Integrated Biological-Behavioural Surveillance in Pandemic-Threat Warning systems/Surveillance Biologico-Comportementale Integree Dans Les Systemes D'alerte De Menaces pandemiques/Vigilancia Integrada De Datos Biologicos Y del Comportamiento En Sistemas De Aviso De Amenazas De Pandemia

Introduction No other modern epidemic or pandemic mobilized the global health community to action like the 2013-2016 Ebola virus disease outbreak in western Africa. Following the outbreak, calls for pandemic-threat warning systems came from both traditional public health policy-makers (1,2) and national governments. (3) As currently conceptualized, 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) Once an outbreak is verified, well-established protocols for disease investigation and control can be swiftly put in place--although it maybe many months before the main risk factors and most effective control measures are identified. The Ebola outbreak in western Africa probably began in December 2013 (5) 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) Monitoring emerging infectious diseases Although human behaviours often increase the risk of acquiring an infectious disease, the systematic investigation of human risk behaviours is seldom included in disease surveillance strategies. (7) However, behavioural surveillance to improve the understanding of human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome has been ongoing for decades. Behavioural assessment was key to the identification of injecting drug users as a high-risk group for HIV infection in the early 1980s. (8) It was also crucial in documenting the risks posed by HIV to women. (9) Subsequently, an innovative, practical method, which combines biological outcome data with behavioural risk factor data--i.e. exposure variables --was developed to document HIV transmission dynamics. Such integrated biological-behavioural surveillance has since become well established and standardized and been frequently implemented globally. (10,11) It has contributed extensively to a biologically-based and quantifiable understanding of the behavioural risk factors associated with the acquisition and transmission of HIV (12) and the early identification of subgroups of the population that may be more vulnerable to HIV infection. (9) More recently, data from integrated surveillance have been used to evaluate the impact of evidence-based interventions to prevent HIV infection and to monitor treatment uptake. (13) Similar surveillance could help identify behavioural risk factors and high-risk subgroups for zoonotic infections such as Ebola--potentially before diseases of pandemic potential are identified in clinical settings or major outbreaks occur in communities. Approximately half of the emerging pandemic threats are zoonotic in origin. (14,15) At the time of writing, the most lethal and costly pandemics of the 21st century, i.e. avian influenza, Ebola, Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS), have all been caused by zoonotic viruses. (16-19) Little is known about either the risk factors that lead to the initial spillover of a zoonotic disease into human populations or the dynamics of any subsequent human-to-human transmission. (20) Much more is known about (i) the locations of so-called hotspots where, many scientists believe, new pandemics of zoonotic disease are likely to emerge; (14) (ii) the kinds of ecological and environmental activities that have been associated with spillover and outbreaks of zoonotic disease in the past; (21) and (iii) the distinct spatial groupings of specific infectious diseases on a global scale, and the associated ecological and virological barriers to the dispersal and establishment of those diseases. (22) In the development of pandemic-threat warning systems, integrated biological-behavioural surveillance can be tightly focused on specific viral families in the high-risk population subgroups that live in identified hotspots and are environmentally or occupationally exposed to animals. …