Reducing transmission in multiple settings is required to eliminate the risk of major Ebola outbreaks: a mathematical modelling study.

The Ebola virus (EV) persists in animal populations, with zoonotic transmission to humans occurring every few months or years. When zoonotic transmission arises, it is important to understand which interventions are most effective at preventing a major outbreak driven by human-to-human transmission. Here, we analyse a mathematical model of EV transmission and calculate the probability of a major outbreak starting from a single introduced case. We consider community, funeral and healthcare facility transmission and conduct sensitivity analyses to explore the effects of non-pharmaceutical interventions (NPIs) that influence these transmission routes. We find that, if the index case is treated in the community, then the elimination of transmission at funerals reduces the probability of a major outbreak substantially (from 0.410 to 0.066 under our baseline model parametrization). However, eliminating the risk of major outbreaks entirely requires combinations of measures that limit transmission in different settings, such as community engagement to promote safe burial practices and implementation of barrier nursing in healthcare facilities. In addition to generating insights into the drivers of Ebola outbreaks, this research provides a modelling framework for assessing the effectiveness of interventions at mitigating outbreaks of other infectious diseases with transmission in multiple settings.