Editorial: Call for a roadmap to manage the Ebola (or the next public health) outbreak

August 21, 2014

As the Ebola virus infiltrates communities throughout West Africa, fears of a global epidemic are even more rampant than the pathogen itself; and facts surrounding the current outbreak only add fuel to the fear. With no approved vaccine or treatment, resulting in up to a 90 percent fatality rate recorded in past outbreaks, the virus has killed more than 1,300 people and infected more than 2,400 across Guinea, Liberia, Sierra Leone and Nigeria. According to the World Health Organization (WHO), these reported numbers are actually much worse, leading to the epidemic being declared a Public Health Emergency of International Concern. Despite the sobering numbers, there is hope that the outbreak will be stopped at its source in Africa, but it will not be easy and it will take many months. We will have to overcome new challenges; and through global partnerships we will need to embrace new responsibilities. Ebola virus disease is a stark reminder that an outbreak anywhere can be a risk everywhere. This is both the harsh reality and the shining truth, but more than just managing this outbreak, we must learn from it and vow to prevent the next one by overcoming social, scientific and economic barriers that inhibit effective public health preparedness and response. Not an easy task, but absolutely attainable with the right global partners all driving a long-term strategy; actually not just a strategy…rather, a roadmap for managing the next Ebola, or any global public health threat, whether naturally occurring or a deliberate attack.

Public health measures for short-term control
The first leg of this journey will require implementation of proper infection control measures and sustained public health capacity building in Africa and elsewhere, a step already in progress with the CDC’s efforts in combination with the WHO’s, and other partners, through the Global Health Security Agenda. Make no mistake, more lives will be lost in the meantime and there are many challenges to overcome in order to bring the Ebola outbreak in West Africa under control, but this outbreak will not reach pandemic proportions. Industrialized countries, including the United States, have the public health and medical infrastructure in place to reduce the possibility of rampant disease transmission. By isolating patients who have become ill and implementing public health measures such as disease tracking and education to help identify and ensure the early reporting of new cases, medical and health authorities can limit exposure within the population.

Establish the need for a long-term response
Looking several months down the road, for many, Ebola will be a somewhat distant memory. However, that is exactly the mindset that we must avoid. Tenacity means the difference between an isolated incident and a full-on outbreak. Until now, sustained interest has not existed. Public health and policy officials have previously noted episodic cases, but development of a vaccine and therapies has not remained top of mind. The death toll in previous outbreaks has remained relatively small, but clearly not so with the latest outbreak. However, blame cannot be placed on a mere lack of attention. The reality remains that until the outbreak in West Africa, the accepted belief was that Ebola could be combated through traditional hospital infection control, isolation, and contract tracing; yet those controls only work when implemented correctly. Combine a lack of public health infrastructure with large, nomadic populations and an added layer of local customs involving the handling of bodies, and the accepted belief no longer applies. Sustained support for the Global Health Security Agenda is one component of the long-term response. Additionally, even in developed countries where effective public health infrastructure is in place, therapeutic capacity building is necessary to address the current lack of vaccines and therapeutics needed by our global partners, but also for the potential national security risks that could arise as a result of bioterror threats. Consequently, the need for a vaccine or therapy, which will both protect frontline health care providers who deploy into harm’s way and safeguard the global population from this deady virus, has been established.

Advance vaccine discoveries
Attention now turns to where vaccine research currently stands. There have been a number of medical countermeasure research and development efforts in this realm for over two decades, but there are only a few Ebola vaccine candidates that have moved beyond discovery and into early development, with only a few antibody and antiviral candidates in early development, too. The National Institute of Health (NIH) recently announced plans to fast-track an experimental Ebola vaccine candidate, which – if proven safe and effective – could be available under limited, emergency-use protocols to health care workers in affected areas as early as 2015. However, much more work is needed to determine if this, and other vaccine candidates can illicit an effective immune response with an acceptable safety profile, and can be scaled-upped for production under exacting manufacturing standards. So how could the global scientific community find itself this far behind the curve? Fact number one: There has not been a market for the vaccine in the past, so the number of researchers focused in this area prior to the outbreak is relatively small. Fact number two: Obtaining licensure required to use these products is difficult, and developing these particular types of vaccines is challenging because testing a therapeutic for something as serious as Ebola rarely presents the opportunity for clinical trials in humans. Fact number three: The two aforementioned facts do not make for an economically viable product to take from “bench to bedside” without sustained public sector and international partner support. So we previously lacked the interest, now we lack sufficient science and technology advancement in this area, and it is highly likely that even with both of those factors resolved, we will continue to lack the funding to bring life-saving Ebola therapeutics to market. It may sound bleak, but remember, we are laying a roadmap and we are still en route.

Bridge the manufacturing gap
The challenge of discovering new vaccines is hard enough, but moving them beyond early development into production presents another speed bump in the form of scalability for manufacturing. Until now, this hurdle created a valley of death for countless revolutionary vaccines and therapeutics; however, thanks to vested interest in domestic manufacturing capabilities from the government and industry partners, Texas is now home to one of only three biodefense centers in the nation standing ready to offer an economically viable, near-immediate response to produce life-saving vaccines for the next global public health threat – whether naturally occurring or in a scenario where the pathogen is used as a weapon in a bioterror attack. Without the flexible and adaptive manufacturing technologies made available by the Texas-based, Biomedical Advanced Research and Development Authority-sponsored center, there is no bridge between the science behind Ebola therapeutics and communities in need of life-saving vaccines, no matter the underlying cause. With the capabilities of such a unique public-private entity and implementation of the necessary steps to ensure public health preparedness and response, the United States will be ready to serve as that bridge on the roadmap to our final destination: Surviving and managing the next outbreak, no matter what form it might take. We just need to make sure we are all reading from the same map in the meantime.

Contributed by Dr. Gerald Parker, vice president for public health preparedness and response at the Texas A&M Health Science Center.

View an infographic for a quick snapshot of the priorities outlined above.

 

— Holly Shive

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