Special mission: Ebola

The Cover Page of the research magazine Horizons. © SNSF

Switzerland is playing an important role in managing the Ebola crisis – both in its position as the seat of the WHO and as a centre of research. We offer a glance behind the scenes of a large-scale medical operation that began late, but has been all the more decisive for it. By Roland Fischer

(From "Horizons" no. 104, March 2015)For a long time, Ebola was just a distant rumble somewhere on the horizon of tropical medicine. If you use Google Trends to trace the search volume for the word ‘Ebola’ over the last ten years, then there are barely visible bumps on the scale for 2005, 2008 and 2012, but then, suddenly, a sharp peak in August 2014 and an even higher peak in October. Since its discovery in 1976, Ebola had been an exotic disease far away from us. It was only half a year ago that it shifted into the global consciousness.

This sudden jump in attention also took place in the medical world. There were good reasons for the reticence shown towards it until now. Blaise Genton is a doctor of tropical medicine and the head of an inoculation study currently running in Lausanne, and he explains it in figures: in 2014, Ebola cost 7,000 people their lives. In that same time period, malaria killed almost a hundred times as many. Besides, the earlier Ebola outbreaks had been quickly halted. “Ebola wasn’t a priority – and certainly not in Africa”, says Marcel Tanner, the Director of the Swiss Tropical and Public Health In-stitute. “We knew about Ebola, but we also knew that each of its outbreaks had been very limited”. This was because the population density and mobility had been low in the affected areas, and because the countries affected had a relatively good health system. None of that applied in the current outbreak, but the World Health Organisation (WHO) did not recognise the seriousness of things straightaway, and so reacted late. Nevertheless, the WHO is being all the more decisive now, both in organisational and in financial terms, and is driving forward the development of a vaccine. Besides England and the USA, Switzerland is one of the scientific centres involved. Large-scale studies are running in Lausanne and Geneva for the two vaccines under trial.

Consciously running risks

But why Switzerland? Claire-Anne Siegrist, the head of the study at the Geneva University Hospital, says that the proximity to the WHO’s headquarters has played an important role, as have the well-established contacts between researchers and healthcare officials here. Furthermore, many people live here that will soon be travelling to an Ebola crisis area: roughly a third of all the volunteers taking part in the Geneva study could thus profit already from a vaccine. This is also an incentive for the WHO to allow the studies with the most participants to take place ‘on its own doorstep’. It’s unusual for a phase I study to be focussing already on the medical use of a vaccine, but time is pressing and so this trial run is being carried out under rather different rules. “One shouldn’t proceed so quickly”, warns Siegrist, “and we’re conscious that it involves risks. But it’s justified in this special case”. They still endeavour to minimise the risks, which is why the Geneva study was interrupted shortly before Christmas, when several of the test subjects began to suffer from joint pains some two weeks after having been given the vaccine.

Besides the possible risks for the participants in the trials, we also have to consider that such a fast-track procedure can place a considerable strain on other research activities and on the normal running of a hospital. “These extraordinary efforts are restricted in terms of both time and location – and that’s quite right, too”, says Siegrist. She would normally have to discuss with the Clinical Trial Unit whether there would be room at short notice for another large-scale study, because the vac-cine trial is now taking up three-quarters of its capacity. Other studies have had to be postponed for several months, which is why Siegrist wanted to be sure “that no one was going to die because of this special case”. But she has been impressed by the positive spirit of cooperation among all those involved.

‘Ebola’ proved to be the magic word. Lawyers confirmed contracts within 24 hours, and Siegrist says that those in charge at Swissmedic also reacted quickly and competently. “Believe me, it means something when I say that – I’ve criticised Swissmedic often enough before”, she says. Even recruiting volunteers has been a lot simpler than usual. Both Siegrist and Genton emphasise that the immense effort being invested in Ebola – not just on the ground in Africa but also in terms of research – is only justified because it promises uses above and beyond this particular case.

Vaccines for haemorrhagic fevers were a secondary research field before now, and there had been hardly any financial incentive to develop them. The main motivation for research used to be the fear that such pathogens could be employed as biological weapons. Genton hopes that we will learn lessons from this Ebola outbreak about how to react best in future emergencies of this kind. But he doesn’t want to be distracted from his other priorities: “I will certainly not stop working on malaria”, he says. On the other hand, Siegrist is certain that the current study will prove useful far beyond Ebola itself, because a vaccination technique is being implemented that would allow for many other applications. Furthermore, there is a lot to be learnt about how a health system can still function at a high level under such unusual circumstances.

Close partnership with industry

While Siegrist is working with a vaccine developed by the state authorities in Canada, Genton is testing a compound from the pharmaceutical company GlaxoSmithKline. He doesn’t see any major difference here, because right from the start he had stipulated that “I would do my research as I see fit”. On the contrary, he is happy to be able to work closely with industry, because he had frustrating research experiences in the past when a compound had seemed very promising in the lab, but hadn’t been produced in the necessary quantities to reach the patients. And Tanner also stresses that a swift reaction in times of crisis is only possible if there is a close partnership between the public and private sectors. “10 to 15 years ago it wouldn’t have run like this. But since then, we’ve found ways of reacting jointly to such medical events, to the greater benefit of the general public”.

Meanwhile, the control over infectious diseases has become part of the United Nations Development Programme and has been declared a ‘global public good’. This category also includes peace, security and climate protection. “A vaccine would be very important for the purposes of prevention, especially if Ebola is going to flare up again repeatedly in future”, says Tanner. “But in the current crisis, too, a vaccine could be extremely helpful if it can be put through an accelerated process and used straightaway in the epidemic areas, as long as no scientific or ethical compromises are made”.

Roland Fischer is a freelance science journalist.

What’s happened so far:

The Ebola epidemic began in February 2014 in south-east Guinea. It rapidly spread to the neighbouring countries Sierra Leone and Liberia, then in early August also reached Nigeria. On 8 August the World Health Organization declared the epidemic to be an international health emergency. In late August they created a roadmap to try and stop the epidemic within the next six to nine months – at a cost of 500 million dollars. By the end of the year, the number of new infections was still rising in Sierra Leone – in contrast to Liberia and Mali. A vaccine developed by Okairos, a biotech company in Basel (taken over in 2013 by GlaxoSmithKline) has been undergoing trials by various research groups since last September, and trials also started in November at the University Hospital of Lausanne. Since December, the tolerance of a second vaccine, developed by the Canadian National Microbiology Laboratory, has been subjected to a large-scale trial at Geneva University Hospital. This study was interrupted just before Christmas, because the test subjects had begun to suffer from unexpected, though minor, side effects.