Dr Richard Hatchett, CEO of the Coalition for Epidemic Preparedness, details the lessons learned from the Ebola outbreak and the urgent need to equip the world to face future epidemics.
How did CEPI come about?
CEPI was formally established at Davos 2017 in January, and initially with funding close to $500 million, provided by five major investors. The original investors were the Wellcome Trust and the Bill & Melina Gates Foundation, and three sovereign investors: Germany, Norway and Japan. We also received the extensive support of the World Economic Forum and the government of India as additional founding partners.
About a year’s worth of prior planning had gone into setting CEPI up; the day that it was formally established, we also issued our first call for proposals to develop vaccines against three high-priority pathogens – Mers, Lassa and Nipah. These pathogens have been identified by WHO on a shortlist that was published as part of their R&D blueprint, as part of their action against epidemic diseases.
CEPI has had a tremendously active year – we’re still very much in our initiation stage. I came on board as CEO in the middle of April and the major activities have been centred around building the organisation, developing a more structured internal organisation chart. When I was appointed at the February board meeting, the initial charge to me was to come back with some revisions to CEPI’s governance, which was specifically and explicitly an interim government structure designed for the initiation stage. The board recognised that the needs of the organisation would evolve over time and so they asked me to come back with recommendations as we move towards a steady-state phase.
How did the collaboration with sovereign investors arise and how many more countries do you hope to get on board?
Currently, the original investors all have well-established connections to global public health – both philanthropic and the sovereign investors. Norway and Germany play outside roles in supporting global public health, and Japan has major commitments in this area, having long made investments in epidemic preparedness. Norwegian scientists and public health officials were instrumental in the only clinical trial for a vaccine during the Ebola crisis that generated definitive data on efficacy – that was the trial that took place in Guinea.
There was a global consensus that things did not go well with Ebola and that we didn’t want to be in a position again where we had vaccines that were almost ready but not quite. There was a real commitment to ensuring that we could buy the world a better insurance policy.
We’ve been actively engaged in further resource mobilisation efforts, and have had three further countries sign up to the coalition: Australia, Belgium and Canada. The collective commitment of these countries is smaller than the original investors and is, initially, limited to one year of investment but we are in active discussions to further this agreement with them. We are pursuing agreements with a number of sovereign partners and hopefully will be able to make announcements in the not too distant future about additional funding.
At present, we have secured $620 million towards our initial funding goal of $1 billion dollars. With the exception of the three smaller investments mentioned, all of our investors have committed to a five year agreement. To be clear, the $620 million will be used over a five-year time horizon.
What is the driving force behind CEPI?
I think Ebola is a really good illustration of the risk epidemic diseases represent and the unpredictability of that risk. Ebola is a disease that we’ve been familiar with for forty years, with around 30 outbreaks over this period. Some of these outbreaks had been fairly large, with the most significant causing around 400 deaths. However, all of those outbreaks had been contained within several months and it’s possible that the world had become a little bit complacent over Ebola. We hadn’t realised the importance of the social milieu and context to whether the outbreak would propagate. What happened in West Africa was there was a disease, which we thought we understood and thought we could control, which got into an environment where public health systems were poor but the road networks were good and the populations were concentrated. Suddenly, a disease that we thought we understood completely exploded.
There are other diseases, like Mers, Lassa and Nipah, that have been manageable to date but have characteristics that make them scary. We’ve seen this in quite public ways, for example in the epidemic in South Korea, where an individual instance gets into the hospital environment and becomes a super-spreader – suddenly, one case becomes a hundred cases. We went through a very careful selection process looking at the diseases on the WHO R&D blueprint list, thinking about their potential for outbreaks and the impact that they might have, as well as the likelihood that vaccines could be successfully developed. We went through a comprehensive screen of all the 11 diseases on the WHO list and mapping against those two dimensions, we prioritised the three diseases we are now focused on.
Is there now a growing concern over the threat infectious diseases pose?
There is a strong sense among public health officials, and there is data to back this up, that the tempo of these disrupting epidemics is increasing and it relates to many factors: growing population, intrusion into previously remote areas, better transportation networks, and greater concentrations of populations. We’ve seen the potential for, not just potential loss of life, but also significant disruption of national economies by epidemic diseases. All of these factors converge to increase the risk to a level greater than it has been previously. There’s always the risk that there will be a diseases that hasn’t had much focus, such as Zika or a new disease, to emerge and spread rapidly.
How is CEPI helping the world to prepare for such an eventuality?
We talk about our investments in terms of two categories: ‘just-in-case’ and ‘just-in-time’. Investments against Mers, Lassa and Nipeh, are ‘just-in-case’ investments, where we want to advance these vaccines to bring them much closer to being ready to deploy, either into clinical trials or emergency use authorisation.
Our investment in rapid-response platforms are part of the ‘just-in-time’ approach. The only vaccine platform that has been accepted by regulators is the influenza platform because they have to manufacture a new influenza vaccine every year. The regulators have become very comfortable if you swap in a new flu virus antigen, then they’ll accept the vaccine with a defined, but limited, amount of testing.
In 2009 in the US, it took about 26 weeks from the identification of H1N to the first doses of vaccine becoming available to the general public. At this time, there weren’t enough vaccines for the public before the late autumn wave of incidents had already come and gone. This means that even in influenza 26 weeks is not a long enough period of time to develop a vaccine and that’s on a platform that we are already familiar with.
Ebola began in late 2013 and really imprinted itself in the world’s consciousness in April/May time and then accelerated through the summer. The first large-scale clinical trials for an Ebola vaccine began in West Africa in early 2015, by that time the epidemic had basically been brought under control. The Ebola vaccines that entered clinical trials had been under development for the better part of a decade and had been developed not for epidemics but to combat the potential of bioterrorism. By the time things began to speed, there was over a decade’s worth of investment before they could be brought into clinical trials, and that was clearly too long.
That is the state of play today. CEPI wants to have these high-priority vaccines ready and sitting in stockpiles so that if there’s ever an epidemic then we can roll them right into clinical trials within weeks, not months or years.
Do we have a tendency to focus on the high-profile epidemics in high-intensity until they fade as a threat rather than being pre-prepared for emerging threats?
I think there has been a drum beat over the last 10 or 15 years, like SARS, Avian Influenza, Ebola, Mers, and Zika – you can’t predict the disease but there is a periodicity to threats emerging to global stability. There is a general awareness among global leaders across the political spectrum that infectious diseases pose global public health threats and security threats. Due to the latter risk, there is the possibility to secure sustained funding even when administrations change or political winds shift.
The concern with the general public is that infectious disease threats have a very limited hold on the public attention. When a public health threat is present or imminent they really want a vaccine but when the threat goes away, people tend to blot it out. Infectious diseases don’t knock buildings down, they just fill up graveyards. The memory of epidemics is very effervescent and that’s a problem when it comes to sustaining political will when it comes to preparedness.