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"Putting Shots in the Locker," The Economist

Friday, 9th of September 2016

Vaccines

Putting shots in the locker

From The Economist

Best viewed at http://www.economist.com/news/science-and-technology/21706240-how-anticipate-epidemics-putting-shots-locker

FOREWARNED, the proverb has it, is forearmed. But what happens when there is no warning? That was the case in December 2013, when an outbreak of Ebola haemorrhagic fever began in Guinea. It spread rapidly to Liberia and Sierra Leone and raged on for over a year. Around 29,000 people were infected. More than 11,000 of them died.

The world responded to this crisis, shipping in doctors, nurses and medical equipment. But what it could not ship in, for none existed, was the thing that would most quickly have stopped the epidemic: a vaccine. Such a vaccine was created eventually, but by the time it was ready, the outbreak was all but over. Had it been available from the beginning, things could have been different.

Next time, though, they might be, for on August 31st a new organisation came into being. CEPI, the Coalition for Epidemic Preparedness Innovations, was founded this week in London, at the headquarters of the Wellcome Trust, a medical charity. It is the joint brainchild of the Wellcome, the Bill and Melinda Gates Foundation, the World Economic Forum and the government of Norway, and its purpose is precisely to forearm the world against future outbreaks of disease, without foreknowledge of what those outbreaks will be.

Paradoxically, part of the inspiration for CEPI´s creation was not the failure to deliver an Ebola vaccine in time for it to be useful, but how close that project came to success. Creating a new vaccine from scratch is a long-winded undertaking, but in the case of Ebola several candidate vaccines were already on the shelf thanks to earlier, but stalled, work by America´s army and that country´s National Institutes of Health. There were also three pharma companies, GlaxoSmithKline, Johnson & Johnson and Merck, willing, pro bono publico, to take these candidates and try to turn them into the real thing as quickly as possible. That they succeeded in doing so by the summer of 2015 was, by most standards, extraordinary—and means vaccines are available the next time Ebola rears its ugly head. If a spontaneous lash-up could achieve such an outcome, the thinking went, an organised approach should do even better.

You can bank on it

CEPI´s plan is to build up a bank of candidate vaccines for as many as possible of the viral diseases that lurk menacingly on the edges of human society, but in which there is insufficient commercial interest for pharmaceutical firms to do the development work. These include Lassa fever, Marburg fever, MERS, SARS, Nipah and Rift Valley fever, but not dengue or influenza. Those two are already well served by drug-company researchers—as is Zika virus, for which a vaccine may be ready for testing in the field next year.

The aim, says Jeremy Farrar, the Wellcome Trust´s director, is not to guess exactly which illness will become epidemic next, as this is a difficult thing to do. Instead CEPI will work through the list in a systematic way. To start with, it will pay for work on up to three viruses.

Scientifically, this means identifying several possible vaccines for each disease, putting these through animal trials, and then carrying out small safety trials on human beings. Those candidates deemed safe will be stored for a future outbreak. This approach maximises the saving of time while minimising cost. If a disease for which there are candidate vaccines does become threatening, larger and more expensive human-efficacy trials can be organised quickly in response. If not, no money is wasted doing so.

Organising efficacy trials quickly, though, illuminates CEPI´s other job. This is to have the bureaucracy for such trials (planning how they might be carried out, and arranging ethical approval) sorted out in advance, along with the means to scale up the production of successful candidates. Indeed, CEPI may even invest in its own surge capacity for the manufacturing of vaccines, rather than forcing drug companies to divert resources from existing vaccine production (with potential consequences for public health).

There are thorny issues here, not least the question of legal risks. Even with the preliminary research already done, speed will be of the essence when the world is faced with an epidemic. Human trials will have to be conducted more hastily than drug companies are used to doing. That might lead to mistakes and thus to law suits. Who should bear the brunt of consequent liabilities needs to be sorted out in advance. This might involve governments offering some sort of reinsurance cover or waiver from such liability.

John-Arne Rottingen, CEPI´s interim boss, argues that paying to prepare for future epidemics is like buying a form of global health insurance. But, unlike other forms of health insurance, the premium need not be paid for ever. No doubt the list of targets will grow as time goes by. But it is not infinite. Should the world wish to address the top 20 threats over the course of the next decade Dr Farrar estimates the total cost would be $1 billion-2 billion.

The next stage is to start raising that money. The organisation hopes to tap governments and charities, including those which helped found it. It will also involve, and thus pick the brains of, drug companies and the World Health Organisation. If things go well, CEPI will be up and running next year. Once that has happened, the threat from epidemic viruses will diminish year by year thereafter.