Abstract
Deciding when to enforce or relax non-pharmaceutical interventions (NPIs) based on real-time outbreak surveillance data is a central challenge in infectious disease epidemiology. Reporting delays and infection under-ascertainment, which characterise practical surveillance data, can misinform decision-making, prompting mistimed NPIs that fail to control spread or permitting deleterious epidemic peaks that overload healthcare capacities. To mitigate these risks, recent studies propose more data-insensitive strategies that trigger NPIs at predetermined times or infection thresholds. However, these strategies often increase NPI durations, amplifying their substantial costs to livelihood and life-quality. We develop a novel model-predictive control algorithm that optimises NPI decisions. We jointly minimise the cumulative risks and costs of interventions of different stringency over stochastic epidemic projections. Our algorithm is among the earliest to realistically incorporate uncertainties underlying both the generation and surveillance of infections. We find, except under extremely delayed reporting, that our projective approach outperforms data-insensitive strategies and show that earlier decisions strikingly improve real-time control with reduced NPI costs. Moreover, we expose how surveillance quality, disease growth and NPI frequency intrinsically limit our ability to flatten epidemic peaks or dampen endemic oscillations and reveal why this potentially makes Ebola virus more controllable than SARS-CoV-2. Our algorithm provides a general framework for guiding optimal NPI decisions ahead-of-time and identifying the key factors limiting practical epidemic control.