title: Dynamics and control of Ebola virus transmission in Montserrado, Liberia: a mathematical modelling analysis.
abstract: BACKGROUND
  A substantial scale-up in public health response is needed to control the unprecedented Ebola virus disease (EVD) epidemic in west Africa. Current international commitments seek to expand intervention capacity in three areas: new EVD treatment centres, case ascertainment through contact tracing, and household protective kit allocation. We aimed to assess how these interventions could be applied individually and in combination to avert future EVD cases and deaths.
  
  
  METHODS
  We developed a transmission model of Ebola virus that we fitted to reported EVD cases and deaths in Montserrado County, Liberia. We used this model to assess the effectiveness of expanding EVD treatment centres, increasing case ascertainment, and allocating protective kits for controlling the outbreak in Montserrado. We varied the efficacy of protective kits from 10% to 50%. We compared intervention initiation on Oct 15, 2014, Oct 31, 2014, and Nov 15, 2014. The status quo intervention was defined in terms of case ascertainment and capacity of EVD treatment centres on Sept 23, 2014, and all behaviour and contact patterns relevant to transmission as they were occurring at that time. The primary outcome measure was the expected number of cases averted by Dec 15, 2014.
  
  
  RESULTS
  We estimated the basic reproductive number for EVD in Montserrado to be 2·49 (95% CI 2·38-2·60). We expect that allocating 4800 additional beds at EVD treatment centres and increasing case ascertainment five-fold in November, 2014, can avert 77 312 (95% CI 68 400-85 870) cases of EVD relative to the status quo by Dec 15, 2014. Complementing these measures with protective kit allocation raises the expectation as high as 97 940 (90 096-105 606) EVD cases. If deployed by Oct 15, 2014, equivalent interventions would have been expected to avert 137 432 (129 736-145 874) cases of EVD. If delayed to Nov 15, 2014, we expect the interventions will at best avert 53 957 (46 963-60 490) EVD cases.
  
  
  CONCLUSIONS
  The number of beds at EVD treatment centres needed to effectively control EVD in Montserrado substantially exceeds the 1700 pledged by the USA to west Africa. Accelerated case ascertainment is needed to maximise effectiveness of expanding the capacity of EVD treatment centres. Distributing protective kits can further augment prevention of EVD, but it is not an adequate stand-alone measure for controlling the outbreak. Our findings highlight the rapidly closing window of opportunity for controlling the outbreak and averting a catastrophic toll of EVD cases and deaths.
  
  
  BACKGROUND
  US National Institutes of Health.
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Lewnard
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA.
authors.forename: Martial L
authors.initials: ML
authors.lastname: Ndeffo Mbah
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA.
authors.forename: Jorge A
authors.initials: JA
authors.lastname: Alfaro-Murillo
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Infectious Diseases Section, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
authors.affiliation: Ministry of Health and Social Welfare, Monrovia, Liberia.
authors.forename: Luke
authors.initials: L
authors.lastname: Bawo
authors.affiliation: Ministry of Health and Social Welfare, Monrovia, Liberia.
authors.forename: Tolbert G
authors.initials: TG
authors.lastname: Nyenswah
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Center for Infectious Disease Modeling and Analysis, Yale School of Public Health, New Haven, CT, USA. Electronic address: alison.galvani@yale.edu.
authors.forename: Alison P
authors.initials: AP
authors.lastname: Galvani
mesh_terms: D050936:Basic Reproduction Number; D018562:Disease Transmission, Infectious / Q000517:prevention & control*; D019142:Hemorrhagic Fever, Ebola / Q000453:epidemiology / Q000517:prevention & control* / Q000635:transmission*; D006801:Humans; D017053:Infection Control / Q000379:methods; D007988:Liberia / Q000453:epidemiology; D008962:Models, Theoretical