Ebola Outbreak Marks 1 Year With Huge Funding Gap, Questions On Vaccine Strategy

Thursday, 1 August, marked the one-year anniversary of the Ebola outbreak in the Democratic Republic of the Congo (DRC), as daily reports of new infections, including 3 more cases in Goma along DRC’s border with Rwanda, fueled new concerns about regional spread of the deadly disease. Meanwhile, the World Health Organization called on international donors to close a huge gap in the estimated US$ 350 million required to fund just the health activities related to the response for the next 6 months.

Uncertainty also remained over whether the DRC government would agree to deploy a second vaccine, produced by Johnson & Johnson, alongside the Merck Ebola vaccine, that is already being used on health care workers and identified contacts of Ebola victims. The Merck vaccine, while highly effective, is only available in limited supplies, and the “ring vaccination” strategy being used has not succeeded in containing the outbreak.

“This first year, the Ebola anniversary, is not a milestone we ever wanted to mark,” said Dr Matshidiso Moeti, Director of the WHO Regional Office for Africa, in a press conference Wednesday, just two weeks after WHO declared the outbreak to be a Public Health Emergency of International Concern (PHEIC).

Some 13 new cases were reported by the DRC’s Ministry of Health on Thursday, including at least one new case in Goma, a city of around 2 million people. According to other reports, two more people had fallen ill, including both the wife and child of a miner who had died of Ebola in Goma on Wednesday. Rwanda reportedly closed its border, a heavily trafficked site, for several hours Thursday after learning of the new Ebola cases.

A joint statement by WHO and other UN agencies warned that the miner’s death “in such a dense population center underscores the very real risk of further disease transmission, perhaps beyond the country’s borders, and the very urgent need for a strengthened global response and increased donor investment.”

Administering an Ebola vaccine at Himbi Health Center in Goma this month. Photo: Olivia Acland/Reuters

The disease had previously passed into Uganda with three confirmed cases in June, but was effectively contained with no further spread into the country, largely due to the high level of preparedness of the Ugandan health system, which had previously dealt with outbreaks of Ebola. WHO is now increasing efforts to ramp up preparedness in other countries that share a border with the DRC, including Rwanda, Burundi and South Sudan, while continuing efforts to contain the disease in the DRC.

The WHO has called on international donors to increase funding to implement its 4th Strategic Response Plan (SRP) for the period of July through December, which is currently being developed and was reported to be released soon. WHO estimates the health response of the plan to cost US$ 350 million, significantly more than the estimated US$ 200 million contributed to the health response since the outbreak began in August 2018.

Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme, said in a press conference on Wednesday that WHO had firm funding commitments amounting to only about US$ 45 million of the US$ 350 million needed to fund the next 6 months of the public health response in the DRC, as well as better preparedness in neighboring countries. This leaves a gap of US$ 305 million to fully fund these two health pillars of the response plan.

Over the past two weeks, the United States pledged US$ 38 million to help end the ongoing outbreak, bringing the total amount of US assistance to US$ 136 million since the outbreak began last year. Additionally, the World Bank pledged to mobilise up to US$ 300 million for a financing facility to provide loans for the Ebola response at the national level, while the United Kingdom pledged £50 million to help deal with the outbreak.

However, Dr Ryan said that it was unclear what proportion of those funds would actually be dedicated to the health activities, as compared to other areas such as security and humanitarian efforts. He said WHO was still discussing the issue with the US and the UK, but anticipated that their contributions to the health efforts “would represent much smaller amounts” than the total pledges.

Effectiveness of the Merck Vaccine; Concerns Regarding Sufficiency of Supply

Controlling the outbreak has been largely supported by the widespread use of the experimental Ebola vaccine developed by Merck, shown to be up to 97 percent effective in preventing Ebola. But there are growing concerns regarding whether the supply of the Merck vaccine will be sufficient to meet the needs of the current vaccine strategy, and whether this strategy should be expanded.

Experts note that the Merck vaccine has likely saved hundreds if not thousands of lives in the current outbreak, and in light of this, they question whether the current outbreak may be even more severe than the previous West Africa outbreak, despite its lower death toll, which is fast approaching 2,000.

The vaccine has been used as part of a “ring vaccination” strategy to vaccinate contacts, and contacts of contacts, of people found to have Ebola. Recently, “pop-up” vaccination centers have also offered vaccination to anyone interested. While over 175,000 people have been vaccinated in the DRC according to WHO, many contacts exposed to the virus have evaded voluntary vaccination efforts, in part due to community mistrust, and in part due to the challenge of tracing every contact.

To meet the needs of these vaccination efforts, the dosage of the Merck vaccine has already been reduced by half in order to extend the supply of the vaccine. There are varying accounts regarding the actual amount of the vaccine that is available, with MSF reporting shortages of the vaccine on the ground in DRC, and WHO reporting that the supply has so far been sufficient.

“We have not experienced any shortage of vaccine on the ground so far during this outbreak,” a WHO official told Health Policy Watch, “but there are concerns about overall supplies of the vaccine. Accelerating the availability of vaccine is a priority.”

The WHO official said that “WHO continues to collaborate with Merck and to monitor and explore scenarios of Ebola vaccine supply and demand. Whether or not the available doses are sufficient to fulfill the demands depends on the evolution of the outbreak, the access to the communities and the successful expansion of the production of additional doses by Merck in early 2020.”

According to Merck, the company has 245,000 1.0 mL doses of the vaccine currently available, which is enough to vaccinate nearly 500,000 people at the reduced 0.5 mL dose. The company also reported plans to produce up to 550,000 additional 1.0 mL doses over the next 12 months.

Dr Mike Ryan of WHO’s Health Emergencies Programme said in Wednesday’s press conference that the “clinical efficacy of an individual dose of the vaccine is very high. The difficulty we face is if everybody doesn’t get vaccinated who needs to, then the overall effectiveness of vaccination as a program is lower than it should be, and that is the case. We haven’t been able to reach every high risk contact with the vaccine.”

Photo: WHO

WHO & Partners Recommend Introducing a Second Vaccine from Johnson & Johnson 

Organisations involved with the Ebola health response, including Médecins Sans Frontières (MSF/Doctors Without Borders) and Wellcome Trust, are calling on the DRC government to introduce the second experimental vaccine developed by Johnson & Johnson (J&J) as part of a more comprehensive vaccination programme, with a focus on prevention around the periphery of the high-transmission areas.

“WHO supports the introduction of a second vaccine, in line with the SAGE [Strategic Advisory Group of Experts on Immunization] recommendations, but subject to the appropriate national approvals,” the WHO official told Health Policy Watch.

Dr Ryan of WHO’s Health Emergencies Programme acknowledged in a 18 July press conference that “the [DRC] Ministry has expressed concerns about introducing a second vaccine, mainly around confusion of the local population… We are working through those issues with them… They still remain open to deploy in areas not affected. We are working with government and [the vaccine] consortium to find the solutions that would allow the vaccine to be deployed.”

The J&J vaccine has been tested in various countries in over 6000 volunteers, has been proven safe and volunteers developed a strong immune response. Although it has not yet been used in an epidemic situation, and this has to be studied further, it seems likely that it will demonstrate a protective effect,” Dr Natalie Robert, MSF’s Operations Manager, told Health Policy Watch

“While obviously the role of the two different vaccines will have to be explained clearly to the affected population, and no-one will ever be forced to accept vaccination, we would encourage the deployment of this second vaccine as well as expanded use of the rVSV Merck vaccine in a coordinated strategy – both to allow more people in the region to access a potentially effective means of protection against Ebola, and to expand our arsenal of tools to better fight this and future epidemics. Any decision within DRC to do so would be welcome,” she said.

In an interview with Health Policy Watch earlier this month, Wellcome Trust’s Epidemics Lead, Josie Golding stressed that the J&J vaccine could be an important “preventative” tool complementing the Merck vaccine. Since there are 1.5 million doses available, it could also be deployed now in areas or populations at more peripheral risk, enhancing preparedness throughout the wider region.

Golding acknowledged that the concerns of the DRC government were understandable, insofar as the Merck vaccine, previously used in the 2014-15 West Africa epidemic, had developed a clear track record in the DRC emergency, provoking a very rapid and effective immune response. Notwithstanding, Golding said that the second vaccine could be used as a second-line of prevention.

Regarding the Merck vaccine, MSF said Wednesday in an update: “If doubts about its future availability persist, we ask the Congolese authorities to reconsider their opposition to using a second investigational vaccine to contain the outbreak.”

Burial workers dressed in protective gear carry the remains of a patient who died from Ebola in Beni, DRC. Photo: AP/Jerome Delay

The former DRC Minister of Health Oly Ilunga opposed the use of the second J&J vaccine, citing lack of sufficient clinical trials to establish efficacy; other safety risks; and potential complications of gaining community trust with the introduction of the new vaccine. He also questioned the likelihood that the vaccine would be decisive in curbing the outbreak, and said he did not support the use of the vaccine as an “experiment” on the DRC population.

In an interview in Le Monde, he said “[translated from French] we have had access to information from the US government forwarded to WHO regarding this vaccine, and its effectiveness is very clearly questioned. Nevertheless, people have tried to force it, in a non-transparent, non-respectful way. And to introduce the vaccine in full epidemic, without the approval of the Congolese health authorities. This is serious both from the point of view of medical ethics and in terms of attacks on the sovereignty of the DRC. I could not accept it.”

The former DRC Health Minister resigned last week after DRC President Felix Tshisekedi relieved him of the responsibility of leading the Ebola response, placing this responsibility directly under the presidency, to be managed by an Ebola response team led by Dr Jean-Jacques Muyembe Tamfum, Director of DRC’s Institut National de Recherche Biomédical. Dr Muyembe, who has been researching Ebola for four decades, has previously supported deployment of the second investigational vaccine under study conditions, and some speculate that he may be more likely to recommend introducing the second vaccine.

As of today, the Congolese government has not said whether or not it plans to introduce the second J&J vaccine.

Current Status of the Ebola Outbreak in DRC

“In the last year, there have been more than 2,600 confirmed cases, including more than 1,800 deaths in parts of Ituri and North Kivu provinces. Almost one in three ‘cases’ is a child. Every single ‘case’ is someone who has gone through an unimaginable ordeal. More than 770 have survived,” said the joint statement by WHO and other UN agencies.

Beni remains the hotspot, accounting for 61 percent of the 79 new cases last week, according to the latest WHO Africa Region situation report.

Source: WHO

“The public health response to an Ebola outbreak requires an exceptional level of investment; 100 per cent of cases must be treated and 100 per cent of contacts must be traced and managed,” the joint statement says, adding that WHO and other UN agencies “will continue to accelerate our response, and we ask partners old and new to do the same.”

“At this critical juncture, we reaffirm our collective commitment to the people of the DRC; we mourn for those we have lost; and we call for solidarity to end this outbreak,” it concludes.

This story was updated on 2 August.

Elaine Ruth Fletcher contributed reporting to this story. 

Image Credits: Olivia Acland/Reuters, WHO, AP/Jerome Delay.

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