Ebola Cases and Health System Demand in Liberia

The authors develop a multi-type branching process model of the 2014 Liberian Ebola outbreak that incorporates the impacts of changes in behavior on potential transmission scenarios, thereby informing the path to containment of the epidemic.In 2014, a major epidemic of human Ebola virus disease emerged in West Africa, where human-to-human transmission has now been sustained for greater than 12 months. In the summer of 2014, there was great uncertainty about the answers to several key policy questions concerning the path to containment. What is the relative importance of nosocomial transmission compared with community-acquired infection? How much must hospital capacity increase to provide care for the anticipated patient burden? To which interventions will Ebola transmission be most responsive? What must be done to achieve containment? In recent years, epidemic models have been used to guide public health interventions. But, model-based policy relies on high quality causal understanding of transmission, including the availability of appropriate dynamic transmission models and reliable reporting about the sequence of case incidence for model fitting, which were lacking for this epidemic. To investigate the range of potential transmission scenarios, we developed a multi-type branching process model that incorporates key heterogeneities and time-varying parameters to reflect changing human behavior and deliberate interventions in Liberia. Ensembles of this model were evaluated at a set of parameters that were both epidemiologically plausible and capable of reproducing the observed trajectory. Results of this model suggested that epidemic outcome would depend on both hospital capacity and individual behavior. Simulations suggested that if hospital capacity was not increased, then transmission might outpace the rate of isolation and the ability to provide care for the ill, infectious, and dying. Similarly, the model suggested that containment would require individuals to adopt behaviors that increase the rates of case identification and isolation and secure burial of the deceased. As of mid-October, it was unclear that this epidemic would be contained even by 99% hospitalization at the planned hospital capacity. A new version of the model, updated to reflect information collected during October and November 2014, predicts a significantly more constrained set of possible futures. This model suggests that epidemic outcome still depends very heavily on individual behavior. Particularly, if future patient hospitalization rates return to background levels (estimated to be around 70%), then transmission is predicted to remain just below the critical point around Reff = 1. At the higher hospitalization rate of 85%, this model predicts near complete elimination in March to June, 2015.Author Summary: There is considerable uncertainty regarding the steps needed to contain the ongoing Ebola crisis in West Africa, the timeline required to achieve control, and the projected burden of mortality. To address these issues, we develop a branching process model for Ebola transmission that focuses on offspring distributions (i.e., the numbers of new infections caused by each case). We use the model to assess the likely progression of Ebola in Liberia. The model assesses the feedback between new cases and hospital demand under a range of plausible intervention scenarios, particularly ramping-up of treatment facilities over time and increasing the number of individuals seeking hospital treatment through outreach and education. Transmission scenarios—to health care workers in hospitals, to caregivers in the community, to hospital visitors, and to individuals preparing bodies for funerals—are described by distinct offspring distributions based on available data. Results suggest that the outcome of the epidemic depends on both hospital capacity and individual behavior. Additionally, the model highlights the conditions under which transmission might have outpaced hospital capacity, and projects possible epidemic trajectories into 2015.