Graeme Hugo is ARC Australian Professorial Fellow, Professor of the Discipline of Geography, Environment and Population and Director of the Australian Population and Migration Research Centre at the University of Adelaide. His research interests are in population issues in Australia and South East Asia, especially migration. He is the author of over four hundred books, articles in scholarly journals and chapters in books, as well as a large number of conference papers and reports. In 2002 he secured an ARC Federation Fellowship over five years for his research project, "The new paradigm of international migration to and from Australia: dimensions, causes and implications and in 2009 he was awarded an ARC Australian Professorial Fellowship over five years for his research project “Circular migration in Asia, the Pacific and Australia: Empirical, theoretical and policy dimensions”. His recent research has focused on migration and development, environment and migration and migration policy. In 2012 he was named an Officer of the Order of Australia (AO) for distinguished service to population research, particularly the study of international migration, population geography and mobility, and through leadership roles with national and international organisations.
The largest outbreak of Ebola virus ever recorded continues to spread in West Africa. In response, the World Health Organisation (WHO) has declared a public health emergency of international concern. The potential for international dissemination of the Ebola virus, via international air travel, is an obvious risk that has already generated considerable interest
Preliminary assessments of the risk of international spread focused solely on the historic volume of international passenger flight traffic between countries
On 27 October 2014 the Australian Government announced a policy change indicating that, effective immediately, new visas would not be granted, and existing temporary visas for individuals who had not yet departed to Australia would be cancelled
The relative risk to Australia, in comparison to countries such as Ghana, Senegal, and the United Kingdom, is small, and hence an assessment of the risk of Ebola importation to Australia has not been previously reported in existing studies, which where not focussed on any specific country. Such an assessment is of obvious benefit to decision makers within Australia, both in its own right, and to allow for the assessment of new visa restriction policy.
We develop data-informed models appropriate to each scenario, and parameterised these models using passenger arrival card or international flight data, and WHO case data from West Africa as at 3 December 2014
In order to assess the risk of an individual with Ebola travelling directly from West Africa to Australia, the direct travel model was constructed. Epidemic dynamics in each of Liberia, Sierra Leone, and Guinea were evolved via a discrete-time stochastic Susceptible-Exposed-Infectious-Removed (SEIR)
The SEIR-type model is a standard epidemiological model for diseases with dynamics like those of Ebola, with the exposed period in particular necessary to account for the latency between initial exposure to the disease and the later onset of symptoms and infectiousness. More complex models have been used to analyse Ebola dynamics in some studies
For a given day, the probability an exposed individual did not travel to Australia that day was:
with
As a baseline case, we assumed a mean latent period of 5.3 days (i.e., σ = 1/5.3) and a mean infectious period of 5.61 days (i.e., γ = 1/5.61), based on parameters reported by Althaus
We considered: a baseline scenario with these parameters and historical transport levels; a scenario in which transport from West Africa was reduced by 50%; a scenario under which visas from West Africa are cancelled and no longer granted (i.e., limiting entry to only Australian residents); and a scenario under which the Ebola contact rate within West Africa was reduced by 20%. We also considered model sensitivity to increases or decreases in mean latent period, in particular demonstrating the impact of increasing latent period to 10 days or decreasing to 3 days. We report median cumulative probabilities of a case entering Australia, based on 1000 simulation runs for each scenario, along with 95% prediction intervals in tables/figures.
All modelling and analysis was performed using R version 3.1.0
In order to assess the risk of an Ebola case entering Australia via an outbreak in a secondary source location (i.e., via an outbreak in a country that does not currently have an outbreak), the global network secondary outbreak model was constructed. Each country worldwide was treated as an individual population, connected through the global flight network. Within each country, spread of ebola was modelled via the same discrete-time stochastic SEIR epidemic model as in the previous section. Each day, the number of individuals in each class was updated, and individuals were allowed to fly between countries: the number of flying individuals between each country being the average daily number of flying individuals between each pair of airports in the countries in question. Data on the annual number of international flights per airport and the number of seats, per airplane per airport, travelling worldwide for the year 2013, were obtained from OAG Aviation Worldwide Ltd (www.oag.com/). Susceptible and exposed individuals (i.e., those either not infected or infected and not yet showing symptoms) were allowed to fly, and the number of exposed individuals flying was modelled as a binomial random variable with probability being the proportion of exposed individuals of those eligible to fly.
Simulations of this model were progressed 211 days (3 December 2014 -- 1 July 2015) and the spread and growth of Ebola virus cases into each country recorded. Disease parameters were as described above. We report results of: (i) a baseline model with historical infection and transport rates and uniform infection rates in each country; (ii) a scenario under which countries that have experienced at least 100 cases then have 50% reduced outgoing traffic; and (iii) a scenario in which higher economic status countries have reduced contact rate. We report, for each scenario, the cumulative probability of entry into Australia at each timestep based on 50 simulations, i.e., the proportion of those simulations for which an entry into Australia had occurred.
Specifically, for the economically-moderated contact rate scenario, countries were classified into four classes based on existing World Bank income classifications
These models were initially constructed based on WHO case data reported on 17 October 2014, and projected forward 200 days. New data became available while the study was in review, and results were subsequently updated to reflect these more recent data, as reported at 3 December 2014. Initial projections from 17 October data were based on a doubling time of 30 days, a conservative choice given the range of doubling times reported at the time
Under the baseline scenario of unchanged epidemic conditions and traffic from West Africa to Australia, the probability of a case entering Australia by 1 July 2015 is 0.34 (Figure 1, Figure 2). Under the scenario of 50% reduced traffic, the probability of a case by 1 July 2015 falls to 0.19 (Figure 3, Figure 4). New Australian Government policy, restricting/cancelling visas from West Africa into Australia, reduced the risk of entry to a probability of 0.16 by 1July 2015 (Figure 2, Figure 3).
Cumulative probability over time (3 December 2014 — 1 July 2015) of an exposed individual flying into Australia from Liberia, Sierra Leone, and Guinea, with historic travel levels.
Probability of an exposed individual having entered Australia by the start of each month, based on historical travel levels (baseline) and new Australian Government visa restrictions from West Africa.
Cumulative probability over time (3 December 2014 — 1 July 2015) of an exposed individual flying into Australia for baseline, 50% flight reduction, and after visa restrictions.
Probability of an exposed individual having entered Australia by the start of each month, based on historical travel levels (baseline), 50% reduced flights, or 20% lower contact rates within West Africa.
Alternately, when we consider the potential impact of reduced Ebola contact rates within existing outbreaks, a reduction of 20% results in a substantial reduction in risk, with the probability of a case entering by 1 July 2015 being only 0.03 (Figure 4, Figure 5).
Cumulative probability over time (3 December 2014 — 1 July 2015) of an exposed individual flying into Australia from Liberia, Sierra Leone, and Guinea, after a 20% reduction in contact rate within these countries.
Increasing the latent period for Ebola to 10 days (provided the doubling time remains constant) increased the probability that a case enters Australia within a given time (Figure 6, Figure 7). The converse is also true - a decrease in latent period to 3 days decreased the probability of entry (Figure 6, Figure 7).
Cumulative probability over time (3 December 2014 — 1 July 2015) of an exposed individual flying into Australia, with variable mean latent period: baseline 5.3 days vs. 3 and 10 days.
Probability of an exposed individual having entered Australia by the start of each month, based on historical travel levels and mean latent periods of 5.3 (baseline), 10, and 5 days.
Under a global outbreak model, with baseline parameters unchanged (infection rates globally uniform, consistent international air traffic), and based on 50 simulation runs, the first date a case entered Australia via an outbreak in a secondary source location was 23 May 2015, and cases had entered Australia by 1 June 2015 in 6% of simulation runs and by 1 July 2015 in 12% of simulation runs (Figure 8).
Cumulative probability over time of an exposed individual having entered Australia via an outbreak in a secondary source location. Based on 50 simulation runs.
Simulations were also performed under two alternate scenarios: (a) the rate of air traffic leaving infected countries was decreased by 50% for each country that has experienced at least 100 cases, and (b) contact rates were decreased within higher-income countries. Under both of these scenarios, no Ebola cases entered Australia by 1 July 2015 under 50 simulations of the global network secondary outbreak model.
Under historic traffic levels from West Africa to Australia (i.e., the direct travel model), and epidemic parameters and initial conditions as reported on 17 October 2014, the probability of a case entering Australia by 1 April 2015 was 0.97. The predicted risk under the same model, with parameters and initial conditions as reported on 3 December 2014, was 0.09 (Figure 9). The probability of a case entering within 200 days of 17 October 2014 was 1.00, compared to a probability of 0.30 within 200 days of 3 December 2014.
Projected risk over time (17 October 2014 -- 1 July 2015) of entry of a case of Ebola into Australia via direct travel from West Africa. Presents results of models based on data available at and initialized on each of 17 October 2014 and 3 December 2014.
Under the Global network secondary outbreak model, the probability of a case entering Australia via an outbreak in a secondary source location within 200 days of 17 October 2014 was 0.76. With updated parameters and initial conditions, the probability of a case entering Australia within 200 days of 3 December 2014 was 0.10 (Figure 10).
Projected risk over time (17 October 2014 -- 1 July 2015) of entry of a case of Ebola into Australia via an outbreak in a secondary source location. Presents results of 50 simulations each based on data available at and initialized on each of 17 October 2014 (blue) and 3 December 2014 (black).
Under current epidemic conditions and historic travel levels into Australia, it is possible that an Ebola case will enter Australia within the first six months of 2015, having travelled directly from West Africa, with a probability of 0.34.
The cessation of granting visas/cancelling existing visas is effectively equivalent to a traffic reduction of approximately 60% (i.e., 83% reduction from Guinea, 60% reduction from Liberia, 56% reduction from Sierra Leone), and its impact is in line with this: the probability of a case entering Australia by 1 July 2015 is reduced by 53% (slightly more than under the 50% reduction in traffic scenario). However, the probability of an eventual case entering Australia within the first six months of 2015 is still sufficiently high as to warrant caution (16%).
It is possible that there may be some decrease in the number of Australian residents travelling to and from affected countries, which may further decrease the probability of a case arriving. Alternatively there may be, within the short term, an increase, if for example visitors to West Africa are returning to Australia at a greater rate than they may previously have in an attempt to avoid Ebola.
A 20% decrease in contact rate within affected West African countries reduced the probability of an eventual case entering Australia substantially (3% chance of introduction by 1 July 2015, vs. 34% under the baseline scenario). It is possible that public health research to determine effective ways to reduce infection rates, combined with foreign aid contributing to increased availability of hospital beds and high- quality treatment, could feasibly result in a decrease in contact rate of this magnitude. Note that at this level of reduced contact, the number of cases no longer increases exponentially, or, rather, the exponential growth is so slow that within the time period considered it is close to linear (Figure 5). If the contact rate is reduced even further than this, the number of Ebola cases will begin to decrease within West Africa. This is consistent with CDC predictions, that Ebola infection decreases under potential control and hospitalization scenarios
We found that, under existing Ebola transmission parameters and historic global flight conditions, it is possible but not likely that Australia may see an Ebola case via an outbreak in a secondary source country within the first six months of 2015, with a probability of approximately 0.12 by 1 July 2015. It is very unlikely that this happens early during this time period, given the time it would take for outbreaks to be established in countries with significant direct air traffic to Australia.
Under a model with global control of air traffic leaving each country in which a significant outbreak has occurred, the probability of a case reaching Australia within the first six months of 2015 is further reduced, such that no simulation runs (from 50) had cases enter Australia within this interval. Some reduction in air traffic to and from affected countries is a reasonable assumption, either due to mandated restrictions, or just the natural desire of people to avoid travelling where epidemic risk is significant.
When the assumption is made that contact rates are likely to be reduced in higher-income countries, which may be reasonable due to a combination of high-quality healthcare, and education relating to disease transmission, global outbreak spread slows significantly. As a result of this, no simulation runs had a case enter Australia within the first six months of 2015 under this scenario.
It may appear unintuitive that there would be less risk of an Ebola case entering Australia within the first six months of 2015 from the global outbreak model than from direct travel. The discrepancy is due to the time scale involved: under the global outbreak model, secondary outbreaks would need to occur and grow in countries with direct connections to Australia for a case to then enter, which would take a significant amount of time. If the time scale were longer, the risk due to global spread would increase and eventually be greater than due to direct travel, and also be less susceptible to control measures such as visa restrictions.
Modelling based on updated parameters and initial conditions, based on data available at 3 December 2014
It is likely that the strong difference between results based on these two datasets is primarily due to two factors: (1) efforts to control the spread of Ebola in West Africa, and (2) more accurate data, restricted to confirmed cases. Significant public health measures for the control of Ebola are underway, and show promising signs. The number of new reported incidences in Liberia was stable or declining by 3 December 2014, and protocols were in place throughout the region to effectively isolate patients, and to ensure safe burial practices
The stochastic SEIR model used here effectively represents the necessary components of Ebola dynamics for this study. More complex models have been applied in other studies, incorporating e.g., specific hospitalisation dynamics or separate removal classes (death vs. recovery) allowing specific incorporation of post-death contact. However, in this study it was most parsimonious to use a simple model with fewer assumptions as to disease dynamics or model parameters. There is some variation in reported parameter values in the literature, e.g., in terms of reported latent period (
One assumption made here, that is likely to significantly influence our predictions, is of consistency, i.e., the assumption that in general future disease dynamics and/or transport dynamics will follow past dynamics. If measures to control Ebola within West Africa are successful in the near future, or if air traffic trends from affected nations have been decreased significantly, then the risk of transport will be decreased. The best case scenario is of control within West Africa such that disease cases decrease to the point of eventual extinction without extensive outbreaks elsewhere (i.e., any individual cases that emerge elsewhere are controlled quickly). In a sense, the status-quo is the most conservative scenario.
We assumed here that 50% of removed individuals die, and 50% recover. Estimates of mortality rates for Ebola have varied considerably
Overall, we have made a large number of assumptions in each of the alternate scenarios we have chosen. The extent to which air traffic, or disease contact rates might decrease is uncertain and will have a nontrivial impact on model results. In particular the choice of contact rate for countries within different economic groups essentially defines that model. In this case, we assumed that high income countries would have contact rates that result only in replacement, on average, in terms of outbreak growth (and as such outbreaks in these countries will die out via stochasticity). This seems reasonable, and is not inconsistent with high quality medical care, contact tracing, etc., but control could certainly be stronger or weaker than this.
Finally, it should be noted that these projections are based upon WHO infection numbers, which it has been suggested may be under-reporting significantly
Based on two alternate models for the spread of Ebola, either via direct travel from West Africa or through spread to secondary sources, we conclude that under existing conditions it is possible that a case of Ebola will enter Australia within the first six months of 2015, with a probability of entry of 0.34 by 1 July 2015 under the baseline direct travel scenario. Reduced traffic due to new government visa restrictions will decrease the probability of this occurring. Comparison between data from 17 October 2014 and 3 December 2014 suggests that control measures within this period have had a positive impact, resulting in reduced risk of importation into Australia. Further control of existing outbreaks within West Africa, and in any further outbreaks in secondary locations, would provide the strongest decrease in risk to Australia. Medical professionals and policy makers should be prepared for the possible entry of an Ebola case into Australia, and continue to undertake public health research and supply aid in an effort to effectively reduce proliferation of Ebola in existing outbreaks.
Thanks to Talia Wittmann for assistance with compiling and curating datasets.
The stochastic SEIR model, for each country, is evolved forward over 200 daily timesteps.
Specifically, the transitions are:
with:
This formulation is similar in concept to that of the τ-leaping approximation for a continuous-time Markov chain. We take