TY - JOUR T1 - Vaccination strategies to control Ebola epidemics in the context of variable household inaccessibility levels JF - bioRxiv DO - 10.1101/665646 SP - 665646 AU - G. Chowell AU - A. Tariq AU - M. Kiskowski Y1 - 2019/01/01 UR - http://biorxiv.org/content/early/2019/06/22/665646.abstract N2 - Despite a very effective vaccine, active conflict and community distrust during the ongoing DRC Ebola epidemic are undermining control efforts, including a ring vaccination strategy that require the prompt immunization of close contacts of infected individuals. However, 20% or more of close contacts cannot be reached or refuse vaccination [1], and it is predicted that the ring vaccination strategy would not be effective with such a high level of inaccessibility. In May 2019, the DRC expanded their control efforts to include a community vaccine strategy. To assess the impact of vaccination strategies for controlling Ebola epidemics in the context of variable levels of community resistance, we employed an individual-level stochastic transmission model that incorporates four sources of heterogeneity: a proportion of the population is inaccessible for contact tracing and vaccination due to lack of confidence in interventions or geographic inaccessibility, two levels of population mixing resembling household and community transmission, two types of vaccine doses with different time periods until immunity, and transmission rates that depend on spatial distance. Our results indicate that a ring vaccination strategy alone would not be effective for containing the epidemic in the context of significant delays to vaccinating contacts even for low levels of household inaccessibility and affirm the positive impact of a supplemental community vaccination strategy. Our key results are that as levels of inaccessibility increase, there is a qualitative change in the effectiveness of the vaccination strategy. For higher levels of vaccine access, the probability that the epidemic will end steadily increases over time, even if probabilities are lower than they would be otherwise with full community participation. For levels of vaccine access that are too low, however, the vaccination strategies are not expected to be successful in ending the epidemic even though they help lower incidence levels, which saves lives, makes the epidemic easier to contain and reduces spread to other communities. This qualitative change occurs for both types of vaccination strategies: ring vaccination is effective for containing an outbreak until the levels of inaccessibility exceeds approximately 10% in the context of significant delays to vaccinating contacts, a combined ring and community vaccination strategy is effective until the levels of inaccessibility exceeds approximately 50%. More broadly, our results underscore the need to enhance community engagement to public health interventions in order to enhance the effectiveness of control interventions to ensure outbreak containment.Author summary Containing Ebola outbreaks hinges on educating local communities. In the context of the ongoing Ebola epidemic in DRC, active conflict and community distrust are undermining control efforts, including vaccination strategies. In this paper, we employed an individual-level stochastic structured transmission model to assess the impact of vaccination strategies on epidemic control in the context of variable levels of household inaccessibility. We found that a ring vaccination strategy would not be effective for containing the epidemic in the context of significant delays to vaccinating contacts even for low levels of household inaccessibility and evaluate the impact of a supplemental community vaccination strategy. For lower levels of inaccessibility, the probability of epidemic containment increases over time. For higher levels of inaccessibility, vaccination strategies are not expected to contain the epidemic even though they help lower incidence levels, which saves lives, makes the epidemic easier to contain and reduces spread to other communities. We found that ring vaccination is effective for containing an outbreak until the levels of inaccessibility exceeds approximately 10%, a combined ring and community vaccination strategy is effective until the levels of inaccessibility exceeds approximately 50%. Our findings underscore the need to enhance community engagement to public health interventions. ER -