Strong Clinical Research Capacity in At-Risk Countries Key to Global Epidemic Prevention

New report outlines urgent need and opportunities in low- and middle-income countries where disease outbreaks most often strike

Robust clinical research capacity in low- and middle-income countries is key to stemming the spread of epidemics, according to a new report from the International Vaccines Task Force (IVTF).

ebolaThe report, entitled Money and Microbes: Strengthening Research Capacity to Prevent Epidemicslays out how to develop the political support, financing and coordination required to build this capacity as a crucial component of global epidemic preparedness. The IVTF was convened by the World Bank Group (WBG) and the Coalition for Epidemic Preparedness Innovations (CEPI) in October 2017.

There have been many global and country-level efforts to strengthen pandemic preparedness and response since the deadly West African Ebola outbreak in 2014-2015 that killed 11,000 people—and the last few weeks have provided evidence of this.

During the current Ebola outbreak in the Democratic Republic of Congo (DRC) with 49 total cases and 26 deaths so far, the government of DRC has approved the use for trials starting this week of a new, as-yet unlicensed Ebola vaccine, the rVSV-ZEBOV. The vaccine has proven highly effective in a clinical trial conducted in Guinea in 2015. Nigeria had its worst Lassa Fever outbreak on record earlier this year, and also pushed forward with conducting clinical trials as the outbreak unfolded.

“Times of crisis present the opportunity to focus capabilities and energy on solving important problems,” said Marie-Paule Kieny, Director of Research at INSERM and co-chair of IVTF. “Robust clinical research capacity is the only way to ensure that we don’t face future outbreaks with the same knowledge gaps over and over again.”

Of the 96 countries that have conducted vaccine trials in the past 20 years, 56 have conducted only between 1 and 10 trials, according to a registry maintained by the World Health Organization (WHO). This is insufficient to advance promising new vaccines, therapeutics and diagnostics for epidemic infectious diseases at the scale that is needed. The report recommends building capacity at a national or regional level that can flexibly scale up to run clinical trials during outbreaks, and focus on ongoing high-priority disease research based on local needs in between outbreaks.

“There are now more robustly trained local researchers working in better equipped facilities in low- and middle-income countries, but their numbers remain far too limited,” said Richard Sezibera, Member of the Senate, Rwanda, and Co-chair of the IVTF. “We must urgently prioritize clinical research both to save lives in low-income settings, and to generate valuable information that is a global public good.”

Besides improving health outcomes, clinical research offers a strong return on investment—publicly-funded research and innovation delivers about a 20 percent annual return on investment, compared with an average of 6.8 percent for the S&P 500, which includes the 500 largest companies listed on the U.S. stock market, according to Science Business.

“Investment in strong clinical research capability is a win-win, paying for itself many times over,” said Tim Evans, Senior Director and head of the Health, Nutrition and Population Global Practice at the World Bank Group. “It saves lives and improves health, drives innovation, and creates high-quality jobs, and also builds global health security from the ground up, making us all safer.”

The IVTF recommends that low- and middle-income countries commit domestic financing to this agenda, building political support and a research-friendly culture. It recommends that WHO develops a global tool and robust indicators for assessing country research capacity, and that the WBG creates an investment framework for national and regional clinical research capacity, using many of its unique financing mechanisms to link clinical research to its overall investments in pandemic preparedness. IVTF also recommends strong private sector engagement through transfer of skills and expertise as well as financing.

“Closing the clinical research gap is essential to ensure that we have the capacity that can be mobilized quickly and effectively whenever and wherever it is needed during outbreaks,” said Richard Hatchett, CEO of CEPI. “Without this, we will not be better prepared for and able to response to current and future epidemic threats.”

Humanitarian crisis in the Central African Republic: lack of funding threatens the free-access to healthcare

27 APRIL, 2015 ¦ BANGUI – A drastic shortage in funding is jeopardizing free access to health care services being provided by the World Health Organization and partners in the Central African Republic for hundreds of thousands of people.

The WHO Representative to the Central African Republic, Dr Michel Yao, says the humanitarian crisis wracking the country has displaced approximately 200 000 people and put around 1.5 million people at risk. Increased effort and funding, he says, is needed to prevent the crisis in the Central African Republic being “forgotten crisis.”

“This year we are really suffering in terms of funding the WHO operations in the Central African Republic” Dr Yao says. “WHO has a gap of more than US$ 14 million and have received only US$ 500 000 this year. The needs for the whole humanitarian health sector are even greater, with another almost US$40 million needed by Health Cluster partners, with less than US$1.5 million provided. The health sector is very challenging. The Central African Republic, for example, has among the world’s highest child and maternal mortality rates.”

Only 55% of the health facilities in Central African Republic are functioning, and they mostly rely on the support of nongovernmental organizations and UN agencies like the WHO, who are collaborating has part of the Health Cluster response. In 2014, Health Cluster partners delivered medical supplies for the treatment of 800 000 patients and provided health care for more than 615 000 people in the Central African Republic.

“WHO supports the people in the Central African Republic by providing free access to health care,” Dr Yao explains. “Outside the capital, Bangui, there is a real challenge to provide this health care if we don’t have funding. If some of the public health facilities do not open, it will make it difficult for people who have moved to Bangui for security and economic reasons to return home. This will mean the overall crisis will not be solved.”

WHO is also filling gaps in disease surveillance, responding to outbreaks and planning health services in coordination with health humanitarian partners.

“One past donor, for example, is not providing funds for the Central African Republic this year as its funding is going towards other crises, like Syria and Yemen,” Dr Yao adds. “I am afraid that we are still a forgotten crisis and this year is even worse than before.”

Dr Yao says the reduced violence in the country means that fewer people are suffering from conflict-related injuries now than one year ago. “But today we have a large displaced population that will soon have no access to healthcare because they cannot pay for it,” Dr Yao says. “Any displacement increases the risk of communicable diseases because people are living in very poor conditions.”

Without a major injection of funding, humanitarian health services will stop delivering conflict-related injuries and they will only be delivering routine care, such as maternal and child health services and treatment for non communicable diseases like heart disease, diabetes and cancer.

Dispatches: Think Again, President Al-Bashir

So far, Sudanese President Omar al-Bashir has avoided arrest for alleged international crimes – including genocide – committed in Darfur. But his world has certainly gotten smaller.

By Elise Keppler

Sudan's President Omar Hassan al-Bashir attends the opening meeting of the Arab Summit in Sharm el-Sheikh, in the South Sinai governorate, March 28, 2015. © 2015 Reuters

Sudan’s President Omar Hassan al-Bashir attends the opening meeting of the Arab Summit in Sharm el-Sheikh, in the South Sinai governorate, March 28, 2015.
© 2015 Reuters

On Monday, al-Bashir planned to visit Indonesia to attend the 60th anniversary of the 1955 Bandung Conference of Asian and African nations. The trip seemed designed to boost the credibility of the leader, who is wanted by the International Criminal Court (ICC) on charges of genocide, war crimes, and crimes against humanity. But his effort backfired, with al-Bashir cancelling the trip at the last moment.

A government source told the news outlet Sudan Tribune that al-Bashir’s plane was denied permission to fly through the airspace of some countries en route to Indonesia, although it is not known which ones. As news of the anticipated visit unfolded, outcry from local civil society groups and members of parliament soared.

These developments reinforce al-Bashir’s status as a fugitive from international justice with limited travel options.

This is not the first time al-Bashir has had trouble traveling, and his movement is rightly restricted. The Sudanese president is subject to two ICC arrest warrants that include charges of unlawful attacks on civilians, murder, acts of extermination, and rape, among other abuses.

The United Nations Security Council resolution that referred the situation in Darfur to the ICC requires Sudan to cooperate with the investigation, but Khartoum has obstructed its efforts. The resolution also urges all states – even those like Indonesia who are not members of the ICC – to cooperate with the court’s work to bring justice to victims in Darfur. Civil society groups – particularly in Africa – have repeatedly called for al-Bashir’s arrest and for governments to ensure he faces justice.

Over the years, many governments have chosen not to welcome al-Bashir on their soil. He has traveled to Asia only once – to China in 2011, amid criticisms by the UN – since becoming subject to arrest. Malaysia in 2011 chose to cancel a visit. South Africa and Botswana have made it clear that al-Bashir risks arrest if he enters their territories.

Al-Bashir also cancelled visits to attend conferences in Turkey and Kenya amid outcry over his possible attendance. In 2012, an African Union summit in Malawi was relocated after Malawi’s president made it clear al-Bashir was not welcome. In 2013, al-Bashir traveled to Nigeria for a conference, only to leave abruptly less than 24 hours later as local activists took legal action to compel his arrest.

The Sudanese president seems set on trying to rehabilitate his image with recent steps such as his certain re-election this month, and Sudan’s decision to join Saudi Arabia’s coalition to fight in Yemen.

But victims in Darfur deserve to see justice and governments should help see this done, including by restricting al-Bashir’s travel. He belongs in one place only – facing charges in The Hague.

Obasanjo writes President -Elect Buhari; Urges him to start binding wounds of fractured nation

“I hasten to congratulate you on your success and victory in the Presidential election of March 28, 2015. Your success and victory after three previous unsuccessful attempts must be great object lessons for you and for all politicians particularly in Nigeria.

“For me, the totality of the 2015 election holds many lessons for our democracy and democratization process which are both maturing. On this occasion, the system has been unnecessarily overheated before and particularly during the campaign when emphasis was more in trivialities and hate, divisive, in dignifying and disrespectful statements and comments rather than on pressing issues requiring attention.

“I know that in victory, you will be magnanimous to start binding the wounds and bitterness occasioned by the campaign and the evil disciples.
“With so much harm already done to many national institutions, in lauding the military which proudly nurtured you and me, you will have a lot to do on institution reform, education, healthcare, economy, infrastructure, power, youth employment, agribusiness, oil and gas, external affairs, cohesiveness of our nation and ridding our land of corruption. Your varied and wide experience will undoubtedly stand you in good stead.

“I am also sure that there are men and women of goodwill, character and virtue across the board that you can mobilise to join hands with you in the reform, repairs and redirection that will be imperative to put Nigeria back on the fast lane of good governance, unity, cohesiveness, development and progress. Once again, I felicitate with you and wish you well” Obasanjo stated.

In its own letter of congratulation, the Nigeria Labour Congress said the election has opened a new and important chapter in the socio-political development of the nation.

President of the Congress, Dr. Ayuba Wabba said: “We at the Nigeria Labour Congress join millions of our compatriots in congratulating you on your victory in perhaps the most keenly contested presidential election in the history of our country.
“We strongly believe that your election has undoubtedly opened a new and important chapter in the socio-political development of our nation as we have finally broken the jinx of transiting from one democratically elected civilian government controlled by a ruling party to one contributed by an opposition party.

“Your victory is a lesson in perseverance and commitment, made possible by the patience, zeal, resolve, resilience and determination of Nigerians many of whom have undying belief in you.

“We believe this special trust reposed in you is a sacred bond between you and the Nigerian people as well as a call to an uncommon duty at a special period in the history of our nation.

“The times are challenging and will draw from you every grain of wisdom and courage, justice and equity, urgency and necessity.

“We at the Nigeria Labour Congress, like other compatriots not only look up to you with great expectations, we look forward to working with and engaging your government. We stand ready to work with you in defining as well as charting a new agenda for Nigeria. As we await your response, please accept the assurances of our highest esteem”.

Nigeria: U.S.-United Kingdom Joint Statement On Elections in Nigeria


Washington, DC — Joint Statement by U.S. Secretary of State John Kerry and UK Foreign Secretary Philip Hammond

Our governments welcome the largely peaceful vote on March 28. The Nigerian people have shown a commendable determination to register their vote and choose their leaders.

 So far, we have seen no evidence of systemic manipulation of the process. But there are disturbing indications that the collation process — where the votes are finally counted — may be subject to deliberate political interference. This would contravene the letter and spirit of the Abuja Accord, to which both major parties committed themselves.

The Governments of the United States and the United Kingdom would be very concerned by any attempts to undermine the independence of the Electoral Commission (INEC), or its Chairman, Prof. Jega; or in any way distort the expressed will of the Nigerian people.

Buhari secures historic election victory in Nigeria

The 72-year-old Buhari built an early lead in northern state [AP]

Former military ruler Muhammadu Buhari has become the first Nigerian to defeat a sitting president through the ballot box, putting him in charge of Africa’s most populous nation and its biggest economy.

Al Jazeera’s Yvonne Ndege, reporting from the capital Abuja, said Buhari was declared the winner after he gained 2.7 million more votes than his rival, incumbent President Goodluck Jonathan.

Our correspondent said that Buhari managed to secure more than 25 percent of votes in 24 states, ruling out a run-off vote.

To win the election, Buhari had needed more than 50 percent of the total votes nationally – and take at least 25 percent of the vote in two thirds of the states.

The All Progressives Congress (APC) party said Buhari received a phone call from incumbent President Goodluck Jonathan during which he immediately conceded defeat and congratulated him on his victory.

“President Jonathan called General Muhammadu Buhari, the winner of the elections, to congratulate him,” Lai Mohammed, spokesman for the APC, said.

“There had always been this fear that he might not want to concede, but he will remain a hero for this move. The tension will go down dramatically,

“Anyone who tries to foment trouble on the account that they have lost the election will be doing so purely on his own,” he added.

Victory for Buhari marks the first time in Nigeria’s history that an opposition party has democratically taken control of the country from the ruling party.

Al Jazeera’s Haru Mutasa, reporting from Lagos, said there was shock that Jonathan had congratulated Buhari and that violence had not followed the announcement. In the 2011 election, more than 800 people were killed in protests after Buhari was defeated by Jonathan.

“The announcement has been greeted with celebrations across the country,” Mutasa said. “Many people are excited and hope this will mark a new beginning and move the country forward.”

Hundreds of Buhari’s supporters gathered to celebrate outside his home in Abuja, with some brandishing brooms to symbolise his promise to clean up corruption.

His supporters told Al Jazeera that the vote was “free, fair and without irregularities” as the country ushered in a new era.

“We don’t have roads, electricty and the youth are looking for jobs,” one supporter said. “The people wanted change and change has now come.”

Buhari supporters celebrate in Kano [Reuters]

Jonathan, whose five years in office have been plagued by corruption scandals and an insurgency by the Boko Haram group, was trailing by around 500,000 votes before votes in pro-opposition areas were counted.

There was a brief protest by Jonathan’s Peoples Democratic Party (PDP) before the counting had resumed on Tuesday.

Former Niger Delta minister Godsday Orubebe accused elections chief Attahiru Jega of being “partial” and “selective”.

Orubebe claimed Jega had refused to investigate PDP complaints about big wins by Buhari in northern states but had launched a probe into claims by the APC of irregularities in Rivers.

Jega said later: “I don’t believe that the allegations are substantial enough to require the cancellation or rescheduling of the elections in Rivers state. We will take the results.”

International observers gave broadly positive reactions to the conduct of the vote, despite late delivery of election materials and technical glitches with new voter authentication devices.

Nigeria’s Transition Monitoring Group, which had observers across the country, said: “These issues did not systematically disadvantage any candidate or party.”

2014 Ebola Outbreak May Have Laid Tracks for Deadly Measles Epidemic in Africa

Princeton University and Johns Hopkins University researchers report the African countries most affected by the 2014 Ebola outbreak — Guinea, Liberia and Sierra Leone — could now be highly susceptible to measles epidemics due to severe disruptions in routine health care such as measles vaccinations. The researchers mapped the distribution of the estimated 778,000 children aged 9 months to 5 years in Guinea, Liberia and Sierra Leone who had not been vaccinated against measles before the Ebola outbreak (A). Based on surveys from healthcare providers, the researchers assumed that vaccinations against measles decreased 75 percent after the onset of Ebola. They then projected how the numbers of children unvaccinated against measles would increase 6 months (B), 12 months (C) and 18 months (D) after Ebola. Panel D includes the pre-Ebola distribution of measles-unvaccinated children in neighboring countries, which would be vulnerable to measles epidemics in Guinea, Liberia or Sierra Leone. Image courtesy of Science/AAAS

The Ebola outbreak that has swept West Africa since 2014 may have cleared the way for a more familiar killer that could claim thousands of more lives — measles. The African countries most affected by the outbreak could now be highly susceptible to measles epidemics due to severe disruptions in healthcare systems caused by Ebola, researchers at Princeton University and Johns Hopkins University report in the journal Science. The closing of and public aversion to clinics and hospitals during the Ebola epidemic resulted in the reduction of routine procedures such as measles vaccination.

The researchers studied the West African nations of Guinea, Liberia and Sierra Leone where the Ebola outbreak was most intense and is still active, having killed nearly 10,000 people and infected more than 24,000. A potential measles outbreak in those nations, the researchers found, could result in an additional 2,000 to 16,000 deaths after 18 months of initial healthcare system disruption. Prior to Ebola, and after significant vaccination campaigns, all three countries reported only 6,937 measles cases from 2004 to 2013.

Saki Takahashi, first author and a Princeton University graduate student of ecology and evolutionary biology, said that the report is intended to draw attention to the growth and impact of measles susceptibility, and encourage vaccination by governments and health organizations. Large-scale vaccination campaigns in countries affected by Ebola are likely to be key to staving off potential measles epidemics, said Takahashi, who began the work while in the research group of corresponding author Justin Lessler, a Johns Hopkins assistant professor of epidemiology.

“The negative legacy of Ebola could be minimized by deploying vaccines and other important public health interventions,” Takahashi says. “It’s about preparing for collateral damage resulting from Ebola. Even after the threat of Ebola begins to recede there is the potential for other infectious disease crises.”

Reports from Ebola-affected countries found that numerous health facilities were closed or devoted to Ebola treatment, while people also stayed away from hospitals and clinics to avoid contracting the virus, she said. The unintended consequences were not only a drop in measles vaccinations, but also reduced polio inoculations, the unavailability of treatment for endemic conditions such as AIDS and malaria, and a reduction in prenatal care, the researchers report.

“The focus on Ebola was clearly necessary to control the disease, and options were extremely limited, but it’s unfortunate that attention and resources were diverted from routine health services such as childhood vaccination,” Takahashi says.

Saad Omer, an Emory University associate professor of global health, epidemiology and pediatrics, said that the report importantly puts a number on the extent to which diseases such as measles can proliferate after a crisis.

“It’s very useful in highlighting that when we have these kind of outbreaks there are other consequences,” says Omer, who is familiar with the work but had no role in it. “It quantifies these potential consequences and highlights the need for focusing beyond the pathogen du jour.”

These pathogenic consequences — be they due to an outbreak, natural disaster or war — are especially important to consider in poor nations with weaker health-care infrastructures, Omer says. The incidences of outbreaks following a societal trauma are established, he says. In Pakistan, for instance, polio cases jumped following severe floods in 2010 that displaced millions of people and disrupted vaccination campaigns.

“We have to be cognizant of these external events socking weak or fragile health systems and having these other consequences,” Omer says. “If you have actual numbers, people tend to pay a lot more attention. This paper will help make the situation a little bit more real for a lot of people.”

The researchers focused on measles because it is a well-known consequence of upheaval, says the report’s second author Jessica Metcalf, a Princeton assistant professor of ecology and evolutionary biology and public affairs.

“Measles tends to follow humanitarian crises,” Metcalf says. “Our work is significant in that it describes the scope of the measles susceptibility problem in Ebola-affected regions. Ideally, this will aid governments and nongovernmental organizations to focus their resources on restarting vaccination programs.”

Co-authors of the report include Matthew Ferrari, an assistant professor of biology at Pennsylvania State University; William Moss, a Johns Hopkins professor of infectious disease epidemiology; Shaun Truelove, a doctoral student in infectious disease epidemiology at Johns Hopkins; Andrew Tatem, an associate professor of environmental sciences at the University of Southampton in the U.K.; and Bryan Grenfell, Princeton’s Kathryn Briger and Sarah Fenton Professor of Ecology and Evolutionary Biology and Public Affairs.

The researchers mapped the distribution of the estimated 778,000 children aged 9 months (the age when the measles vaccine can be administered) to 5 years in Guinea, Liberia and Sierra Leone who had not been vaccinated against measles before the Ebola outbreak. They then projected how those numbers would increase up to 18 months after Ebola struck an area.

Based on surveys from healthcare providers, the researchers assumed that vaccinations against measles decreased 75 percent after the onset of Ebola (they also ran calculations for reductions of 25, 50 and 100 percent). This meant that for each month that a healthcare system was in turmoil over Ebola, an average of more than 19,500 additional children went unprotected from measles.

In the end, a measles outbreak in Guinea, Liberia and Sierra Leone before the Ebola crisis would have resulted in between 84,000 and 181,000 cases. By the researchers’ calculations, 18 months of healthcare disruptions increases those numbers to between 153,000 and 321,000 cases with approximately 2,000 to 16,000 additional deaths.

The researchers used data from the national measles surveillance systems, administrative reports to the World Health Organization, and Demographic and Health Surveys, which include information such as where people live and if their children are vaccinated for measles. They also used data from the WorldPop project, which is directed by Tatem and provides high-resolution geographic data on birth rates and population size.

Takahashi plans to expand these techniques to incorporate environmental and epidemiological characteristics to better understand the global landscape of disease susceptibility, she says.

“Measles vaccination provides life-long protection, and improving our understanding of inequities in vaccination coverage to help target control efforts is a key direction for reducing the burden of this disease in vulnerable communities,” she adds.

The upcoming Princeton-Fung Global Forum hosted by Princeton and to be held Nov. 2-3, 2015, in Dublin, Ireland, will focus on the current Ebola crisis as a critical case study of a modern plague.

The paper, “Reduced vaccination and the risk of measles and other childhood infections post-Ebola,” was published online March 12 by Science.

The research was supported by Bill and Melinda Gates Foundation grants (nos. OPP1094793, OPP1106427 and 1032350); the U.S. Department of Homeland Security Science and Technology Directorate (no. HSHQDC-12-C-00058); the RAPIDD program of the Department of Homeland Security Science and Technology Directorate; the National Institutes of Health’s Fogarty International Center; and the NIH’s National Institute of Allergy and Infectious Diseases (R01 AI102939 and U19AI89674).

Source: Princeton University

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