Estimating the effectiveness of syndromic screening at airports for Bundibugyo ebolavirus disease

We used a stochastic simulation model to estimate the effectiveness of combined exit and entry airport screening for Bundibugyo ebolavirus disease (BVD), using natural-history parameters from a Bayesian re-analysis of the 2012 Isiro outbreak. For a 12-hour international flight from DRC or Uganda at 86% screening sensitivity, we estimate 65% of infected travellers would arrive undetected (95% CrI: 38 - 76%). The main driver of this outcome is the relative duration of the the incubation period (approximately 7.7 days) and the onset-to-severe-disease interval (approximately 4 days): most infected travellers board before symptom onset and are undetectable by any syndromic screen, whilst those who are symptomatic progress rapidly to illness severe enough to preclude travel. This is compounded during active epidemic growth, when recently exposed (and therefore pre-symptomatic) cases are overrepresented among travellers. Syndromic airport screening offers limited protection against BVD spread via air travel, and should be complemented by outbreak control at source and strengthened clinical surveillance in receiving countries with high travel connectivity to affected areas.