MSF, WHO lock horns over Ebola vaccine deployment

MANILA — Médecins Sans Frontières wants more aid organizations to take part in the Ebola vaccination supply and deployment discussions. The international medical humanitarian organization has wanted to expand people’s access to vaccination in the Ebola-affected region of the Democratic Republic of the Congo, but said this has been impossible with the World Health Organization’s vaccination restrictions.

“Every morning when our teams go to get the vaccines and try and vaccinate people, they face these quite arbitrary rules from the WHO,” Natalie Roberts, MSF emergency coordinator, told Devex.

“They're allowed to go and get some vials of vaccines from the WHO, then they're allowed to open the vial, but only when there's a certain number of people who are on a list. So if these people who are on the list are waiting to be vaccinated, they're allowed to open the vaccine vial. But if they don't have people whose names are on the list, then they're not allowed to open the vial and they're not allowed to vaccinate people,” Roberts said.

Roberts said those on the list are supposed to include all people known to be contacts of a confirmed case, and contacts of contacts. But it's “almost impossible to achieve that,” she said.

“We do know that we miss a lot of people from those lists. It's not surprising. It's a huge, huge region. And people are moving around a lot within the region, including when they're sick … It's almost quite ridiculous to think that ... the only people that need vaccinations are people on those lists because we know that ... it's just impossible to collect all the names of people who should be vaccinated,” she added.

WHO disagreed with MSF’s characterization. Spokeswoman Margaret Harris said WHO has “implemented and expanded vaccination guided by recommendations made by the Strategic Advisory Group of Experts on vaccination,” and that WHO has deployed both the ring strategy approach as well as the “targeted geographic vaccination” approach.

The ring strategy approach is when people who’ve come into contact with a person confirmed to have Ebola, as well as contacts of contacts, are given the vaccine. The targeted geographic vaccination approach, meanwhile, is when vaccination is offered to people at risk of contracting Ebola.

“This strategy involves vaccinating everyone in the neighbourhood, or village, rather than vaccinating only the known contacts and contacts of contacts. Targeted geographic vaccination was used successfully when the outbreak spread to Chowe in South Kivu,” Harris wrote in an email.

Ibrahima Socé Fall, WHO assistant director-general for emergency response, told Devex that when it's challenging to investigate and identify contacts — because of difficulty of access in a small population, especially when security is an issue — they use a targeted geographic approach to vaccination.

Investigating and identifying contacts, and contacts of contacts, is necessary — despite the amount of work it requires.

“It's very easy just to go and vaccinate anybody you can vaccinate. But if you miss the high risk contacts because you don't investigate, it does not add value to the ring vaccination strategy,” Fall said.

MSF said at least 2,000 to 2,500 people should be vaccinated each day. But at present, the numbers are only reaching about 500 to 1,000 people.

Fall said having a target number of vaccinated people per day “does not have scientific value” because contacts identified are vaccinated within 24 to 48 hours. When the cases are in clusters, for example within the same family, it’s likely they came in contact with some common groups of people.

There are also areas where several people have already been vaccinated, and it’s important to identify who these people are so as not to repeat vaccination, Fall said.

“Like in Kalunguta, where we discovered that 60% of the contacts we have identified have already been vaccinated. Meaning you only have to vaccinate 40% of them. So if you don't go to the field, you don't do real work, you cannot have all these analyses and information,” he said.

The WHO officials acknowledged that it is a challenge to inoculate everyone.

“When a ring is ‘defined’ this is based on disease detective work to identify all contacts and contacts of contacts. If people are frightened or mistrustful of the response they may deny being in contact, hide or leave the area, so yes there is always a chance that a complete list is not compiled. This is something we continually strive to improve but remains a major challenge,” Harris said.

In addition, Fall said vaccination is given on a voluntary basis. But when people are eligible and want to be vaccinated, “we vaccinate them all the time,” he said.

Call for an independent coordination body on vaccines

The limited access to the vaccine is likely contributing to a cycle of recurrence of Ebola in a number of areas, including Beni, Roberts said.

“The other impact we're seeing is that the epidemic passes through some areas and then keeps returning back [to] the same areas,” she said. “For example in Beni, some of the areas of Beni are kind of recurrent hotspots now, and that wouldn't have happened if what we've done is just said, ‘look this case is in this community’. So it means that everybody in this community is potentially a contact of contact. Everybody could be in contact with Ebola. So we're just going to offer everybody in this community a vaccine.’”

Roberts said MSF has raised the organization’s concerns with WHO, but were only told there are no issues on vaccine supply or vaccination capacity. They wrote in July to WHO Director-General Tedros Adhanom Ghebreyesus to raise their concerns, but had not yet heard back, she said.

Fall said what MSF wrote in the letter was already in the expert group’s recommendations.

“Dr. Tedros is open to discussion with all partners, and anytime he comes to the field he meets with the NGOs, but if some of them are not there, it's difficult to have [that conversation],” he said.

MSF would like to see an international, independent coordination committee formed to make decisions on how many vaccines to deploy, where to deploy them and what strategy to use for deployment, It envisages the committee being comprised of WHO as well as MSF, the International Federation of the Red Cross and Red Crescent Societies and UNICEF. The model is similar to the International Coordination Group on Vaccine Provision for Epidemic Meningitis Control established in 1997 during meningitis outbreaks in Africa.

“It needs to be that you have a group of people discussing together how best to use this vaccine, and not just one actor … the ICG was set [up] precisely for this reason, to put people around the table with their different perspectives, and to come to a final decision about how to use the vaccines,” Roberts said.

But WHO’s Harris told Devex that a model like ICG is only deployed to manage the stockpile and supply of licensed vaccines.

“Both Ebola vaccines currently being used are experimental and therefore their use is strictly governed by an approved protocol to ensure that ethical and scientific oversight is appropriate to protect individuals being vaccinated,” she said.

Fall also said there is “no lack of transparency” on vaccine deployment.

“I think what we really need at this stage is ... firm collaboration and real partnership from everybody,” he said.

The recent approval in DRC of a second Ebola vaccine, developed by Johnson & Johnson, could help expand coverage.

The vaccine will still need to pass certain administrative and ethical approvals before being deployed, but one important work to be done is raising community awareness before its roll-out, to avoid confusion.

“There's a lot of work that needs to go on now that people know that vaccine would be deployed in discussion with the communities, explain why there are two different vaccines, why they're eligible for one vaccine and not the other vaccine. That will take a couple of weeks to make sure that we've got people on board with what we're trying to do before we start rushing in and creating more confusion,” Roberts said.