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Transmission dynamics and control of Ebola virus
disease (EVD): a review
Chowell and Nishiura
Chowell and Nishiura BMC Medicine 2014, 12:196
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Chowell and Nishiura BMC Medicine 2014, 12:196
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Medicine for Global Health

REVIEW

Open AccessTransmission dynamics and control of Ebola virus
disease (EVD): a review
Gerardo Chowell1,2* and Hiroshi Nishiura3

Abstract
The complex and unprecedented Ebola epidemic ongoing in West Africa has highlighted the need to review the
epidemiological characteristics of Ebola Virus Disease (EVD) as well as our current understanding of the transmission
dynamics and the effect of control interventions against Ebola transmission. Here we review key epidemiological
data from past Ebola outbreaks and carry out a comparative review of mathematical models of the spread andcontrol of Ebola in the context of past outbreaks and the ongoing epidemic in West Africa. We show thatmathematical modeling offers useful insights into the risk of a major epidemic of EVD and the assessment of the
impact of basic public health measures on disease spread. We also discuss the critical need to collect detailed
epidemiological data in real-time during the course of an ongoing epidemic, carry out further studies to estimate
the effectiveness of interventions during past outbreaks and the ongoing epidemic, and develop large-scalemodeling studies to study the spread and control of viral hemorrhagic fevers in the context of the highly
heterogeneous economic reality of African countries.
Keywords: Ebola Virus Disease, Transmission model, Control interventions, Basic reproduction number, West Africa,
Incubation, Serial interval, Case fatality ratio, Isolation, Behavior change

BackgroundA complex epidemic of Zaire ebolavirus (EBOV) has been
affecting West Africa since approximately December
2013, with the first cases likely occurring in southern
Guinea [1]. The causative Ebola strain is closely related toa strain associated with past EBOV outbreaks in Central
Africa [2] and could have been circulating in West Africa
for about a decade [2]. However, the current epidemic was
not identified until March 2014 [1], which facilitated several transmission chains to progress essentially uncheckedin the region and to cross porous borders with neighboring Sierra Leone and Liberia and seed a limited outbreakin Nigeria via commercial airplane on 20 July 2014 [3].
The World Health Organization declared the Ebola epidemic in West Africa a Public Health Emergency of International Concern on 8 August 2014 [4], with exponential
dynamics characterizing the growth in the number of new* Correspondence: gchowell@asu.edu
1School of Human Evolution and Social Change, Arizona State University,
Tempe, AZ, USA
2
Division of International Epidemiology and Population Studies, Fogarty
International Center, National Institutes of Health, 31 Center Drive, MSC 2220,
Bethesda, MD 20892-2220, USA
Full list of author information is available at the end of the article

cases in some areas [5-9]. Economic and sociocultural
factors together with the delay in identifying the outbreakin urban settings have hindered a timely and effective
implementation of control efforts in the region [10,11].
Remarkably, the current size of the ongoing EBOV epidemic far surpasses the total number of cases reported forall previous Ebola outbreaks combined. A total of 6,553
cases, with 3,083 deaths, have been reported to the World
Health Organization as of 23 September 2014.
A serious shortage of timely resources in the region is the
key factor responsible for the onset and disproportionate
scale of the ongoing epidemic in West Africa [11]. In
particular, the epidemic is unfolding in a region characterized by limited public health infrastructure including:(1) a lack of essential supplies to implement infection
control measures in health care settings; (2) scarcity ofhealth care workers and staff to manage a growing caseburden and carry out essential contact tracing activities
to find new cases quickly so that these can be effectively
isolated [12]; and (3) the absence of epidemiological surveillance for the timely identification of case clusters[13,14]. Containing the ongoing epidemic poses an unprecedented challenge as the virus has moved from Guinea© 2014 Chowell and Nishiura; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of theCreative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public
Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in thisarticle, unless otherwise stated.

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to reach urban areas after crossing the unprotected borders of neighboring Liberia and Sierra Leone. A major
coordinated operation on the ground is needed to limit
the geographic extension of the epidemic.
The causative agent of Ebola virus disease (EVD) is an
RNA virus of the family Filoviridae and genus Ebolavirus.
Five different Ebolavirus strains have been identified,namely Zaire ebolavirus (EBOV), Sudan ebolavirus(SUDV), Tai Forest ebolavirus (TAFV), Bundibugyo
ebolavirus (BDBV) and Reston ebolavirus (RESTV),
with fruit bats considered as the most likely reservoir
host [15]. The great majority of past Ebola outbreaks
in humans have been linked to three Ebola strains:
EBOV, SUDV and BDBV [16]. The Ebola virus, EBOV,(formerly designated Zaire ebolavirus), the deadliestof the five Ebolavirus strains, was first identified in
1976 in Zaire (now the Democratic Republic of Congo)
and its name was derived from the Ebola River locatednear the source of the first outbreak. Past Ebola outbreaks
have been reported on average every 1.5 years [17], with a
total of 7 prior outbreaks generating over 100 reported
cases [18]. A recent study has estimated 22 million people
distributed in areas of Central and West Africa to be atrisk of Ebola [19].
Ebola is characterized by a high case fatality ratio which
was nearly 90% in a past outbreak [20]. After an incubation
period mostly ranging from 2 to 21 days, nonspecific symptoms appear, including sudden onset of fever, weakness,
vomiting, diarrhea, headache and a sore throat. A fractionof patients may later develop severe internal and external
hemorrhagic manifestations and experience multiple organ
failures [21]. Except for RESTV, all other Ebola strains arepathogenic to humans. Human outbreaks may stem fromdirect human exposure to fruit bats or intermediate infected hosts that primarily comprise non-human primates(that is, gorillas, chimpanzees and monkeys). Human epidemics subsequently take off by direct human-to-humancontact via bodily fluids or indirect contact with contaminated surfaces. Hence, stopping Ebola transmission should
be feasible when the cases are detected early and managed
properly, because this virus is not transmitted through the
air or water [22]. Nevertheless, Ebola has been shown to
spread through the air under carefully controlled laboratory
conditions [23]. Hence, amplification of human-to-humantransmission can result in the presence of suboptimal infection control measures in healthcare settings [24-26]. Unsafe
burials that involve direct contact with Ebola-infectedbodies also pose a major infection risk [20].
A review of key epidemiological parameters of EVD and
our current understanding of the transmission dynamics
and the effect of basic control interventions against thisdisease would be useful for guiding and assessing thepotential effectiveness of control interventions during
Ebola outbreaks. Specifically, here we review epidemiologicalPage 2 of 16

data from past Ebola outbreaks including the basic
reproduction number, the serial interval and the casefatality ratio. Subsequently, we carry out a comparative
review of mathematical models of the spread and control of Ebola in the context of past and the ongoing
epidemic in West Africa. We show that mathematicalmodeling offers useful insights into the risk of a major
epidemic of EVD and the assessment of the impact ofbasic public health measures on disease spread. We
illustrate the effects of demographic characteristics,
such as the effective population size, size of spillover
event (for example, details of initial conditions), baseline
infection control measures in health care settings, andthe timing of initiation of control interventions including enhancing the effectiveness of isolating infectious
individuals, contact tracing to bring infectious individuals
into isolation and social distancing interventions in
the community.
Natural history parameters of EVD

Due to the relatively few past Ebola outbreaks, available
epidemiological data to infer the natural history parametersof EVD remain limited. Moreover, past outbreaks have beencaused by different virus strains, making it difficult to judge
whether a certain observed epidemiological characteristic is unique to the causative strain. Here, we extract
published evidence and review Ebola epidemiologicalparameters from the literature, integrating estimates ofthe basic reproduction number, the asymptomatic ratio, the incubation period, the latent period, the symptomatic period, the infectious period, the serial interval
and the case fatality ratio.
The basic reproduction number, R0

The basic reproduction number, R0, is interpreted as theaverage number of secondary cases caused by a typicalinfected individual throughout its entire course of infection
in a completely susceptible population and in the absenceof control interventions [27,28]. In the context of a partiallysusceptible population owing to prior exposure or vaccination, the (effective) reproduction number, R, quantifies
the potential for infectious disease transmission. If R <1,transmission chains are not self-sustaining and are unable
to generate a major epidemic. By contrast, an epidemic
is likely to occur whenever R >1. When measured overtime t, the effective reproduction number Rt , can be
helpful to quantify the time-dependent transmission
potential and evaluate the effect of control interventions in almost ‘real time’ [29]. In summary, R0 is
regarded as a summary measure of the transmissibilityof infectious diseases, playing a key role in determining
the required control effort (for example, intensity ofquarantine and isolation strategies). R0 could also be
useful for guiding the numbers of antivirals andChowell and Nishiura BMC Medicine 2014, 12:196
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vaccines that would be needed to achieve control
whenever these are available.
R0 estimates for prior Ebola outbreaks in Central Africa

R0 has been estimated for prior EVD outbreaks in Central
Africa using mathematical modeling and epidemiological
data for two Ebola outbreaks, namely the 1995 outbreakin Democratic Republic of Congo and the 2000 Uganda
outbreak, respectively [30,31]. Unlike the ongoing epidemicin West Africa, past outbreaks in Central Africa have been
confined to relatively rural and isolated areas without
spreading to urban sectors which facilitated the effective implementation of control interventions. Using a homogenous
mixing SEIR (Susceptible-Exposed-Infectious-Removed)model that accounted for a gradual decay in the transmission rate at the start of interventions, Chowell et al. [32]estimated R0 at 1.83 for Congo and 1.34 for Uganda. Using
the same epidemic model but employing a Bayesian estimation method, Lekone and Finkenstadt [33] estimatedslightly lower values at 1.33 to 1.35 for the outbreak in
Uganda. Legrand et al. employed a different modelingapproach [19]: while allowing for homogeneous mixing, thestudy took into account three different transmission
settings, that is, transmissions in community, hospitalsettings and during funerals. R0 was estimated at 2.7 forCongo, 1995 and 2.7 for Uganda, 2000, but estimates
showed substantial uncertainty. Transmission from burials
alone accounted for 1.8 secondary transmissions in Congo
while community transmission in Uganda accounted for2.6 secondary transmissions. Variability in R0 estimatesacross studies can be attributed to differences in model
structure and underlying assumptions.
An assessment of R0 based on the growth rate of the 2014
Ebola epidemic in West Africa

A quick look at the ongoing epidemic in West Africa
without delving into a too detailed analysis permits us
to grasp the level of R0 for the ongoing Ebola outbreak.
Assuming that the early epidemic data in Sierra Leone
and Liberia are sufficient to be characterized by exponential growth dynamics, with growth rate r, the incidence (that is, the number of new cases at calendar
time t) is modeled asiðt Þ ¼ k expðrt Þ;
where k is a constant. As the observed data are cumulative
I(t), we integrate the above equation from the starting timeof exponential growth t0 to the latest time t, that is,kI ðt Þ ¼ ½expðrt Þ−expðrt 0 Þ:r
It should be noted that the cumulative number ofcases does not follow a single exponential growth term.

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Assuming that the observed number of cases is Poisson
distributed, the maximum likelihood estimate for r for
Liberia is estimated at 0.053 (95% confidence interval(CI): 0.051, 0.055). The growth rate in Sierra Leone islargely divided into two phases with a greater growthrate in the early phase (which could reflect initial caseclusters in hospital settings). Hence, r is estimated at 0.085(95% CI: 0.080, 0.090) and 0.021 (95% CI: 0.019, 0.023) forthe early and late phases, respectively (Figure 1a). Assumingthat the mean generation time is 12 days (with standard
deviation 5.2 days) based on contact tracing data from an
outbreak in Uganda 2000 [34] (see below), R0 for Liberia isestimated at 1.96 (95% CI: 1.92, 2.01). For Sierra Leone, R0
is 3.07 (95% CI: 2.85, 3.32) and 1.30 (95% CI: 1.26, 1.33) forthe early and late phases, respectively (Figure 1b). Estimatesin Liberia and the late phase of Sierra Leone are roughly
consistent with those published by Chowell et al. [30].
A comparison of the growth trends for past outbreaks
in Central Africa (Congo 1995 and Uganda 2000) withthe ongoing epidemic in Liberia is shown in Figure 2.
Mathematical modeling studies of the 2014 Ebola epidemicin West Africa

Recent studies have started to shed light on the transmission potential of the ongoing EVD epidemic. Specifically,
three studies have estimated the basic reproduction number of EVD in the range of 1.5 to 2.5 [8,9,35]. Althaus [8]employed an SEIR model with the time-dependency of the
reproduction number to capture effects of control interventions, following the model by Chowell et al. [18]; analyzing
the country-specific data independently for each country,
the estimates were 1.5 for Guinea, 2.5 for Sierra Leone
and 1.6 for Liberia [8]. Gomes et al. [35] explicitly
accounted for the risk of international spread, and thebasic reproduction number ranged from 1.5 to 2.0.
More importantly, this study employed a global epidemic
model with mobility data, indicating that the short-termrisk of international spread to outside Africa is small andthat the expansion of the ongoing epidemic is more likely
to occur in African countries [35]. Moreover, Fisman et al.
estimated R0 at 1.8 using a two-parameter mathematicalmodel that describes the epidemic growth and control [9].
Real-time estimation of the effective (time-dependent)
reproduction number revealed estimates in line with R0
estimates derived from other studies. For instance, by
measuring temporal variations in the epidemic growth rateduring periods of epidemic growth, the reproduction number was approximated based on a classic formula of R0 for
the SEIR model, which provided estimates in the rangeof 1.4 to 1.9 [36]. A different modeling study accounted
for both local transmission and transnational spread acrossseverely affected countries using a multivariate renewal
process model which allowed the derivation of global andcountry-specific estimates of the reproduction number [7].

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Figure 1 Early transmission dynamics of Ebola virus disease (EVD) in Sierra Leone and Liberia, 2014. a) The cumulative number ofconfirmed and probable cases of EVD as a function of calendar time [3]. Filled circles represent cases in Liberia, while unfilled triangles represent
cases in Sierra Leone. The solid line shows the exponential growth fit to the incidence curve in Liberia. The dashed line is the exponential fit to
the early phase in Sierra Leone (up to 8 July 2014), while the dotted line shows the exponential fit to the later phase in the same country. b) The
relationship between the exponential growth rate and the corresponding reproduction number for EVD based on a Weibull distributed generation
time with shape and scale parameters of 2.59 and 13.60, respectively. Arrows indicate the uncertainty range (95% confidence interval) of the
exponential growth rate estimated from the corresponding epidemic data.

This study indicated that the effective reproduction number
Rt from June to August 2014 ranged from 1.4 to 1.7 in
Sierra Leone and Liberia. Hence, control could bereached by halting over half of the secondary transmissions
per primary case whenever the reproduction number isbelow 2 [7]. Moreover, it is worth noting that the exponential growth in Ebola incidence is placing great pressure on
healthcare facilities, which could affect time- and spacedependent variations in transmission dynamics and thesurveillance system [37]. The analysis of available datausing mathematical modeling should, therefore, carefully
assess the quality and consistency of the surveillancesystem employed to collect epidemiological data. Hence,
mathematical models should ideally be tied to characteristics of the surveillance system as much as possible
to avoid potential bias [38].
Comparing R0 with other infectious diseases

For comparison with other filoviruses, the R0 for the 2005
Marburg Fever Outbreak in Angola has been consistently
estimated at 1.6 using two different statistical modelingapproaches [39,40]. For comparison with other infectious
diseases transmitted by direct contact, R0 has been estimated at 2.6 for an outbreak of acute hemorrhagic
conjunctivitis in Mexico [41]. In contrast, for respiratory infections, the reproduction number has been estimated for the SARS outbreaks in 2003 in the range
2.2 to 3.7 based on fitting transmission models to theprogression of weekly cases prior to the start of control
interventions [42,43], in the range 1.2 to 1.6 for seasonal
influenza [44], 1.4 to 5.2 for influenza pandemics [45-50],
15 for pertussis, 17 for measles [27] and 1.2 to 1.3 formeningococcal meningitis [51].
Asymptomatic infection and incubation period

Asymptomatic infection with Ebola virus is known tooccur in a certain fraction of exposed individuals [52]. By
analyzing the antibody responses among 24 asymptomatic
close contacts of symptomatic patients, Leroy et al. foundthat 11 (45.8%) developed both immunoblobulin M (IgM)
and IgG responses to Ebola antigens. However, the study
subjects were only those who experienced close contacts,
and an estimate of asymptomatic ratio for the general
population was not obtained. The majority of cases developed illness 6 to 11 days after infection. A classical studyof the Zaire strain [53] indicated that the mean incubation
period, that is, the mean length of time from infection toillness onset, is 6.3 days with the 95% quantile 21 days. Reanalyzing the data set of household contacts during theEbola outbreak in the Democratic Republic of Congo in
1995, Eichner et al. estimated the mean incubation period
at 12.7 days (with standard deviation 4.31 days) [54]. The
fitted lognormal distribution is redrawn in Figure 3a. Bytaking the 99 percentile point as the length of quarantine,
Eichner et al. argues for movement restrictions of exposed
healthy individuals for 25 days. Based on data for the firstChowell and Nishiura BMC Medicine 2014, 12:196
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Number of Ebola cases[Uganda 2000]

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Time (days)

Figure 2 Comparison of the growth trends for past outbreaks in Central Africa (Congo 1995 and Uganda 2000) with the ongoing
Ebola epidemic in Liberia. Time series of new Ebola case reports prior to the implementation of control interventions for the outbreak inCongo 1995 (9 May 1995) [24] and Uganda 2000 (22 October 2000) [100] and for the ongoing epidemic in Liberia from 15 June to 15 August
2014. Incidence data for the outbreaks in Central Africa are shown according to the dates of symptoms onset while the weekly incidence curvefor the epidemic in Liberia comprises total cases based on the daily epidemic curve estimated in [7].

9 months of the ongoing Ebola epidemic, a recent study
estimated the mean incubation period at 11.4 days withno significant variation across the affected West Africancountries [6].
The serial interval

The serial interval defined as the time from illness onset
in the primary case to illness onset in the secondary case[55], has been relatively well observed for EVD based onhousehold or contact-tracing studies. A household study
during the outbreak in DRC indicated that the minimum
serial interval was 7 days, while the maximum was 17days [56]. Findings based on contact tracing data for theoutbreak in Uganda in 2000 were roughly consistent
with those derived from household data [34]: mean (SD)and median (quartiles) estimates for the serial interval
were 12.0 (5.2) and 11.5 (8 to 17) days, respectively.

Figure 3b shows the serial-interval distribution alongwith a fitted Weibull distribution with scale and shapeparameters estimated at 13.6 (95% CI: 11.4, 16.1) and 2.6(95% CI: 1.8, 3.5), respectively. The Cramér-von Mises
goodness-of-fit test did not reveal significant deviations
between the observed data and fitted model distribution(W2 = 0.05, P =0.25). This estimate is in good agreementwith that derived from data of the first 9 months of theongoing epidemic in West Africa, which has been estimated at 15.3 ± (SD =9.3) days [6]. This distribution is
key to quantifying the reproduction number using the
exponential growth rate of cases during the early stageof an epidemic, because the conversion from the growthrate of cases to the reproduction number requires estimates of the generation time distribution [57] which is
known to be informed by the serial interval and the incubation period [58].

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Figure 3 Incubation period and generation time of Ebola virus disease (EVD). a) The probability density function of the incubation period,that is, the time from infection to illness onset, fitted to a lognormal distribution is shown. The mean and the standard deviation are 12.7 and 4.3
days, respectively [54]. b) The generation time distribution, as collected from contact tracing data during the Ebola outbreak in Uganda, 2000, isfitted to a Weibull distribution. The mean and the standard deviation are 12.0 and 5.2 days, respectively.

The latent and infectious periods

Other parameters associated with the time course of EVD
have not been rigorously ascertained. However, according
to Bayesian model-based estimates from a past Ebola outbreak [33], the mean latent and infectious periods havebeen estimated at 9.4 and 5.7 days, respectively, using avague prior and 10.1 and 6.5 days, respectively, for an
informative prior. These exponential distributions basedon a mathematical modeling study are the only available
empirical evidence for these two time periods. The mean
length of time from illness onset to death is approximately 10 days [24,56], but the transmissibility fromthe deceased from Ebola may account for a certain
fraction of secondary transmissions [19]. Hence, theinfectious period could be longer than the observabletime to death if the burial is extended.
The case fatality ratio

The case fatality ratio (CFR) is calculated as the proportionof deaths among the total number of EVD cases, thereby
informing the virulence of the infectious pathogen. EVD
can be fatal, but it is important to note that the CFR being‘almost 100%’ for EVD in general does not rest on any empirical arguments. For the well documented outbreaks ofEbola (excluding only isolated cases who are likely to haveacquired infection from animal contact), the expected valueof CFR has always been below 90% [31], with the range
from 41% to 89%. The so-called Zaire strain is considered
to be slightly more fatal than the Sudan strain. While the
CFR for the Sudan strain ranges from 41% to 65%, the CFR
for the Zaire strain ranges from 61% to 89%. Consideringthat the corresponding quartile for the Zaire strain, as
determined by the distribution of outbreak-specificestimates, ranges from 73.3% to 84.3%, the CFR of theongoing epidemic among cases with definitive recorded
clinical outcomes for Guinea, Liberia and Sierra Leone has
been consistently estimated at 70.8% (95% CI: 68.6 to 72.8),
which is in good agreement with estimates from prioroutbreaks. Nevertheless, it must be noted that earlier
studies have not addressed ascertainment bias. It is important to follow up the reasons why the estimated 53%(as of 31 August 2014 which involved an underestimation
bias due to time delay from illness onset to death) in realtime has been much lower than the published estimate of
70.8% among a portion of cases. Given the potential presence of asymptomatic cases, addressing ascertainment error
may be the key to appropriately capture the disease
burden for the entire population. Table 1 summarizes
key epidemiological parameters for EVD.
Models of Ebola transmission dynamics and control

The transmission dynamics of Ebola outbreaks in confinedsettings in Central Africa have been previously describedusing an SEIR epidemiological model [30] with the goal ofquantifying the effects of social distancing interventions.
In this model, the time-dependent transmission rate
parameter β(t) captures the effects of implementing
basic public health interventions over time. For instance,
once interventions are put in place τ days after the onsetof the outbreak, the time-dependent transmission rate
could be modeled to shift from a ‘free course’ baseline
value β0 to a value β1, where β1 < β0. More realistically,Chowell and Nishiura BMC Medicine 2014, 12:196
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Table 1 Summary of empirical estimates of epidemiologicalparameters for Ebola virus disease (EVD)
Description

Value

Reference

Incubation period

12.7 days (mean)[54]

Latent period

10.1 days (mean)[33]

Infectious period

6.5 days (mean)[33]

Serial interval

12.0 days (mean)[34]

Generation time

16.6 days (mean)[34]

Time from illness onset to death

10 days (mean)[24,56]

Case fatality ratio

41% to 65% (Sudan)[31]

61% to 89% (Zaire)

one can assume that the full effect of interventions is
not seen immediately but gradually takes hold in the
population, as modeled in [30]. In these models, thebasic reproduction number, R0, in a completely susceptible population and in the absence of control interventions is computed as the product of the meantransmission rate during the intervention-free courseof the outbreak, β0, and the mean infectious period, 1/γ.
Hence, R0 is given by:
R0 ¼ β0 =γMore detailed epidemiological data and information
about the contributions of different settings to transmission
could guide the design of more elaborate models that could
be helpful to quantify the effects of more specific intervention strategies. Legrand et al. [31] developed a structured
transmission model to describe Ebola epidemics with contributions to the force of infection from the community,
funerals and healthcare settings. The most distinctive
feature of this model is that transmission during burial
rituals is modeled by accounting for the duration of
the burial and the intensity of transmission with infectious bodies. This model is comprised by six epidemiologically relevant states and thirteen parameters. The
model was calibrated to data of the Ebola outbreaks in
the Republic of Congo in 1995 and Uganda in 2000 by
fitting three transmission rate parameters, one for eachtransmission setting and one parameter to quantify theeffectiveness of interventions. The full model can beapplied to the West African epidemic particularly for
Guinea, Sierra Leone and Liberia where burial practices involve the touching of bodies of the deceased[59]. But this feature is believed to be less influential intransmission in the context of Nigeria where a limited
outbreak developed. To illustrate the effects of control
interventions during Ebola outbreaks, here we only accountfor transmission in the community and in healthcare
settings by adjusting baseline transmission rates, diagnostic rates and enhancement of infection-control measures(for example, strict use of protective equipment by healthcare workers and effective isolation of infectious individuals)(see for example, [27,28,42,43,60,61]). In this simpler setting,the population is divided into five categories: susceptible individuals (S); exposed individuals (E); infectious
and symptomatic individuals (I); hospitalized individuals(H); and removed individuals after recovery or diseaseinduced death (R).
Susceptible individuals infected through contact with
infectious individuals (secondary cases) enter the latent
period at rate β(t) (I + l(t) H) /N(t) where β(t) is the meanhuman-to-human transmission rate per day, l(t) quantifies
the relative transmissibility of hospitalized patients compared to symptomatic patients in the community, and N(t) is the total population size at time t. Thus, values of l(t)between 0 and 1 would reflect the effectiveness of hospital
isolation measures that decrease Ebola transmission probability below that seen in the community, and values above
1.0 denote increased transmission in the hospital relative tothe community, potentially due to biological and/or epidemiological reasons (for example, exposure to body fluids).
Symptomatic infectious individuals I are hospitalized at the
time-dependent average rate γa(t) or recover without being
hospitalized at the average rate γI. Individuals in the‘removed’ class do not contribute to the transmission
process. For simplicity, one can assume that the timedependent transmission rate β(t), relatively transmissibility of hospitalized patients, l(t), and the diagnostic
rate γa(t), remain constant values at β0, l0, and γa0 prior
to the implementation of comprehensive countermeasures. Hence, in this model the basic reproduction
number, R0, is given by the following expression:
R0 ¼ β0 1= γ a0 þ γ I þ l0 ð1=γ r Þ γ a0 = γ a0 þ γ I :In this equation, (1/(γa0 + γI) is the mean infectious
period of community cases, γa0 /(γa0 + γI) is the fractionof symptomatic cases that are hospitalized, and 1/γr isthe mean infectious period of hospitalized cases. This
expression can be decomposed as the sum of the contributions of infectious individuals in the community andthe hospital as follows:
R0 ¼ Rcomm þ Rhosp
where Rcomm = β0 /(γa0 + γI) andRhosp = β0 l0 (1/γr)(γa0 /(γa0 + γI)).
Importantly, the above components for the reproduction
number underscore the fact that the actual reproduction
number could vary across regions as a function of thelocal capacity public health context (for example, infection control practices and availability of personal
protective equipment for health care workers) and any
local cultural practices that may influence transmission

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Page 8 of 16(for example, funeral traditions). Consequently, an outbreak
may be very unlikely to unfold in developed countries
simply as a result of baseline infection control measuresin place (that is, R0 < 1) whereas poor countries withextremely weak or absent public health systems may beunable to control an Ebola outbreak (that is, R0 > 1).
This suggests that local socioeconomic and sociocultural
conditions are key determinants of disease spread, particularly in the context of the transmission dynamics of EVD.
The impact of infection-control measures in health caresettings is illustrated in Figure 4 for different initial valuesof baseline R0. The combined effect of the effectiveness of
isolation measures and the diagnostic rate of symptomatic
individuals on R0 is given in Figure 5.
Initial transmission dynamics

The natural reservoir hosts of the Ebola virus have yet
to be confirmed [62,63], but laboratory studies point tofruit bats as the most likely culprit harboring the Ebola
virus in the natural habitat [63-66]. Ebola outbreaks among
humans have been associated with direct exposure to fruitbats and mortality among other wild animals, which tend
to succumb to the infection [67-69]. Epidemiological data
support the notion that spillover events of Ebola virus froma natural reservoir (that is, fruit bats) or an intermediate

host, such as non-human primates, into human populations occur with a certain frequency (for example, [70,71]),
but only a small number of those introductions are evercorrectly diagnosed and reported or successfully unfold
human-to-human transmission chains that lead to outbreaks. This hinders our understanding of the frequency of
spillover events as a function of time (for example, season)and its relationship with variation in climatological or
socioeconomic variables. We note that two studies haveassociated the onset of Ebola outbreaks with climatologicalvariables [72,73]. Specifically, Pinzon et al. reported
evidence that Ebola outbreaks are correlated with drastic shifts from dry to wet conditions [72] while a more
recent study by Ng et al. found lower temperature andhigher absolute humidity associated with the onset of
EVD outbreaks during 1976 to 2014 [73].
In the context of the ongoing Ebola epidemic in West
Africa, a recent study suggests that people in Sierra Leone
have been previously exposed to the Ebola virus, but those
introductions have not sparked major epidemics [2,71].
Moreover, the ongoing epidemic may have been triggeredby a single spillover event as suggested by limited epidemiological data indicating that chains of transmission of reported cases can be traced back to one or two
individuals [74]. This may be explained by the fact that

1.8

1.7

Reproduction number

1.6

1.5

1.4

1.3

1.2

1.1

1

0.9

0

0.1

0.2

0.3

0.4
0.5
0.6
Isolation effectiveness

0.7

0.8

0.9

1

Figure 4 The effects of isolation strategies on R0. Basic reproduction number as a function of level of isolation effectiveness in health caresettings for three different baseline values of R0: 1.3, 1.5 and 1.8. Epidemiological parameter values for EVD are shown in Table 1. The mean timefrom symptoms onset to diagnosis (γa0) is assumed to be three days. The isolation effectiveness is given by 100*(1-l0) where l0 is the relative
infectiousness of infectious individuals in health care settings. Baseline values of R0 are calibrated by adjusting the transmission rate β to achievea given R0. EVD, Ebola virus disease; R0, basic reproduction number. Three lines represent results for three baseline values of R0: 1.3, 1.5 and 1.8.

Time to diagnosis (days)

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3

2.1

2.8

2

2.6

1.9

2.4

1.8

2.2

1.7
1.6

2

1.5

1.8

1.4

1.6

1.3

1.4

1.2
1.2
1.1
1

0

10

20

30

40

50

60

70

80

90

100

Isolation effectiveness (%)

Figure 5 The effects of isolation strategies and diagnostic rate on R0. Basic reproduction number as a function of the combined effect of
the level of isolation effectiveness and the diagnostic rate. Epidemiological mean parameter values for EVD are shown in Table 1. The mean timefrom symptoms onset to diagnosis (γa0) is varied from one to three days. The isolation effectiveness is given by 100*(1-l0) where l0 is the relative
infectiousness of infectious individuals in health care settings. The baseline value of R0 is set at 1.8. EVD, Ebola virus disease; R0, basic
reproduction number.

Ebola introductions have historically tended to occur
in remote, rural areas with sparse population structurescharacterized by higher disease extinction rates [75,76]. By
contrast, the unprecedented size of the ongoing epidemic
could have benefited from high population mobility acrossinvisible borders, super spreading events [2] and secondary transmissions linked to health care settings[77]. Figure 6 illustrates the role of the size of spillover
events (for example, the number of infectious cases
initially introduced in the population) in triggering
Ebola epidemics in naive populations by showing that theprobability that a major epidemic occurs rapidly increases
as a function of the initial number of Ebola cases. For
instance, single-case introductions go extinct without developing into epidemics more than 60% of the time while
five-case introductions lead to major epidemics more than
90% of the time.
Delays in outbreak detection

Several factors hamper the timely identification of Ebola
outbreaks in Africa. First, only a small number of Ebola
outbreaks have occurred in East and Central Africa since
the first identified outbreak in 1976 relative to the regional burden of other endemic infectious diseases,
such as malaria. Moreover, some areas at risk of Ebola

have yet to experience Ebola outbreaks, which severely
limits community-level knowledge of the disease. For
instance, the ongoing 2014 epidemic of EVOB is reportedly the first to occur in West Africa [10]. Second,
early symptoms of Ebola virus disease tend to be nonspecific (for example, many cases are only febrile) [24],which increases the likelihood of misdiagnosing Ebola
with malaria or other locally endemic infectious diseases[13]. Unsuccessful treatment of febrile patients and/or theappearance of more specific symptoms during the courseof the disease (for example, hemorrhagic manifestations)
could increase the likelihood of an ‘astute’ public-healthworker suspecting Ebola or other viral hemorrhagic fever[78]. Third, lack of epidemiological surveillance systems
and diagnostic testing in poor countries further exacerbates
the delay in detecting outbreaks. Consequently, the implementation of public health interventions may not start untilcase or death clusters start to be detected and investigatedin the community by public health authorities. In general,the longer the delay in the implementation of control interventions, the higher the chances that the virus percolates
from remote and sparsely populated areas into areas ofhigh population density. The probability of observing
major Ebola outbreaks is highly sensitive to the timing of
initiation of control interventions as illustrated in Figure 7.

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70

Probability of no major outbreak (%)

60

50

40

30

20

10

0

0

5

10
15
20
Size of spillover event (Initial cases)

25

30

Figure 6 The effects of size of spillover event on the likelihood of observing an outbreak. Probability that no major outbreak unfolds as afunction of the initial number of infectious cases introduced into the population. Epidemiological parameter values for EVD are shown in Table 1.
The mean time from symptoms onset to diagnosis (γa0) is set at three days. The isolation effectiveness is set at 0 (that is, l0. =1). Population size N
is set at 100,000. The baseline value of R0 is set at 1.8. The curve corresponds to the mean of the results obtained from 500 model simulations.
EVD, Ebola virus disease; R0, basic reproduction number.

This figure shows that a five-day delay is highly unlikely toresult in major Ebola outbreaks. By contrast, more significant delays exceeding two weeks are likely to lead to Ebola
outbreaks (Figure 7).
Lack of public health infrastructure

Basic infection control measures in health care settingsare essential to avoid further spread of the disease to other
patients, health care workers and visitors. Unfortunately,
under-resourced African regions not only suffer from a
critically low ratio of health-care workers to total population, but also lack essential personal protective equipment(PPE) (for example, gloves, gowns, face masks) to practicestandard infection control measures. They also often
lack the infrastructure and local capacity necessary toeffectively trace contacts and isolate infectious individuals.
Consequently, it is not surprising that Ebola outbreaks
have been amplified in health care settings [24,25,79,80]
including the ongoing epidemic in West Africa. Indeed, atotal of 375 health care workers have developed EVD as of
23 September 2014 [81]. Fortunately, past experience also
indicates that early and drastic enhancement of infection
control measures in health care settings can substantiallyreduce the size and geographic scope of Ebola outbreaks[82,83]. For instance, Figure 8 shows that the rising trend
in infected health care workers during the1995 Ebola
outbreak in Congo rapidly declined following the implementation of control interventions. The combined impactof the rate of diagnosing symptomatic cases and the relative
infectiousness of hospitalized cases on the probability ofobserving major epidemics is illustrated in Figure 9.
Socio-cultural factors

Socio-cultural factors have not only contributed significantly to Ebola spread, but have also complicatedthe implementation of control interventions. Specifically, cultural practices involving touching the body ofthe deceased naturally (and greatly) contribute to thedissemination of the Ebola virus [59]. In particular, thepotential for transmission to neighboring and distantareas by exposed funeral attendants could facilitate thedevelopment of major epidemics [1,31]. Moreover, thelack of prior experience or knowledge of the disease
can lead communities to deny its existence and to associate illness with witchcraft or conspiracy theories
presumably created by governments to gain control of
populations or attract resources from the international
community [77,80]. For instance, during the ongoingChowell and Nishiura BMC Medicine 2014, 12:196
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Figure 7 The effects of size of baseline isolation effectiveness and timing of control interventions on the likelihood of observing an
outbreak. Probability that no major epidemic unfolds as a function of isolation effectiveness and timing of implementation of control
interventions. Epidemiological parameter values for EVD are shown in Table 1. The mean time from symptoms onset to diagnosis (γa0) is set atthree days. The relative infectiousness of hospitalized cases is given by l0. Population size N is set at 100,000. The baseline value of R0 is set at 1.8
by adjusting the transmission rate. After the start of interventions, the transmission rate is reduced by 80% and the relative infectiousness of
hospitalized individuals is reduced by 95% (that is, l0 = 1, l1 = 0.05). The curves shown correspond to the mean of the results obtained from 500
model simulations. EVD, Ebola virus disease; R0, basic reproduction number.

epidemic in West Africa, a group of individuals looted
equipment and potentially contaminated materials in
an isolation facility in a quarantined neighborhood[84]. Finally, the stigma carried by Ebola survivors andfamily members of Ebola victims could exacerbate disease spread. In particular, uninformed families tend tohide relatives and friends infected with Ebola to avoid
being shunned by their own communities, which enhances transmission rates [85]. The problem is compounded by the high case fatality ratio of EVD whereby
misinformed communities tend to associate case isolation with a death sentence.
Future directions and conclusions

The ongoing epidemic in West Africa offers a unique
opportunity to improve our current understanding of
the transmission characteristics of EVD in humans, including the duration of immunity among Ebola survivors
and the case fatality ratio in the presence or absence of

supportive therapy [86,87], as well as the effectivenessof various control interventions [37]. For this purpose,
there is a critical need to collect detailed epidemiological data in real-time during the ongoing epidemic
through the establishment of efficient epidemiologicalsurveillance systems in the affected areas. In addition,
we cannot overemphasize the importance of collecting
data relating to population behaviors influencing disease
spread and control and how these have changed overtime. It would also be important to record the level ofadoption of preventive and social distancing measuresin the community and adherence to infection control
measures in health care settings. Detailed data regarding
control interventions would also be critical to assess
their effectiveness in reducing secondary transmissions
including information on the changing numbers of isolation and treatment centers, healthcare workers, intensityof contact tracing activities and awareness campaigns in
the community.

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16

Health−care worker
Community case2

10

Cumulative number of Ebola cases

Daily number of new Ebola cases

14

12

10

8

6

4

1

10

2

0

Symptoms onset date08−May−95

05−May−95

29−Apr−95

02−May−95

26−Apr−95

23−Apr−95

20−Apr−95

17−Apr−95

14−Apr−95

11−Apr−95

08−Apr−95

05−Apr−95

02−Apr−95

30−Mar−95

27−Mar−95

24−Mar−95

21−Mar−95

18−Mar−95

15−Mar−95

12−Mar−95

09−Mar−95

06−Mar−95

07−Jul−95
10−Jul−95

22−Jun−95
25−Jun−95
28−Jun−95
01−Jul−95
04−Jul−95

20−May−95
23−May−95
26−May−95
29−May−95
01−Jun−95
04−Jun−95
07−Jun−95
10−Jun−95
13−Jun−95
16−Jun−95
19−Jun−95

05−May−95
08−May−95
11−May−95
14−May−95
17−May−95

18−Mar−95
21−Mar−95
24−Mar−95
27−Mar−95
30−Mar−95
02−Apr−95
05−Apr−95
08−Apr−95
11−Apr−95
14−Apr−95
17−Apr−95
20−Apr−95
23−Apr−95
26−Apr−95
29−Apr−95
02−May−95

1006−Mar−95
09−Mar−95
12−Mar−95
15−Mar−950Symptoms onset date

Figure 8 The impact of Ebola on health care workers during the 1995 Ebola outbreak in The Republic of Congo. Stacked bar plot of theepidemic curve of the 1995 Ebola outbreak in Republic of Congo to show the contributions of community and health-care worker cases. (left)
Remarkably, the number of health care workers affected reached about 27% of the total number of reported Ebola cases. The vertical dashed line
indicates the start of control interventions. The cumulative numbers of total cases (black stars) and of health care workers (blue circles) inlogarithmic scale reveal a similar growth rate for both epidemic curves (right). Data were adapted from [24].

There is a scarcity of empirical studies quantifying
transmission and the effects of control interventions
implemented during past Ebola outbreaks [30,31]. Further
work is also needed to quantify the effects of various
interventions put in place during the ongoing epidemicin West Africa. Specifically, careful mathematical andstatistical modeling studies could help ascertain therole of social distancing interventions (for example, school
closures and cancellation of mass gathering events), infection control measures in health care settings (for example,
isolation and other infection control measures among
health care workers) and contact tracing and quarantine efforts [42,43,61,88-92]. In addition to individual
epidemiological data, the timing of such interventions
should be recorded along with the scale and extent ofinterventions (for example, closure of class rooms or entire
schools). Intervention studies could reveal, for instance,
whether effective infection control mechanisms in hospitalsettings could suffice to bring an epidemic under control
or whether a combination of control strategies would becritical to ensure epidemic control (for example, R <1).
While a significant number of computational models
have been developed to inform preparedness plans against
pandemic influenza [93-95], comprehensive modeling studies to examine the spread and control of viral hemorrhagic
fevers, including Ebola, in the context of the highly heterogeneous economic reality of African countries are
yet to be developed. The shortage of modeling efforts
could be explained by the fact that large Ebola outbreaks

affecting large population settings were largely unexpecteduntil now. To start filling this gap, datasets comprisingdetailed demographic, socio-economic, contact rates andpopulation mobility estimates in the region (for example,
commuting networks, air traffic) need to be integrated.
Given that the disease is highly fatal, dynamic features ofcontact and mobility should also be closely investigated.
Modeling studies with local demographic characteristics
and human movement could be useful not only to assess
the likelihood of major epidemics and carry out sensible
projections on epidemic outcomes, but also to guidecontrol efforts in the field, such as the estimation of
the number, size and location of isolation facilities, thenumber of health workers and staff and essential supplies that would be needed to respond to a particularoutbreak scenario as well as to quantify the effects ofpotential quarantine efforts in certain areas, borderclosures and air travel restrictions.
Proven treatments or vaccines against Ebola are still
not available. Hence, our current working toolbox
available to control the spread of Ebola still hinges on
supportive medical care to increase the survival of
those infected and basic non-pharmaceutical publichealth measures [96] to prevent transmission, namely:
1) infection control measures including standard precautions in health care settings; 2) rapid contact tracing andisolation of infectious individuals; and 3) social distancing
interventions in the community which may include thedissemination of awareness campaigns to inform theChowell and Nishiura BMC Medicine 2014, 12:196
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Figure 9 The effects of size of baseline isolation effectiveness and diagnostic rate on the likelihood of observing an outbreak.
Probability that no major epidemic unfolds as a function of isolation effectiveness and time from symptoms onset to diagnosis. Epidemiologicalparameter values for EVD are shown in Table 1. The mean time from symptoms onset to diagnosis (γa0) is set at one, two and three days. The
relative infectiousness of hospitalized cases (l0) is varied from 0 to 1. Population size N is set at 100,000. The baseline value of R0 is set at 1.8 byadjusting the transmission rate. The curves shown correspond to the mean of the results obtained from 500 model simulations. EVD, Ebola virus
disease; R0, basic reproduction number.

population on how to avoid contracting the disease,quarantining individuals potentially exposed to infectious
individuals and restricting the movement of communities
exhibiting local transmission to prevent onward transmission. These actions must be conducted in close collaboration with local community leaders to effectively
reach the population at large. With the ongoing epidemicin West Africa, the development of treatments and vaccines
against Ebola is accelerating [96,97]. For instance, emergency use of a trickle of doses of an experimental drugwith unknown efficacy or safety record in humans has
been initiated during the outbreak [97]. Recent experiments in monkeys provide promising evidence that
this experimental drug could have a significant impact
on mortality burden during Ebola outbreaks [98]. Furthermore, a promising bivalent Ebola vaccine against

the Zaire and Sudan Ebola strains is entering humansafety trials in September 2014 [99] with an initial goalof building a stockpile of 10,000 doses by November
2014. Nevertheless, apart from pharmaceutical effects
on the prognosis of infection, we have yet to examine
how medication changes the transmission dynamics.
Hence, careful studies could be useful for assessing theimpacts of treatment on contact, transmission and diagnosis as well as on the disease burden [100]. If an Ebola
vaccine is developed successfully, one could assess theeffectiveness of pre-emptive and reactive treatment andvaccination plans in the context of limited stockpiles.
Finally, it is worth noting that our efforts to prepare
against current and future infectious disease threats
should also include potential deliberate attempts totrigger epidemics, which are largely unexpected events

Chowell and Nishiura BMC Medicine 2014, 12:196
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but could pose high impact on public health and global
economic activities.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
GC and HN drafted and revised the manuscript. Both authors read andapproved the final manuscript.
Acknowledgements
GC acknowledges financial support from the NSF grant 1414374 as part of
the joint NSF-NIH-USDA Ecology and Evolution of Infectious Diseases program,
UK Biotechnology and Biological Sciences Research Council grant BB/M008894/
1, NSF grant 1318788. III: Small: Data Management for Real-Time Data Driven
Epidemic Spread Simulations, the Division of International Epidemiology andPopulation Studies, The Fogarty International Center, US National Institutes of
Health, and the Visiting Foreign Scholar program of the Heiwa Nakajima
Foundation for supporting a sabbatical research visit at the University of Tokyo.
HN received funding support from the Japanese Society for the Promotion of
Science (JSPS) KAKENHI Grant Number 26700028, St Luke's Life Science InstituteResearch Grant for Clinical Epidemiology Research 2014 and the Commissioned
Research program of the Ministry of Health, Labour and Welfare, Japan(H26-ShinkoJitsuyoka- General-016).
Author details
1
School of Human Evolution and Social Change, Arizona State University,
Tempe, AZ, USA. 2Division of International Epidemiology and Population
Studies, Fogarty International Center, National Institutes of Health, 31 Center
Drive, MSC 2220, Bethesda, MD 20892-2220, USA. 3Department of Global
Health Policy, Graduate School of Medicine, The University of Tokyo, Hongo
7-3-1, Bunkyo-ku, Tokyo 110-0033, Japan.
Received: 3 September 2014 Accepted: 30 September 2014

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Cite this article as: Chowell and Nishiura: Transmission dynamics andcontrol of Ebola virus disease (EVD): a review. BMC Medicine 2014 12:196.

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