Louis gripped his coffee mug. The liquid inside, slowly getting colder in his hands, had been called in early, very early,
and the usual office chatter had been replaced by hushed conversations held rapidly behind closed doors.
Yes, there was something new in the air. The Pasteur Institute's today attention, a sense of unease.
He was picking up more whispers about the cases in Guinea. Of course, everyone had known about those since the start of the year.
But these rumours were different. These rumours were saying that the unknown illness.
Well, it wasn't unknown anymore. Joanna, do you know what's happening?
As his colleague walked past, he caught her eye and murmured his question in a muted, secretive tone.
If confirmed as Louis this morning and say, the Ebola virus, it looks like it's spreading.
Welcome to 2014 and the last episode in our history of ending the outbreak we're focussing on today is one
you're likely to remember both because it happened to the and because the disease has never really gone away.
While the event will cover ended in 2016, this virus has caused an outbreak nearly every year.
You are, of course, talking about Ebola.
And given our discussion at the start of this year about whether this may have been caused, the plague that we have in some ways come full circle.
Our guides today have been working at the forefront of tackling the Ebola virus.
Dr. Kevin de Cock. We've already met Surplused, the team leader at the Centres for Disease Control and Prevention,
for their Ebola response in Liberia, and Dr. Keiji, who is currently a senior immunologist.
Oxford Ebola vaccine. First, though, as we often do, let's cheque in with Dr. Bloche Obuchi about what this disease actually means.
Ebola virus disease is a severe disease caused by the Ebola virus,
which is a member of the fight of virus family, and it occurs in humans and also other primates.
The disease emerged in 1976, almost simultaneous outbreaks in the DRC and Sudan at the time.
The incubation period is around two to 21 days.
And the onset of the illness, you have a non-specific picture fever, headache, muscle pain, suffering, intense weakness.
Sometimes that can be diarrhoea and vomiting present.
Some people develop rash red eyes because they can have derange kidney, liver function and also internal and external bleeding rhinovirus.
Disease is fatal, about 40 to 90 percent of all critically ill cases that this depends on the virus species.
Also how old the person is and those of other factors.
And it was fascinating to hear Bloche. And then Kevin and Kiki talk through what we do and still don't know about where Ebola might have come from.
There are many species of Ebola or several known species of the better, four of which had been meant to cause disease in humans.
It's thought to be, as you know, six. So that's an infectious disease which is caused by a pathogen that is jumped from a non-human animal to a human.
Although the natural reservoir is unknown, despite extensive investigations,
currently non-human primates have been seen as the source of human infection.
However, they're not thought to be the reservoir because when they develop Ebola,
they also get fatal illnesses and they die essentially one house and the animal reservoir,
they are called a reservoir because they tolerate the pathogen really well.
And that means and that they they is longer and therefore able to then act as a source of infection for other species.
So no one knows exactly what the reservoir is, the virus.
We don't know the natural reservoir. It's probably a bat. It's probably a fruit.
But it's a very similar virus to Marburg. Virus in the reservoir is more definite from Marburg, but it's probably a fruit bat.
And it's it's an infection that's, you know, natural in the forest.
And there is a reservoir there. We must expect that there will be further outbreaks and we have to be able to contain them.
I don't know if it's but me. It's definitely been confirmed.
I must admit, at the time, the anecdote was that it was a kid playing in a tree.
Webb bats feasted and there was lots of faeces around and that it might have been picked up and contaminated faeces that way.
The professor in the case of any Ebola outbreak is usually for in contact with blood or secretions or organs or opposition.
It's from an infected animal. She's in the first case and I think the first case in West Africa was likely to be via exposure to bats.
Then the virus becomes transmitted from person to person, from Armitt contact with blood secretions, organs and bodily fluids.
And people can also become infected if they come into contact with objects, soiled clothing, things have been contaminated, most infected secretions.
That's why health care workers tend to be the most affected subgroup of people during epidemics.
Then you also have some cultural practises which play a role in transmission. I think it's been mentioned before.
So you have traditional burial practises. So mourners come and they have direct contact with the bodies.
They wash the deceased. And the bodies of those that have died of Ebola still are highly infectious with Ebola.
I think in the West African outbreak. This this. Practise did cause the propagation of the of the outbreak.
Wilson, talk about the 2014 outbreak, but first I wanted to ask Kevin when we first discovered how deadly a threat Ebola posed.
I mean, the first recognised epidemic, which really began as sort of gone down as a legend almost in global health history,
was in 1976 in the quarter province of western DRC, northwestern DRC, in a small settlement called Yambuku.
It was a Belgian missionary station with a hospital and a school.
And about 18 missionary staff, nuns and priests.
An outbreak of an unknown disease occurred late in the year, in the autumn.
I think it was a schoolteacher who I imagine it may need to be corrected on that.
But an individual came into the hospital and died. Then other hospital staff and other patients became ill and died.
And it was apparent within a few weeks a very severe epidemic was occurring.
The Ministry of Health in Kinshasa was alerted and sent to a team.
And long story short, an international investigation was mounted.
The virus was isolated. It was called Ebola after a name of a local river.
And it was a very severe outbreak, widely described and talked about was wrapped up within a few weeks or months.
A lot of field investigations. I think there were there were over 300 cases and something like 280 deaths by the time it was all over.
And that was the first documented outbreak, something like eleven out of 18 or so of the missionary staff actually died.
But since 1976, there've been about 29 or so documented outbreaks.
One very interesting observation that I think merits more attention or discussion is that of those 29 outbreaks since 1976,
they've accounted for close to 35000 cases, cumulative.
Over 90 percent of those cases have actually occurred in the last six years.
The huge outbreak in West Africa and the second largest outbreak was the DRC outbreak in eastern Congo from 2018 to 2020.
So that's striking. It suggests something's changed or something's different.
The West African outbreak resulted in something like between 28 and twenty nine thousand cases and between eleven and twelve thousand deaths.
A huge geographic area affected, including cities and including capital cities.
I mean, Conakry and Guinea, Freetown, Sierra Leone and Monrovia in Liberia all had outbreaks.
You know, all of that was pretty unprecedented. And then in DRC, in 2018 to 2020, again, over 3000 cases, very,
very large geographic area and cities affected because places like Bhutan, Bob and Beneš, which many people wanted heard of.
I was absolutely staggered when I went to Tembo and saw that this is a city of a million people.
So things have changed.
And, you know, the simple way and the classic way of thinking about disease epidemiology is that it's the interaction of the agent.
That's the virus, the host. That's us. I mean, inhuman epidemics and the environment, which includes the social environment.
And, you know, you have to ask, well, why why did why do we have the outbreak in West Africa?
That's that's the farthest west that Ebola has ever been described.
Apart from the big outbreak, the only time had been described in West Africa was a in a Swiss veterinarian in the 1990s.
And she got infected doing an autopsy on a dead chimpanzee who died in the Thai forest.
Chimps get affected by Ebola and their groups can be severely affected.
So what changed to to push it that far west and why these huge geographic areas?
And I think one of the reasons that I think one of the issues for the geographic extension is population mobility, not least because of motorcycles.
You go to you go to the DRC in a place like Goma. It is just staggering the thousands and thousands of motorcycles and the distances they can travel.
So it's rather striking observation. Two striking observations, the geographic extension and the very large outbreaks, I think, merit more notice.
It's fascinating what kinds of things can play a major role in the spread of disease.
Moving onto the focus of today's episode, I asked first Katie and then Katie, what do we know about how the 2014 outbreak began?
Say the first case in this outbreak was thought to be a young child, a toddler,
somewhere in very rural Guinea in December and about, yeah, in December 2013, he became the first case to be identified.
And there was a small number of cases of diarrhoea in that population and it created a small alert in that area.
But nothing, you know, massive. And then it was confirmed after the disease had actually spread to Conakry in in sort of March ships the next year.
And by that time, it was already in a major city and the outbreak was declared shortly after that.
But those first few cases were kind of identified retrospectively, if you like.
They were identified as an unidentified disease, but not necessarily thought to be Ebola.
Well, retrospectively, the first case probably occurred just before Christmas in twenty thirteen in Guinea,
in the forest area of Guinea, in a little village called Melley Undo.
And now that forest area is close to where the three countries, the boundaries of the three countries come together with Sierra Leone and Liberia,
loafer county in Liberia within a few weeks of that initial case.
And this is retrospective analysis by Dr. WHL investigator trying to trace what happened.
Within a few weeks, there had been two or three further generations of cases.
Infection had reached the town of Grecco Do. In Guinea and very quickly had reached Conakry, the capital.
All of that was in the early months of 2014. In the latter half of March, some cases were reported from Liberia, from love for county up in the north.
And there was actually an investigation by an international group.
A colleague of mine, Joel Montgomery, who was working in Kenya.
I was the country director, so I was his immediate boss locally.
He was asked to go to Liberia and went for a couple of weeks and it seemed that the outbreak was was dying out.
You know, there was no major. They did not appear to be a major emergency. But in the following months, things changed.
And clearly, you know, the world did not pay enough attention.
It began to fester in Sierra Leone and cases were increasing in Liberia.
I remember actually in late June reading a CDC report, there's a known internal daily update of epidemics going on around the world.
I remember reading about, you know, ongoing transmission, apparently in Guinea and Liberia and thinking, you know, really we ought to be doing.
Sounds like more ought to be being done about this. I actually wrote this to some of my senior colleagues back in Atlanta.
Anyway, we around the same time, we actually got a request from the Ministry of Health through the U.S. embassy in Monrovia,
a request to CDC for assistance. I happened to be back in Atlanta in early July and I was asked, well, can you go to Liberia?
And I said, well, OK. I actually arrived there. I remember exactly that just happened to be my sister's birthday.
I arrived on the 16th of July. I flew from Kenya, arrived on the 16th.
And within a couple of days, a few other people arrived, four or five A.I.S officers.
These guys or women doing their two year initial training programme.
And we took it from there. So where did you start? You know, you arrive in a place and you sort of you have to figure it out for yourself.
I mean, there is a there is a standard way, a logical way of investigating in an epidemic.
And it's the best analogy for it is it's not as a as a medical student.
You're taught how to examine a patient in clinical medicine. And there's a there's a you know, how to take a history and how to examine a patient.
And there's a very systematic way of doing it. And the same is actually true for an outbreak.
There's some very logical series of steps.
You know, the first question is, is there an epidemic like they're asking, is this patient really sick or not?
Sometimes you get asked to investigate or to go somewhere.
And actually there isn't an epidemic. It's just that reporting practise has changed.
Or you have a new Kiene public health person who actually does his job or something like that.
Is there an epidemic? Is it due to what you think it's. Is it is it due to what you've been told.
It's stupid. Is there a case definition? And can you organise the data in time, place and person?
When did it start? What's new in time? The classic thing to do is to draw an epidemic curve place.
Where is it person who's affected age, sex and other.
Demographic characteristics. So, you know, you try and organise yourself that way.
But that's easier said than done and it certainly was much easier said than done in Liberia initially and in fact, in the whole epidemic.
Because you look at an epidemic curve of the outbreak, the whole West African outbreak.
And, you know, we've we've published one. There are published versions of it.
And you sort of look at it, you think, well, how close to reality is it is really because of underreporting under recognition,
inadequate laboratory capacity, et cetera, et cetera.
So the figure of the overall figure I gave of, you know, twenty eight thousand six hundred and forty six cases, how accurate is that?
I'm not really sure. I suspect it's an underestimate. But by how much is impossible to say.
I was keen to hear more about Kevin's personal experience during those early days of the outbreak.
The early situation in Monrovia was truly extraordinary. As I've said, firstly, the country is so very, very weak.
It had gone through two civil wars and infrastructure was very weak,
very poor physical infrastructure, still a lot of damage from the fighting and so on.
Very few highly trained individuals.
You know, again, one of the one of the 10 weakest countries on Earth in relation to development, human development and capacity.
And literally every day those first 10 days I was there were remarkable because every day something a stunning thing would happen.
For example, I had been there less than a week, a colleague and I worked particularly closely with I mean,
we had the ISI officers had to assign them tasks and so on.
And I worked at the most senior of this group of folks who was with me was a colleague called Satish Pinay.
And Satish was really this sort of he was he was a linchpin in our work.
He and I would go to the task force meeting at the Ministry of Health,
and they had formed a task force and we'd go every day and it was rather disorganised.
Anybody could come. It might be as many as 80 people in the room.
Sometimes the president showed up and the minister was there and somebody ran the meeting and there was an agenda.
But the next day there wouldn't really be any follow up and it would sort of be a repeat of the day before.
And I said to my colleague Satish, after a few days, I said, look, this isn't gonna work.
What we really need is an incident management system.
Now, an incident management system is a very structured way of dealing with emergencies.
And it's it's how CDC does it when we we have an up an emergency operations centre in Atlanta.
And when there's a severe health event that says that centre gets activated,
it's sort of the nerve centre of the response, if you will, information centre.
There is one person in charge, the incident manager, with a very structured organisational structure underneath him or her to deal with logistics.
In this case, with epidemiology, with laboratory, with communications, et cetera, et cetera.
And the incident manager reports afterwards to the minister, the president, the CDC director, whoever, whoever.
But it was a very structured system. And I said to him, look, this isn't gonna work.
We have to go and see the minister and advise him to to change the structure and have an incident management system.
I remember very clearly, I think I was on a Wednesday, it's about a week after it arrived,
went to his office on the third floor of the Ministry of Health,
sat down, literally opened my mouth when the secretary came in and said, we have to evacuate the building.
The buildings on fire. The minister goes, who is this was, I think, a seventy six or seven seven year old surgeon.
He was a very good man, actually. Very good man. He sort of starts shuffling around his computer and so on.
I say to Satish, we got to get out of here.
As I started hearing people shouting and more commotion and I saw people streaming out of the building through the window.
So we go down the stairs and by now there's smoke in the hallway, in the stairwell.
And it actually made it made us cough, got out of the building and hundreds of people in the car park and get our folks together,
find all our CDC folks and head out pretty smartly in two or three vehicles we had.
And it later turned out that somebody had actually piled all the plastic chairs together in the conference room where we had been meeting,
poured kerosene over them and set the building on fire. I never quite found out what the reason was,
although rumour was that it was a disgruntled or affected member of the public who
had lost a relative to Ebola and was just very angry about the whole situation.
But it sort of set the tone of the whole environment and that the the element of fear that was in the air,
I mean, the tension that you could literally feel wherever you went, it was remarkable.
And it's I it was something I, despite many years of experience, is something I'd never experienced to that degree.
So but every day. Something else would happen that you think, I just can't believe this is happening.
It was around that time that very famous episode of the rather senior well-connected Liberian individual who flew to Lagos,
visibly ill, flew to Lagos, collapsed in the airport, was taken to a hospital.
A correct diagnosis was made by the consultant physician in Lagos, but a secondary cluster of infections of Ebola was established in Lagos.
And I think the total number of cases where I counted was 18 or 20, something like that.
Fortunately, only two or three generations of cases. Nigeria responded very, very well to that outbreak, contained it.
The consultant physician who correctly made the diagnosis died from Ebola.
And the fact that they got on top of it so quickly was unquestionably the field epidemiologist training programme.
The capacity that had been built and the resources of the polio eradication initiative in
Nigeria all contributed in a major way to contain that epidemic very without outbreak.
Very quickly, I mean, the thoughts of Ebola spreading in Nigeria, as Lassa has done,
for example, this sort of Ebola spreading, it would be, you know, truly frightening.
And very quickly, Kevin got used to cooperating with other organisations to try to get the outbreak under control.
One of the first things you do when you arrive, obviously, is gonna introduce yourself and look around,
you know, is this really Ebola and how do we know where is it being tested, et cetera?
So, you know, we've done a bit of all of that and had visited a couple of the local hospitals,
including a facility called Elwha, which stands for Eternal Love Africa.
It was a faith based organisation that ran the hospital and they had seen some Ebola cases and had set up a very rudimentary Ebola treatment unit.
Now, the folks, the folks who have really experienced in dealing with Ebola treatment and looking after patients, which is not what CDC does,
a group that really is well recognised for this is MSF medicine support yet and MSF were heroic in West Africa, but by this time very, very stretched.
They had been active in loafer county and across the border in in Guinea in could do.
But they were absolutely stretched. And what they did, rather, and this actually illustrates the the uniqueness of this outbreak of this epidemic.
They had worked with another organisation called Samaritan's Purse,
which is an American faith based organisation, not politically and philosophically.
MSF and Samaritan's Purse are about as different as chalk and cheese.
Samaritan's Purse was actually set up by the evangelist Billy Graham's son.
It's a very evangelical organisation. They are very connected, very well connected politically to the religious right in Washington.
They've done some very, very good work in many different places.
They had worked with MSF to get their staff who had been in Liberia for a very long time and knew the country well.
They had worked with MSF to get trained up in Ebola and be able to set up any T.U., an Ebola treatment unit and care for patients.
Anyway, a few days after the ministry episode I described,
I was asked to chase up a lab result by Samaritan's Purse colleagues because we were helping.
We were coordinating lab work, not actually doing it, but had managed to sort of persuade people to work together and stuff.
So I chase up this resolved and get it to two to then eventually learn.
It actually was a false name and that the actual specimen came from the lead doctor
in the Samaritan's Purse group who had woken up on a Tuesday or so with fever,
had isolated himself and eventually got tested for Ebola.
And yes, lo and behold, was infected.
Now, this was the first time that a expatriate health worker other than, you know, those initial nuns and priests who died in Yambuku.
To my knowledge, this was the first time an expatriate, certainly in modern time, not an expatriate health worker, had gotten infected.
And we then had to figure out what to do. I mean, it wasn't my decision, obviously, but we frankly,
we did not have in place a system for dealing with the now increasing number of health care workers from outside.
What to do with them if they got sick? Long story short, Samaritan's Purse were able to evacuate the Dr. Kent Brantly to Atlanta, to Emory University,
which is right next to CDC, to the hospital in Atlanta, where they had set up a unit that could.
For Ebola patients. And he was evacuated. There was a second.
Actually, there were two other Samaritan's Purse infections. One was a Liberian hygienist who died.
And one was a an American nurse, Nancy Writable, who also got evacuated and also survived.
So this was all in about the first two weeks of 10 days, two weeks of being.
There is a pretty dramatic situation. It certainly sounds dramatic.
Meanwhile, back in Oxford, the work quickly began on researching this disease and what might be done about it.
As Keiki reports, yes, that this stamp was from that first outbreak made their way to institute Pasteur.
Is there a kind of visual reference centre?
So anything that's called the viral haemorrhagic fever will go to a reference centre for presumptive identification.
And then as soon as a case of a disease like Ebola is identified, then, you know,
you're going to let the W.H, you know, that's the standard, a standard procedure at that time.
It was then already spreading widely through West Africa to the two neighbouring countries of Liberian Sierra Leone.
It was rapidly established in the capitals, which was one of the things that kind of sets us apart from other outbreaks that we've seen.
And really by July, it was beginning to become apparent that this was going to be a bit more than a usual handful of cases in a remote region.
I went to a holiday to France on the 1st of August, at which time the word Ebola was not widely mentioned in this institute.
And I was away for two weeks. And by the time we came back, they were well on our way to, you know,
undertaking some work to participate in evaluating some vaccines that were available before vaccines.
And later, the teams on the ground were working on more standard public intervention.
Historically, these outbreaks have always been brought under control through community engagement and basic public health measures.
There are no silver bullets for these types of diseases, even with vaccines, because they are hard to access places with poor infrastructure.
Which means even if you've got a vaccine available, as we often talk about with with vaccine deployment,
it's that last mile, five miles, 10 miles, delivering the vaccine.
That's always the most difficult. And there's problems persist. So in terms of interventions and control measures prior to vaccines, I mean,
if you look at most of the outbreaks that have happened in Central Africa,
they've been brought under control through usual processes of contact tracing, safe burials, implementation, better sanitation and all those.
There's real basic tenets of public health. An epidemiologist, really.
And let me just start by quickly saying, how do we actually control Ebola with, you know, with what we know today?
The basics are the same. Isolate the sick safely.
Bury the dead. Follow the contacts and isolate them immediately if they get sick,
that it is the isolation of the sick that drops the basic reproductive rate below one and extinguishes will extinguish transmission.
And you probably from the modelling that's been done at CDC,
you probably need to achieve 70 percent or so rapid isolation within three days of symptom onset to,
you know, to get there a lot more difficult than it sounds, especially in these difficult areas.
In addition to those three things,
we have to strengthen infection control in health care settings because in some situations there's a lot of transmission in health care settings,
probably in West Africa, between 10 and 15 percent, probably 10 percent or so of people with Ebola and deaths.
We're actually in health care workers.
So strengthen infection control, provide treatment for the people with Ebola that we now have better therapeutics,
particularly the monoclonal antibody preparations. And finally, we have a vaccine.
So vaccinate the contacts of cases and vaccinate health care workers.
And increasingly today recognised vaccinate the contacts of survivors because survivors can harbour
the virus and sometimes transmitted sexually or actually also rarely suffer recrudescence.
So those are the basics of control. However, as Professor Brian Angas outlines, these basics of control are often easier to implement.
In theory, the Maillol during the practical reality of the pandemic, because what I mean, again,
what tends to happen often in West Africa was people would run away, you know, and it an Ebola outbreak.
We would want to get as far away as possible, you know, carefully understandable.
But as far as transmission of the disease was concerned, that was one of the worst things you could do.
But again, asking people to stay, stay and potentially stay and die because there's no treatment is is very difficult.
And again, you have to think what you would do in that situation as well. How would you react to being to do that?
And similarly, how would you react to being told to do something?
Against your culture, against religious beliefs, for example, to avoid a disease that no one has actually explained to you.
I'm so grateful to see particularly I think it's difficult when it relates to things like sexual health, but also relates to funeral rites as well.
And a lot of a lot of things have been hurt, seem to be related to culturally how societies deal with dead bodies,
particularly in transmission of these things. And also, it's interesting that that something should evolve to take advantage of that weakness to HIV.
We found that niche in sexual promiscuity, Ebola seem to find a niche.
Funeral practises. And it always seems to be that infectious diseases particularly find a weak spot.
That we've got and and multiply within that within that weeks.
That isn't the only challenged tackling the rapid spread of the disease.
Weak medical infrastructure within a country alongside the concurrent return of other diseases can make this an incredibly difficult situation.
The proportion of doctors to people in in these kind of countries is is ridiculous.
I think it's something like thousand patients per doctor in Sierra Leone compared with something like 400 patients.
But doctors in the US.
So just the capacity and the general infrastructure to treat our share information and escalate up to somebody in the National Ministry of Health,
for example, is going to do anything about it. It is really minimal. As soon as you then have an outbreak of something like Ebola,
the first thing that happens is the very minimal existing public health work it is going on.
So things like, you know, childhood vaccinations, malaria prevention, all of those things just stop.
So in addition to things like Ebola, you have resurgence of diseases like malaria, measles outbreaks,
all those things then starts to break down along side to make a pretty dire situation a lot worse.
And it takes time for things like vaccination campaigns to catch up even once the outbreak is contained.
The first thing to say is the continent is extremely heterogeneous.
I mean, we tend to sort of, you know, in global parlance, we sort of tend to treat Africa as just one big village where,
you know, everybody lives at the same level of subsistence and it's pretty poor.
And that's just such a misrepresentation.
It is such a heterogeneous continent in many, many different ways and culture, economies, peoples and disease.
So, I mean, to go back to Ebola, when I arrived in Liberia in mid-July, in 2014, I was truly shocked.
That's a word I very rarely use in in medicine.
I you know, I, I always tell people, you know, when I read manuscripts, for example,
and see someone use the word dramatic, I, I always strike it out and say, look, we do medicine, we don't do drama.
You go to drama school. I was truly shocked in Liberia by two things.
One, the severity of the Ebola epidemic coming up.
It was just extraordinary. But secondly, that there was nothing there.
The infrastructure and the capacity of the country was so, so weak.
It was I was truly surprised. And, you know, decades before I'd worked in Cote d'Ivoire, which is not only bordering Liberia.
And that was to a couple of you know, that was several decades ago. And it was just completely different.
You know, Liberia, Sierra Leone and Guinea, they've all had conflict.
They've had was they've had civil strife. But they're really they have really been neglected and kind of forgotten.
And they're at the bottom of the any scale that you see of human development, health, et cetera.
That's very different from East Africa and certainly Kenya, which, you know,
which has made seen extraordinary changes over the last couple of decades in terms of,
well, firstly dealing with the AIDS epidemic, but extraordinary progress in child survival, life expectancy and a change in the pattern of disease.
And they still have a dual pattern with a lot of infectious disease and also a
rapidly emerging problem of non-communicable diseases cardiovascular disease,
hypertension, diabetes, obesity, cancers, chronic respiratory disease.
So a very mixed picture. Its development economists who are best placed to ask why are some countries developed and others not?
But a characteristic of these Low-Income countries is weakness of systems,
weakness of health systems, of the educational sector, under-investment in these poor management.
And of course, if you have governance issues of corruption, if you have weakness in one sector, I mean, if you find that, you know,
the public transport sector or the educational sector is weak, well, it's not gonna be any different in any other sector.
So that is pervasive. Intrinsic problems of.
System's capacity training and so on with that underlying structural problem.
I was curious as to where the CDC and organisations like it concentrate their resources in preparing for a pandemic like Ebola.
There are four areas where we've focussed, particularly disease surveillance and health information systems, the strengthening of laboratory systems,
the development of the workforce, particularly in epidemiologic capacity to investigate outbreaks and things like that.
And then fourthly, in the use of data data for making decisions, investment and implementation,
science, if you will, operational research more broadly referred to as implementation science.
So those are some of the areas we focussed on. And I must say, in Kenya, the country I know best.
We've seen remarkable. The country has changed remarkably over the last couple of decades.
Moving now towards the end of the 2014 16 Ebola outbreak, I asked Kerry how they finally started to get this disease under control in Liberia.
Control was pretty rapidly achieved. Then there are clusters that happen and further small outbreaks.
But by isolating the cases and getting enough Ebola treatment unit beds, the outbreak was contained.
And then there were clusters here and there that had to be dealt with in the same way.
And there were some secondary transmissions from Ebola survivors, including sexual transmission.
Where is all this going? Well, the DRC has it well.
West Africa was eventually declared Ebola free in 2016 and there were no more cases.
The DRC has had three outbreaks since 2018.
There was a smaller one in the Aquata province, followed by the very big one that went on for two years.
And we're not coming to the end of the third outbreak in the last couple of years.
That's the 11th DRC outbreak overall in a quarter. That's just coming to an end.
Now, throughout this time, Haiti and her colleagues at Oxford have been working away on vaccine development.
The vaccine that we were involved in, hireling was developed by the US government at the NIH and I.
D It was commissioned under George Bush's administration as a potential defence against bioterrorism.
So it wasn't being developed as a kind of public health intervention.
It was on a list of microorganisms that the U.S. government thought could be went against them as a biological agent.
And so for that reason, these vaccines were creeping through clinical development and they were creeping through.
They'd been in development for many years before this outbreak happened.
So all that really happened was we accelerated the process, the clinical evaluation of safety testing here,
because we have the capacity and the expertise of evaluating Nipah back to vaccines.
The timelines involved for this were quite phenomenal in terms of how long it took to submit the ground, get the grant reviewed, get ethical approval.
And, you know, all of that happened in a fraction of the time it would usually take.
And then from the time of, you know, first conceiving of the well through to first vaccination,
last vaccination of publication of data was unprecedented at that time.
And the Oxford team also played a key role in the manufacture of a vaccine.
It wasn't just that we accelerated clinical trials. We accelerated the development of manufacturing as well.
And I think one of the things about pandemics that we launched we value one of the lasting
legacies of it is that everything just happened too slowly and the money wasn't there.
Whereas now there is much more funding available for Outweight putting two vaccines through SEPI or through the usual routes of funding.
But there's much more pressure to do things at a rapid pace now and get these vaccines ready and deployed, you know, in a in a reasonable timeframe.
It sounded like this outbreak had a significant impact on vaccine development.
It had a huge impact on a lot of different aspects of it.
I mean, we've mainly focussed on the sort of vaccine development and evaluation side, but it had an impact in things like, you know,
the ethics of how clinical trials performed in pandemics and how you have a clinical
trial design to evaluate a vaccine when you can't ethically give people a placebo.
If you think there's a possibility that the vaccine training might work.
It's had impacts and things like whether pregnant women should be included in the early stage assessment of vaccines.
Well, you know, this pandemic potential. And similarly,
children to populations that are largely excluded from the early stage development and testing of vaccines for obvious reasons and reasonable reasons.
It's had an impact on academic publishing. For example,
say the Ebola outbreak was really the first time that we saw widespread use of preprint service
for getting data out there and rapid publication of results from clinical trials in journals.
The New England Journal of Medicine, which would traditionally take much longer to publish that kind of data and The Lancet,
and it's it's it's shaken up so much of the normal kind of processes, you know, rapid ethical approval, rapid approval from things like the MHRA.
Well, those kinds of things have been facilitated by the outbreaks.
It has had a huge impact in terms of what the world's going to look like going forward in terms of global pandemics even before this pandemic.
I think it was important in opening up lots of different channels and and speeding up lots of things that have been unnecessarily cumbersome.
So that experience should make us better at dealing with future pandemics.
The overwhelming thing that came out of it scientifically was that there were too many diseases
that we just didn't have vaccines in the pipeline for and that nobody was prepared to fund,
because it's unreasonable to a certain extent to expect commercial organisations
to manufacture vaccines for diseases that there is no commercial market. It's not what they do.
That doesn't mean that the world doesn't need them, which means there has to be some alternative funding for those vaccine programmes.
And that's where SAPI has really stepped in to fill that gap quite effectively with Ebola.
We already had those vaccines in early stage clinical development that turned out to be highly effective against Ebola.
So we already had the tools we needed.
There just wasn't that drive to get them through and get them out and get them licenced and stockpiled and ready.
And I think the more we interact with wildlife, you know, if you look at all of the emerging zoonoses, they will come from wildlife.
There will viruses.
And if it's as easy to make a vaccine against something as devastating as Ebola is, it is for any of those other emerging pathogens.
And really there's no excuse to push ahead and do it. And I think it's really galvanised the scientific community into sort of pushing
ahead with some of those other vaccines against some of these pathogens.
The WHL produced a document called the R&D Blueprint, which has a list of all of the diseases that they think are a priority for vaccine development,
and that also includes Disease X, and it now also includes Saar's cabi, too.
And that really laid down a roadmap for what the WHL would expect from a vaccine that was going to be developed against any of these pathogens.
And it's it's a really helpful focus. The vaccine developers to kind of start approaching some of these questions.
And we have vaccines in development here at the Janner against many of those diseases on the on the blueprint document.
We're going to talk about Disease X in a bonus episode, which we'll have recorded by the time you hear this.
But for now, I want you to stick with the Ebola outbreak and ask what else we might have learnt.
I think two obvious questions are what is population movement doing?
And secondly, is environmental change in terms of logging, the logging of forests and stuff like that.
Is that making a difference and just bringing the natural reservoir closer to human populations?
One other characteristic of the West African outbreak was the enormous political relevance of this outbreak and its its broader impact.
For the first time, military were heavily engaged in the outbreak response.
President Obama in mid-September of 2014 committed 3000 troops to Liberia for several months and the British military in Sierra Leone as well.
Really the rather unique and of course, lots of discussion about the role of WHL,
the strengths and weaknesses of WHL need for reform and better application of the international health regulations and all of that.
I think it's widely agreed and widely acknowledged at WHL was slow off the ground.
They should probably have declared it earlier. And they didn't back a public health emergency of international concern.
The outbreak might have come under control sooner.
If action had been taken earlier, that might be one parallel that you could draw with the current outbreak as well.
And finally, in DRC, very important in the twenty eighteen to 2020 outbreak.
This was in eastern DRC in North Keibel. Wendy Tuori province says this is an area of instability and fighting very, very difficult, an insecure area.
And the ability for the world to intervene in these areas of insecurity needs a lot more thought and attention.
With that in mind, I was curious to know how prepared Havenport, we were now for future outbreaks of this nature.
Well, I worry about the whole concept of preparedness. I mean, the West African epidemic was so awful and so severe.
People shook their heads and said never again. Well, memories are short.
And when I reflect and think, well, who is really prepared? You know, adequately prepared, properly prepared.
Public health is not the only group that really is prepared. Is the military.
They spend their time training, doing nothing but training and preparing for something they hope will never happen.
Now, I don't think the rest of society can say that, yes, we put in resources.
Yes, we work on preparedness, but not to the degree that the military do for their cause death.
And I think that merits some thinking about what do we really mean by preparedness and how much are we really prepared to do for preparedness.
Finally, coming to the end of the episode and our series, I was keen to understand from my guests how they saw Ebola in relation to other pended,
for example, where we've right to include it now, list of ten. I think it deserves to be that just because of the impact it had.
Even though in terms of mortality, it probably isn't the most pressing public health issue in the world at that time.
I mean, we had 11000 over 11000 deaths from Ebola during the West African outbreak.
Five hundred thousand people die every year from malaria. And if you look at the resources that were put into dealing with the Ebola outbreak,
similar resources were pumped into dealing with malaria, potentially save a lot more lives.
So maybe malaria ought to be on your list as well. And Brian Falta comparison between Ebola and coal would provide useful context for my question.
So I get the impression that you have some vulnerability to cause it.
I think there seems to be something that we're not quite sure completely yet what it is.
So I will say, I said junior staff is a bit like genetic reflect if you get it.
There may be something in your genetic code that means you're prone to getting severe disease.
Might be what your E to receptor looks like. And of course, we've never really looked at these two receptors before.
We no reason to look at genetics, these two receptors. But there are quite a couple of polymorphisms things may make you more prone to get severe.
So where is Ebola? Just looks as though it just kills everyone.
If you get it. So from that token, you know, I think if I if I if I contracted corvids, then I would think I'd maybe had a chance.
If I contracted Ebola with no treatment, then I. I think probably not.
But as I say, we've if we've evolved if you look at Ebola outbreak at the beginning, mortality was quoted 80 percent.
By the end of it, it was about 40 percent. And that was purely with good medical care.
And similarly with SA, with a Corvette, with SA School V two, if you look at the beginning,
mortality in our intensive care units in UK was probably about 60 percent.
And in fact, no, we see it's probably about 30 percent. So we've learnt how to do the basic stuff without having any specific treatment.
But just how to manage the illness that the patients have much better.
On that more optimistic note, we'll conclude our series on the history of pandemics.
We didn't set out to provide a comprehensive account of the disease outbreaks that humanity is faced,
but to invite you to discover along with us more about 10 world events that may
have had a significant impact on the way we think about and prepare for pandemics.
We hope you've taken a lot from the series. And the good news is it's not quite over yet.
Coming soon, we'll be releasing a bonus on how organisations around the world,
including many people here at Oxford, are preparing for what the World Health Organisation Pooles Disease acts.
I do hope you can join us then. I'm Peter Milliken and you've been listening to Future Makers.
Future Makers is created in-house at the University of Oxford School for the series, was composed and recorded by Richard once.
Today's voice actor was me, Benjamin Morales. The podcast is presented by me.
Professor Peter Milliken from Hartford. And the episodes are produced and edited by Ben Hogwood and Steve Fritjof,
who've done most of the work and to whom I'm hugely grateful and thank you on behalf of the whole team.
Listening to our history of Pandemic's.