Abstract
Controlling many infectious diseases, including SARS-Coronavirus-2 (SARS-CoV-2), requires surveillance followed by isolation, contact-tracing and quarantining. These interventions often begin by identifying symptomatic individuals. However, actively removing pathogen strains causing symptomatic infections may inadvertently select for strains less likely to cause symptomatic infections. Moreover, a pathogen’s fitness landscape is structured around a heterogeneous host pool; uneven surveillance efforts and distinct transmission risks across host classes can meaningfully alter selection pressures. Here, we explore this interplay between evolution caused by disease control efforts and the evolutionary consequences of host heterogeneity. Using an evolutionary epidemiology model parameterized for coronaviruses, we show that intense symptoms-driven disease control selects for asymptomatic strains, particularly when these efforts are applied unevenly across host groups. Under these conditions, increasing quarantine efforts have diverging effects. If isolation alone cannot eradicate, intensive quarantine efforts combined with uneven detections of asymptomatic infections (e.g., via neglect of some host classes) can favor the evolution of asymptomatic strains. We further show how, when intervention intensity depends on the prevalence of symptomatic infections, higher removal efforts (and isolating symptomatic cases in particular) more readily select for asymptomatic strains than when these efforts do not depend on prevalence. The selection pressures on pathogens caused by isolation and quarantining likely lie between the extremes of no intervention and thoroughly successful eradication. Thus, analyzing how different public health responses can select for asymptomatic pathogen strains is critical for identifying disease suppression efforts that can effectively manage emerging infectious diseases.