an epidemiological investigation, implementing full-scale surveillance on the case's close contacts, movement trajectories, and the flow of associated animals. (QH-A-28)
		Data sharing	16	Data silos and other related issues persist among different sectors. (ON-O-49) Once data barriers are removed, it should be fairly straightforward for the disease control sector to conduct risk assessment. (SR-O-51)
Innovation	18	Detection technology	10	During significant public health emergencies or fatal incidents, we can retrieve etiological data through infrared cameras. (SR-O-51)
		Surveillance technologies	2	The transmission mechanism is relatively complex, and the threat persists at all times, requiring the improvement of monitoring measures. (ON-A-44)
		Risk analytic methods	6	At present, only basic data analysis is conducted, including the composition ratio and distribution of relevant indicators, with the epidemiological three-dimensional distribution as the core analytical approach. (QH-H-27) University researchers often lack sufficient practical experience when studying these models; meanwhile, many relevant data are difficult to collect in practice, which seriously affects the application of the models. (HK-H-6)
Capacity building	84	Financial investment	23	In the event of a major animal-borne disease outbreak, such as African swine fever, substantial support is typically allocated. In contrast, funding for common diseases tends to be relatively limited. (QH-A-29) At present, there is still an insufficiency in financial support at the national level for the implementation of these related works. (ON-O-49)
		Laboratory capacity	21	The focus is on strengthening basic capabilities, with additional instruments and equipment provided to each sector. (ON-A-47) Test samples shall be sent to provincial-level institutions for testing and result issuance. (YX-A-34)
		Workforce	40	Insufficient human resources is a common challenge faced by all relevant institutions, not just ours. (XJ-H-42) For those working at the grassroots level, there are basically no postgraduates, very few undergraduates either. (SR-A-50)
Implementation process	122	Risk identification	61	Provincial mandates are issued annually, and we adhere to the specific requirements, which vary each year. For instance, the sampling percentage is determined strictly in accordance with the official document. (QH-H-30) There is a notable lack of regulatory oversight in the aquaculture sector, where a sound supervision system has not yet been established. (SR-O-51)
		Risk analysis	3	The assessment is confined to basic data processing, with primary focus on proportion and distribution analysis. (QH-H-27)
		Risk characterization	5	In the case of African swine fever, high-risk zones are delineated within a specified radius based on the issued guidelines. (QH-A-30)
		Risk management recommendations	53	There is a joint meeting mechanism, with regular sessions held to collectively discuss and formulate response measures. (NC-E-43)

3.2. Multilevel institutional structure

Within the institutional structure, authorities from the human, animal, environmental, and other relevant sectors participate in the risk assessment of EIDs (ON-A-44). Multilevel and multisectoral workflow has been established to guide and standardize coordination across administrative levels (Fig. 3). The institutional structure of EID risk assessment operates under the oversight of the National People’s Congress and the State Council. Functionally, subordinate administrative sectors are organized into human health sectors (e.g., National Health Commission), animal health sectors (e.g., Ministry of Agriculture and Rural Affairs), environmental sectors (e.g., Ministry of Ecology and Environment), and other relevant sectors (e.g., Customs) (ON-A-48). By administrative hierarchy, these sectors are structured at four levels: national, provincial, municipal, and county-level, with the work of each level determined by the level immediately above (NC-E-43). Additionally, human, animal, environmental, and other relevant sectors engage in collaborative efforts when abnormal events arise, including identification of suspected cases and disease outbreaks (ON-A-48).

Fig. 3.

Multilevel institutional structure for EID risk assessment. “Others” include legislative, administrative, regulatory, and supporting sectors beyond the human, animal, and environmental domains, such as the people’s congress system, development and reform, finance, education, transportation, and customs. Abbreviations: NPC: National People’s Congress; ESCPHC: Education, Science, Culture and Public Health Committee; ARAC: Agriculture and Rural Affairs Committee; ERPC: Environmental and Resources Protection Committee; NDRC: National Development and Reform Commission; MOF: Ministry of Finance of the PRC; MOT: Ministry of Transportation of the PRC; MOE: Ministry of Education of the PRC; NHC: National Health Commission of the PRC; CDC: Chinese Center for Disease Control and Prevention; NDCPA: National Disease Control and Prevention Administration; MARA: Ministry of Agriculture and Rural Affairs of the PRC; BAHV: Bureau of Animal Husbandry and Veterinary; MNR: Ministry of Natural Resources of the PRC; NFGA: National Forestry and Grassland Administration; MEE: Ministry of Ecology and Environment of the PRC; GACC: General Administration of Customs of the PRC; SAMR: State Administration for Market Regulation; NBS: National Bureau of Statistics; PPC: Provincial People’s Congress; PHC: Provincial Health Commission; PCDC: Provincial Center for Disease Control and Prevention; PARB: Provincial Animal Husbandry and Veterinary Bureau; PFGB: Provincial Forestry and Grassland Bureau; PEE: Provincial Department of Ecology and Environment; PC: Provincial Customs; PMR: Provincial Market Supervision; MPC: Municipal People’s Congress; MCDC: Municipal Center for Disease Control and Prevention; MARB: Municipal Animal Husbandry and Veterinary Bureau; MFGB: Municipal Forestry and Grassland Bureau; MEE: Municipal Department of Ecology and Environment; MC: Municipal Customs; MMR: Municipal Market Supervision; CPC: County People’s Congress; CCDC: County Center for Disease Control and Prevention; CARB: County Animal Husbandry and Veterinary Bureau; CFGB: County Forestry and Grassland Bureau; CEE: County Department of Ecology and Environment; CMR: County Market Supervision.

National policies have outlined procedures for intersectoral collaboration, with each sector’s workflow specified in the operational guidelines (HK-O-2). Although the Law of the People’s Republic of China on the Prevention and Treatment of Infectious Diseases (2025 Revision) provides a legal basis for such collaboration, its provisions remain relatively broad and require more detailed implementation guidelines. Participants noted that a more refined overarching policy framework (SR-O-51) and stronger collaboration platforms (ON-A-47) could further strengthen governance (Table 2).

3.3. Identification of sectoral responsibilities during the implementation

3.3.1. Responsibilities of each sector

Interviewees noted that sectoral responsibilities for EID risk assessment were clarified by laws and regulations issued across different administrative levels, from the national to the county level (Table S3). Human health authorities were responsible for human health surveillance, epidemiological investigation, risk assessment, and outbreak response. Additionally, they were tasked with the overall coordination and advancement of risk assessment (HK-H-6). Animal health authorities conducted surveillance, investigations, risk characterization, and response actions for animals and animal products (QH-A-28). Environmental health sectors were tasked with environmental disinfection and harmless treatment of animal carcasses (QH-H-10). In addition, authorities including customs, public security, medical institutions, education, and commerce sectors contributed to multi-point surveillance, supporting the efforts of human, animal, and environmental health authorities (QH-H-27) (Fig. 4).

Fig. 4.

Cross-sectoral collaboration for risk assessment. Human health refers to CDC, NHC, NDCPA, hospitals, and other units that focus on managing human health. Animal health refers to ACDC, ARAC, and other units that focus on managing animal health. Environmental health refers to MEE, FGA, and other units that focus on managing the health of environment and wildlife. Others refer to units that do not specialize in the management of human, animal, or environmental health but assist or contribute to these efforts. Abbreviations: ACDC: Chinese Center for Animal Disease Control and Prevention; ARAC: Agriculture and Rural Affairs Committee; CDC: Chinese Center for Disease Control and Prevention; FGA: Forestry and Grassland Administration; MEE: Ministry of Ecology and Environment of the PRC; NDCPA: National Disease Control and Prevention Administration; NHC: National Health Commission of the PRC.

All sectors were responsible for information reporting, which entailed vertical information transmission within individual administrative sectors (e.g., human health) (XJ-H-42). China has explicitly stipulated an infectious disease reporting and notification system, with a specific focus on notifiable diseases. Any confirmed cases were required to be submitted through the official mechanism (YX-A-34).

3.3.2. Cross-sectoral collaboration among multiple sectors

Multiple sectors collaborated to advance the implementation of risk assessment. In the event of a confirmed case, human, animal, and environmental health authorities shall conduct mutual notification of relevant information (HK-A-1), primarily through telephone (YX-H-37). Human health authorities shared information on confirmed human cases’ activity ranges and animal exposure histories with animal and environmental health sectors. Based on this information, animal health authorities conducted targeted animal surveillance in their respective jurisdictions, culling any positive cases identified (QH-A-28). Environmental health sectors supported the process by performing environmental disinfection and providing guidance to animal health authorities on standardized procedures for animal culling and harmless treatment (QH-H-10). Correspondingly, upon detection of animal positive cases, the animal health sector promptly informed the health authorities (HK-H-6). It was noted that this collaborative mechanism underwent maturation following the COVID-19 outbreak (QH-H-27) (Fig. 4).

Inadequate detailed responsibilities in technical guidelines posed substantial obstacles to multisectoral coordination. According to the Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System, issued by the National Administration of Disease Prevention and Control in 2024, China has recently implemented a multi-point trigger surveillance and early warning system, which places higher demands on the integration of multi-source surveillance data (HK-O-2). In practice, barriers to cross-sectoral data access impeded effective communication and cooperation among sectors (SR-O-51). Information sharing was found to occur primarily between human and animal health sectors. Participants provided minimal information on collaboration with environmental sectors (HK-H-6).

3.4. Implementation progress of the four processes

3.4.1. Risk identification

Risk identification relied on active and passive surveillance. Active surveillance focused on notifiable diseases via sentinel sampling. Initially, national health authorities performed an annual epidemiological analysis to identify priority diseases and high-risk zones (QH-A-29). The annual surveillance tasks were issued by national authorities to provincial-level counterparts, with sequential dissemination to municipal- and county-level agencies. The scope, methods and sample size were refined in operation guidelines (QH-A-30). Passive surveillance provided data on unknown diseases, especially those linked to wildlife due to tracking difficulties (XJ-H-42).

In terms of surveillance targets, humans and animals were the main focus. Human health data was primarily from medical institutions, particularly hospitals (QH-H-27). Animal surveillance focused on terrestrial species, excluding aquatic and wild animals from surveillance framework (SR-O-51). Furthermore, environmental surveillance was incorporated solely within the surveillance frameworks for plague and COVID-19 (ON-A-48), indicating incomplete implementation of the policy mandate for multi-point triggered disease monitoring (Table 2).

3.4.2. Risk analysis

Risk analysis was conducted using integrated surveillance data from multiple sectors to comprehensively analyze the occurrence probability and potential consequence severity of diseases. Disease prevalence and case distribution were systematically benchmarked against historical data from the same period of the previous years (QH-H-27). A risk alert was triggered when these observed metrics exceeded predefined thresholds, which were calibrated based on disease type, regional profiles, and other contextual factors (HK-H-6).

3.4.3. Risk characterization

Risk characterization referred to determine risk level based on the results of risk analysis. In practice, it was guided by clear specifications in operational guidelines, which covered analysis frequency, risk characterization criteria, and risk zone delineation (QH-A-30). One participant noted that a 3 km radius around confirmed positive cases was designated a high-risk area, in accordance with higher-level mandates (QH-A-28).

3.4.4. Risk management recommendations

Relevant sectors discussed and formulated risk management recommendations for EID threats within the multisectoral joint prevention and control mechanism. Multiple sectors held regular joint meetings to collaboratively discuss response strategies for disease threats (NC-E-43). Emergency response plans were proposed in advance and revised when emergencies occurred to adapt to the specific context and form tailored operational protocols (QH-A-30). Responses to confirmed cases were recommended in accordance with the provisions stipulated in the operational guidelines (QH-H-27). Additionally, health education was provided to the public to raise their protective awareness, such as distributing brochures (HK-O-2) and offering epidemic prevention courses (XJ-H-42) (Table 2).

3.5. Multidimensional strengthening of capacity building

3.5.1. Financial investment

National, provincial, and municipal authorities have allocated funds for risk assessment. Routine funds sustained annual risk surveillance activities (QH-A-29). In contrast, designated funds were specifically allocated by authorities during major infectious disease outbreaks, such as brucellosis and dengue fever. Notably, the scale of designated funding showed a positive correlation with the severity of harm associated with the disease (QH-A-29). Despite explicit legal and regulatory mandates for adequate funding of risk assessment, financial support remains insufficient and continues to impede the effective implementation (ON-O-49). Moreover, designated funds were restricted to predetermined purposes, resulting in limited flexibility and responsiveness during public health emergencies (SR-A-50).

3.5.2. Laboratories capacity

Laboratories supporting risk assessment were supplied with essential instruments, apparatus, reagents, and related materials (ON-A-47). The allocation of technical equipment showed a clear hierarchical pattern, increasing with administrative level. Basic, user-friendly devices were typically available at the county level, whereas sophisticated, high-precision instruments were concentrated at the provincial level (YX-E-39). Samples of suspected cases should be submitted from grassroots to provincial authorities for confirmatory testing (YX-A-34).

3.5.3. Workforce

Workforce capacity at the grassroots level remained inadequate, with a majority of sectors grappling with workforce shortages. Inadequate staffing was primarily attributable to shortages of personnel for sampling and testing during risk surveillance (XJ-H-42). In addition, personnel generally held low academic qualifications, with only a small subset possessing postgraduate degrees. This trend was particularly pronounced within the animal health sector (SR-A-50). To enhance the professional competencies of workforce, relevant authorities occasionally organize surveillance training programs (YX-E-35) (Table 2).

3.6. Characteristics of analytic methods and detection technologies

3.6.1. Detection technologies

Detection technologies served as core technical support in risk surveillance. Technologies required to identify novel pathogens were outfitted at national and provincial authorities (QH-H-27). Furthermore, China has been actively applying novel technologies to identify risks. For instance, infrared cameras and tracking chips were applied to monitor abnormal conditions in animals (SR-O-51). Participants noted that weak detection technology limited the precision of identifying novel pathogens (YX-H-40).

3.6.2. Data analytic methods

Data analytic methods were primarily qualitative methodologies, which were characterized by simplicity and rapidity (QH-H-27). According to China’s Technical Programme for the Risk Assessment of Public Health Risks of Emergencies (Trial), methods used for public health emergencies include the expert consultation method, the Delphi method, the risk matrix method, and the analytical flowchart method. Lack of appropriate analytic models limited the application of quantitative methods (HK-H-6), thereby hindering the development of an intelligent risk early warning system in China (Table 2).

3.7. Barriers identified in this study

This study summarized the key barriers to EID risk assessment in practice by comparing recent national policy requirements with current implementation in China (Table 3, Table S4). Barriers to risk assessment of EIDs were summarized in Table S5. They were categorized by code frequency, with higher frequency indicating greater risk level. These risk stratifications were visualized in Fig. 5 via a color gradient, where darker shades denoted the higher risk and lighter shades represented the lower risk. Significant barriers were identified, including minimal surveillance of unknown diseases, as well as of aquatic and wild animals, which elevate the risk of undetected spillover and delayed response to EIDs. Insufficient staffing size and weak professional competence further hampered risk surveillance. Moreover, barriers to cross-sectoral data sharing and collaboration posed significant barriers, with the exclusion of environmental sectors being particularly pronounced.

Table 3.

Barriers to emerging infectious diseases risk assessment identified from policy–practice comparison.

Theme	Practice	Related policies	Document
Governance system	Inadequate overarching policies	The state shall establish and improve a risk assessment system for infectious disease epidemics	Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases (2025 Revision)
	Underdeveloped collaboration platform	Establish and improve a multi-department risk assessment and consultation mechanism	Measures for the Management of Infectious Disease Epidemic Risk Assessment (Trial)
	Inadequate workflow guidance	Formulate and refine supporting documents, including administrative measures and technical specifications, and specify the division of responsibilities, work procedures, and technical standards	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
Duty	Urgent enhancement of cross-sectoral cooperation	The departments of health, education, civil affairs, agriculture and rural affairs, customs, cyberspace affairs, forestry and grassland, and other relevant departments shall, in accordance with their respective responsibilities, jointly carry out infectious disease surveillance	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
	Difficulties in data sharing	Establish and improve a multi-department risk assessment and consultation mechanism, and regularly share multi-channel surveillance information on infectious disease epidemics	Measures for the Management of Infectious Disease Epidemic Risk Assessment (Trial)
	Poor data quality	Establish and improve the administration system for reporting infectious disease epidemics, and strengthen training, routine administration, and quality control with respect to the reporting of infectious disease epidemics and related information	Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases (2025 Revision)
Innovation	Weak detection technology	Strengthen scientific research on technologies for infectious disease pathogen detection, data governance, early warning and forecasting, intelligent decision support, and other related fields	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
	Lack of data-driven risk analytic methods	Employ technical means such as big data, cloud computing, and artificial intelligence to automatically capture abnormal signals of infectious disease epidemics	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
	Inadequate surveillance technologies	Conduct multi-pathway and multi-channel surveillance for multiple pathogens, establish a smart multi-point trigger mechanism, and improve the sensitivity and accuracy of surveillance	Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases (2025 Revision)
Capacity building	Insufficient staffing size and professional competence	Strengthen the development of specialized personnel for infectious disease surveillance and early warning in disease control and relevant departments, and optimize the echelon of professional personnel	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
	Insufficient detection capabilities	Promote capacity building for pathogen detection in the pathogenic microorganism laboratories of medical and health institutions, and improve the etiological diagnosis rate of infectious diseases	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
	Insufficient financial investment	Local governments at all levels and relevant departments, including finance and development and reform departments, shall continue to implement funding support policies for infectious disease surveillance and early warning and give priority to key areas	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System
Implementation process	Minimal surveillance of unknown diseases	Disease prevention and control institutions shall strengthen surveillance of infectious diseases of unknown origin and enhance their capacity for rapid detection and timely identification	Law of the People’s Republic of China on Prevention and Treatment of Infectious Diseases (2025 Revision)
	Minimal surveillance of aquatic and wild animals	Regularly organize or entrust relevant scientific research institutions to investigate, monitor, and assessment wild animals and the conditions of their habitats	Wild Animal Conservation Law of the People’s Republic of China (2022 Revision)
	Insufficient integration of environmental data	Monitor risk factors such as online public opinion, the number of inbound and outbound travelers, environmental conditions, and meteorological conditions	Guiding Opinions on Establishing and Improving an Intelligent Multi-point Triggering Infectious Disease Monitoring and Early Warning System

Fig. 5.

Barriers on the risk assessment of emerging infectious diseases in China. Codes referencing challenges from the five major themes were extracted. The color gradient indicates coding frequency from low to high is used to visualize the areas of concern. ∗Note: due to nearly no implementation of this work, it is directly regarded as a significant challenge without being ranked based on coding frequency.

4. Discussion

This study explored the progress and barriers in the implementation of policies related to the EID risk assessment in China through in-depth interview across human, animal, and environmental health sectors. The results were analyzed from five themes: governance system, duty, implementation process, capacity building, and innovation. Overall, China advanced risk assessment of EIDs across operating guidelines, financial investment, cross-sectoral coordination, technology, personnel, and equipment allocation. Among the five themes identified in this study, innovation had the lowest coding frequency, suggesting, to some extent, a limited focus on risk assessment technologies. The results revealed four challenges between policy design and actions: (1) minimal surveillance of unknown diseases, (2) minimal surveillance of aquatic and wild animals, (3) insufficient staffing size and weak professional competence, and (4) inadequate cross-sectoral collaboration.

Previous global experience has demonstrated that legal instruments serve as effective tools for outbreak prevention and control by coordinating resources and mobilizing efforts [22,23]. Therefore, an underdeveloped national legal framework was considered as the main reason for the minimal surveillance of unknown diseases, and aquatic and wild animals [9,24]. To our knowledge, the recently updated laws and regulations have not yet incorporated these surveillance targets. Moreover, the responsibilities of sectors participating in risk assessment should be clearly defined [24]. Vague role definitions may dampen the initiative of sectors to engage proactively. In particular, the role of the environment sectors should be clearly defined to ensure their genuine participation. It is recommended to formally publish a list of sectors involved in risk assessment, accompanied by explicit descriptions of respective responsibilities. This list should encompass all relevant sectors across human, animal, environmental, and other sectors.

The risk assessment technologies in China remain to be further advanced. It is urgent to apply the quantitative analytic methods in the practice of risk assessment. Risk analytic models developed by academic community often rely on overly complex scenarios. The application is hindered by insufficient data due to data unavailability or poor quality. These findings align with previous studies, indicating that the gaps between scientific knowledge and realities might constrain both the effectiveness and the impact of implementation strategies [25]. Models should be developed based on operational needs and grounded in real scenarios, thereby facilitating the transition of quantitative modeling from theory to practice. In addition, novel pathogen detection technologies are essential to identify new risk factors [26]. Yet, novel pathogens are difficult to recognize even with sensitive surveillance tools [5,27]. The new biosecurity risks need to be underpinned by a collaborative strategy that effectively integrates multidisciplinary wisdom [28].

The difficulties observed in information sharing suggest that fragmented data systems remain a major constraint on effective cross-sectoral collaboration. In light of this challenge, previous studies have suggested that developing a minimum essential dataset (MED) may offer a practical strategy to improve data standardization and sharing across sectors [29]. MED refers to the smallest set of elements that must be collected during disease surveillance, with standardized data formats specified [30,31]. It could define the essential data items required to exchange across multiple sectors in performing risk surveillance. The unified format for cross-sectoral data sharing effectively prevents information access difficulties caused by isolated systems among different sectors [[32], [33], [34]]. Although China has established MEDs for tuberculosis and other major diseases, these MEDs represented limited consideration of animal and environmental factors [35,36]. Previous studies have shown that animal, social, and environmental factors are important elements in predicting infectious disease risks [37]. It is essential to fully adopt the One Health approach by establishing a MED that comprehensively integrates human, animal, and environmental factors to support national risk assessment of EIDs in China.

Risk assessment practices in China could be further refined by incorporating insights and lessons from internationally established successful cases. The World Health Organization (WHO), World Organization for Animal Health (WOAH) and Food and Agriculture Organization of the United Nations (FAO) issued The Tripartite Zoonoses Guide, emphasizing the critical importance of conducting risk assessment for emerging and endemic zoonotic diseases using a One Health approach [38]. In 2021, they released Joint Risk Assessment Operational Tool (JRA OT) to provide technical guidance [39]. In 2022, the One Health Joint Plan of Action (2022–2026) launched by the One Health Quadripartite (FAO, WHO, WOAH, and the United Nations Environment Programme) noted that countries should closely monitor the drivers of zoonotic diseases and develop guidance on risk assessment [40]. Canada has established a rapid risk assessment framework supported by a committee composed of decision-makers, practitioners, and partners. This committee is responsible for determining the necessity of initiating a rapid risk assessment. Once authorized, the assessment is carried out by a multidisciplinary panel of experts [41]. French set up REACTing, a national collaborative network, sustaining scientific research in order to rapidly prioritize research when new outbreaks occur [42]. By establishing strong linkages among stakeholders–including modelers, policymakers, and subject matter experts–TB Modeling and Analysis Consortium collaboratively identify priority issues for tuberculosis control modeling, effectively enhancing the relevance and feasibility of the models [43].

Drawing on the key findings of this study, we put forward the following recommendations. Firstly, legislation should be strengthened by refining legal provisions concerning surveillance targets, collaborating agencies, and sectoral duties. Secondly, both of the detection technologies for novel pathogens and quantitative analytic methods should be continuously advanced. Sustained collaboration should be established among infectious disease modelers, policymakers, and frontline practitioners. Thirdly, there is a need to develop an effective and practical tool enabling data sharing across multi-sectors. Develop a MED covering human, animal, and environmental factors to facilitate data sharing across multiple sectors, thus enhancing cross-sectoral collaboration. Finally, strengthen capacity building through increasing investment in disease surveillance funding, particularly in the provision of testing equipment and materials; establishing dedicated professional teams and multidisciplinary expert committees to provide centralized guidance [39]; and conducting regular training for personnel [44].

There were several limitations in this study. Firstly, potential recall and subjectivity bias may affect qualitative data based on participants’ recollection, possibly leading to vague descriptions of departmental responsibilities and implementation barriers. Secondly, despite involving experts from human, animal, and environmental sectors, perspectives tended to remain siloed within departmental boundaries, and collaboration challenges may have limited deeper integrative insights. Thirdly, while providing in-depth perspectives, the small sample may not fully represent variations in risk assessment practices across regions, disease types, and socioeconomic contexts in China, limiting the generalizability of our results. Fourth, the study did not analyze financial inputs into China’s surveillance system, precluding risk assessment of cost-effectiveness or return on investment of related interventions. Fifth, interviewers’ professional background might influence participants’ responses. We performed standardized training for interviewers and used a semi-structured protocol to mitigate such effects.

5. Conclusion

This study reveals the progress and persistent barriers in implementing policies related to risk assessment of EIDs in China using a grounded theory approach. Despite the government’s efforts, there are still challenges such as inadequate laws and missing surveillance targets. Based on the One Health concept, improve the legal system, promote cross-sectoral cooperation, enhance the professionalism of grassroots personnel, and strengthen scientific research cooperation are recommended, which could contribute to China's ability to cope with EIDs.

CRediT authorship contribution statement

Tianyun Li: Writing – review & editing, Writing – original draft, Visualization, Validation, Methodology, Conceptualization. Ne Qiang: Writing – review & editing, Writing – original draft, Visualization, Validation. Lijun Jia: Writing – review & editing, Visualization, Validation. Zelin Zhu: Writing – review & editing, Visualization, Validation. Xinyu Feng: Writing – review & editing. Xiaoxi Zhang: Writing – review & editing, Visualization, Validation. Jinjun Ran: Writing – review & editing, Validation. Lefei Han: Writing – review & editing, Visualization, Validation, Methodology, Formal analysis, Data curation, Conceptualization.

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Shanghai Jiao Tong University School of Medicine (SJUPN-2024-036-KS1).

Funding

This research was supported by National Natural Science Foundation of China (grant number 72504177), Shanghai Science and Technology Development Foundation (grant number 23YF1421200).

Declaration of competing interest

The authors declare that they have no competing interests to disclose.

Appendix A. Supplementary data

The following is the Supplementary data to this article: