Integrating behavioral surveillance into emerging infectious disease prevention

Pandemics associated with emerging infectious diseases, particularly zoonotic infections, are increasing in both frequency and impact. Over the past decade, attempts to control deadly zoonotic viruses like severe acute respiratory syndrome (SARS) and Middle Eastern respiratory syndrome (MERS) coronaviruses, and highly pathogenic avian influenza viruses, have been, out of necessity, almost entirely reactionary. The Ebola outbreak in West Africa, which is not yet contained, and the recent MERS outbreak in South Korea, highlight the rapidity with which these deadly infections can spread. While detection of Ebola was relatively slow in West Africa and response even slower, MERS in South Korea was identified quickly. Yet cases in South Korea ballooned to 164 within 30 days with 24 deaths despite a lack of evidence of sustained human-to-human transmission. Both epidemics share underlying super-spreader mechanisms of transmission attributable directly to cultural practices that were not immediately considered or addressed. In settings where infectious disease surveillance exists, the focus is on the biological monitoring of a population, often in sentinel hospitals. When emerging infectious disease outbreaks occur and surviving infected individuals come to hospital, an outbreak has generally already established itself in at least one community. Once a pathogen is newly identified or occurs in a novel environment, outbreak investigations are implemented. Standard operating procedures in outbreak investigations are listed in Box 1. This is the best case scenario. In many countries with a high risk of zoonotic disease spillover from animals to humans, systematic infectious disease surveillance does not exist. In this situation, investigations are implemented when outbreaks come to the attention of medical authorities—and the authorities are influential and persistent enough to bring about action. In terms of outbreak investigation and response, South Korea provides a best case example, West Africa a worst. Yet both experienced epidemics graver than expectations would have predicted, particularly after the outbreaks had been confirmed and control and prevention measures implemented. Contact tracing (Step 5) and survey development and implementation (Step 6), the cornerstones of disease control, are detailed in their biological assessment of disease and focused on identifying cases (i.e., infected individuals) and contacts of cases. These elements are essential in efforts to control and prevent emerging infectious disease transmission. Yet these types of traditional outbreak surveys are developed by medical personnel and epidemiologists, and Box 1. Epidemiologic steps of an outbreak investigation