Abstract
Economically and politically disruptive disease outbreaks are a hallmark of the 21st century. Although pandemics are driven by human behaviours, current surveillance systems for identifying pandemic threats are largely reliant on the monitoring of disease outcomes in clinical settings. Standardized integrated biological–behavioural surveillance could, and should, be used in community settings to complement such clinical monitoring. The usefulness of such an approach has already been demonstrated in studies on human immunodeficiency virus, where integrated surveillance contributed to a biologically based and quantifiable understanding of the behavioural risk factors associated with the transmission dynamics of the virus. When designed according to Strengthening the Reporting of Observational Studies in Epidemiology criteria, integrated surveillance requires that both behavioural risk factors – i.e. exposure variables – and disease-indicator outcome variables be measured in behavioural surveys. In the field of pandemic threats, biological outcome data could address the weaknesses of self-reported data collected in behavioural surveys. Data from serosurveys of viruses with pandemic potential, collected under non-outbreak conditions, indicate that serosurveillance could be used to predict future outbreaks. When conducted together, behavioural surveys and serosurveys could warn of future pandemics, potentially before the disease appears in clinical settings. Traditional disease-outcome surveillance must be frequent and ongoing to remain useful but behavioural surveillance remains informative even if conducted much less often, since behaviour change occurs slowly over time. Only through knowledge of specific behavioural risk factors can interventions and policies that can prevent the next pandemic be developed.
Highlights
No other modern epidemic or pandemic mobilized the global health community to action like the 2013–2016 Ebola virus disease outbreak in western Africa
The first step in the identification of a pandemic threat requires an outbreak of sufficient size to come to the attention of medical personnel who are sufficiently influential and persistent to ensure action.[4]
The Ebola outbreak in western Africa probably began in December 20135 but it took another year before traditional burial practices were found to be a leading cause of the rapid spread of the causative virus.[6]
Summary
No other modern epidemic or pandemic mobilized the global health community to action like the 2013–2016 Ebola virus disease outbreak in western Africa. As current behaviours may not reflect the behaviours that originally exposed the individuals who are found seropositive to the virus of interest, both current and lifetime behaviours need to be investigated This is the strategy that has proved successful in identifying subtle exposure risks in the field of HIV, such as backloading of syringes with drug solution by injecting drug users.[55] In identifying specific behavioural risk factors, integrated biological–behavioural surveillance will be most effective when the reported syndromic symptoms are recent, e.g. occurring in the previous 12 months, and their probable association with a zoonotic virus can be confirmed by a positive serological test result
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