Deterministic epidemic models with explicit household structure

For a wide range of airborne infectious diseases, transmission within the family or household is a key mechanism for the spread and persistence of infection. In general, household-based transmission is relatively strong but only involves a limited number of individuals in contact with each infectious person. In contrast, transmission outside the household can be characterised by many contacts but a lower probability of transmission. Here we develop a relatively simple dynamical model that captures these two transmission regimes. We compare the dynamics of such models for a range of household sizes, whilst constraining all models to have equal early growth rate so that all models fit to the same early incidence observations of an epidemic. Finally we consider the use of prophylactic vaccination, responsive vaccination, or antivirals to combat epidemic spread and focus on whether it is optimal to target controls at entire households or to treat individuals independently.     

A fully coupled, mechanistic model for infectious disease dynamics in a metapopulation: movement and epidemic duration

The drive to understand the invasion, spread and fade out of infectious disease in structured populations has produced a variety of mathematical models for pathogen dynamics in metapopulations. Very rarely are these models fully coupled, by which we mean that the spread of an infection within a subpopulation affects the transmission between subpopulations and vice versa. It is also rare that these models are accessible to biologists, in the sense that all parameters have a clear biological meaning and the biological assumptions are explained. Here we present an accessible model that is fully coupled without being an individual-based model. We use the model to show that the duration of an epidemic has a highly non-linear relationship with the movement rate between subpopulations, with a peak in epidemic duration appearing at small movement rates and a global maximum at large movement rates. Intuitively, the first peak is due to asynchrony in the dynamics of infection between subpopulations; we confirm this intuition and also show the peak coincides with successful invasion of the infection into most subpopulations. The global maximum at relatively large movement rates occurs because then the infectious agent perceives the metapopulation as if it is a single well-mixed population wherein the effective population size is greater than the critical community size.     

Models of infectious diseases in spatially heterogeneous environments

Most models of dynamics of infectious diseases have assumed homogeneous mixing in the host population. However, it is increasingly recognized that heterogeneity can arise through many processes. It is then important to consider the existence of subpopulations of hosts, and that the contact rate within subpopulations is different than that between subpopulations. We study models with hosts distributed in subpopulations as a consequence of spatial partitioning. Two types of models are considered. In the first one there is direct transmission. The second one is a model of dynamics of a mosquito-borne disease, with indirect transmission, and applicable to malaria. The contact between subpopulations is achieved through the visits of hosts. Two types of visit are considered: a first one in which the visit time is independent of the distance travelled, and a second one in which visit time decreases with distance. There are two types of spatial arrangement: one dimensional, and two dimensional. Conditions for the establishment of the disease are obtained. Results indicate that the disease becomes established with greater difficulty when the degree of spatial partition increases, and when visit time decreases. In addition, when visit time decreases with distance, the establishment of the disease is more difficult when the spatial arrangement is one dimensional than when it is two dimensional. The results indicate the importance of knowing the spatial distribution and mobility patterns to understand the dynamics of infectious diseases. The consequences of these results for the design of public health policies are discussed.     

Two-phase importance sampling for inference about transmission trees

There has been growing interest in the statistics community to develop methods for inferring transmission pathways of infectious pathogens from molecular sequence data. For many datasets, the computational challenge lies in the huge dimension of the missing data. Here, we introduce an importance sampling scheme in which the transmission trees and phylogenies of pathogens are both sampled from reasonable importance distributions, alleviating the inference. Using this approach, arbitrary models of transmission could be considered, contrary to many earlier proposed methods. We illustrate the scheme by analysing transmissions of Streptococcus pneumoniae from household to household within a refugee camp, using data in which only a fraction of hosts is observed, but which is still rich enough to unravel the within-household transmission dynamics and pairs of households between whom transmission is plausible. We observe that while probability of direct transmission is low even for the most prominent cases of transmission, still those pairs of households are geographically much closer to each other than expected under random proximity.     

Transmission and dynamics of tuberculosis on generalized households

Tuberculosis (TB) transmission is enhanced by systematic exposure to an infectious individual. This enhancement usually takes place at either the home, workplace, and/or school (generalized household). Typical epidemiological models do not incorporate the impact of generalized households on the study of disease dynamics. Models that incorporate cluster (generalized household) effects and focus on their impact on TB's transmission dynamics are developed. Detailed models that consider the effect of casual infections, that is, those generated outside a cluster, are also presented. We find expressions for the Basic Reproductive Number as a function of cluster size. The formula for R0 separates the contributions of cluster and casual infections in the generation of secondary TB infections. Relationships between cluster and classical epidemic models are discussed as well as the concept of critical cluster size.     

The time to extinction for a stochastic SIS-household-epidemic model

We analyse a Markovian SIS epidemic amongst a finite population partitioned into households. Since the population is finite, the epidemic will eventually go extinct, i.e., have no more infectives in the population. We study the effects of population size and within household transmission upon the time to extinction. This is done through two approximations. The first approximation is suitable for all levels of within household transmission and is based upon an Ornstein-Uhlenbeck process approximation for the diseases fluctuations about an endemic level relying on a large population. The second approximation is suitable for high levels of within household transmission and approximates the number of infectious households by a simple homogeneously mixing SIS model with the households replaced by individuals. The analysis, supported by a simulation study, shows that the mean time to extinction is minimized by moderate levels of within household transmission.     

Coevolution of pathogens and cultural practices: a new look at behavioral heterogeneity in epidemics

The effect of heterogeneity within populations on the spread of infectious diseases has been a recent focus of research. Such heterogeneity may be, for example, spatial, temporal or behavioral in form. Generally, models that include population subdivision have assumed that individuals are permanently assigned to given behavioral states represented by the subpopulations. We consider a simple epidemic model in which a behavioral trait affects disease transmission, and this trait may be transferred among hosts as a consequence of social interaction. This creates a situation where the frequencies of different behavioral traits and disease states as well as their associations may change over time. We consider the impact of the culturally transmitted trait on the criterion for initial spread of the disease. We also explore the evolution of cultural traits in response to pathogen dynamics and show some conditions under which behavioral traits that reduce transmission evolve. We find that behaviors increasing the risk of infection can also evolve when they are inherently favored or when there is sufficient clustering of contacts between like behaviors.     

An SIS epidemiology game with two subpopulations

There is significant current interest in the application of game theory to problems in epidemiology. Most mathematical analyses of epidemiology games have studied populations where all individuals have the same risks and interests. This paper analyses the rational-expectation equilibria in an epidemiology game with two interacting subpopulations of equal size where decisions change the prevalence and transmission patterns of an infectious disease. The transmission dynamics are described by an SIS model and individuals are only allowed to invest in daily prevention measures like hygiene. The analysis shows that disassortative mixing may lead to multiple Nash equilibria when there are two interacting subpopulations affecting disease prevalence. The dynamic stability of these equilibria is analysed under the assumption that strategies change slowly in the direction of self-interest. When mixing is disassortative, interior Nash equilibria are always unstable. When mixing is positively assortative, there is a unique Nash equilibrium that is globally stable.     

An SIS epidemiology game with two subpopulations

There is significant current interest in the application of game theory to problems in epidemiology. Most mathematical analyses of epidemiology games have studied populations where all individuals have the same risks and interests. This paper analyses the rational-expectation equilibria in an epidemiology game with two interacting subpopulations of equal size where decisions change the prevalence and transmission patterns of an infectious disease. The transmission dynamics are described by an SIS model and individuals are only allowed to invest in daily prevention measures like hygiene. The analysis shows that disassortative mixing may lead to multiple Nash equilibria when there are two interacting subpopulations affecting disease prevalence. The dynamic stability of these equilibria is analysed under the assumption that strategies change slowly in the direction of self-interest. When mixing is disassortative, interior Nash equilibria are always unstable. When mixing is positively assortative, there is a unique Nash equilibrium that is globally stable.     

Estimating and interpreting secondary attack risk: Binomial considered biased

The household secondary attack risk (SAR), often called the secondary attack rate or secondary infection risk, is the probability of infectious contact from an infectious household member A to a given household member B, where we define infectious contact to be a contact sufficient to infect B if he or she is susceptible. Estimation of the SAR is an important part of understanding and controlling the transmission of infectious diseases. In practice, it is most often estimated using binomial models such as logistic regression, which implicitly attribute all secondary infections in a household to the primary case. In the simplest case, the number of secondary infections in a household with m susceptibles and a single primary case is modeled as a binomial(m, p) random variable where p is the SAR. Although it has long been understood that transmission within households is not binomial, it is thought that multiple generations of transmission can be neglected safely when p is small. We use probability generating functions and simulations to show that this is a mistake. The proportion of susceptible household members infected can be substantially larger than the SAR even when p is small. As a result, binomial estimates of the SAR are biased upward and their confidence intervals have poor coverage probabilities even if adjusted for clustering. Accurate point and interval estimates of the SAR can be obtained using longitudinal chain binomial models or pairwise survival analysis, which account for multiple generations of transmission within households, the ongoing risk of infection from outside the household, and incomplete follow-up. We illustrate the practical implications of these results in an analysis of household surveillance data collected by the Los Angeles County Department of Public Health during the 2009 influenza A (H1N1) pandemic.     

Estimating the immunity coverage required to prevent epidemics in a community of households

An estimation of the immunity coverage needed to prevent future outbreaks of an infectious disease is considered for a community of households. Data on outbreak size in a sample of households from one epidemic are used to derive maximum likelihood estimates and confidence bounds for parameters of a stochastic model for disease transmission in a community of households. These parameter estimates induce estimates and confidence bounds for the basic reproduction number and the critical immunity coverage, which are the parameters of main interest when aiming at preventing major outbreaks in the future. The case when individuals are homogeneous, apart from the size of their household, is considered in detail. The generalization to the case with variable infectivity, susceptibility and/or mixing behaviour is discussed more briefly. The methods are illustrated with an application to data on influenza in Tecumseh, Michigan.     

Analysis of Binary Multivariate Longitudinal Data via 2-Dimensional Orbits: An Application to the Agincourt Health and Socio-Demographic Surveillance System in South Africa

We analyse demographic longitudinal survey data of South African (SA) and Mozambican (MOZ) rural households from the Agincourt Health and Socio-Demographic Surveillance System in South Africa. In particular, we determine whether absolute poverty status (APS) is associated with selected household variables pertaining to socio-economic determination, namely household head age, household size, cumulative death, adults to minor ratio, and influx. For comparative purposes, households are classified according to household head nationality (SA or MOZ) and APS (rich or poor). The longitudinal data of each of the four subpopulations (SA rich, SA poor, MOZ rich, and MOZ poor) is a five-dimensional space defined by binary variables (questions), subjects, and time. We use the orbit method to represent binary multivariate longitudinal data (BMLD) of each household as a two-dimensional orbit and to visualise dynamics and behaviour of the population. At each time step, a point (x, y) from the orbit of a household corresponds to the observation of the household, where x is a binary sequence of responses and y is an ordering of variables. The ordering of variables is dynamically rearranged such that clusters and holes associated to least and frequently changing variables in the state space respectively, are exposed. Analysis of orbits reveals information of change at both individual- and population-level, change patterns in the data, capacity of states in the state space, and density of state transitions in the orbits. Analysis of household orbits of the four subpopulations show association between (i) households headed by older adults and rich households, (ii) large household size and poor households, and (iii) households with more minors than adults and poor households. Our results are compared to other methods of BMLD analysis.     

Spatial heterogeneity and the design of immunization programs

Conventional epidemiological models usually assume homogeneous mixing, with susceptible and infected individuals mingling like the molecules in an ideal gas. It has recently been noted, however, that variability in transmission rates—arising, for example, from some hosts being in dense aggregates while others are in small or remote groups—can result in the intrinsic reproductive rate, R₀, of a microparasitic infection being greater than would be estimated under the usual assumption of homogeneous mixing; this implies the infection may be harder to eradicate under a homogeneously applied immunization programme (that is, a larger proportion of the population must be vaccinated) than simple estimates might suggest. In this paper we consider a spatially heterogeneous population arbitrarily subdivided into n groups, with one transmission rate among individuals within any one group, and another, lower transmission rate between groups. We define an optimum eradication program as that which—treating different groups differently—achieves its aim by immunizing the smallest overall number in each cohort of newborns, and we show this optimum program requires fewer immunizations than would be estimated under the (false) assumption that the population is homogeneously mixed. We prove this result in general form, and illustrate it for some special examples (in particular, for a population subdivided into one large ”city“ and several small ”villages“).     

Modelling tree shape and structure in viral phylodynamics

Epidemiological models have highlighted the importance of population structure in the transmission dynamics of infectious diseases. Using HIV-1 as an example of a model evolutionary system, we consider how population structure affects the shape and the structure of a viral phylogeny in the absence of strong selection at the population level. For structured populations, the number of lineages as a function of time is insufficient to describe the shape of the phylogeny. We develop deterministic approximations for the dynamics of tips of the phylogeny over evolutionary time, the number of ‘cherries’, tips that share a direct common ancestor, and Sackin''s index, a commonly used measure of phylogenetic imbalance or asymmetry. We employ cherries both as a measure of asymmetry of the tree as well as a measure of the association between sequences from different groups. We consider heterogeneity in infectiousness associated with different stages of HIV infection, and in contact rates between groups of individuals. In the absence of selection, we find that population structure may have relatively little impact on the overall asymmetry of a tree, especially when only a small fraction of infected individuals is sampled, but may have marked effects on how sequences from different subpopulations cluster and co-cluster.     

Invasion and persistence of infectious agents in fragmented host populations

One of the important questions in understanding infectious diseases and their prevention and control is how infectious agents can invade and become endemic in a host population. A ubiquitous feature of natural populations is that they are spatially fragmented, resulting in relatively homogeneous local populations inhabiting patches connected by the migration of hosts. Such fragmented population structures are studied extensively with metapopulation models. Being able to define and calculate an indicator for the success of invasion and persistence of an infectious agent is essential for obtaining general qualitative insights into infection dynamics, for the comparison of prevention and control scenarios, and for quantitative insights into specific systems. For homogeneous populations, the basic reproduction ratio R(0) plays this role. For metapopulations, defining such an 'invasion indicator' is not straightforward. Some indicators have been defined for specific situations, e.g., the household reproduction number R*. However, these existing indicators often fail to account for host demography and especially host migration. Here we show how to calculate a more broadly applicable indicator R(m) for the invasion and persistence of infectious agents in a host metapopulation of equally connected patches, for a wide range of possible epidemiological models. A strong feature of our method is that it explicitly accounts for host demography and host migration. Using a simple compartmental system as an example, we illustrate how R(m) can be calculated and expressed in terms of the key determinants of epidemiological dynamics.     

Impact of the Infection Period Distribution on the Epidemic Spread in a Metapopulation Model

Epidemic models usually rely on the assumption of exponentially distributed sojourn times in infectious states. This is sometimes an acceptable approximation, but it is generally not realistic and it may influence the epidemic dynamics as it has already been shown in one population. Here, we explore the consequences of choosing constant or gamma-distributed infectious periods in a metapopulation context. For two coupled populations, we show that the probability of generating no secondary infections is the largest for most parameter values if the infectious period follows an exponential distribution, and we identify special cases where, inversely, the infection is more prone to extinction in early phases for constant infection durations. The impact of the infection duration distribution on the epidemic dynamics of many connected populations is studied by simulation and sensitivity analysis, taking into account the potential interactions with other factors. The analysis based on the average nonextinct epidemic trajectories shows that their sensitivity to the assumption on the infectious period distribution mostly depends on , the mean infection duration and the network structure. This study shows that the effect of assuming exponential distribution for infection periods instead of more realistic distributions varies with respect to the output of interest and to other factors. Ultimately it highlights the risk of misleading recommendations based on modelling results when models including exponential infection durations are used for practical purposes.     

Epidemic growth rate and household reproduction number in communities of households,schools and workplaces

In this paper we present a novel and coherent modelling framework for the characterisation of the real-time growth rate in SIR models of epidemic spread in populations with social structures of increasing complexity. Known results about homogeneous mixing and multitype models are included in the framework, which is then extended to models with households and models with households and schools/workplaces. Efficient methods for the exact computation of the real-time growth rate are presented for the standard SIR model with constant infection and recovery rates (Markovian case). Approximate methods are described for a large class of models with time-varying infection rates (non-Markovian case). The quality of the approximation is assessed via comparison with results from individual-based stochastic simulations. The methodology is then applied to the case of influenza in models with households and schools/workplaces, to provide an estimate of a household-to-household reproduction number and thus asses the effort required to prevent an outbreak by targeting control policies at the level of households. The results highlight the risk of underestimating such effort when the additional presence of schools/workplaces is neglected. Our framework increases the applicability of models of epidemic spread in socially structured population by linking earlier theoretical results, mainly focused on time-independent key epidemiological parameters (e.g. reproduction numbers, critical vaccination coverage, epidemic final size) to new results on the epidemic dynamics.     

Spatial models of virus-immune dynamics

To date, the majority of theoretical models describing the dynamics of infectious diseases in vivo are based on the assumption of well-mixed virus and cell populations. Because many infections take place in solid tissues, spatially structured models represent an important step forward in understanding what happens when the assumption of well-mixed populations is relaxed. Here, we explore models of virus and virus-immune dynamics where dispersal of virus and immune effector cells was constrained to occur locally. The stability properties of our spatial virus-immune dynamics models remained robust under almost all biologically plausible dispersal schemes, regardless of their complexity. The various spatial dynamics were compared to the basic non-spatial dynamics and important differences were identified: When space was assumed to be homogeneous, the dynamics generated by non-spatial and spatially structured models differed substantially at the peak of the infection. Thus, non-spatial models may lead to systematic errors in the estimates of parameters underlying acute infection dynamics. When space was assumed to be heterogeneous, spatial coupling not only changed the equilibrium properties of the uncoupled populations but also equalized the dynamics and thereby reduced the likelihood of dynamic elimination of the infection. In line with experimental and clinical observations, long-lasting oscillation periods were virtually absent. When source-sink dynamics were considered, the long-term outcome of the infection depended critically on the degree of spatial coupling. The infection collapsed when emigration from source sites became too large. Finally, we discuss the implications of spatially structured models on medical treatment of infectious diseases, and note that a huge gap exists in data accurately describing infection dynamics in solid tissues.     

Effects of pathogen dependency in a multi-pathogen infectious disease system including population level heterogeneity – a simulation study

Background

Increased computational resources have made individual based models popular for modelling epidemics. They have the advantage of incorporating heterogeneous features, including realistic population structures (like e.g. households). Existing stochastic simulation studies of epidemics, however, have been developed mainly for incorporating single pathogen scenarios although the effect of different pathogens might directly or indirectly (e.g. via contact reductions) effect the spread of each pathogen. The goal of this work was to simulate a stochastic agent based system incorporating the effect of multiple pathogens, accounting for the household based transmission process and the dependency among pathogens.

Methods

With the help of simulations from such a system, we observed the behaviour of the epidemics in different scenarios. The scenarios included different household size distributions, dependency versus independency of pathogens, and also the degree of dependency expressed through household isolation during symptomatic phase of individuals. Generalized additive models were used to model the association between the epidemiological parameters of interest on the variation in the parameter values from the simulation data. All the simulations and statistical analyses were performed using R 3.4.0.

Results

We demonstrated the importance of considering pathogen dependency using two pathogens, and showing the difference when considered independent versus dependent. Additionally for the general scenario with more pathogens, the assumption of dependency among pathogens and the household size distribution in the population cohort was found to be effective in containing the epidemic process. Additionally, populations with larger household sizes reached the epidemic peak faster than societies with smaller household sizes but dependencies among pathogens did not affect this outcome significantly. Larger households had more infections in all population cohort examples considered in our simulations. Increase in household isolation coefficient for pathogen dependency also could control the epidemic process.

Conclusion

Presence of multiple pathogens and their interaction can impact the behaviour of an epidemic across cohorts with different household size distributions. Future household cohort studies identifying multiple pathogens will provide useful data to verify the interaction processes in such an infectious disease system.