Wednesday, May 17, 2017

40 years after the first Ebola outbreak are we able to handle the next epidemic?

By Esther Nakkazi

(An edited version of this piece was published in The EastAfrican newspaper (no link) in September 2016. I wrote it when I was a resident Journalist at the Institute of Tropical Medicine. Just uploaded it in light of the recent Ebola outbreak in DRC)

Driven by discoveries over the last 40 years since the first Ebola outbreak, scientists are optimistic that the new tools and data at hand will limit the damage for the next epidemic.

Since September, 1976, in Yambuku, Zaire - now the Democratic Republic of Congo, when the first outbreak of the disease was reported, 25 Ebola outbreaks have happened but the 2014 West African outbreak was unprecedented.

In nearly two years in three countries there were 11,000 deaths. Over Ebola’s existence of 40 years, 30,900 cumulative cases have occurred with12,800 deaths at an annual average death of 322. 

At the 8th International Symposium on Filoviruses in Antwerp, Belgium, hosted by the Antwerp Institute of Tropical Medicine, on 12-15 September 2016, which reviewed global progress against Ebola, scientists said they have enough Ebola arsenal; vaccines, diagnostics, clinical data and therapeutics ready for the next epidemic.

For the academia and researchers, so much has been discovered over the past 40 years. As Micheal Kurilla, the director biodefence research at the National Institute of Allergy and Infectious Diseases said at the symposium, ‘the once one pager on hemorrhagic fever in text books is now being constantly rewritten and updated.’

“The silver lining of the epidemic is that there has been some solid research from epidemiological, social, anthropological, therapeutic and vaccine research,” said Peter Piot the director of the London School of Hygiene and Tropical Medicine, UK.

Three microbiologists, Professors Peter Piot, Guido van der Groen and Jean-Jacques Muyembe are no strangers to Ebola. The two Belgians received the first ‘unknown’ virus at the Antwerp Institute of Tropical Medicine from the former who sent it from Kisansha and they discovered Ebola.

Top insights on research:

Ebola is not all the time killing it can also save some lives. ITM spearheaded the use of blood and plasma from recovered patients to cure victims although it was not very successful and has since developed diagnostics.

“We have moved relatively quickly, gained a lot of time and learned a lot of things on how to do things better,” said Prof. Dr. Johan Van Griensven who heads the HIV and Neglected Tropical Diseases Unit at ITM.

There is also a general desire to progress Ebola R&D faster through initiatives like the coalition for epidemic preparedness innovations which is creating partnerships and giving incentives to develop vaccines, therapeutics and diagnostics where there is no market to contain outbreaks of emerging infectious diseases. This is at the back drop of limited epidemic R&D market incentives.

There are also efforts to share data and not duplicate funding. What happened in the West African outbreak was terrible. Chinese came in just to pick samples, institutions owned data and refused to share it.

Now efforts have been made to share data and to encourage players to play into each other’s comparative advantage, said Dr. Barbara Kerstiens, the deputy Head Fighting Infectious Diseases and Advancing Public Health Unit, DG for Research and Innovation at the European Commission.

Overall, the WHO has also made harmonised clinical trials a blue print plan for action.

Various pharmaceutical companies have also gone ahead to develop vaccines. On 12 September, Johnson & Johnson, announced that its subsidiary Janssen Vaccines & Prevention B.V had submitted its investigational preventive Ebola prime-boost vaccine regimen to the World Health Organisation (WHO) to be used in emergencies.

“If listed for emergency use, the investigational Janssen vaccine regimen could be a vital prevention tool for rapid outbreak response,” said Johan Van Hoof, Global Therapeutic Area Head, Infectious Diseases and Vaccines, Janssen Pharmaceutical Companies.

It would particularly be available for health workers and vulnerable communities on the front-lines who suffer the most in Ebola outbreaks. It has already been tested and passed in animal models and for safety.

Many other vaccines have passed the test for animal models - which do not necessarily represent the pathogenesis - that occurs in humans. For many Ebola vaccines and treatments when scientists caused disease in rodent species they would be mildly affected although it was deadly in humans. Scientists therefore did not know which animal models would be predictive and this limited advancing.

When the outbreak happened in West Africa everything changed. It was a windfall. The unexpected opportunity to test the animal models under real life conditions was presented.

“It gave us an opportunity to advance and focus on the most appropriate animal models so that the future counter measures will have a much higher probability of success in the next outbreak” said Kurilla. “We got a lot of ‘proof of concept’ for interventions although at some point it was less than ideal to move forward.”

Furthermore, there are new lessons to learn from long studies. For instance, 40 years ago it was unknown that the Ebola virus is spread sexually and that it survives in survivors bodies for a long time 

And a lot to learn from research that did not work like the ITM convalescent plasma treatment that had held a lot of hope. “Data should not be undervalued because showing that something does not work is equally as important and has enormous value,” said Kurilla.

It is also new research that age and viral load where key determinants for the survival against Ebola, not necessarily solely supportive care as many thought.

The WestAfrican Ebola outbreak flipped to the usual; a humanitarian emergency having outbreaks to an outbreak becoming a humanitarian emergency. There were also unnecessary delays and a reluctance both government and international community levels to consider it a humanitarian crisis and not just another health problem until gears shifted.

Thus, institutions like World Health Organisation have made reforms. With no historical formal mechanism in countries for managing outbreaks but a clear architecture in the way humanitarian crisis are managed for conflict and natural disasters changes are underway.

“Previously, the humanitarian and outbreak departments were separate but they are now merged,” said Dr. Rick Brennan the Director, Emergency Risk Management and Humanitarian Response at WHO.

WHO is also working to create a system with standard procedures to support a more predictable mechanism with better leadership and coordination especially working to leverage that capacity to manage large scale outbreaks, said Brennan.

“We need more experience of the humanitarian sector, which is dominated by logistics, organisation, coordination that could be more boring and bureaucratic but I believe we need more of that in the first place,” said Piot.

WHO has also linked up with the World Bank for a ‘unified framework for preparedness’ . This will strengthen preparedness at the country level not just for outbreaks but for emergencies.

The reasoning is that every country is prone to emergencies and its capacity to respond to them needs a baseline study to understand the average patterns faced and how they can prepare.

“We have done this because regardless of the event there are some basics that you always need,” said Brennan. These include good medicine management, information capacity, communication capacities, strong logistic.

WHO has also put in place a special procedure to fast track R&D the WHO Emergency Use Assessment and Listing (EUAL) that can be implemented when there is an outbreak with high rates of morbidity and mortality and a lack of treatment or prevention options.

Janssen Vaccines & Prevention B.V has submitted its investigational preventive Ebola prime-boost vaccine regimen for it.

“If the WHO grants an emergency use listing, this will accelerate the availability of Janssen’s investigational vaccine regimen to the international community in the event another Ebola crisis occurs,” said Paul Stoffels, the Chief Scientific Officer, Johnson & Johnson.

The DRC which has recorded seven outbreaks, the highest ever in a single country, also has lessons. At the epic of the West Africa outbreak it had its own.

“The first thing is to detect, report and test. We now have a good surveillance system and we have trained some health workers,” said Prof Muyembe.

Muyembe who leads the national coordinating committee on Ebola in the country and is the director general of the National Institute of Biomedical Research (INRB) said these are key ingredients to control the virus.

In addition, there is strong community engagement and ownership to implement, control and prevent Ebola. For them dialogue is important and only negotiated solutions are implemented. Ebola survivors are used to disseminate information.

“Many people can now identify Ebola. If the outbreak happened right now they would know exactly what to do,” said Muyembe.

“I think that indirectly DRC demonstrates that you can control this epidemic in the absence of a fantastic health system. A strong leadership, experience and an equipped laboratory were able to bring the epidemic under control,” said Piot.

But the environment was also very different. Currently, the urgency has waned. Unless something is done it is back to business as usual.

In 1977, Piot a young doctor, attended his first WHO meeting after visiting Yambuku. At the WHO meeting strong statements were made like ‘we shall invest in epidemic preparedness, support to build health systems and primary health care’ and believed it.

In 2015 Piot travelled with Muyembe back to Yambuku to see what had come of all the promises.

“We arrived at the mission and what we saw was very sad. A nurse survivor who had survived Ebola in 1976 was there. He runs the hospital laboratory of the hospital. He has a decent microscope and some reagents and that is it. No one pays him.”

Except for tonnes of plumpy’nut which is not required in this region that hardly suffers from malnutrition, there were no anti-HIV and malaria drugs.

“We owe it to the people who died in this epidemics to do much better. When the headlines have gone we should continue with the work,” said Piot.


(An edited version of this piece was published in The EastAfrican newspaper in September 2016. I wrote it when I was a resident Journalist at the Institute of Tropical Medicine. Just uploaded it in light of the recent Ebola outbreak in DRC

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