The 2014 Ebola virus disease outbreak in Pujehun, Sierra Leone: epidemiology and impact of interventions

Background: In July 2014, an outbreak of Ebola virus disease (EVD) started in Pujehun district, Sierra Leone. On January 10th, 2015, the district was the first to be declared Ebola-free by local authorities after 49 cases and a case fatality rate of 85.7 %. The Pujehun outbreak represents a precious opportunity for improving the body of work on the transmission characteristics and effects of control interventions during the 2014-2015 EVD epidemic in West Africa. Methods: By integrating hospital registers and contact tracing form data with healthcare worker and local population interviews, we reconstructed the transmission chain and investigated the key time periods of EVD transmission. The impact of intervention measures has been assessed using a microsimulation transmission model calibrated with the collected data. Results: The mean incubation period was 9.7 days (range, 6-15). Hospitalization rate was 89 %. The mean time from the onset of symptoms to hospitalization was 4.5 days (range, 1-9). The mean serial interval was 13.7 days (range, 2-18). The distribution of the number of secondary cases (R-0 = 1.63) was well fitted by a negative binomial distribution with dispersion parameter k = 0.45 (95 % CI, 0.19-1.32). Overall, 74.3 % of transmission events occurred between members of the same family or extended family, 17.9 % in the community, mainly between friends, and 7.7 % in hospital. The mean number of contacts investigated per EVD case raised from 11.5 in July to 25 in September 2014. In total, 43.0 % of cases were detected through contact investigation. Model simulations suggest that the most important factors determining the probability of disease elimination are the number of EVD beds, the mean time from symptom onset to isolation, and the mean number of contacts traced per case. By assuming levels and timing of interventions performed in Pujehun, the estimated probability of eliminating an otherwise large EVD outbreak is close to 100 %. Conclusions: Containment of EVD in Pujehun district is ascribable to both the natural history of the disease (mainly transmitted through physical contacts, long generation time, overdispersed distribution of secondary cases per single primary case) and intervention measures (isolation of cases and contact tracing), which in turn strongly depend on preparedness, population awareness, and compliance. Our findings are also essential to determine a successful ring vaccination strategy.