Coevolution of pathogens and cultural practices: a new look at behavioral heterogeneity in epidemics

The effect of heterogeneity within populations on the spread of infectious diseases has been a recent focus of research. Such heterogeneity may be, for example, spatial, temporal or behavioral in form. Generally, models that include population subdivision have assumed that individuals are permanently assigned to given behavioral states represented by the subpopulations. We consider a simple epidemic model in which a behavioral trait affects disease transmission, and this trait may be transferred among hosts as a consequence of social interaction. This creates a situation where the frequencies of different behavioral traits and disease states as well as their associations may change over time. We consider the impact of the culturally transmitted trait on the criterion for initial spread of the disease. We also explore the evolution of cultural traits in response to pathogen dynamics and show some conditions under which behavioral traits that reduce transmission evolve. We find that behaviors increasing the risk of infection can also evolve when they are inherently favored or when there is sufficient clustering of contacts between like behaviors.     

Covariation between the physiological and behavioral components of pathogen transmission: host heterogeneity determines epidemic outcomes

Although heterogeneity in contact rate, physiology, and behavioral response to infection have all been empirically demonstrated in host–pathogen systems, little is known about how interactions between individual variation in behavior and physiology scale‐up to affect pathogen transmission at a population level. The objective of this study is to evaluate how covariation between the behavioral and physiological components of transmission might affect epidemic outcomes in host populations. We tested the consequences of contact rate covarying with susceptibility, infectiousness, and infection status using an individual‐based, dynamic network model where individuals initiate and terminate contacts with conspecifics based on their behavioral predispositions and their infection status. Our results suggest that both heterogeneity in physiology and subsequent covariation of physiology with contact rate could powerfully influence epidemic dynamics. Overall, we found that 1) individual variability in susceptibility and infectiousness can reduce the expected maximum prevalence and increase epidemic variability; 2) when contact rate and susceptibility or infectiousness negatively covary, it takes substantially longer for epidemics to spread throughout the population, and rates of epidemic spread remained suppressed even for highly transmissible pathogens; and 3) reductions in contact rate resulting from infection‐induced behavioral changes can prevent the pathogen from reaching most of the population. These effects were strongest for theoretical pathogens with lower transmissibility and for populations where the observed variation in contact rate was higher, suggesting that such heterogeneity may be most important for less infectious, more chronic diseases in wildlife. Understanding when and how variability in pathogen transmission should be modelled is a crucial next step for disease ecology.     

Network frailty and the geometry of herd immunity

The spread of infectious disease through communities depends fundamentally on the underlying patterns of contacts between individuals. Generally, the more contacts one individual has, the more vulnerable they are to infection during an epidemic. Thus, outbreaks disproportionately impact the most highly connected demographics. Epidemics can then lead, through immunization or removal of individuals, to sparser networks that are more resistant to future transmission of a given disease. Using several classes of contact networks-Poisson, scale-free and small-world-we characterize the structural evolution of a network due to an epidemic in terms of frailty (the degree to which highly connected individuals are more vulnerable to infection) and interference (the extent to which the epidemic cuts off connectivity among the susceptible population that remains following an epidemic). The evolution of the susceptible network over the course of an epidemic differs among the classes of networks; frailty, relative to interference, accounts for an increasing component of network evolution on networks with greater variance in contacts. The result is that immunization due to prior epidemics can provide greater community protection than random vaccination on networks with heterogeneous contact patterns, while the reverse is true for highly structured populations.     

A generalized model of social and biological contagion

We present a model of contagion that unifies and generalizes existing models of the spread of social influences and microorganismal infections. Our model incorporates individual memory of exposure to a contagious entity (e.g. a rumor or disease), variable magnitudes of exposure (dose sizes), and heterogeneity in the susceptibility of individuals. Through analysis and simulation, we examine in detail the case where individuals may recover from an infection and then immediately become susceptible again (analogous to the so-called SIS model). We identify three basic classes of contagion models which we call epidemic threshold, vanishing critical mass, and critical mass classes, where each class of models corresponds to different strategies for prevention or facilitation. We find that the conditions for a particular contagion model to belong to one of the these three classes depend only on memory length and the probabilities of being infected by one and two exposures, respectively. These parameters are in principle measurable for real contagious influences or entities, thus yielding empirical implications for our model. We also study the case where individuals attain permanent immunity once recovered, finding that epidemics inevitably die out but may be surprisingly persistent when individuals possess memory.     

Coupled Contagion Dynamics of Fear and Disease: Mathematical and Computational Explorations

Background

In classical mathematical epidemiology, individuals do not adapt their contact behavior during epidemics. They do not endogenously engage, for example, in social distancing based on fear. Yet, adaptive behavior is well-documented in true epidemics. We explore the effect of including such behavior in models of epidemic dynamics.

Methodology/Principal Findings

Using both nonlinear dynamical systems and agent-based computation, we model two interacting contagion processes: one of disease and one of fear of the disease. Individuals can “contract” fear through contact with individuals who are infected with the disease (the sick), infected with fear only (the scared), and infected with both fear and disease (the sick and scared). Scared individuals–whether sick or not–may remove themselves from circulation with some probability, which affects the contact dynamic, and thus the disease epidemic proper. If we allow individuals to recover from fear and return to circulation, the coupled dynamics become quite rich, and can include multiple waves of infection. We also study flight as a behavioral response.

Conclusions/Significance

In a spatially extended setting, even relatively small levels of fear-inspired flight can have a dramatic impact on spatio-temporal epidemic dynamics. Self-isolation and spatial flight are only two of many possible actions that fear-infected individuals may take. Our main point is that behavioral adaptation of some sort must be considered.     

Lattice Model for Influenza Spreading with Spontaneous Behavioral Changes

Individual behavioral response to the spreading of an epidemic plays a crucial role in the progression of the epidemic itself. The risk perception induces individuals to adopt a protective behavior, as for instance reducing their social contacts, adopting more restrictive hygienic measures or undergoing prophylaxis procedures. In this paper, starting with a previously developed lattice-gas SIR model, we construct a coupled behavior-disease model for influenza spreading with spontaneous behavioral changes. The focus is on self-initiated behavioral changes that alter the susceptibility to the disease, without altering the contact patterns among individuals. Three different mechanisms of awareness spreading are analyzed: the local spreading due to the presence in the neighborhood of infective individuals; the global spreading due to the news published by the mass media and to educational campaigns implemented at institutional level; the local spreading occurring through the “thought contagion” among aware and unaware individuals. The peculiarity of the present approach is that the awareness spreading model is calibrated on available data on awareness and concern of the population about the risk of contagion. In particular, the model is validated against the A(H1N1) epidemic outbreak in Italy during the season, by making use of the awareness data gathered by the behavioral risk factor surveillance system (PASSI). We find that, increasing the accordance between the simulated awareness spreading and the PASSI data on risk perception, the agreement between simulated and experimental epidemiological data improves as well. Furthermore, we show that, within our model, the primary mechanism to reproduce a realistic evolution of the awareness during an epidemic, is the one due to globally available information. This result highlights how crucial is the role of mass media and educational campaigns in influencing the epidemic spreading of infectious diseases.     

Dynamic health policies for controlling the spread of emerging infections: influenza as an example

The recent appearance and spread of novel infectious pathogens provide motivation for using models as tools to guide public health decision-making. Here we describe a modeling approach for developing dynamic health policies that allow for adaptive decision-making as new data become available during an epidemic. In contrast to static health policies which have generally been selected by comparing the performance of a limited number of pre-determined sequences of interventions within simulation or mathematical models, dynamic health policies produce "real-time" recommendations for the choice of the best current intervention based on the observable state of the epidemic. Using cumulative real-time data for disease spread coupled with current information about resource availability, these policies provide recommendations for interventions that optimally utilize available resources to preserve the overall health of the population. We illustrate the design and implementation of a dynamic health policy for the control of a novel strain of influenza, where we assume that two types of intervention may be available during the epidemic: (1) vaccines and antiviral drugs, and (2) transmission reducing measures, such as social distancing or mask use, that may be turned "on" or "off" repeatedly during the course of epidemic. In this example, the optimal dynamic health policy maximizes the overall population's health during the epidemic by specifying at any point of time, based on observable conditions, (1) the number of individuals to vaccinate if vaccines are available, and (2) whether the transmission-reducing intervention should be either employed or removed.     

Population structure and the spread of disease

A common assumption of many mathematical models for the spread of disease is that there is random mixing among all individuals in the host population. This paper analyzes and develops a model for the spread of disease in a population consisting of several interacting subpopulations. The model considers 2 different types of interactions between individuals: 1) within a subpopulation because of geographic proximity, and 2) of the same or different subpopulations because of attendance at common social functions. A stability analysis performed on the equilibria of the model shows 2 stable states: 1) a population composed solely of susceptible individuals with no disease present, and 2) an interior point where there are susceptible, infective, and recovered individuals present at all times. The analysis shows that the threshold for disease maintenance is more easily exceed in centers that are members of a small local cluster than in randomly mixing centers, but that the spread of the disease throughout the population occurs more rapidly when the initial case attends a randomly mixing center. The conditions under which a disease will become established are dependent upon the transmission rate for the disease, the birth and death rate in each neighborhood, the recovery rate from the disease in each neighborhood, and the movement patterns of the individuals in the population. The study of the spread of disease in a population by means of mathematical models provides a valuable addition to the statistical data analyzed by epidemiologists. This model is relevant any time there is a division of the population into several interacting groups in which the probability of disease spread is a function both of neighborhood contact because of geographic proximity and of social interactions between groups.     

Dynamic population epidemic models.

Most multipopulation epidemic models are of the contact distribution type, in which the locations of successive contacts are chosen independently from appropriate contact distributions. This paper is concerned with an alternative class of models, termed dynamic population epidemic models, in which infectives move among the populations and can infect only within their current population. Both the stochastic and deterministic versions of such models are considered. Their threshold behavior is analyzed in some depth, as are their final outcomes. Velocities of spread of infection are considered when the populations have a spatial structure. A criterion for finding the equivalent contact distribution epidemic for any given dynamic population epidemic is provided, enabling comparisons to be made for the velocities and final outcomes displayed by the two classes of models. The relationship between deterministic and stochastic epidemic models is also discussed briefly.     

The Effects of Media Reports on Disease Spread and Important Public Health Measurements

Controlling the spread of influenza to reduce the effects of infection on a population is an important mandate of public health. Mass media reports on an epidemic or pandemic can provide important information to the public, and in turn, can induce positive healthy behaviour practices (i.e., handwashing, social distancing) in the individuals, that will reduce the probability of contracting the disease. Mass media fatigue, however, can dampen these effects. Mathematical models can be used to study the effects of mass media reports on epidemic/pandemic outcomes. In this study we employ a stochastic agent based model to provide a quantification of mass media reports on the variability in important public health measurements. We also include mass media report data compiled by the Global Public Health Intelligence Network, to study the effects of mass media reports in the 2009 H1N1 pandemic. We find that the report rate and the rate at which individuals relax their healthy behaviours (media fatigue) greatly affect the variability in important public health measurements. When the mass media reporting data is included in the model, two peaks of infection result.     

The impacts of network topology on disease spread

Individuals in a population susceptible to a disease may be represented as vertices in a network, with the edges that connect vertices representing social and/or spatial contact between individuals. Networks, which explicitly included six different patterns of connection between vertices, were created. Both scale-free networks and random graphs showed a different response in path level to increasing levels of clustering than regular lattices. Clustering promoted short path lengths in all network types, but randomly assembled networks displayed a logarithmic relationship between degree and path length; whereas this response was linear in regular lattices. In all cases, small-world models, generated by rewiring the connections of a regular lattice, displayed properties, which spanned the gap between random and regular networks.Simulation of a disease in these networks showed a strong response to connectance pattern, even when the number of edges and vertices were approximately equal. Epidemic spread was fastest, and reached the largest size, in scale-free networks, then in random graphs. Regular lattices were the slowest to be infected, and rewired lattices were intermediate between these two extremes. Scale-free networks displayed the capacity to produce an epidemic even at a likelihood of infection, which was too low to produce an epidemic for the other network types. The interaction between the statistical properties of the network and the results of epidemic spread provides a useful tool for assessing the risk of disease spread in more realistic networks.     

Effects of behavioral changes in a smallpox attack model

The impact of individual and community behavioral changes in response to an outbreak of a disease with high mortality is often not appreciated. Response strategies to a smallpox bioterrorist attack have focused on interventions such as isolation of infectives, contact tracing, quarantine of contacts, ring vaccination, and mass vaccination. We formulate and analyze a mathematical model in which some individuals lower their daily contact activity rates once an epidemic has been identified in a community. Transmission parameters are estimated from data and an expression is derived for the effective reproduction number. We use computer simulations to analyze the effects of behavior change alone and in combination with other control measures. We demonstrate that the spread of the disease is highly sensitive to how rapidly people reduce their contact activity rates and to the precautions that the population takes to reduce the transmission of the disease. Even gradual and mild behavioral changes can have a dramatic impact in slowing an epidemic. When behavioral changes are combined with other interventions, the epidemic is shortened and the number of smallpox cases is reduced. We conclude that for simulations of a smallpox outbreak to be useful, they must consider the impact of behavioral changes. This is especially true if the model predictions are being used to guide public health policy.     

Risk perception and effectiveness of uncoordinated behavioral responses in an emerging epidemic

Beyond control measures imposed by public authorities, human behavioral changes can be triggered by uncoordinated responses driven by the risk perception of an emerging epidemic. In order to account for spontaneous social distancing, a model based on an evolutionary game theory framework is here proposed. Behavioral changes are modeled through an imitation process in which the convenience of different behaviors depends on the perceived prevalence of infections. Effects of misperception of risk induced by partial or incorrect information concerning the state of the epidemic are considered as well. Our findings highlight that, if the perceived risk associated to an epidemic is sufficiently large, then even a small reduction in the number of potentially infectious contacts (as a response to the epidemic) can remarkably affect the infection spread. In particular, the earlier the warning about the epidemic appears, the larger the possible reduction of the peak prevalence, and of the final epidemic size. Moreover, the epidemic spread is delayed if individuals' perception of risk is based on a memory mechanism and the risk of infection is initially overestimated. In conclusion, this analysis allows noteworthy inferences about the role of risk perception and the effectiveness of spontaneous behavioral changes during an emerging epidemic.     

The effect of risk perception on the 2009 H1N1 pandemic influenza dynamics

Background

The 2009 H1N1 pandemic influenza dynamics in Italy was characterized by a notable pattern: as it emerged from the analysis of influenza-like illness data, after an initial period (September–mid-October 2009) characterized by a slow exponential increase in the weekly incidence, a sudden and sharp increase of the growth rate was observed by mid-October. The aim here is to understand whether spontaneous behavioral changes in the population could be responsible for such a pattern of epidemic spread.

Methodology/Principal Findings

In order to face this issue, a mathematical model of influenza transmission, accounting for spontaneous behavioral changes driven by cost/benefit considerations on the perceived risk of infection, is proposed and validated against empirical epidemiological data. The performed investigation revealed that an initial overestimation of the risk of infection in the general population, possibly induced by the high concern for the emergence of a new influenza pandemic, results in a pattern of spread compliant with the observed one. This finding is also supported by the analysis of antiviral drugs purchase over the epidemic period. Moreover, by assuming a generation time of 2.5 days, the initially diffuse misperception of the risk of infection led to a relatively low value of the reproductive number , which increased to in the subsequent phase of the pandemic.

Conclusions/Significance

This study highlights that spontaneous behavioral changes in the population, not accounted by the large majority of influenza transmission models, can not be neglected to correctly inform public health decisions. In fact, individual choices can drastically affect the epidemic spread, by altering timing, dynamics and overall number of cases.     

Stochastic two-group models with transmission dependent on host infectivity or susceptibility

ABSTRACT

Stochastic epidemic models with two groups are formulated and applied to emerging and re-emerging infectious diseases. In recent emerging diseases, disease spread has been attributed to superspreaders, highly infectious individuals that infect a large number of susceptible individuals. In some re-emerging infectious diseases, disease spread is attributed to waning immunity in susceptible hosts. We apply a continuous-time Markov chain (CTMC) model to study disease emergence or re-emergence from different groups, where the transmission rates depend on either the infectious host or the susceptible host. Multitype branching processes approximate the dynamics of the CTMC model near the disease-free equilibrium and are used to estimate the probability of a minor or a major epidemic. It is shown that the probability of a major epidemic is greater if initiated by an individual from the superspreader group or by an individual from the highly susceptible group. The models are applied to Severe Acute Respiratory Syndrome and measles.     

Persistence of viral infections on the population level explained by an immunoepidemiological model

We consider a mathematical model of viral spread in a population based on an immune response model embedded in an epidemic network model. The immune response model includes virus load and effector and memory T cells with two possible outcomes depending on parameters: (a) virus clearance and establishment of immune memory and (b) establishment of a non-zero viral presence characterized with increased T-cell concentrations. Isolated individuals can have different immune system parameters and, after a primary infection, can either return to the infection-free state or develop persistent or chronic infection. When individuals are connected in the network, they can reinfect each other. We show that the virus can persist in the epidemic network for indefinite time even if the whole population consists of individuals that are able to clear the virus when isolated from the network. In this case a few individuals with a relatively weak immune response can maintain the infection in the whole population. These results are in contrast to implications of classical epidemiological models that a viral epidemic will end if there is no influx of new susceptibles and if individuals can become immune after infection.     

Network epidemic models with two levels of mixing

The study of epidemics on social networks has attracted considerable attention recently. In this paper, we consider a stochastic SIR (susceptible-->infective-->removed) model for the spread of an epidemic on a finite network, having an arbitrary but specified degree distribution, in which individuals also make casual contacts, i.e. with people chosen uniformly from the population. The behaviour of the model as the network size tends to infinity is investigated. In particular, the basic reproduction number R(0), that governs whether or not an epidemic with few initial infectives can become established is determined, as are the probability that an epidemic becomes established and the proportion of the population who are ultimately infected by such an epidemic. For the case when the infectious period is constant and all individuals in the network have the same degree, the asymptotic variance and a central limit theorem for the size of an epidemic that becomes established are obtained. Letting the rate at which individuals make casual contacts decrease to zero yields, heuristically, corresponding results for the model without casual contacts, i.e. for the standard SIR network epidemic model. A deterministic model that approximates the spread of an epidemic that becomes established in a large population is also derived. The theory is illustrated by numerical studies, which demonstrate that the asymptotic approximations work well, even for only moderately sized networks, and that the degree distribution and the inclusion of casual contacts can each have a major impact on the outcome of an epidemic.     

Information-related changes in contact patterns may trigger oscillations in the endemic prevalence of infectious diseases

It is well known that behavioral changes in contact patterns may significantly affect the spread of an epidemic outbreak. Here we focus on simple endemic models for recurrent epidemics, by modelling the social contact rate as a function of the available information on the present and the past disease prevalence. We show that social behavior change alone may trigger sustained oscillations. This indicates that human behavior might be a critical explaining factor of oscillations in time-series of endemic diseases. Finally, we briefly show how the inclusion of seasonal variations in contacts may imply chaos.     

Modeling the AIDS epidemic in Mexico City

To study the future course of the AIDS epidemic in Mexico City, we use an open compartmental model to forecast new AIDS cases among homosexual and bisexual males and among heterosexual males and females. For each group three compartments are defined: uninfected persons, infected but asymptomatic persons, and persons diagnosed with AIDS. It is assumed that the AIDS epidemic will follow the propagation of infectious disease model, where spread of infection is proportional to the product of the number of healthy persons and the number of infected ones. The compartmental model is represented by a system of nonlinear differential equations describing the rate of change in the number of persons in each compartment. The impact of preventive measures is explored by decreasing the probability of HIV transmission, which is one of the model parameters representing behavioral patterns. By April 1989, 491 AIDS cases had been reported in Mexico City and classified as sexually related. Our model predicts that the AIDS incidence will continue to rise in Mexico City for the foreseeable future and will spread among the heterosexual population. Decreasing the transmission probability by 10% in all groups (through education programs) will result in a decrease of 18.1% in the number of accumulated cases over a 5-year period. A 20% decrease would prevent more than 31% of the cases. We conclude that mathematical models can be valuable in predicting the spread of the AIDS epidemic and the impact of behavioral change on its spread.