How to prevent Ebola’s perfect storm?

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The 2014 Ebola outbreak was devastating. The virus affected 4 West African countries: Guinea, Liberia, Nigeria and Sierra Leone, killing some 10.000 people and infecting more than 25.000. Since 1976 the Ebola-virus has not caused a major epidemic. What went wrong in 2014? Peter Piot explains how a local outbreak can turn into a major epidemic with massive casualties.

Peter Piot, director and professor of Global Health at the London School of Hygiene & Tropical Medicine in London,  co-discovered the Ebola-virus in 1976 in Zaire, while working at the Institute of Tropical Medicine in Antwerp. Piot describes last year’s outbreak as ‘the perfect storm’. Dysfunctional health care systems, decades of war and corruption, slow response rates, poverty, low public trust in government and Western medicine and even denials about the cause or existence of the virus, turned out to be the ingredients for a deadly cocktail.

“The virus was already circulating in West Africa in bats – we didn’t know the virus had spread to that part of Africa, as previous outbreaks had only occurred in remote villages in Central Africa. Bats are important reservoirs of the Ebola virus and combined with the problematic situation in these countries, outbreak control was almost non-existent. Soon after, the virus had spread to major urban areas. It took nearly 4 months after the first patient died in December 2013 before the outbreak was confirmed as being caused by the Ebola virus. Despite the efforts by Médecins Sans Frontières to bring attention to the outbreak, the WHO and the governments concerned only declared the epidemic a public health emergency in August 2014,” explains Piot.

“The virus will return, there is no doubt about that. But next time we should be able to prevent a large epidemic, and fast diagnosis will be key. Secondly swift action, both local and international, is equally important to successfully controlling future outbreaks”.

The research priorities are clear: fast diagnostics and a vaccine

Piot is a clear on what the ideal diagnostic test should entail: “we need a fast test. Not only in performance, it is also very important to detect the virus as fast as possible after infection. The different tests currently under development, which detect different parts of the viral RNA-genome, still have sensitivity problems. Diagnosis should also be easy to perform and ‘safe for healthcare workers performing the tests. Handling infected blood is a serious challenge.

Biocartis chasing Ebola-RNA

‘Biocartis’ diagnostic tool Idylla presents an interesting solution,’ says Piot ‘as it is a fully closed system’. Piot joined Biocartis as independent board member in April:  ‘as soon as the sample is introduced in the Ebola test cartridge there is no way it can still infect someone. A good test for Africa needs to be very practical. When someone comes down with a fever, the healthcare providers need to know immediately if it is Ebola or Malaria, the latter easy to treat and not requiring special precautions or handling. The impact of Ebola is enormous and requires point-of-care detection of the virus’.

Janssen Pharmaceutica is ready to test Ebola vaccines in humans

Piot is enthusiastic about the collaboration with Janssen Pharmaceutica: “our school in London collaborates with Janssen for the evaluation of their experimental vaccines. In human primates it showed excellent results. Also Merck and GSK are developing a vaccine;  vaccines can have an enormous impact, and is especially important in protecting healthcare workers against infections. During last’s year outbreak the virus killed more than 500 doctors and nurses. In countries where the number of medical workers was already limited, the result of the outbreak was devastating: there were no nurses or doctors left to help”.

There are currently three experimental vaccines being tested in humans. Clinical trials face a challenge now that the peak of infection has passed; it will take more people and time before statistically significant results will be available.

We need to bring experimental therapies and vaccines into clinical trials

“If we would have had candidate vaccines which had gone through phase 1 trials 4 months ago, things would have been totally different’, Piot explains. ’The products that were available – some financed by the American Department of Defense in the anti-Bioterrorism program – were never tested on humans and without phase I trials, we couldn’t use them”.

“This is an important issue we are facing; how can we make sure that vaccines and therapies with little to no market incentive and public health incentive, are being produced and tested in expensive clinical trials? Several investigational drugs, including the monoclonal antibody-based therapy Zmapp and convalescent plasma from recovered Ebola virus disease patients, have been used to treat Ebola patients. But data from randomized controlled clinical trials are not available. This means information regarding the safety and efficacy of these drugs is also not yet available”.

Piot remains optimistic: “We are slowly moving in the right direction – for the first time in history, clinical research was initiated during an epidemic. That has never been done before”.

Peter Piot is director of the London School of Hygiene & Tropical Medicine in London. A full-time job, wouldn’t you think? But Ebola remains high on his list: “Development of a vaccine is essential so we are working hard to make it happen!” He also invests time into the development of lessons learned and global governance. He continues to be active in development of public policies regarding AIDS  and his institute currently has several projects focusing on anti-microbial resistance, an increasingly serious threat to global public health – but that’s for the next interview!