Table.

Examples of disruptive factors and their manifestations that require mitigation for effective preparedness

	Disruptive factors	Examples of manifestations
Political and institutional	National governments; international agencies; non-governmental organisations and charities; corporate entities; academic institutions	Weakness in behavioural change guidance from national and international organisations; scarcity of sustainable leadership and financing in failed states leading to neglected or uncoordinated health systems; increasing duration and frequency of insecurity or conflict zones hindering efforts to recognise and respond to health threats; failure of countries to report disease outbreaks because of fear of economic consequences
Social	Travel patterns, migration, and interconnectivity; trade; technology and digital revolution, including those that affect human interaction; expansion and control of information; patterns of communication including social media; expectations and definition of expertise; social conflict and privacy	Failure of host countries to protect the health of refugees and migrants; epidemic of devastating rumours and fake news on social media due to increased digital connectivity; emergence of social influencers exerting influence on politicians and institutions; increased resistance and hesitancy within communities to health interventions because of opposition by local experts
Environment	Geography affecting biological diversity; planned and unplanned urbanisation; climate change; interaction between humans, animals, and vectors; human development; state of the economy; state of health systems	Climate change resulting in increased flooding with failed sanitation and safe water; altered distribution of zoonotic disease reservoirs and vectors; emerging zoonosis with increased agricultural production and human encroachment into animal environments; changing national priorities resulting in sharply reduced investment in health systems
Pathogenesis	Changing disease biomes; relationship between hosts and pathogens; pathogen evolution and changes; technologies such as synthetic biology, and the risks of manufacturing pathogens and their accidental or deliberate release; characteristics of a population such as underlying disease condition	Increased opportunities for mutation or reassortment of infectious agents; increasingly reduced effectiveness of conventional vaccines and therapeutics for prevention and treatment of diseases; failure of conventional control measures to break the chain of transmission of infectious agents