T he World Health Organization vaccination strategy for the prolonged outbreak of Ebola in the Democratic Republic of the Congo is under fire, with borderless doctors blaming the agency for rational vaccines and calling for an independent committee to ensure "more transparent governance" of the situation.
The widespread site, released on Monday, follows a sustained effort by borderless doctors to launch a campaign to make more use of the still unlicensed vaccine developed by Merck. More than 226,000 vaccine doses have been administered in the provinces of the North Kivu and Ituri provinces since August 2018, but Doctors Without Borders, one of the non-profit groups playing a leading role in responding to the crisis, says those doses are being distributed at based on too narrow criteria.
"We believe that increasing vaccination rates is necessary and feasible. At least 2000-2,500 people could be vaccinated every day instead of 500-1
A heated debate over how to use the vaccine in this outbreak has erupted. Merck vaccine – the only Ebola vaccine for which phase III efficacy data are available – and how and where to use the J&J product for which human efficacy is not yet available
called the ring vaccination floor sh. When the case is confirmed, trained response officers work to identify who the person has had contact with and list the contacts of the contacts. They were offered a vaccine.
The idea is to protect people around known cases and to block the virus's ability to spread further. But contact tracing, always a difficult job, is especially so in this part of the DRC, which has been a conflict zone for decades. Last spring, the WHO agreed, on the advice of the vaccine advisory group, also to continue targeted geographic vaccination – offering the vaccine to anyone – in communities where for safety reasons the likelihood of vaccination is likely to be short.
MSF insists on more such use with the argument that many of the observed new cases are among known contacts of cases that have not been vaccinated. The group's statement fails to note the fact that, in many cases, known case contacts refuse to cooperate with Ebola workers, and some will not agree to be vaccinated.
However, the frustration of the organization from the limitations of the ring approach to vaccination was clear.
"It's like giving firefighters a bucket of water to put out a fire, but just letting them use one glass of water a day," says Dr. Natalie Roberts, MSF Emergency Coordinator. "Every day we see some contacts of confirmed Ebola patients who did not receive their dose even though they were eligible for vaccination."
Up to now, between 450,000 and 600,000 people in the region have had to be vaccinated, MSF claims , using the estimate that the contact rings around each case – so far close to 3,200 – should typically number between 150 and 200 people.
But Dr Socé Fall, WHO Assistant Director-General for Emergency Response, stated that MSF criticism did not take into account the social nature of Ebola transmission. The cases cluster into families and social networks, which means that there is a lot of overlap in making contact lists.
The move to a more massive vaccination approach will burn through expensive vaccine supplies and use a lot of human resources, he said. He added that this would mean vaccinating people who are not in the path of the virus.
This approach "is the most effective way to stop transmission because Ebola is a very social ailment," Fol said.
Earlier this year, there were concerns about whether the supply of the Merck vaccine might be leaking, but this picture seems brighter these days. The WHO said on Monday that there are currently 390,000 doses – significantly more than used in the first 14 months of this outbreak – and another 650,000 will be produced in the next six to 18 months.
There are approximately 2 million courses of J&J vaccine to be administered in two doses spaced 56 days apart. The first dose of the vaccine is expected to generate some protection. (In contrast, the Merck vaccine is administered in a single dose and protects for about 10 days.)
Repeated Phase 1 and Phase II studies of the J&J vaccine. But the only time to determine if the Ebola vaccine is actually safe is during a fire. As a result, it is of great interest to see whether the vaccine works and whether it can help end this difficult epidemic.
Talks about bringing her out of the field have been ongoing for months, spurred by a consortium consisting of MSF, CEPI, the London School of Hygiene and Tropical Medicine, the trust of Wellcome and others. Johnson and Johnson are on board.
The company "is ready to assist the DRC by donating the necessary doses of Janssen's investigative vaccine regimen. We are committed to the fight against Ebola – and we will always join forces with partners in the international community in the quest to save lives, "the statement said.
But there is deep concern about how to use the vaccine – in particular, how close to the outbreak area can be located. The use of two vaccines with different dosage regimens will create significant communication challenges. If not done correctly, confidence in both vaccines could be hurt, people involved in the response warn.
There are rumors in the outbreak area of the impending arrival of a second vaccine. Community surveys conducted in the region indicate that some respondents felt they could wait for this vaccine, which is rumored to be a better option in some areas.
"This is useless. All people are still getting Ebola and they have to make a second vaccine that will work, "says one respondent in one such report obtained by STAT.
Just makes people return at the right time for the second dose of J&J vaccine will could be a significant challenge in a region where people are constantly on the move and may not have official identification. At one point, researchers writing the test protocol for the J&J vaccine proposed using iris scanning machines, though the idea is considered not applicable, given However, the prevailing lack of trust in authorities spread to people in this part of the DRC
however, can be used to identify traders who move daily between Rwanda and the DRC, said Dr. Jeremy Farrar, director of the Welcom Trust. These traders, numbering thousands, form a group that both Congolese and Rwandan governments are eager to get vaccinated for because of their cross-border travel. In a statement on Friday, the Congo Ministry of Health said it would be the first people to offer the J&J vaccine.
Farrar and others have been pushing for months to use the vaccine near the outbreak area; one idea is to create a wall of immunity to prevent the rooting of the virus in Goma, the capital of North Kivu and home to 2 million people. It is located south of the hearth area.
Twice in recent months, infected people have made their way to Goma; in the second event, several members of the infected family became infected with the virus. But Merck's vaccine unfolded quickly and the transmission chain was stopped.
"We have the ability to protect populations at the end of the epidemic zone," says Farrar. "Places like Goma remain at high risk."
But others argue that the J&J vaccine should not be used close to where the Merck vaccine is used. "I think it's really important to have a very clear line of communication about this vaccine – and not get close to the outbreak," says the WHO crash.
A statement on Friday by the Congolese Ministry of Health mentioned that the J&J vaccine was being used to create a "corridor of immunity" to South Kivu, a province south of Goma, which has also been observed in a number of cases recently. The statement did not say where this corridor would begin.
It is not clear how soon the J&J vaccine trial will begin. There are some speculations that it may start by mid-October, but Farrar said it may be optimistic. He added: "I thought this was going to happen in June, and now we're in September and it hasn't happened yet. So I'm not the best predictor of time scales. "