PARIS/GOMA – More than a year into the ongoing Ebola outbreak in northeastern Democratic Republic of Congo (DRC), the disease has killed over 2,000 people. The mortality rate in this outbreak is around 67 per cent , which is comparable with the mortality rate in the 2014-2016 West Africa outbreak, when neither therapeutic treatments, nor a vaccine, were available. While a highly effective vaccine is now able to offer some protection, the number of people vaccinated is not enough. The pace of vaccination activities is too slow and only a fraction of the eligible population is benefiting from this critical tool , says Doctors Without Borders/Médecins Sans Frontières (MSF). One reason is the opaque management of the vaccine supplies by the World Health Organization (WHO), who imposes strict limits on the number of doses deployed in the field. MSF urges for an independent committee to be formed to manage Ebola vaccination programmes.
Thanks to the efforts of the DRC Ministry of Health and WHO, close to 220,000 people have been vaccinated with rVSV-ZEBOV, an investigational vaccine produced by Merck that has shown very high levels of efficacy. This number remains largely insufficient though, as shown by the fact that the outbreak keeps returning to areas that have been supposedly covered by vaccination.
Vaccination – especially of healthcare workers – can be scaled up
“We think that upping the pace of vaccination is necessary and feasible: at least 2,000-2,500 people could be vaccinated each day, instead of 500 – 1,000 people as is currently the case” says Dr Isabelle Defourny, MSF director of operations. “We have a vaccine that is proven to be safe and effective; we have teams ready to be deployed; there is no problem with the cold chain; there are enough doses to cover the current needs and to allow for an extension of vaccination coverage, as recently confirmed by Merck, the vaccine manufacturer; and when people are aware of the vaccine, the vast majority of them want to be vaccinated.”
“Yet WHO is restricting the availability of the vaccine in the field and the eligibility criteria for people to be vaccinated for reasons that are unclear,” Dr Defourny continues. “Even when it comes to frontline health workers – a known, easily reachable population – in a hotspot of the outbreak such as Beni, almost a third of them reported they have not been vaccinated.”
MSF medical staff in full protective equipment undertake a shift in the high risk zone to check people with suspected cases of Ebola. Bunia, Ituri province, DRC, June 2019.
New treatments available, yet disease hotspots keep flaring up
Despite the new vaccine and new therapeutic treatments available in this outbreak that can dramatically increase a person’s chances of survival, the outbreak continues to rage a year on, having so far claimed over 2,000 lives, around two-thirds of those who have been diagnosed with the disease.
As many as 40 per cent of the deaths are represented by people who died at home before they could even be identified as patients. These rates have been relatively stable over time . While the pace of transmission appears to have slightly ebbed in recent months, some areas have been active hotspots for over a year now and other hotspots have become active after extended periods without reporting new cases.
“Community mistrust and resistance have often been pointed out as the major obstacles in the fight against Ebola,” says Dr Natalie Roberts, MSF Emergency Coordinator. “In reality, people would seek medical care at the onset of symptoms if we told them loud and clear that they can be cured with treatments recently proven  to greatly increase their chances of survival.”
“They would also come to be vaccinated in greater numbers if more people were aware they can be protected from the virus by a vaccine proven to be highly effective against Ebola” , Dr Roberts continues. “We need to stop blaming communities for their own deaths and make sure more people have access to treatments and vaccines.”
WHO tightly controlling vaccine supplies and access
MSF’s efforts to expand access to vaccination, in collaboration with the Ministry of Health and according to the recommendations of the Strategic Advisory Group of Experts (SAGE)  in May 2019, have been frustrated by the tight controls on supply and eligibility criteria imposed by WHO. MSF vaccination teams have often been forced to remain on standby in North Kivu, waiting to receive a handful of doses reserved to people on a pre-defined list.
“Time is of the essence in an outbreak: medical teams should be able to rapidly provide treatments or vaccines based on what they see on the ground,” says Dr Roberts. “If a mother has been caring for her sick child who is then diagnosed with Ebola, not only do we want to diagnose and treat the child, but also we also want to provide the mother with post-exposure prophylaxis that could potentially prevent her from developing the disease, and vaccinate her whole community so that if she does get sick, they will have already developed immunity.”
“But our capacity to carry out real-time assessments and react accordingly is severely undermined by a rigid system which is hard to comprehend,” Dr Roberts says. “It’s like giving firefighters a bucket of water to put out a fire, but only allowing them to use one cup of water a day. Every day we see known contacts of confirmed Ebola patients who have not received their dose despite being eligible for vaccination.”
Such restrictions seem unjustified: rVSV-ZEBOV vaccine has demonstrated a good safety profile and a high level of protection against the virus in a Phase-3 clinical trial in Guinea in 2015. In the absence of regulatory approval, the Congolese Ministry of Health and WHO allowed the vaccine to be used under an ‘Expanded Access’ framework. Manufacturer Merck recently stated that in addition to the 245,000 doses already delivered to WHO, they are ready to ship another 190,000 doses if required, and that 650,000 additional doses will be available over the next six to 18 months.
A health worker in full personal protective equipment starts the careful process of disinfection and undressing after working in the high risk zone of the MSF Ebola treatment centre in Goma. North Kivu province, DRC, August 2019.
Independent coordination committee needed to manage vaccines
“To allow for the best possible use of experimental tools in an outbreak context, transparency is key,” continues Dr Roberts. “How can we support the Congolese authorities in using these tools, how can we expect the Congolese people to trust a system that is not even transparent to front-line health workers like MSF?”
Médecins Sans Frontières calls for the urgent creation of an independent, international coordination committee, based on the model of the International Coordination Group created in 1997 composed of MSF, the International Federation of Red Cross, UNICEF and WHO, which proved successful in managing massive meningitis, cholera and yellow fever outbreaks with limited vaccine supplies. The committee would bring partners together to improve coordination on vaccination, increase transparency in stock management, share data, foster an open dialogue with the manufacturers and ultimately ensure that the vaccine is provided to all those most at risk of being exposed to the virus.