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. 2026 May 28;27:168. doi: 10.1186/s12910-026-01492-6

Ethical reporting and oversight in outbreak investigations conducted in India, 2015–2025: a systematic review

Praveen Kumar S 1,✉,#, Rajeev Aravindakshan 1,#, Mohammed Shoyaib Khazi 2,#, Chandru R 1,#
PMCID: PMC13483749  PMID: 42210347

Abstract

Background

Outbreak investigations generate actionable evidence to identify sources of infection and guide effective control measures. In outbreak settings, ethical considerations become even more significant because such investigations often involve vulnerable populations, the collection of identifiable data, and interventions under conditions of uncertainty. The Indian Council of Medical Research states that while there may be a need to undertake research quickly, this should not compromise scientific validity or the need to uphold ethical requirements. However, the extent to which outbreak investigations in India comply with ethics oversight reporting has not been systematically examined. The objective was to evaluate ethical considerations in outbreak investigations conducted in India, published between 2015 and 2025 that reported ethical statements, obtained ethical approval, and participant informed consent.

Methods

The review was registered in PROSPERO 2025 CRD420251140176. Human outbreak investigations conducted in India, published from 1 January 2015 to 25 August 2025, were searched in databases viz., Embase, PubMed, Scopus, and Web of Science. Analysis was conducted using R software.

Results

A total of 76 outbreak investigations were included. Overall, 14 (18%) did not report an ethics statement, while 31 (41%) reported an ethics statement without Institutional Ethics Committee approval, and 31 (41%) reported both an ethics statement and approval. Participant consent was not obtained in 41 (54%) publications, written consent was obtained in 26 (34%), and 9 (12%) reported verbal consent. Investigations published in later years demonstrated significantly higher levels of ethics oversight (p < 0.001), and ethics oversight varied significantly across disease groups (p = 0.04); no association was observed with study setting or methodological completeness.

Discussion

Ethics reporting in outbreak investigations in India remains inconsistent. Routine ethics preparedness requires IEC readiness for rapid review and integration with outbreak investigation initiation.

Conclusion

Less than half documented formal Institutional Ethics Committee approval. The findings highlight the need to strengthen ethical preparedness within outbreak response systems. Strengthening ethical preparedness through rapid review mechanisms, integration of ethics oversight within IDSP-linked investigations, standardised reporting practices, and capacity building of field investigators may help ensure a more ethically robust and transparent outbreak response system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-026-01492-6.

Keywords: Ethical considerations, Institutional ethics approval, Medical ethics, Outbreak investigation, Public health emergency

Introduction

Outbreak investigations generate actionable evidence to identify sources of infection and guide effective control measures [1]. They are defined as a systematic, field-based epidemiological process aimed at identifying the source, transmission dynamics, and populations at risk to implement timely control and preventive measures [2]. In such contexts, research is necessary to enable efficient and appropriate health and humanitarian responses during the ongoing emergency, while also informing the preparedness for similar health events in future [3].

In outbreak settings, ethical considerations are of critical significance, as such investigations often involve vulnerable populations, the collection of identifiable data, and interventions are carried out under conditions of uncertainty [4]. Ethics committee review upholds core principles such as autonomy, beneficence, non-maleficence, and justice, which are essential in safeguarding participant dignity, minimising harm, and ensuring equitable distribution of risks and benefits [5, 6]. The World Health Organisation recommends that ethical considerations are maintained during emergencies through expedited review processes rather than being bypassed [7]. Further emphasis is given on the ideology of “core ethical standards must remain intact, even if procedures are expedited” [8].

In India, the Indian Council of Medical Research has progressively strengthened ethics oversight frameworks, culminating in the National Ethical Guidelines for Biomedical and Health Research Involving Human Participants (2017), which explicitly address public health research and emergency settings (Sect.  12 – pg.137). The guidelines state that the urgency of research should not compromise scientific validity or adherence to the requirements of ethical conduct of research [9]. However, Outbreak investigations are often conducted under the Epidemic Diseases Act of 1897, which facilitates rapid public health response but does not explicitly address ethical safeguards for research participants [10]. This creates a structural gap between legal authority and ethical governance.

Outbreak investigations, therefore, operate at a critical interface between public health practice and research, where the urgency of response must be balanced with ethical standards. This urgency may lead to the assumption that ethics review and informed consent procedures can be deferred or bypassed, which creates a fundamental opposition between operational efficiency and ethical accountability. In the Indian context, it is further shaped by the coexistence of legal mandates for outbreak control and ethics guidelines that emphasise the protection of participant rights and scientific integrity.

The extent to which outbreak investigations in India adheres to ethics oversight reporting has not been systematically examined. This systematic review was undertaken to assess human outbreak investigations published in India between 2015 and 2025, with a specific focus on the reporting of ethical approval, informed consent, and adherence to recommended investigation practices. By examining these dimensions, the study aims to identify gaps in ethical compliance and highlight the need for stronger alignment with established ethical guidelines in outbreak research.

Primary Objective

  1. To evaluate ethical considerations in outbreak investigations conducted in India and published during 2015 to 2025, including reporting of ethical statements, obtaining ethics approval, and participant informed consent.

Secondary objective

  1. To assess the completeness of outbreak investigation practices using the standard 10-step Field Epidemiology Training Programme (FETP) framework.

Methodology

Review protocol

This systematic review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Table S3). The review protocol was developed after careful discussion with all the authors and was registered in PROSPERO (Registration Number: CRD420251140176). The registered protocol specified the research question, eligibility criteria, data extraction procedures, and planned methods of analysis. The review was conducted in accordance with this protocol, and no major deviations were made during the study.

Search strategy

The search strategy was developed in accordance with the components of the PRESS (Peer Review of Electronic Search Strategies) 2015 guideline. The search strategy aimed to identify all relevant published literature without any restrictions on language. The search algorithm (Table S1) was finalised in consultation with all authors and was based on a previous systematic review of outbreak investigations [11]. A systematic search was conducted in the following databases: PubMed, Embase, Scopus, and Web of Science. The results were downloaded in RIS format.

Selection criteria

The study selection process was conducted in two stages. Duplicate detection was performed in Excel using DOIs (digital object identifiers); studies with duplicate DOIs were removed. Two independent reviewers (P.K.S. & C.R.) screened titles and abstracts of records retrieved from the database searches against the inclusion and exclusion criteria. The full texts of potentially relevant studies were assessed for final inclusion by the reviewers (P.K.S. & C.R.) independently. Inter-reviewer agreement at this stage was 97.8%, with a Cohen’s kappa of 0.91 (n = 90), indicating almost perfect agreement. Any discrepancies between the reviewers were resolved by third reviewers (R.A. and M.S.K.) to reach consensus.

Inclusion criteria

Studies were included if they met the following criteria:

  1. Population: Investigations involving human populations affected by infectious disease outbreaks, with explicit reporting of an outbreak investigation.

  2. Setting: Studies conducted within India, including community, hospital, or institutional settings.

  3. Study Type: Original outbreak investigation reports, including descriptive or analytical epidemiological studies (e.g., case-control or cross-sectional investigations conducted as part of outbreak response).

  4. Time Frame: Published between 1 January 2015 and 25 August 2025, to capture ethical practices in the period surrounding and following the release of the Indian Council of Medical Research (ICMR) National Ethical Guidelines (2017).

Exclusion criteria

Studies were excluded if they met any of the following criteria:

  1. Reports with only laboratory analysis, genomic studies and secondary data analysis.

  2. Review articles, systematic reviews, meta-analyses, editorials, commentaries, perspectives, and letters without primary outbreak data, Conference abstracts, proceedings, and dissertations.

  3. Animal studies, laboratory-based (in-vitro) studies, or environmental investigations not involving human participants.

Data extraction

A standard data extraction form (Table S2) was prepared in consultation with all authors and was pilot tested on four outbreak investigation publications. Data extraction was conducted by author PKS and it was verified for accuracy and completeness by author CR independently, with blinding. Study authors were not contacted for further information.

The data extraction form captured the year of publication, year of outbreak, disease involved, agency conducting the investigation, place of outbreak (area/setting), ethical considerations statement, ethics approval, informed consent processes, details of each step of the outbreak investigation, type of analytical study, and environmental investigations conducted. Studies were included based on the year of publication (1 January 2015 to 25 August 2025), irrespective of the year in which the outbreak investigation was carried out. The year of outbreak investigation was extracted separately as a study characteristic for analysis, as some studies described outbreaks that occurred before 2015 but were published within the eligible time frame. To assess methodological completeness, we adapted the outbreak investigation checklist for the 10-step approach used by the Field Epidemiology Training Programme (FETP) at ICMR-NIE for data extraction [12]. Each of the ten FETP outbreak investigation steps comprises multiple predefined subcomponents (e.g., step 1 “confirm diagnosis” includes excess cases, background rates checked, surveillance system changes, and population changes). During data extraction, each subcomponent was noted as “reported” or “not reported” based on explicit mention in the publication.

A step was considered completed if at least one of its subcomponents was reported. This approach was adopted to account for variability in reporting practices across outbreak investigations. Notably, the absence of detailed documentation does not necessarily indicate that all elements of a step were not performed.

Risk of bias assessment

Given the descriptive and methodological focus of this review on mapping reported ethical practices rather than quantifying intervention effects, a risk of bias assessment of individual studies was not conducted. The objective was to document the presence or absence of ethical reporting, not to judge the internal validity of therapeutic or observational findings.

Synthesis methods

The unit of analysis was the individual outbreak investigation publication, with each included study considered as one observation. Data synthesis was primarily quantitative, with studies grouped by disease category and ethical reporting characteristics. Descriptive and inferential analyses were conducted using R software (version 4.5.1).

Results are presented using descriptive statistics, including frequencies and percentages. Inferential analyses were performed to examine associations between ethics oversight and study characteristics. Associations between categorical variables were assessed using the Pearson’s Chi-square test or Fisher’s exact test, as appropriate. Fisher’s exact test was applied when more than 20% of cells had expected counts < 5 or when any expected cell count was < 1. A p-value of < 0.05 was considered statistically significant.

Results

Screening of articles

A total of 1483 articles were identified through the initial search. After removing duplicates & conference abstracts, 871 articles were screened based on titles and abstracts. Of these, 90 articles underwent full-text screening, and 76 articles were included for the analysis and review. “Figure 1” shows the PRISMA flow diagram.

Fig. 1.

Fig. 1

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PRISMA flow diagram of the study selection process

Descriptive summary of ethical consideration

Among 76 publications included, 14 (18%) did not report an ethics statement, while 31 (41%) reported an ethics statement without Institutional Ethics Committee (IEC) approval, and 31 (41%) reported both an ethics statement and IEC approval. Among 27 publications on outbreak investigation that documented the timing of IEC review, 20 (74%) were prospectively conducted, while the remaining reported retrospective approvals. Regarding the annual distribution of outbreak investigation publications, there is an overall increase in reports over time, with a marked increase after 2020. The number of publications increased gradually since 2015, and a sudden surge is observed during the year 2020. The proportion of investigations reporting an ethics statement gradually increased over time, as given in Fig. 2. Participant consent was not reported in 41 (54%) publications; written consent was obtained in 26 (34%), and 9 (12%) reported on obtaining verbal consent only (Table 1). Consent practices showed no consistent pattern over the years of the outbreak, as shown in Fig. 3.

Fig. 2.

Fig. 2

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Year-wise distribution of outbreak investigation publications and investigated outbreaks & Proportion of outbreak investigations that obtained ethical approval by outbreak year (Bottom)

Table 1.

Descriptive summary statistics of Ethical consideration

Characteristic N n (%)/mean (SD)
Ethics Oversight 76
 No ethics statement 14(18%)
 Ethics statement +, IEC approval not obtained 31(41%)
 Ethics statement +, IEC approval obtained 31(41%)
IEC Timeline 27
 Prospectively 20 (74%)
 Retrospectively 7 (26%)
PIC 76
 No 41 (54%)
 Yes (verbal) 9 (12%)
 Yes (written) 26 (34%)
FETP steps completed (out of 10) 76
 6 1 (1.3%)
 7 2 (2.6%)
 8 7 (9.2%)
 9 52 (68%)
 10 14 (18%)
Number of subcomponents completed out of 25 76 17.82 (2.96)
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Fig. 3.

Fig. 3

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Proportion of outbreak investigations obtained participant informed consent by outbreak year

Socio-demographic distribution of included reports

Among the 76 outbreak investigations, 41 (54%) of the investigations were conducted in the community setting, 25 (34%) were in hospital settings, while 5 (6.6%) were in mixed community and hospital settings, and the rest were conducted in institutional settings (viz., colleges, military camps). Most investigations were conducted in urban areas 39 (51%), and the rest in rural regions 35 (46%). With respect to outbreak investigations that involved collaborations between multiple institutions, 34 (45%) investigations were done with collaboration among 2–3 agencies, and 23 (30%) single investigations were carried out by a single agency. The remaining investigations were done in collaboration among 4 agencies. The most frequently involved agencies included State Health Institutes 25 (33%), followed by the Government medical colleges 23 (30%), and Other Government Agencies in 23 (30%). The number of published outbreak investigations was higher in the period during or after 2018, i.e., 41 (54%), than in the period before 2018. Food and waterborne diseases constituted the largest category of diseases that warranted an outbreak investigation at 29 (38%). It was followed by airborne/respiratory diseases at 15 (20%) and vector-borne 8 (11%), respectively. (Table 2). State-wise distribution of outbreak investigation showed substantial variation across India (Figure S6).

Table 2.

Descriptive summary statistics of the included outbreak reports

Characteristic N1 = 76
Year of Outbreak Investigation
 <2018 35 (46%)
 ≥2018 41 (54%)
Study Setting
 Community based 41 (54%)
 Hospital and community based 5 (6.6%)
 Hospital-based 25 (33%)
 Institution setting 5 (6.6%)
Location Setting
 Not mentioned 2 (2.6%)
 Rural 35 (46%)
 Urban 39 (51%)
Outbreak Year 2,018.3 (3.2)
Number of agencies
 Single agency 23 (30%)
 2–3 agencies 34 (45%)
 > 4 agencies 19 (25%)
Type of agencies involved in the investigation#
 State Health Institute 25 (33%)
 Other Central Government Agency 23 (30%)
 Government Medical College 23 (30%)
 ICMR 19 (25%)
 Foreign Institute 17 (22%)
 NCDC 15 (20%)
 IDSP 13 (17%)
 Private Hospital/College 11 (14%)
 MoHFW 4 (5.3%)
 Other Agency 1 (1.3%)
Disease Group
 Airborne/Respiratory 15 (20%)
 Bloodborne/Body Fluids 8 (11%)
 Food/Waterborne 29 (38%)
 Neurological/Other 8 (11%)
 Ocular 2 (2.6%)
 Vector-borne 8 (11%)
 Zoonotic/Contact 6 (7.9%)
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1n (%)

#Percentages were calculated using 76 as the denominator; frequencies exceed 76 because some studies involved multiple collaborating agencies

Ethics oversight and study characteristics association

Ethics oversight was analysed as a three-category variable: no ethics statement, ethics statement without approval, and ethics statement with approval. Ethics oversight was significantly associated with year of publication (Fisher’s exact test, p < 0.001), suggesting differences in reporting across publication periods, and disease group (Fisher’s exact test, p = 0.04), suggesting variation across disease categories.

No statistically significant association was observed between ethics oversight and outbreak year (Pearson’s Chi-square test, p = 0.081), study setting (Fisher’s exact test, p = 0.10), completeness of outbreak investigation FETP steps (Fisher’s exact test, p = 0.70), or number of collaborating agencies (Fisher’s exact test, p = 0.20). Indicating that ethics oversight did not vary significantly across these study characteristics. Details given in (Table 3).

Table 3.

Ethics oversight and Study Characteristics

Characteristic N No statement Statement, no approval Statement + approval p-value
N = 14* N = 31* N = 31*
Publication year 76 < 0.001 f
 <2018 7 (50%) 1 (3.2%) 3 (9.7%)
 ≥2018 7 (50%) 30 (97%) 28 (90%)
Outbreak year 76 0.081c
 <2018 10 (71%) 14 (45%) 11 (35%)
 ≥2018 4 (29%) 17 (55%) 20 (65%)
Study setting 76 0.1f
 Community based 10 (71%) 17 (55%) 14 (45%)
 Hospital-based 1 (7.1%) 9 (29%) 15 (48%)
 Hospital and community based 1 (7.1%) 3 (9.7%) 1 (3.2%)
 Institution setting 2 (14%) 2 (6.5%) 1 (3.2%)
FETP steps completed (out of 10) 76 0.7f
 6 0 (0%) 0 (0%) 1 (3.2%)
 7 0 (0%) 1 (3.2%) 1 (3.2%)
 8 1 (7.1%) 4 (13%) 2 (6.5%)
 9 12 (86%) 18 (58%) 22 (71%)
 10 1 (7.1%) 8 (26%) 5 (16%)
No. of agencies 76 0.2f
 Single agency 4 (29%) 6 (19%) 13 (42%)
 2–3 agencies 8 (57%) 14 (45%) 12 (39%)
 > 4 agencies 2 (14%) 11 (35%) 6 (19%)
Disease group 76 0.04f
 Airborne/Respiratory 5 (36%) 3 (9.7%) 7 (23%)
 Bloodborne/Body Fluids 2 (14%) 1 (3.2%) 5 (16%)
 Food/Waterborne 5 (36%) 18 (58%) 6 (19%)
 Neurological/Other 0 (0%) 3 (9.7%) 5 (16%)
 Ocular 1 (7.1%) 0 (0%) 1 (3.2%)
 Vector-borne 0 (0%) 3 (9.7%) 5 (16%)
 Zoonotic/Contact 1 (7.1%) 3 (9.7%) 2 (6.5%)
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* n (%)

f Fisher’s exact test

c Pearson’s Chi-squared test

#Values shown in bold represent statistically significant results at p < 0.05

Completion of subcomponents for each step in an outbreak investigation

The completeness of the outbreak investigation practices was assessed using the revised ten-step FETP framework (ICMR-NIE). Among 76 outbreak investigations, 14 (18%) completed all 10 steps, 52 (68%) completed 9 out of 10 steps, 7 (9.2%) completed 8 out of 10 steps and merely 3 (3.9%) completed 7 − 6 steps as given in Table 1. The most consistently reported step was “Conclusions formulated”, i.e., among 76 (100%). In contrast, the least consistent step completed by the investigators was “Effectiveness evaluation”, where only 14 (18%) had completed this step (Table 4). Food/waterborne outbreak investigations demonstrated the highest methodological completeness, with 9 (31%) out of 29 completing all ten steps (Table S5).

Table 4.

Distribution of outbreak reports (2015–25) by the completion of subcomponents for each step in an outbreak investigation

Steps Components N1 = 76 (%)
Step 1: Confirm outbreak existence Excess of cases 73 (96%)
Background rates checked 41 (54%)
Surveillance system changes 22 (29%)
Population changes 8 (11%)
Step 2: Confirm diagnosis Clinical description 75 (99%)
Specimens collected 73 (96%)
Safe transport 35 (46%)
Step 3: Define cases Case definition 69 (91%)
Time/place/person description 75 (99%)
Step 4: Search for cases Active case search 67 (88%)
Line listing 67 (88%)
Step 5: Descriptive epidemiology Epidemic curve 62 (82%)
Spot map 38 (50%)
Incidence by age/gender 45 (59%)
Hypothesis interviews 65 (86%)
Step 6: Analytical study Analytical study 33 (43%)
Step 7: Draw conclusions Analysis performed 63 (83%)
Conclusions formulated 76 (100%)
Step 8: Refine hypothesis Environmental study 53 (70%)
Literature review 74 (97%)
Peer discussion 25 (33%)
Step 9: Communicate findings Findings communicated 75 (99%)
Step 10: Implement control measures and evaluate effectiveness Specific recommendations 74 (97%)
Implementation relevance 52 (68%)
Effectiveness evaluation 14 (18%)
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1n (%)

Discussion

This systematic review of outbreak investigations published in India between 2015 and 2025 reveals substantial gaps in the reporting of ethics oversight. Only 41% of the included investigations documented both an ethics statement and Institutional Ethics Committee (IEC) approval; a further 41% reported an ethics statement without formal approval, and 18% provided no ethics statement at all. Taken together, these findings suggest a persistent assumption that outbreak investigations conducted during public health emergencies are exempt from formal ethics oversight. This assumption is at odds with international guidance, which holds that emergency contexts do not waive ethical obligations but instead require adapted mechanisms, such as expedited review processes, to uphold them [13]. In several reports, waivers were granted by the conducting institute rather than by an IEC, with the activities classified as standard public health response. This indicates a structural gap in ethical governance and reflects ambiguities between public health practice and research oversight that have been documented globally. During the West African Ebola outbreak, for instance, unclear regulatory boundaries led to inconsistent ethics review and consequent delays in implementing critical research [14]. The spatial heterogeneity observed in our review further suggests that institutional maturity, research culture, and the presence of functional IECs together influence adherence to ethical reporting practices. Outbreak investigations occupy a regulatory grey zone between public health practice and research governance, a tension that has been recognised in global bioethics deliberations on health-emergency research [15].

Consent practices in our sample reflect the operational and ethical complexities of emergency fieldwork. Nearly half of the investigations did not report obtaining participant consent; among those that did, written consent was documented in roughly one-third of studies and verbal consent in a smaller proportion. This pattern likely reflects both genuine practical constraints and variability in how field teams recognise their ethical obligations. International guidance endorses context-sensitive approaches, including verbal consent or formal waivers when justified, but it consistently emphasises the need for clear documentation and oversight. Because outbreaks frequently affect socioeconomically vulnerable populations, inconsistent or undocumented consent practices risk exacerbating existing inequities and eroding the community trust on which an effective public health response depends [16].

The significant association between ethics oversight and publication year suggests that temporal trends, including evolving editorial expectations, influence ethical reporting. The association with disease group similarly suggests that the nature of the outbreak shapes the likelihood of obtaining or reporting ethics approval, plausibly reflecting differences in perceived risk, regulatory scrutiny, and the standardisation of investigation protocols. Evidence from the global governance of COVID-19 research reinforces this interpretation: strengthened regulatory oversight and explicit publication requirements during the pandemic were associated with improved reporting of ethics approvals [17]. By contrast, the lack of significant association between ethics oversight and outbreak year, study setting, FETP-step completeness, or the number of collaborating agencies indicates that ethical reporting is not consistently linked to the structural or methodological characteristics of investigations. This pattern implies that current compliance is driven more by external reporting expectations than by embedded institutional processes.

Around 43% of the included investigations incorporated analytical study designs, a modest improvement over earlier reviews [11]. Structural barriers nonetheless persist. India currently lacks a formal mechanism for expedited ethics review of public health research conducted during outbreaks arising from public health emergencies [18]. International guidance recommends rapid-review systems capable of reviewing and approving protocols within 24–72 h so that critical research is not delayed [13, 19]. Although the Integrated Disease Surveillance Programme (IDSP) issues weekly outbreak bulletins that support the timely initiation of investigations [20], the absence of a parallel rapid-review pathway means that timeliness in surveillance is not matched by timeliness in ethics review.

Disease-specific patterns add further nuance. Food- and waterborne outbreaks showed the highest methodological completeness, with 31% completing all ten FETP steps. This likely reflects better operational standardisation in food-safety investigations, mature investigation protocols, and intersectoral coordination between food-safety regulators and public health teams. Comparable trends have been observed elsewhere, where structured surveillance and standardised investigation protocols are associated with improved methodological rigour and ethical compliance [21]. The increase in outbreak-investigation publications and reported ethics oversight observed in 2020 is most plausibly attributable to the COVID-19 pandemic and the heightened scrutiny it brought to research conducted during emergencies [15].

These findings carry several implications for strengthening the preparedness of IECs to support outbreak response. First, standardised ethics-reporting templates should be developed so that authors and reviewers can document oversight in a consistent and verifiable manner. Second, mechanisms for expedited review within 24–72 h should be formally established; such mechanisms are widely endorsed as a means of preserving ethical safeguards without compromising the timeliness of public health action [15]. Third, training in ethical decision-making for field-epidemiology teams should be strengthened, in line with global capacity-building initiatives [22, 23]. Finally, integrating ethics oversight into existing surveillance platforms such as IDSP would enhance both compliance and accountability and would align national practice with evolving global standards for ethical governance of public health emergencies [16]. Collectively, these measures would help ensure that the integrity of India’s epidemic response is matched by the integrity of its ethical oversight.

Strengths and limitations

This review offers a system-level ethical perspective grounded in a policy-relevant research question. Its use of quantifiable indicators, namely the reporting of ethics statements, IEC approvals, and informed-consent procedures as outcomes, allows for an objective assessment of ethical compliance across the published literature.

Methodological rigor was reinforced by prospective protocol registration, standardised data-extraction procedures, and pre-specified eligibility criteria. Independent screening and verification further support the internal consistency and reproducibility of the findings.

Several limitations should be considered when interpreting these results. First, the analysis was restricted to peer-reviewed outbreak investigations; grey literature, including IDSP field reports and internal surveillance documents, could not be comprehensively retrieved, and ethically conducted investigations that went unpublished because they lacked IEC approval are necessarily excluded. The findings should therefore be interpreted in light of both publication and reporting bias. Second, ethical assessment was based solely on information reported in the published articles and was not verified through correspondence with authors. The absence of documented approval or consent should accordingly be read as a limitation in ethical reporting, transparency, and journal disclosure norms rather than as direct evidence of unethical conduct. Third, the FETP ten-step framework was applied retrospectively to published reports, so steps that are routinely performed in practice but not explicitly described in publications (for example, peer discussions under Step 8) may be underrepresented, introducing a potential for misclassification bias.

Conclusion

This systematic review shows that although most outbreak investigations in India include an ethical statement at the time of publication, less than half document formal IEC approval, indicating a persistent gap between ethical principles and their implementation. In recent years, hospital-based investigations and experiments were more likely to provide an ethical statement, indicating growing awareness in institutional preparedness for ethical compliance. Investigator-driven decisions to waive ethical review, which is supposed to be made by the IEC, point to a continued lack of clarity in ethical governance during public health emergencies.

These findings highlight the need for strengthening ethical preparedness within outbreak response systems. Incorporating ethical governance into outbreak surveillance frameworks, standardising ethics reporting practices, and establishing institutional procedures for expedited IEC review might improve compliance during emergencies. Capacity building of field epidemiology teams in ethical decision-making, along with robust oversight mechanisms, is essential for maintaining scientific integrity.

Future research should examine barriers to ethical compliance in outbreak settings, assess the effectiveness of expedited review mechanisms, and incorporate grey literature such as IDSP reports to provide a more comprehensive understanding of ethical practices. Strengthening ethical governance during public health emergencies is essential to safeguard participant rights, maintain public trust, and enhance the credibility of outbreak response systems.

Tables.

Supplementary information

12910_2026_1492_MOESM1_ESM.docx (964.2KB, docx)

Supplementary Material 1. [24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99]

Acknowledgements

Not applicable.

Abbreviations

c

Pearson’s Chi-squared test

CIOMS

Council for International Organisations of Medical Sciences

f

Fisher’s exact test

FETP

Field Epidemiology Training Programme

IEC

Institutional Ethics Committee

ICMR

Indian Council of Medical Research

IDSP

Integrated Disease Surveillance Programme

IRB

Institutional Review Board

N

Total number in the sample (denominator)

n

Number within the category (numerator)

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

SD

Standard Deviation

S

Supplement

WHO

World Health Organisation

Authors' contributions

PKS conceptualized the study, conducted data extraction, performed analysis, and drafted the manuscript. CR contributed to study selection, data verification, and interpretation of findings. RA and MSK provided methodological oversight, resolved screening discrepancies, and critically revised the manuscript for intellectual content. All authors read and approved the final manuscript.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Data availability

All data analysed during this study are included in this published article and its supplement materials (Table S4).

Declarations

Ethical approval and consent to participate

This study is a systematic review based exclusively on analysis of published literature and did not involve direct interaction with human participants, human data, or human biological material. Ethical approval and informed consent were therefore not required.

Consent for publication

This manuscript does not contain any person’s data, images, or identifiable information.

Competing interests

The authors declare no competing interests.

Footnotes

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Praveen Kumar S and Mohammed Shoyaib Khazi contributed equally to this work.

References

  • 1.Macklin R, Cowan E. Conducting research in disease outbreaks. PLoS Negl Trop Dis. 2009;3(4):e335. 10.1371/journal.pntd.0000335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.Reintjes R, Zanuzdana A. Outbreak investigations. Modern infectious disease epidemiology. New York: Springer; 2009:159–76. [Google Scholar]
  • 3.Sigfrid L, Maskell K, Bannister PG, et al. Addressing challenges for clinical research responses to emerging epidemics and pandemics: a scoping review. BMC Med. 2020;18:190. 10.1186/s12916-020-01624-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 4.Ethical issues in outbreaks and emergencies. Available from: https://www.who.int/teams/health-ethics-governance/emergencies-and-outbreaks.
  • 5.Ensuring ethical standards and procedures for research with human beings. Available from: https://www.who.int/activities/ensuring-ethical-standards-and-procedures-for-research-with-human-beings.
  • 6.Barrett DH, Ortmann LW, Brown N, DeCausey BR, Saenz C, Dawson A. Public health research. Public health ethics: cases spanning the globe. Cham: Springer; 2016. [PubMed] [Google Scholar]
  • 7.Guidance for Research Ethics Committees for Rapid Review of Research During Public Health Emergencies. 1st ed. Geneva: World Health Organization; 2020;1.
  • 8.Smith MJ. Ethics of pandemic research. Principles and practice of emergency research response. Cham: Springer; 2024. [PubMed] [Google Scholar]
  • 9.Mathur R, editor. National ethical guidelines for biomedical and health research involving human participants. New Delhi: Indian Council of Medical Research; 2017. [DOI] [PubMed] [Google Scholar]
  • 10.Government of India. The Epidemic Diseases Act. 1897. Available from: https://www.indiacode.nic.in/bitstream/123456789/15942/1/epidemic_diseases_act%2C1897.pdf
  • 11.Kurup KK, John D, Ponnaiah M, George T. Use of systematic epidemiological methods in outbreak investigations from India, 2008–2016: a systematic review. Clin Epidemiol Glob Health. 2019;7(4):648–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 12.Murhekar M, Moolenaar R, Hutin Y, Broome C. Investigating outbreaks: practical guidance in the Indian scenario. Natl Med J India. 2009;22(5):252–6. [PubMed] [Google Scholar]
  • 13.World Health Organization. Ethics in epidemics, emergencies and disasters: research, surveillance and patient care training manual. Geneva: WHO. Available from: https://www.who.int/publications-detail/ethics-in-epidemics-emergencies-and-disasters-research-surveillance-and-patient-care-training-manual. Cited 2026 Apr 18.
  • 14.Jecker NS, Dudzinski DM, Diekema DS, Tonelli M. Ebola virus disease: ethics and emergency medical response policy. Chest. 2015;148(3):794–800. 10.1378/chest.15-0135. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 15.Nuffield Council on Bioethics. Research in global health emergencies: ethical issues. London: Nuffield Council on Bioethics. Available from: https://www.nuffieldbioethics.org/publications/research-in-global-health-emergencies. Cited 2026 Apr 18.
  • 16.Council for International Organizations of Medical Sciences (CIOMS). International ethical guidelines for health-related research involving humans. Geneva: CIOMS. Available from: https://cioms.ch/publications/product/international-ethical-guidelines-for-health-related-research-involving-humans/. Cited 2026 Apr 18. [PubMed]
  • 17.Health Research Authority. Approved COVID-19 research. London: HRA. . Available from: https://www.hra.nhs.uk/covid-19-research/approved-covid-19-research/. Cited 2026 Apr 18.
  • 18.Vedachalam SK Choudhary S. Balancing Urgency and Ethics in the Kyasanur Forest Disease Investigation in Shivamogga: The Outbreak Dilemma. Int. J. Public Health. 2025;70:1608861. 10.3389/ijph.2025.1608861. [DOI] [PMC free article] [PubMed]
  • 19.World Health Organization. Guidance for managing ethical issues in infectious disease outbreaks. Geneva: World Health Organization. 2016. Available from: https://www.who.int/publications/i/item/9789241549837. Cited 2026 May 5.
  • 20.Integrated Disease Surveillance Programme. Outbreaks. New Delhi: Ministry of Health and Family Welfare. Available from: https://idsp.mohfw.gov.in/index4.php?lang=1&level=0&linkid=403&lid=3685.  Cited 2026 Apr 18.
  • 21.Centers for Disease Control and Prevention. Field epidemiology manual. Atlanta: CDC. Available from: https://www.cdc.gov/field-epi-manual/php/about/. Cited 2026 Apr 18.
  • 22.Training Programs in Epidemiology and Public Health Interventions Network (TEPHINET). About TEPHINET. Atlanta: TEPHINET. Available from: https://www.tephinet.org/. Cited 2026 May 5.
  • 23.Saxena A, Horby P, Amuasi J, Afolabi MO, Chandramohan D, Greenwood B, et al. Ethics preparedness: facilitating ethics review during outbreaks—recommendations from an expert panel. BMC Med Ethics. 2019;20:29. 10.1186/s12910-019-0366-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 24.Kerketta S, Rout UK, Kshatri JS, Kerketta AS, Paikaray AK, Dash A et al. An acute diarrheal disease outbreak in urban setting of Odisha, India. BMC Infect Dis. 2025;25(1). Available from: 10.1186/s12879-025-10683-2. [DOI] [PMC free article] [PubMed]
  • 25.N PK PMA, Saini P, Suresh SAR, Samuel A et al. P,. Is the Zika virus re-emerging as a distinct genetic lineage in India? Access Microbiol. 2025;7(5). Available from: 10.1099/acmi.0.000857.v4. [DOI] [PMC free article] [PubMed]
  • 26.Mahajan V, Singh MP, Sharma A, Kanta P, Gupta S, Guglani V Measles Outbreak Investigation in Chandigarh in 2023: A Case Series. Indian Pediatr., Vasan V, Kumar AS, Pandit K, Shetty P, Debnath R. J., Outbreak investigation of community-acquired pneumonia in trainees: An insight into the changing epidemiological patterns. Med J Armed Forces India. 2025. [DOI] [PubMed]
  • 27.Vasan AS, Kumar K, Pandit P, Shetty P, Debnath R. Outbreak investigation of community-acquired pneumonia in trainees: An insight into the changing epidemiological patterns. Med J Armed Forces India. 2025. 10.1016/j.mjafi.2025.06.006.
  • 28.Gautam P, Goswami VP, Bajpai I, Sakalle S, Dixit S. An Epidemiological Investigation of Cholera Outbreak in a Residential School for differently abled children and adolescents in Central India. Indian J Community Health. 2025;37(1):130–6. [Google Scholar]
  • 29.Vedachalam SK, Vedachalam SK, Rajput BL, Rajput BL, Choudhary S, Choudhary S, et al. Kyasanur Forest Disease: An Epidemiological Investigation and Case-Control Study in Shivamogga, Karnataka, India-2022. Int J Public Health. 2024;69:1606715. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 30.Murugesan A, Murugesan A, Arunan A, Arunan A, Sastry A, Sastry A et al. Clinical profile and risk factors associated with Elizabethkingia anophelis infection in neonates born in a tertiary care hospital-a case-control study and outbreak investigation. J Trop Pediatr. 2024;70(5). [DOI] [PubMed]
  • 31.Kuchelkar SP, Kuchelkar SP, Dias A, Dias A, Gomes E, Gomes E, et al. Study of the clinical manifestations and risk factors in people affected during the first Kyasanur Forest Disease outbreak in Goa, India: A mixed method study. J Vector Borne Dis. 2024;61(1):23–8. [DOI] [PubMed] [Google Scholar]
  • 32.Majumdar T, Majumdar T, Guha H, Guha H, Tripura A, Tripura A, et al. Outbreak of waterborne acute diarrheal disease in a South District village of Tripura: A public health emergency in the Northeast region of India. Heliyon. 2024;10(11):e31903. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 33.Yadav RM, Gomare M, Gaikwad A, Waghmare U, Betodkar U, Vashi MD et al. Interplay of missed opportunity for vaccination and poor response to the vaccine led to measles outbreak in a slum area of Eastern Mumbai, India. Epidemiol Infect. 2024;152. Available from: 10.1017/S0950268824000426. [DOI] [PMC free article] [PubMed]
  • 34.Sarmah P, Sarmah P, Baruah PJ, Baruah PJ, Phukan C, Phukan C, et al. An outbreak of acute diarrhoeal disease caused by Shigella sonnei in a village in Dibrugarh district, Assam. Indian J Med Res. 2024;160(1):87–94. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 35.Thakur A, Sharma D, Singh MP, Chauhan P, Shah A, Angra V, et al. Clinical and molecular investigation of acute haemorrhagic conjunctivitis outbreak in North India (2023). Int Ophthalmol. 2024;44(1):444. [DOI] [PubMed] [Google Scholar]
  • 36.Francis F, Balasundaran K, Kumar KCS, Sankar KKL. Neonatal Meningitis Outbreak by Elizabethkingia: A Case Series and Epidemiological Investigation Findings. J Neonatol. 2024;38(3):382 EP – 388.
  • 37.Roy D, Mondal TR, Indwar P. Outbreak of cholera due to contaminated pond water utilisation in a rural area of West Bengal, India, 2021. Int J Hyg Environ Health. 2024;261. [DOI] [PubMed]
  • 38.Hariprasad R, Baruah PJ, Kumar MS, Sarmah P, Mahanta TG, Bhatnagar T. Investigation of an outbreak of acute diarrheal disease in Dibrugarh district, Assam, India, 2023. Clin Epidemiol Glob Health. 2024;29.
  • 39.Parai D, Parai D, Pattnaik M, Pattnaik M, Choudhary HR, Choudhary HR, et al. Investigation of human anthrax outbreak in Koraput district of Odisha, India. Travel Med Infect Dis. 2023;56:102659. [DOI] [PubMed] [Google Scholar]
  • 40.Begam NN, Mondal S, Afroz E, Das A, Biswas A, Wig N. The Outbreak of SARS-CoV-2 in a Medical Ward and Its Containment: An Experience From a Tertiary Care Centre in North India. Cureus. 2023 July; Available from: 10.7759/cureus.41795. [DOI] [PMC free article] [PubMed]
  • 41.Satapathy P, Goel K, Sharma V, Sarkar S, Kang M, Dhingra S et al. Outbreak investigation of acute febrile illness from the Himalayan foothills: Solving the puzzle of fever. Front Pharmacol. 2023;14. Available from: 10.3389/fphar.2023.1159377. [DOI] [PMC free article] [PubMed]
  • 42.Fomda B, Velayudhan A, Siromany VA, Bashir G, Nazir S, Ali A et al. An outbreak of Burkholderia cepacia bloodstream infections in a tertiary-care facility in northern India detected by a healthcare-associated infection surveillance network. Infect Control Hosp Epidemiol. 2023;44(3):467 EP – 473. [DOI] [PubMed]
  • 43.Sharma S, Patel P, Kulkarni SV, Deoshatwar A, Yadav R, Tanwar S, et al. An outbreak of acute neurological illness associated with drinking water source following a cyclone in Eluru, West Godavari district, Andhra Pradesh, India, December 2020. Clin Epidemiol Glob Health. 2023;20:101261. [Google Scholar]
  • 44.Ahad WA, Naik MA, Mehraj S, Ala A, Shafi A, Clinical biochemical profile, and outcome of cholera outbreak in a rural population of Kashmir Valley North India: a retrospective observational study. Asian J Pharm Clin Res. 2023;16(3):145 EP – 147.
  • 45.Ponnaiah M, Dikid T, Yadav R, Thangaraj JWV, Velusamy S, Vaisakh TP et al. Litchi consumption and missed meals continue to be associated with acute encephalopathy syndrome among children: an investigation of the 2019 outbreak in Muzaffarpur district, Bihar, India. Trans R Soc Trop Med Hyg. 2023;117(1):45 EP – 49. [DOI] [PubMed]
  • 46.Barman K, Tobgyel DN, Islam B, Narain JP. Malaria outbreak along the India-Bhutan border town of Saralpara, Assam, India. J Vector Borne Dis. 2023;60(3):324 EP – 327. [DOI] [PubMed]
  • 47.Khan V, Sanghai AA, Rajan J, Sharma AK, Nayak S, Das VK. Clusters of Varicella Zoster in the Tribal-dominated District of Western India: An investigation Report. J Indian Med Assoc. 2023;121(10):18. EP – 23. [Google Scholar]
  • 48.Sharma S, Sharma S, Sahu R, Sahu R, Taneja NS, Taneja NS, et al. Epidemiological investigation of viral hepatitis E outbreak in two colocated training centers. Med J Armed Forces India. 2022;78(Suppl 1):S116–22. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 49.Shah HD, Shah HD, Desai B, Desai B, Jadav P, Jadav P, et al. An epidemiological investigation of a cholera outbreak in peri-urban slum settlements of Gujarat, India. J Fam Med Prim Care. 2022;11(10):6061–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 50.Kujur A, Kiran KA, Kujur M. An Epidemiological Study of Outbreak Investigation of Chickenpox in Remote Hamlets of a Tribal State in India. Cureus. 2022; Available from: 10.7759/cureus.26454 [DOI] [PMC free article] [PubMed]
  • 51.Abu Bashar M, Abu Bashar M, Soundappan K, Soundappan K. Outbreak investigation of acute watery diarrhea in a village of North India: timely action saved lives. J Infect Dev Ctries. 2022;16(5):843–9. [DOI] [PubMed] [Google Scholar]
  • 52.Singhai M, Sood V, Singh G, Siddiqui C, Nale T, Jha P, et al. Rabies Outbreak in the Urban Area of Delhi: An Investigation Report and One Health Perspective for Outbreak Management. Infect Dis Rep. 2022;14(6):1033–40. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 53.Singh A, Singh A, Talyan A, Talyan A, Chandra R, Chandra R, et al. Risk factors for melioidosis in Udupi District, Karnataka, India, January 2017-July 2018. PLOS Glob Public Health. 2022;2(12):e0000865. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 54.Singh CM, Singh CM, Naik BN, Naik BN, Pandey S, Pandey S, et al. Investigation of an acute surge of COVID-19 associated mucormycosis (CAM) cases reported to a tertiary health care institution in Bihar, India. J Fam Med Prim Care. 2022;11(6):2802–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 55.Madurapandian Y, Rubeshkumar P, Raju M, Janane A, Ganeshkumar P, Selvavinayagam TS et al. Case report: An outbreak of viral conjunctivitis among the students and staff of visually impaired school, Tamil Nadu, India, 2020. Front Public Health. 2022;10. Available from: 10.3389/fpubh.2022.978200. [DOI] [PMC free article] [PubMed]
  • 56.Navya CJ, Shanbhag D, Joseph B. An Outbreak of Measles among adolescents in a Health Care Setting, Bangalore, Karnataka, India. Indian J Public Health Res Dev. 2022;13(2):94 EP – 100.
  • 57.Datta S, Ghosh M, Paul M, Halder P, Mallik S, Mukhopadhyay S et al. Comprehensive investigation of fever cases enrolled during 2019 dengue outbreaks from three hyperendemic regions of North 24 Parganas district of West Bengal, India. J Med Virol. 2022;94(2):540 EP – 548. [DOI] [PubMed]
  • 58.Nimonkar R, Goyal A, Ahmed S, Pardal M, Singh S. Clinico-epidemiological study of an outbreak of typhoid in North India. J Fam Med Prim CARE. 2022;11(7):3570–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 59.Sheoran P, Sheoran P, Rammayyan A, Rammayyan A, Shukla HK, Shukla HK, et al. An outbreak investigation of acute Diarrheal Disease, Nagpur District, Maharashtra, India. Indian J Public Health. 2021;65(Supplement):S14–7. [DOI] [PubMed] [Google Scholar]
  • 60.Patil AA, Patil AA, Velayudhan A, Velayudhan A, Durairaj GK, Durairaj GK, et al. Outbreak investigation of foodborne illness among political rally attendees, Cuddalore, Tamil Nadu, India. Indian J Public Health. 2021;65(Supplement):S55–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 61.Gupta G, Gupta G, Singh A, Singh A, Dikid T, Dikid T, et al. Acute diarrheal disease outbreak in Muzaffarpur Village, Chandauli District, Uttar Pradesh, India. Indian J Public Health. 2021;65(Supplement):S34–40. [DOI] [PubMed] [Google Scholar]
  • 62.Dzeyie KA, Dzeyie KA, Lowang D, Lowang D, Dikid T, Dikid T, et al. Measles outbreak investigation at Indo-Myanmar border, Longding District, Arunachal Pradesh, India, 2017. Indian J Public Health. 2021;65(Supplement):S23–8. [DOI] [PubMed] [Google Scholar]
  • 63.Dzeyie KA, Dzeyie KA, Dhanapaul S, Dhanapaul S, Rubeshkumar P, Rubeshkumar P, et al. Outbreak of ceftriaxone-resistant Salmonella enterica serotype Typhi-Tiruchirappalli, Tamil Nadu, India, June 2018. IJID Reg. 2021;1:60–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 64.Deepanjali S, Deepanjali S, Jharna M, Jharna M, Chanaveerappa B, Chanaveerappa B, et al. An outbreak of Salmonella Enteritidis food poisoning following consumption of chicken shawarma: A brief epidemiological investigation. F1000Research. 2021;10:851. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 65.Varghese SM, Varghese SM, Sheeja AL, Sheeja AL, Samuel Johnson AK, Samuel Johnson AK, et al. Together let us confront it: An outbreak investigation of hepatitis B in Pathanamthitta district, Kerala. J Fam Med Prim Care. 2021;10(6):2159–65. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 66.Vardhan V, Vardhan V, Dikid T, Dikid T, Yadav R, Yadav R, et al. Foodborne Disease outbreak associated with eating Gaajar Halwa at a Wedding - Palghar District, Maharashtra, India, 2018. Indian J Public Health. 2021;65(Supplement):S10–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 67.Sahu R, Ray AL, Yadav AK, Kunte R, Faujdar DS, Group W. Acute gastroenteritis outbreak in a school associated with religious ceremony in Mirzapur District, Uttar Pradesh, India. Indian J Public Health. 2021;65(5):18. [DOI] [PubMed] [Google Scholar]
  • 68.Velayudhan A, Velayudhan A, Nayak J, Nayak J, Murhekar MV, Murhekar MV, et al. Shellfish poisoning outbreaks in Cuddalore District, Tamil Nadu, India. Indian J Public Health. 2021;65(Supplement):S29–33. [DOI] [PubMed] [Google Scholar]
  • 69.Priyamvada K, Bindroo J, Sharma MP, Chapman LAC, Dubey P, Mahapatra T et al. Visceral leishmaniasis outbreaks in Bihar: community-level investigations in the context of elimination of kala-azar as a public health problem. Parasites Amp Vectors. 2021;14(1). Available from: 10.1186/s13071-020-04551-y. [DOI] [PMC free article] [PubMed]
  • 70.Jain A, Jain A, Choudhary S, Choudhary S, Saroha E, Saroha E, et al. Cholera outbreak in an informal settlement at Shahpur huts, Panchkula District, Haryana State, India, 2019. Indian J Public Health. 2021;65(Supplement):S51–4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 71.Anandan M, Vs S, Rubeshkumar P, Ponnaiah M, Jesudoss P, Karumanagounder K, et al. Outbreak of acute diarrhoeal disease attributed to consumption of faecal contaminated water supplied through damaged pipelines in Thiruper, Tiruvallur district, Tamil Nadu, India, 2016. Clin Epidemiol Glob Health. 2021;10:100701. [Google Scholar]
  • 72.Sathyapalan DT, Antony R, Nampoothiri V, Kumar A, Shashindran N, James J et al. Evaluating the measures taken to contain a Candida auris outbreak in a tertiary care hospital in South India: an outbreak investigational study. BMC Infect Dis. 2021;21(1). Available from: 10.1186/s12879-021-06131-6. [DOI] [PMC free article] [PubMed]
  • 73.Singh C, Biswas B, KG N, Hari H, Pandey S, Naik BN. Epidemiological investigation of a food poisoning outbreak: a study among hostel dwelling students and resident doctors of a tertiary healthcare facility of India. Indian J Community Health. 2021;33(3):480–5.
  • 74.Mummadi M, Pandurangi R, Geddam J, Sinha S, Rajendran A, Sivaperumal P et al. Investigation of an acute neurological outbreak in Eluru, India, 2020. PLoS ONE. 2021;16(11). [DOI] [PMC free article] [PubMed]
  • 75.Pallivalappil B, Pallivalappil B, Ali A, Ali A, Thulaseedharan NK, Thulaseedharan NK, et al. Dissecting an Outbreak: A Clinico-epidemiological Study of Nipah Virus Infection in Kerala, India, 2018. J Glob Infect Dis. 2020;12(1):21–7. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 76.Kankaria A, Kankaria A, Gupta M, Gupta M, Bashar MA, Bashar MA, et al. Epidemiological investigation of an outbreak of Acute Viral Hepatitis A and E in a semi-urban locality in Chandigarh, North Indian Union Territory, 2016-17. J Fam Med Prim Care. 2020;9(4):1856–67. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 77.Maramraj KK, Subbalakshmi G, Ali MS, Dikid T, Yadav R, Sodha SV et al. A community-wide acute diarrheal disease outbreak associated with drinking contaminated water from shallow bore-wells in a tribal village, India, 2017. BMC Public Health. 2020;20(1). Available from: 10.1186/s12889-020-8263-2. [DOI] [PMC free article] [PubMed]
  • 78.Kumar A, Saurabh S, Jamil S, Kumar V. Intensely clustered outbreak of visceral leishmaniasis (kala-azar) in a setting of seasonal migration in a village of Bihar, India. BMC Infect Dis. 2020;20(1). Available from: 10.1186/s12879-019-4719-3. [DOI] [PMC free article] [PubMed]
  • 79.Singh A, Gupta R, Dikid T, Saroha E, Sharma NC, Sagar S et al. Cholera outbreak investigation, Bhadola, Delhi, India, April-May 2018. Trans R Soc Trop Med Hyg. 2020;114(10):762 EP – 769. [DOI] [PubMed]
  • 80.Arunkumar G, Arunkumar G, Chandni R, Chandni R, Mourya DT, Mourya DT, et al. Outbreak Investigation of Nipah Virus Disease in Kerala, India, 2018. J Infect Dis. 2019;219(12):1867–78. [DOI] [PubMed] [Google Scholar]
  • 81.Moghe CS, Moghe CS, Goel P, Goel P, Singh J, Singh J, et al. Mumps outbreak investigation in Jaisalmer, Rajasthan, India, June-September 2016. J Med Virol. 2019;91(3):347–50. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 82.Goswami S, Goswami S, Jha A, Jha A, Sivan SP, Sivan SP, et al. Outbreak investigation of cholera outbreak in a slum area of urban Wardha, India: An interventional epidemiological study. J Fam Med Prim Care. 2019;8(3):1112–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 83.Bajaj S, Bajaj S, Dudeja P, Dudeja P. Food poisoning outbreak in a religious mass gathering. Med J Armed Forces India. 2019;75(3):339–43. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 84.Kumar T, Shrivastava A, Bhatia D, Mitra Y, Kumar A, Hussain S et al. Jaundice outbreak likely caused by HEV in Amritsar, Punjab, India, 2013. BMC Public Health. 2019;19(S3). Available from: 10.1186/s12889-019-6786-1 [DOI] [PMC free article] [PubMed]
  • 85.Meyers J, Logaraj M, Ramraj B, Narasimhan P, MacIntyre CR. Epidemic Varicella Zoster Virus among University Students, India. Emerg Infect Dis. 2018;24(2):366–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 86.Sahay RR, Sahay RR, Yadav PD, Yadav PD, Majumdar T, Majumdar T, et al. Clinico-epidemiological investigation on Varicella Zoster Virus indicates multiple clade circulation in Maharashtra state, India. Heliyon. 2018;4(8):e00757. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 87.Rakesh PS, Rakesh PS, Mainu TTCR, Mainu TTCR, Raj A, Raj A, et al. Investigating a community wide outbreak of hepatitis A in Kerala, India. J Fam Med Prim Care. 2018;7(6):1537–41. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 88.Vaidya SR, Tilavat SM, Kumbhar NS, Kamble MB. Chickenpox outbreak in a tribal and industrial zone from the Union Territory of Dadra and Nagar Haveli, India. Epidemiol Infect. 2018;146(4):476–80. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 89.Rakesh PS, Rakesh PS, Thiagesan R, Thiagesan R, Ramachandran R, Ramachandran R. A point source outbreak of acute gastroenteritis among school students in Kerala, India. Indian J Public Health. 2017;61(4):302–4. [DOI] [PubMed] [Google Scholar]
  • 90.Sadanandane C, Elango A, Marja N, Sasidharan PV, Raju KHK, Jambulingam P. An outbreak of Kyasanur forest disease in the Wayanad and Malappuram districts of Kerala, India. Ticks Tick-Borne Dis. 2017;8(1):25 EP – 30. [DOI] [PubMed]
  • 91.Tilavat SM, Vaidya SR, Hamde VS. Mumps outbreak in a tribal population from the Union Territory of Dadra and Nagar Haveli, India. J Med Virol. 2017;89(12):2064. EP – 2068. [DOI] [PubMed] [Google Scholar]
  • 92.Debnath F, Ponnaiah M, Acharya P. Dengue fever in a municipality of West Bengal, India, 2015: An outbreak investigation. Indian J Public Health. 2017;61(4):239 EP – 242. [DOI] [PubMed]
  • 93.Rathi P, Narendra V, Sathiya V, Kini S, Kumar A, Sana N, et al. Measles outbreak in the adolescent population - Matter of concern? J Clin Diagn Res. 2017;11(8):LC20–3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 94.Rakesh PS, Rakesh PS, Narayanan V, Narayanan V, Pillai SS, Pillai SS, et al. Investigation of an Outbreak of Acute Gastroenteritis in Kollam, Kerala, India. J Prim Care Community Health. 2016;7(3):204–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 95.Roy JS, Roy JS, Saikia L, Saikia L, Medhi M, Medhi M, et al. Epidemiological investigation of an outbreak of typhoid fever in Jorhat town of Assam, India. Indian J Med Res. 2016;144(4):592–6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 96.Raveendran S, Raveendran S, Rakesh PS, Rakesh PS, Dev S, Dev S, et al. Investigation of an Outbreak of Hepatitis A in a Coastal Area, Kerala, Southern India. J Prim Care Community Health. 2016;7(4):288–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 97.Gurav YK, Gurav YK, Bondre VP, Bondre VP, Tandale BV, Tandale BV, et al. A large outbreak of Japanese encephalitis predominantly among adults in northern region of West Bengal, India. J Med Virol. 2016;88(11):2004–11. [DOI] [PubMed] [Google Scholar]
  • 98.Raoot A, Dewan DK, Dubey AP, Batra RK, Seth S. Measles Outbreak in High Risk Areas of Delhi: Epidemiological Investigation and Laboratory Confirmation. Indian J Pediatr. 2016;83(3):200–8. [DOI] [PubMed] [Google Scholar]
  • 99.Mondal TK, Mondal TK, Ghosh S, Ghosh S, Dasgupta S, Dasgupta S, et al. Suspected anthrax outbreak: Investigation in a rural block of west Bengal and public health response. Indian J Public Health. 2015;59(4):302–5. [DOI] [PubMed] [Google Scholar]

Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

12910_2026_1492_MOESM1_ESM.docx (964.2KB, docx)

Supplementary Material 1. [24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70, 71, 72, 73, 74, 75, 76, 77, 78, 79, 80, 81, 82, 83, 84, 85, 86, 87, 88, 89, 90, 91, 92, 93, 94, 95, 96, 97, 98, 99]

Data Availability Statement

All data analysed during this study are included in this published article and its supplement materials (Table S4).

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