Changes in behavior and biomarkers during the diagnostic decision period for COVID-19, influenza, and group A streptococcus (GAS): a two-year prospective cohort study in Israel

Background: Limited knowledge exists regarding behavioral and biomarker shifts during the period from respiratory infection exposure to testing decisions (the diagnostic decision period), a key phase affecting transmission dynamics and public health strategy development. This study aims to examine the changes in behavior and biomarkers during the diagnostic decision period for COVID-19, influenza, and group A streptococcus (GAS). Methods: We analyzed data from a two-year prospective cohort study involving 4795 participants in Israel, incorporating smartwatch data, self-reported symptoms, and medical records. Our analysis focused on three critical phases: the digital incubation period (from exposure to physiological anomalies detected by smartwatches), the symptomatic incubation period (from exposure to onset of symptoms), and the diagnostic decision period for influenza, COVID-19, and GAS. Findings: The delay between initial symptom reporting and testing was 39 [95% confidence interval (CI): 34–45] hours for influenza, 53 [95% CI: 49–58] hours for COVID-19, and 38 [95% CI: 32–46] hours for GAS, with 73 [95% CI: 67–78] hours from anomalies in heart measures to symptom onset for influenza, 23 [95% CI: 18–27] hours for COVID-19, and 62 [95% CI: 54–68] hours for GAS. Analyzing the entire course of infection of each individual, the greatest changes in heart rates were detected 67.6 [95% CI: 62.8–72.5] hours prior to testing for influenza, 64.1 [95% CI: 61.4–66.7] hours prior for COVID-19, and 58.2 [95% CI: 52.1–64.2] hours prior for GAS. In contrast, the greatest reduction in physical activities and social contacts occurred after testing. Interpretation: These findings highlight the delayed response of patients in seeking medical attention and reducing social contacts and demonstrate the transformative potential of smartwatches for identifying infection and enabling timely public health interventions. Funding: This work was supported by the European Research Council, project #949850, the Israel Science Foundation (ISF), grant No. 3409/19, within the Israel Precision Medicine Partnership program, and a Koret Foundation gift for Smart Cities and Digital Living.