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Significance Numerous factors affect early transmission by a newly infected host. A less symptomatic initial infection can persist longer due to reduced immune response, but at the cost of reduced transmission. Assuming simple trade-offs for progression and transmission rates in the initial infectious stage, we couple epidemiological and evolutionary dynamics. We find that fully asymptomatic, less symptomatic, or fully symptomatic first stages are possible evolutionary outcomes, with possible surprising bistability between zero and maximal asymptomatic behavior. This bistability implies that small changes in parameter values followed by reversion to their original values could lead to an alternative stable state with a qualitative difference in degree of first-stage symptoms. Therefore, disease control strategies can have dramatic evolutionary outcomes, cascading to epidemiological consequences.

Dynamics in a simple evolutionary-epidemiological model for the evolution of an initial asymptomatic infection stage