The outbreak of Ebola virus disease (EVD) that started in December 2013 has defied several months of mitigation and containment efforts. In July 2014 it was still evolving in Guinea, Liberia and Sierra Leone. As of 20 August, the toll in those countries had reached 844 EVD confirmed deaths 1. On 20 July, the outbreak reached Nigeria through an infected traveler coming from Liberia. The Nigerian official reports list 12 probable cases, and it is not clear if the outbreak has been contained.
EVD is caused by infection with a virus of the family Filoviridae, genus Ebolavirus 2. EVD transmission during the incubation period is very unlikely and occurs via direct contact with blood, secretions, and/or other bodily fluids of dead or living infected persons. Gene sequencing of the virus causing the 2014 West African (2014WA) outbreak has demonstrated 98% homology with the Zaire Ebola virus, with a 55% case fatality ratio (CFR) across the affected countries 3. Unfortunately there are no licensed treatments available for EVD, and severely ill patients can only be cared for with intensive supportive care.
The 2014WA outbreak is the largest ever observed, both by number of cases and geographical extension. For this reason, on 6-7 August, an Emergency Committee of the WHO 4 advised the 2014WA outbreak constitutes an ?extraordinary event? and a public health risk to other States. Indeed, although the outbreak started in an isolated region of Guinea, transmission has occurred in large cities (Conakry, Freetown, Monrovia and Lagos) of the four affected countries. These urban areas have major international airports, thus raising concern about a quick internationalization of the outbreak (see Fig. 1). While importation of cases should not generate large outbreaks in countries where prompt isolation of cases in appropriate health care facilities occurs, it is clear that a quantitative analysis of the risk of importation of cases (likelihood, timeline, number of cases) in countries not affected at the moment by the outbreak may provide valuable intelligence on the evolution of the 2014WA outbreak.
So far most of the analyses on the risk of international spread of the outbreak have focused on the analysis of the sheer volume of international passenger traffic across countries 5,6. These analyses however do not consider the local evolution of the outbreak in the affected countries and the specific etiology of the disease (incubation time scale, etc.). Here we provide a quantitative assessment of the international spread based on large-scale computer microsimulations of the 2014WA outbreak that generate stochastic simulations of epidemic spread worldwide, yielding, among other measures, the case importation events at a daily resolution for 3,362 subpopulations in 220 countries. We use the Global Epidemic and Mobility Model that integrates high-resolution data on human demography and mobility on a worldwide scale in a metapopulation stochastic epidemic model 7,8,9. The disease dynamics within each population consider explicitly that EVD transmissions occur in the general community, in hospital settings, and during funeral rites 10. For parameter inference, we use a Monte Carlo likelihood analysis that considers more than 1,000,000 simulations that sample the disease model space and the data on the 2014WA outbreak up to 9 August 2014. This approach selects the disease dynamic model that we use to generate numerical stochastic simulations of an epidemic?s local (within West African countries) and global progression.
We evaluate the progression of the epidemic in West Africa and its international spread under the assumption that the EVD outbreak continues to evolve at the current pace. The numerical simulation results show a steep increase of cases in the West Africa region, unless the transmissibility of the EVD is successfully mitigated. The overall basic reproductive number of the epidemic in the region is estimated to be in the range 1.5 − 2.0. We find that, although surveillance and containment measures have been in place for several months, the transmissibility in hospital and funeral rites are likely an appreciable component of the overall transmissibility. The probability of case exportation is extremely modest (upper bound less than 5%) for non-African countries, with the exception of the United Kingdom (UK), Belgium, France and the United States (US). As of the beginning of September, the countries with the largest probability of seeing the arrival of EVD cases are Ghana, UK and Gambia. The overall probability of international spread will increase if the Nigerian outbreak is not promptly controlled. We also show that as of the end of September, the size distribution of outbreaks due to the international spread of the EVD is contained (median value <4 cases) for countries outside of the African region. Severe travel restrictions to and from the affected areas (80% airline traffic reduction) generates only a 3-4 weeks delay in the international spreading.
The lack of detailed data on the 2014WA EVD outbreak makes any modeling approach vulnerable to the many assumptions and uncertainty about basic parameters and the quality of data. However, we hope that the characterization of the EVD 2014WA outbreak and the associated risk of international spread provided here may be useful to national and international agencies in allocating resources for interventions to contain and to mitigate the epidemic.