The lessons from Ebola

22nd May 2015

Despite his country being declared free of Ebola, Liberian doctor Mosoka Fallah fears development finance may not be as forthcoming as it was when the deadly virus first emerged in West Africa. By Adam Pitt.

Ever since the first reports of an Ebola outbreak in West Africa began to emerge, efforts to curb what the World Health Organisation (WHO) described as ‘the most severe, acute health emergency in modern times’ have been plagued by a catalogue of misrepresentations that have undermined the credibility of the response and caused suffering among non-Ebola patients, the Harvard-trained physician believes.

More than 10,000 people have died from Ebola following the outbreak that began in 2014, with new cases still being reported in Sierra Leone and Guinea. Yet, while devastating, this figure is less than half the 18,449 lives claimed by the H1N1 pandemic in 2003. Equally concerning for Dr Fallah are early WHO reports to the media that suggested the number of cases could rise to 10,000 a week and that US$1 billion would be needed to avoid a ‘human catastrophe’, when its own experts said they were dealing with 500 cases a week. This, he says, has led to scepticism and uncertainty among donors.

“At the time predictions were made, I was involved with Ebola and I think there were certain mistakes made when it came to calculating the doubling time of the disease,” he adds. “It happened during the height of the epidemic and meant major bottle necks at Ebola Treatment Units were not given consideration. I am not sure the intention was to deceive, but I don’t think we’ll see the same financial support now.”

In fact, the withdrawal of support may already be happening. According to reports, US$5 billion was promised by heads of state and other international donors, but by March 2015 it was reported that less than half of this amount had materialised – though Dr Fallah also admits this may have proven to be a blessing in disguise for thousands of patients seeking access to routine medical assistance in Liberia.

“The influx of funding led to a situation where there was an increase in the presence of the international community, but this has had a negative impact on non-Ebola medical services,” he says. “At a certain point we had to stop some treatment centres from opening in order to push to have some funding redirected to other equally importance health services. Speaking about this is still a struggle. I had a patient suffering with very serious pain but we couldn’t get her to a hospital. These services are still suffering today.”

In August 2014, Liberia’s Foreign Minister, Augustine Kpehe Ngafuan, was quoted as saying that the number of deaths from treatable conditions could outstrip those of Ebola by three to four times, as Liberians became increasingly fearful of, and shunned medical centres. He said that the nation’s healthcare system had also been brought to its knees as medical workers fled the epidemic.

Dr Daniel Bausch, Associate Professor of Tropical Medicine at the Tulane University School of Public Health
Dr Daniel Bausch, Associate Professor of Tropical Medicine at the Tulane University School of Public Health

However, Dr Daniel Bausch, Associate Professor of Tropical Medicine at Tulane University’s School of Public Health, says criticism of the international community should be measured. “It seems WHO and others in the international community, which have been broadly criticised for not acting swiftly enough, are now being criticised for acting too forcefully,” he says. “Unless you have a crystal ball, it’s hard to know what will happen. Maybe if the reaction hadn’t been so strong 500 cases may well have become 10,000.”

The arrival of a ‘new candidate vaccine’

The Ebola outbreak follows a decade in which the healthcare system in Liberia had been rebuilt after two devastating periods of civil war. Having brought about an end to the spread of Ebola in mid-May, Dr Fallah says that that process of rebuilding will have to be restarted once more in Africa’s oldest republic, regardless of the financial support that is or isn’t offered by the international community.

As the Liberian healthcare sector returns to normal, a candidate vaccine developed by GlaxoSmithKline has raised fresh hopes that Sierra Leone and Guinea will soon be Ebola free too, says a spokesperson at the British pharmaceutical giant. The GSK vaccine is one of a number of drugs being tested with the help of the US National Institutes of Health. Another is being tested by the Canadian Public Health Agency with Merck, while a third is being analysed by Johnson and Johnson alongside Bavarian Nordic.

“The candidate vaccine was tested in four phase 1 studies in the UK, US, Switzerland and Mali involving 300 people,” the spokesperson says. “Initial data showed it to have an encouraging safety and immune profile. Based on this data, GSK has selected an appropriate dosage for the next phases of clinical testing.”

In February 2015, a large phase 2 and 3 clinical trial began in Liberia, with the US National Institutes of Health directing a Partnership for Research on Ebola Vaccines in Liberia (PREVAIL). It is anticipated that 27,000 people will take part – double the number of deaths from the Ebola outbreak. One third of those taking part will receive the GSK candidate vaccine, which will then be compared to a Merck vaccine and a control vaccine, to assess if responses in phase 1 translate into meaningful protection from Ebola.

In April 2015, more than 600 Liberians participated in the first stage of PREVAIL. Based on interim safety reviews from the Data and Safety Monitoring Board, and recommendations from the US Food and Drug Administration, the National Institutes of Health will continue enrolling volunteers onto phase 2 of the trial. As Ebola is now gone in Liberia, the National Institutes of Health are evaluating the possibility of extending phase 3 of the trial to either Guinea or Sierra Leone, according to GlaxoSmithKline.

While positive, “clinical development for a new vaccine is typically a long, complex process that can last up to 10 years, or more,” the spokesperson adds. “It is difficult to accelerate this process, but given how urgent the international health emergency was, and the fact that WHO requested for GSK to provide assistance to control the Ebola outbreak, we’re exploring options to accelerating development.”

West Africa ‘not out of the woods yet’

Examples of ways in which the vaccine is being expedited include the speed in which regulatory agencies are prioritising reviews of the trials, enabling them to begin quickly. At the same time those responsible for developing vaccines are working to scale up manufacturing capacities to industrial levels, without knowing whether the vaccine candidate has an acceptable safety and immunogenicity profile.

Nevertheless, Dr Fallah says that West Africa is not out of the woods just yet. “There have been no new cases for some time in Liberia. This is good news, it’s very good news,” he says. “But while we may have won the battle, we haven’t won the war. As long as Sierra Leone and Guinea continue to report new cases there’s still a threat; so there’s a way to go before we can say Ebola is completely gone.”

Supported in part, by a £2.8 million grant from the Wellcome Trust, the Medical Research Council, and the UK Department for International Development, the GSK vaccine, like others being developed, may come with a price tag of up to US$25 million. And, Doctor Bausch, argues it is this cost of production, rather than the complexity of its development that has delayed the manufacturing of a vaccine.

He suggests the reason for this is that the National Institutes of Health and US Government normally undertake early testing on animals, but advanced clinical testing is left to pharmaceutical companies.

“Candidate vaccines are now being fast-tracked, but in reality we’ve been able to reduce mortality rates in monkeys for some time. The problem is justifying production costs for distribution in an impoverished region. From a purely business, as opposed to humanitarian perspective, it doesn’t make much sense.”

Technological breakthroughs

In addition to his work on Ebola, Dr Fallah says support for the long-term recovery and improving Liberia’s overall healthcare infrastructure will be important in determining the nation’s ability to contain future outbreaks of infectious diseases. In doing so, one thing that he is full of praise for is the role that technology has played in monitoring the spread of Ebola, and in cutting the high risk of transmission.

“I manage a project where we have tracked sick people using mobile phone technology and a mobile app we developed with Yale University,” he says. “This app was given to community leaders, who can report to us every evening about signs of new infections. So far we have been able to map over 200,000 houses just using the data from the mobile app coming to our data centre. Another mobile app has been developed and allows me to coordinate all of these tracking systems from a central location using my computer.”

Beyond Liberia, the United Nations Development Programme in Sierra Leone says it has used mobile technology to send hazard payments to more than 16,000 nurses, reducing the need for non-essential interactions that could increase the risk of transmitting the disease. IBM also joined Scripps Research Institute in a project that offered people around the world the chance to donate processing time on their computers and mobile devices towards important medical research into the Ebola virus.

“The possibilities of mobile technology are truly immense and have shown their value,” says Dr Fallah. “They have removed a lot of the inconveniences that those involved in the response go through. They have also reduced the risk of transmission, but now these technologies need to be built up.”

Quite how these mobile technologies are to be built up, and by whom, will require further discussion and investment according to Dr Fallah, but Dr Bausch is of the opinion that “technology doesn’t do anything unless you have people to establish it and act on it”.

That technology and policies can still fall short when it comes to engaging communities, is something that Dr Fallah further validates.

“In certain areas the response has been led by the military with quarantines and legislation, but no measure of technology or policing can stop a disease,” he says. “You can’t have 24-hour surveillance; a policeman at the door of every house, and expect to reach zero cases. It has to be about engaging the communities and building trust. Then, communities accept what you’re doing and work with you, not against you.”

His comments echo that of representatives of the United Nations that gathered in Brussels in March 2015 to discuss the next stage of the response to Ebola – recovery. During which WHO Director-General, Dr Margaret Chan, focused on the need build trust with affected communities and a large part of that process will most likely involve ensuring that reporting is more closely aligned with reality.

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