Lessons learned from Ebola Vaccine R&D during a public health emergency

Vaccine Innovation Meta-Model for Pandemic Contexts

Purpose

Over the past decade, successive outbreaks and epidemics of infectious diseases have challenged the emergency preparedness and response systems of global public health institutions, a context in which vaccines have become the centerpiece to strengthening global health security. Nevertheless, vaccine research and development (R&D) is a complex, lengthy, risky, uncertain, and expensive process. Alongside strict, time-consuming regulatory compliance, it takes multiple candidates and many years to register a new vaccine. This is certainly not welcome in a global health crisis such as the COVID-19 pandemic. Therefore, this study aims to understand the R&D paradigm shift in pandemic contexts and its impacts on the value chain of vaccine innovation.

Methods

To that end, this paper carried out a systematic literature review and meta-synthesis of 27 articles and reports (2011-2021) that addressed vaccine R&D in contexts of global health threats, disease outbreaks, epidemics, or pandemics.

Results

The research findings are synthesized in a meta-model, which describes a fast-track R&D for pandemic contexts, its driving forces, innovations, mechanisms, and impacts in the value chain of vaccine innovation.

Conclusions

The study demonstrates that, in pandemic contexts, a fast-track R&D process based on close collaboration among regulators, industry, and academia and leveraging enabling technologies can drastically reduce the time required to bring safe, stable, and effective vaccines to market by an average of 11 years compared to the traditional R&D process. Furthermore, pharmacovigilance and rigorous monitoring of real-world evidence became critical to ensuring that quality and safe products were authorized for use during a pandemic.

Strengthening clinical development activities and preparedness for vaccine manufacturers from emerging countries: Results of a survey

Vaccine development, in most cases, is a long, complex process, often lasting years and involving a combination of public and private stakeholders. Particularly, the vaccine clinical development process is highly regulated by several guidelines, regulatory pathways and science-based recommendations from experts. Designing and executing a successful clinical development plan for any candidate vaccine requires a solid scientific, medical, operational and regulatory knowledge and expertise, to comply with regulations and assure adequate benefit-risk balance for the product to be used in mass vaccination of healthy populations. The purpose of this study was to assess the approaches and practices related to Clinical Development functions, and related activities among vaccine manufacturers based in emerging countries, and to identify industry needs in terms of organizational development and training needs. A structured questionnaire designed specifically for assessing indicators of clinical activities, in the last five years, comprised of four sections aimed to collect information on (1) the organizational structure and the activities conducted by the clinical functions; (2) the clinical trial design ability and the management of clinical trial documents; (3) the clinical trial management and monitoring activities; (4) the quality aspects of clinical activities. The results suggest that the great majority of respondents is engaged in intense clinical development activities, as indicated by the high number of licensed vaccines available and supplied in the national markets or in foreign markets, including vaccines with WHO prequalification status. Areas to further strengthen the clinical activities and medical research preparedness were identified. Greater engagements of stakeholders' and investments will be required to expand the clinical basis in vaccine R&D, and to support achieving a high level of preparedness in emerging countries, for development of new vaccines against future regional epidemics and global pandemics.

Leveraging mRNA Platform Technology to Accelerate Development of Vaccines for Some Emerging and Neglected Tropical Diseases Through Local Vaccine Production

The mRNA vaccine technology platform may enable rapid response to some emerging infectious diseases (EIDs), as demonstrated through the COVID-19 pandemic. Beyond the role it could play in future EID response, mRNA technology also could have an important role in accelerating the development of, and access to, vaccines for some neglected tropical diseases (NTDs), which occur mainly in impoverished regions of the world. Despite their significant disease burden, few vaccines against NTDs have been developed, in part because of the uncertain market and return on investment. In addition, the probability of technical and regulatory success is considered to be low for developing vaccines against multicellular parasites, or organisms that have sophisticated mechanisms for evading immunological surveillance, such as many of the NTD pathogens. The global 2021-2030 road map for neglected tropical diseases sets ambitious targets for the eradication, elimination, and control of NTDs. For some, effective interventions exist but are underutilized. For others, vaccines need to be developed or their use expanded to meet global targets on control and elimination. This article discusses the application of the mRNA technology platform to the development of vaccines for NTDs as well as EIDs, highlights the challenges in bringing these products to the market, and indicates potential areas which could be explored, including leveraging investment for vaccines with a more profitable market potential and enabling local manufacturing in regions where NTDs are endemic. Such regional production could include collaborations with the mRNA vaccine technology transfer hubs that are being established with the support of WHO and COVAX partners.

Between Ambitious Strategies and Reality: The African Union Strategy on COVID-19 Vaccine

A key learning lesson from country responses to COVID-19 pandemic was the impact of the strategies that are followed on combating the pandemic. Since the development of different vaccines and their supply globally, most countries have developed their own strategies to effectively provide sufficient doses for their population and start the vaccination process with the best outcomes. In this perspective, we review the African Union vaccination strategy by exploring the implementation of the strategy and its outcomes. We report on the strategy initiatives, vaccines distribution, administration, and the impact on new COVID-19 cases in African countries.

Bushmeat, wet markets, and the risks of pandemics: Exploring the nexus through systematic review of scientific disclosures

The novel coronavirus (SARS-CoV-2) is the third coronavirus this century to threaten human health, killing more than two million people globally. Like previous coronaviruses, SARS-CoV-2 is suspected to have wildlife origins and was possibly transmitted to humans via wet markets selling bushmeat (aka harvested wild meat). Thus, an interdisciplinary framework is vital to address the nexus between bushmeat, wet markets, and disease. We reviewed the contemporary scientific literature to: (1) assess disease surveillance efforts within the bushmeat trade and wet markets globally by compiling zoonotic health risks based on primarily serological examinations; and (2) gauge perceptions of health risks associated with bushmeat and wet markets. Of the 58 species of bushmeat investigated across 15 countries in the 52 articles that we analyzed,one or more pathogens (totaling 60 genera of pathogens) were reported in 48 species, while no zoonotic pathogens were reported in 10 species based on serology. Burden of disease data was nearly absent from the articles resulting from our Scopus search, and therefore was not included in our analyses. We also found that perceived health risks associated with bushmeat was low, though we could not perform statistical analyses due to the lack of quantitative perception-based studies. After screening the literature, our results showed that the global distribution of reported bushmeat studies were biased towards Africa, revealing data deficiencies across Asia and South America despite the prevalence of the bushmeat trade across the Global South. Studies targeting implications of the bushmeat trade on human health can help address these data deficiencies across Asia and South America. We further illustrate the need to address the nexus between bushmeat, wet markets, and disease to help prevent future outbreaks of zoonotic diseases under the previously proposed "One Health Framework", which integrates human, animal, and environmental health. By tackling these three pillars, we discuss the current policy gaps and recommend suitable measures to prevent future disease outbreaks.

Ebola outbreaks: A stress test of the preparedness of medicines regulatory systems for public health crises

In a globalized world, infectious diseases of international concern are inevitable. When they (re-)emerge, the regulatory system works towards mitigating their impact. Ebola outbreaks marked a turning point in regulatory preparedness and efforts led to the accelerated development of therapeutic agents, in a catastrophic environment. However, only one clinical trial determined a vaccine's efficacy. Key lessons were considered and applied thereafter. The collaborative work resulted in the approval of the first therapeutic options against Ebola, a milestone in public health preparedness. The response demonstrated the successful implementation of regulatory mechanisms fostering development, early access and assessment of therapeutic agents, and the flexibility to embrace innovative regulatory solutions. The current system is robust to address health crises and protect global health.

Barriers Influencing Vaccine Development Timelines, Identification, Causal Analysis, and Prioritization of Key Barriers by KOLs in General and Covid-19 Vaccine R&D

A frequently mentioned factor holding back the introduction of new vaccines on the market are their prohibitively long development timelines. These hamper their potential societal benefit and impairs the ability to quickly respond to emerging new pathogens. This is especially worrisome since new pathogens are emerging at all-time high rates of over one per year, and many age-old pathogens are still not vaccine preventable.Through interviews with 20 key-opinion-leaders (KOLs), this study identified innovation barriers that increase vaccine development timelines. These innovation barriers were visualized, and their underlying causes revealed by means of qualitative root cause analysis. Based on a survey the innovation barriers were quantitatively ranked based on their relative impact on both regular, and Covid-19 vaccine development timelines. KOLs identified 20 key innovation barriers, and mapping these barriers onto the Vaccine Innovation Cycle model revealed that all phases of vaccine development were affected. Affected by most barriers is the area between the preclinical studies and the market entry. Difficult hand-off between academia and industry, lack of funding, and lack of knowledge of pathogen targets were often mentioned as causes. Quantitative survey responses from 93 KOLs showed that general vaccine development and Covid-19 vaccine development are impacted by distinct sets of innovation barriers. For the general vaccine development three barriers were perceived of the highest impact; limited ROI for vaccines addressing disease with limited market size, limited ROI for vaccines compared to non-vaccine projects, and academia not being able to progress beyond proof of principle. Of highest impact on Covid-19 vaccine development, are lack of knowledge concerning pathogen target, high risk of upscaling unlicensed vaccines, and proof of principle not meeting late-stage requirements. In conclusion, the current study demonstrates that barriers hampering timelines in vaccine development are present across the Vaccine Innovation Cycle. Prioritizing the impact of barriers in general, and in Covid-19 vaccine development, shows clear differences that can be used to inform policies to speed up development in both war and peace time.

Build a Sustainable Vaccines Industry with Synthetic Biology

The vaccines industry has not changed appreciably in decades regarding technology, and has struggled to remain viable, with large companies withdrawing from production. Meanwhile, there has been no let-up in outbreaks of viral disease, at a time when the biopharmaceuticals industry is discussing downsizing. The distributed manufacturing model aligns well with this, and the advent of synthetic biology promises much in terms of vaccine design. Biofoundries separate design from manufacturing, a hallmark of modern engineering. Once designed in a biofoundry, digital code can be transferred to a small-scale manufacturing facility close to the point of care, rather than physically transferring cold-chain-dependent vaccine. Thus, biofoundries and distributed manufacturing have the potential to open up a new era of biomanufacturing, one based on digital biology and information systems. This seems a better model for tackling future outbreaks and pandemics.

Development of a TB vaccine trial site in Africa and lessons from the Ebola experience

Tuberculosis is the deadliest infection of our time. In contrast, about 11,000 people died of Ebola between 2014 and 2016. Despite this manifest difference in mortality, there is now a vaccine licensed in the United States and by the European Medicines Agency, with up to 100% efficacy against Ebola. The developments that led to the trialing of the Ebola vaccine were historic and unprecedented. The single licensed TB vaccine (BCG) has limited efficacy. There is a dire need for a more efficacious TB vaccine. To deploy such vaccines, trials are needed in sites that combine high disease incidence and research infrastructure. We describe our twelve-year experience building a TB vaccine trial site in contrast to the process in the recent Ebola outbreak. There are additional differences. Relative to the Ebola pipeline, TB vaccines have fewer trials and a paucity of government and industry led trials. While pathogens have varying levels of difficulty in the development of new vaccine candidates, there yet appears to be greater interest in funding and coordinating Ebola interventions. TB is a global threat that requires similar concerted effort for elimination.

Coronavirus disease 2019: International public health considerations

On December 31, 2019, the Chinese government announced an outbreak of a novel coronavirus, recently named COVID-19. During the following weeks the international medical community has witnessed with unprecedented coverage the public health response both domestically by the Chinese government, and on an international scale as cases have spread to dozens of countries. While much regarding the virus and the Chinese public health response is still unknown, national and public health institutions globally are preparing for a pandemic. As cases and spread of the virus grow, emergency and other front-line providers may become more anxious about the possibility of encountering a potential case. This review describes the tenets of a public health response to an infectious outbreak by using recent historical examples and also by characterizing what is known about the ongoing response to the COVID-19 outbreak. The intent of the review is to empower the practitioner to monitor and evaluate the local, national and global public health response to an emerging infectious disease.

Challenges and opportunities for China entering global research and development for emerging infectious diseases: a case study from Ebola experience

Background

China has emerged as a powerful platform for global pharmaceutical research and development (R&D) amid the 2014 Ebola outbreak. The research and development impact of developing countries on prevention and control of infectious disease outbreaks has long been underestimated, particularly for emerging economies like China. Here, we studied its research and development progress and government support in response to Ebola outbreak by timeline, input, and output at each research and development stage. This study will contribute to a deeper understanding of the research and development gaps and challenges faced by China, as well as providing evidence-based suggestions on how to accelerate the drug development process to meet urgent needs during future outbreaks.

Methods

Data were obtained from the National Nature Science Foundation of China database, PubMed database, Patent Search System of the State Intellectual Property Office of China, National Medical Products Administration, national policy reports and literature between Jan 1st, 2006 and Dec 31st, 2017. An overview of research funding, research output, pharmaceutical product patent, and product licensed was described and analyzed by Microsoft Excel. A descriptive analysis with a visualization of plotting charts and graphs was conducted by reporting the mean ± standard deviation.

Results

China has successfully completed the research and development of the Ebola Ad5-EBOV vaccine within 26 months, while the preparation and implementation of clinical trials took relative long time. The National Nature Science Foundation of China funded CNY 44.05 million (USD 6.27 million) for Ebola-related researches and committed strongly to the phase of basic research (87.8%). A proliferation of literature arose between 2014 and 2015, with a 1.7-fold increase in drug research and a 2.5-fold increase in diagnostic research within 1 year. Three years on from the Ebola outbreak, six Ebola-related products in China were approved by the National Medical Products Administration.

Conclusions

China has started to emphasize the importance of medical product innovation as one of the solutions for tackling emerging infectious diseases. Continuing research on the development of regulatory and market incentives, as well as a multilateral collaboration mechanism that unifies cross-channel supports, would advance the process for China to enter global R&D market more effectively.

L’épidémiologie entre le terrain des épidémies et l’approche populationnelle, XIX-XXesiècle

L’émergence d’une épidémiologie moderne est fréquemment associée au basculement de la discipline, d’une science des épidémies vers une science des populations. L’avènement et le développement d’une épidémiologie fondée sur une approche statistique et mathématique n’exclut cependant pas la persistance d’une épidémiologie sur le terrain des épidémies, dans le sillage de l’hygiène publique et de la bactériologie triomphante du tournant des XIXeet XXesiècles. De plus, l’histoire de l’épidémiologie ne saurait être cantonnée à une histoire de savoirs scientifiques ou de savoir-faire techniques et organisationnels. Elle doit intégrer, plus sans doute encore que d’autres branches de la médecine, les dimensions économiques et politiques qui participèrent à l’institutionnalisation et au développement de la discipline et à son inscription dans les processus de décision.

The Special Pathogens Research Network: Enabling Research Readiness

The 2013-2016 epidemic of Ebola virus disease (EVD) that originated in West Africa underscored many of the challenges to conducting clinical research during an ongoing infectious disease epidemic, both in the most affected countries of Guinea, Liberia, and Sierra Leone, as well as in the United States and Europe, where a total of 27 patients with EVD received care in biocontainment units. The Special Pathogens Research Network (SPRN) was established in the United States in November 2016 to provide an organizational structure to leverage the expertise of the 10 Regional Ebola and Other Special Pathogen Treatment Centers (RESPTCs); it was intended to develop and support infrastructure to improve readiness to conduct clinical research in the United States. The network enables the rapid activation and coordination of clinical research in the event of an epidemic and facilitates opportunities for multicenter research when the RESPTCs are actively caring for patients requiring a biocontainment unit. Here we provide an overview of opportunities identified in the clinical research infrastructure during the West Africa EVD epidemic and the SPRN activities to meet the ongoing challenges in the context of Ebola virus and other special pathogens.