How the lessons from Ebola helped the COVID-19 response

In 2021, the world finally beat the Zaire Ebolavirus, commonly called Ebola. A cycle of research and development (R&D) began in earnest in 2014 after the West African Ebola outbreak. Finally, it delivered two vaccines, two biological treatments and one reliable rapid diagnostic test to help contain the disease’s Zaire strain. The impact of these new tools can be measured in the lives they saved.

Over 11,000 people died throughout the West African epidemic, causing more than $50 billion in economic disruption. The next outbreak, in 2018 in the Democratic Republic of Congo’s (DRC) North Kivu province, led to another 2,299 deaths before it was controlled in mid-2020, with the help of more than 300,000 doses of the then newly approved rVSV-ZEBOV-GP vaccine.

When the Zaire strain of Ebola struck North Kivu again in February and October of 2021, each outbreak lasted less than three months and led to fewer than 10 fatalities. The same tools are now being deployed, albeit less conclusively, against a late 2022 outbreak of the previously rarer Sudan strain in Uganda.

This product development ultimately cost under $2.5 billion over the seven years to 2020 – a fraction of the economic costs of even a small Ebola outbreak and only a little more than half of the $4.68 billion funders gave to COVID-19 R&D in 2020 alone.

Only about half the $2.5 billion eventually required to eliminate the pandemic threat from Ebola was provided by the end of the West African outbreak in 2016. Then, with no patients to participate in trials, product development ground to a halt and vaccines, tests and treatments remained in stasis until Ebola struck again.

The global R&D response to Ebola, which led to multiple registered products in record time, is both a great success and a cautionary tale. Unfortunately, the world was too slow to fund a cure for Ebola and the 2018 DRC outbreak was the price we paid for that delay.

When COVID-19 began to spread internationally in early 2020, the response from funders was bigger, faster and more diverse than anything we saw with Ebola.

Some of this improved R&D response was due to the pandemic’s much wider scale. For most funders of R&D, COVID-19 suddenly hit much closer to home than either Ebola or Zika. But the ability to respond so much more quickly was down to the lessons learned from Ebola. In 2017, the Coalition for Epidemic Preparedness Innovations (CEPI) was established to lead the vaccine response to existing and potential future epidemic diseases.

Alongside CEPI, funding targeting “Disease X” – a name given to the pandemic-level threat of unknown pathogens – rose tenfold between 2016 and 2020. That uplift was mostly thanks to the rapid growth in funding for platform technologies representing multi-purpose approaches that can be quickly adapted for use against different diseases.

CEPI helped lead the global response to COVID-19, committing $28 million by the end of January 2020, which accounted for nearly half of the world’s funding. New platform technologies, for their part, were swiftly modified to deal with COVID-19, with Oxford’s ChAdOx1 platform serving as the basis for AstraZeneca’s AZD1222 vaccine.

One key lesson from Ebola’s stalled product development following the West African outbreak was the vital importance of speed when dealing with a disease that can grow exponentially and disappear just as suddenly. For COVID-19, Dexamethasone, the first widely-administered pharmaceutical intervention, reduces mortality among mechanically ventilated patients by 36% and is estimated to have saved 650,000 lives over the second half of 2020.

Even without any benefit in reducing transmission, if the RECOVERY trial – a national UK clinical trial to identify treatments for adults hospitalised by COVID-19 – had begun even a week earlier, that would have saved tens of thousands of lives.

Global product development moved much faster in response to COVID-19 than it had for Ebola, aided by spiralling caseloads, which meant there was no shortage of potential clinical trial participants. While trial and approval processes were sometimes streamlined for the pandemic’s response, many decision-makers remained wedded to procedures that weren’t designed for the rapid spread of epidemic disease. Many nations experienced repeated, lengthy delays in expanding access to vaccines and treatments even after their efficacy had been demonstrated.

There were also challenges in expanding the manufacturing base to meet the scale required by the pandemic, despite having months to prepare for the production and distribution of the products in development. And the resulting delays in vaccine supply led to terrible inequities in the provision of vaccines to low- and middle-income countries.

The world can do better when the next pandemic inevitably arrives. But one particular lesson from the COVID-19 response is that the identification of treatments must be handled with the same urgency as vaccine development.

Drug trials typically require less than a tenth as many participants as trials for vaccines, giving them huge speed and cost advantages. But while COVID-19 vaccine funding was first announced in mid-January, the first meaningful funding for COVID-19 therapeutics R&D – around $4 million from the Japanese government – didn’t come until 13 February, weeks after CEPI’s first vaccine grant. There is still no peak body to support and coordinate drug research the way CEPI does for vaccines and this is likely both a cause and a consequence of the focus of R&D funding on vaccines.

Funding for vaccines was more than double the amount provided for drug and biological treatments. Consequently, rather than serving as the first line of defence as we waited on longer vaccine development cycles, drug R&D was a mess. It offered false promises (chloroquine, ivermectin) and uncovered effects too late to matter (fluvoxamine).

Learning to deal with Ebola took us seven years. Learning to live with COVID-19 will take us, perhaps, another three. But, if we take away the right lessons, we can end the next pandemic much sooner and with much less pain.