Today marks 100 days since the World Health Organization declared the Ebola BDBV outbreak in the Democratic Republic of Congo and Uganda a public health emergency of international concern (PHEIC). Africa CDC followed a day later with its own declaration of a continental emergency. The outbreak is already the largest in DRC’s history, and in recent weeks WHO has warned that, at its current pace, it could become the largest Ebola outbreak the world has ever seen.
For those of us working in pandemic and epidemic response, it was a familiar scenario with an unfamiliar twist: Ebola was back, but this time as a different and rarer species, Bundibugyo, for which there was no licensed vaccine, no approved treatment, and no rapid test able to detect it at the bedside.
Yet these 100 days also tell another story: the response has been one of the fastest we have ever seen.
Speed of response
The speed of this response has been markedly faster than previous outbreaks. Just ten weeks after the emergency was declared, a Phase I trial for a Bundibugyo-specific vaccine candidate began dosing volunteers. A second candidate followed close behind, giving the response two vaccine candidates in trial within eleven weeks of declaration. Two therapeutic trials also began enrolling patients within seven to nine weeks of the declaration. One is testing treatments for people already infected with BDBV; the other is trialling post-exposure prophylaxis, a treatment course given to close contacts of a confirmed case, to try to stop the disease taking hold before symptoms appear. By Day 94, one of these trials had already enrolled 200 patients, an unprecedented pace.
Meanwhile, testing quickly ramped up to track the outbreak. Existing tests, designed for Zaire ebolavirus, initially failed to detect Bundibugyo, a gap that cost the response valuable early time. But once the virus had been identified, a near-point-of-care test, usable in district hospitals rather than only in reference laboratories, was mobilised and deployed rapidly, and laboratory capacity expanded quickly behind it. Testing capacity rose from 30 tests a day to 3,000 within eight weeks, and the number of laboratories testing for BDBV grew from two to 19, including two mobile laboratories deployed across borders. Genome sequencing began within 72 hours of the PHEIC declaration, and more than 500 genomes have since been sequenced, helping researchers understand how the virus is mutating and spreading. Africa CDC, WHO, PATH, FIND and Unitaid are working together to validate a wider range of tests against BDBV. Separately, three have now reached WHO Emergency Use Listing, the pathway that allows a test to be used in emergency contexts.
Uganda has also since been declared Ebola free. This is a marked shift from 2014, when the West Africa Ebola epidemic had already been spreading for eight months by the time WHO declared a PHEIC, and vaccine efficacy trials did not begin until six months after that. This time, trials began in a fraction of that time.
Why the response was faster
The progress of these first 100 days did not happen by accident. This pace was made possible by preparedness: scientific and regulatory groundwork laid in advance, and lessons carried over from previous Ebola outbreaks.
Master protocols for therapeutic trials had already been written, ready to be activated when needed. Vaccine platforms that could be adapted to a new pathogen, such as Oxford’s ChAdOx platform, also used for the Oxford/AstraZeneca Covid-19 vaccine, and Moderna’s mRNA platform, developed at speed and scale during the same pandemic, had already been developed through years of prior research. Within nine days of the declaration, WHO had opened its established Emergency Use Listing procedure to begin identifying potential tests. Pre-established partnerships were rapidly activated to support the response: a consortium led by Africa CDC and WHO, working with PATH, FIND and Unitaid, developed a framework to validate diagnostics quickly. Promising treatment candidates were also identified for trial almost immediately, thanks to years of prior investment in therapeutics research. Manufacturing readiness mattered too. Because ChAdOx1-BDBV could draw on the existing ChAdOx production line, the Serum Institute of India was able to manufacture vaccine doses at risk within two weeks.
The machinery moved quicker than before, particularly across Africa, led by continental institutions such as Africa CDC and the African Medicines Agency, neither of which existed at the time of the 2014 Ebola outbreak, working alongside WHO and national institutions. National research centres, such as INRB in the DRC, brought deep Ebola expertise and long-established international partnerships to bear on the research and trial response.
This is what preparedness looks like: not the absence of a crisis, but the ability to respond rapidly when one strikes.
The Day 100 paradox
But moving fast is not the same as being ready. Despite the remarkable progress of the past 100 days, this outbreak is the largest in DRC’s history, and it continues to grow.
At Day 100, there is still no true point-of-care test, approved treatment, or licensed vaccine for Bundibugyo Ebola. Trial enrolment has been encouraging, and the scientific feat to accomplish this at pace has been laudable, but we do not yet know whether these vaccine and therapeutic candidates will work. And those that do will still need to be manufactured at scale and distributed equitably to reach the populations that need them.
These first 100 days reveal a paradox: we are getting much better at responding once emergencies emerge, while underinvesting in the preparedness that makes that speed possible.
Diagnostics illustrate this point starkly. Without a true point-of-care test, one that does not depend on a hospital or a reference laboratory at all, we cannot see the full scale and spread of Ebola BDBV. In eastern DRC, terrain, infrastructure and the ongoing conflict make it very difficult to get samples to a district hospital, let alone a reference laboratory. Cases can go undetected as a result, and an undetected case is one that keeps spreading. Diagnostics remain a neglected tool in pandemic preparedness: less politically compelling than vaccines, less commercially attractive than treatments, yet crucial to the use of both. Looking ahead, we need diagnostics that can detect multiple Ebola species at once. This outbreak was first missed because existing tests were built to detect Zaire ebolavirus, not Bundibugyo. A multi-species test would have caught it from the first sample, and could do the same for whatever species emerges next.
The next 100 days
So, what is needed over the next 100 days? We need to sustain the collective action already underway, and work together to build on this progress, to change the trajectory of this outbreak.
While trials have begun for therapeutics and vaccines, they will require continued investment to sustain recruitment and complete the studies. If the therapeutics and vaccines are found to be effective, or a point-of-care diagnostic is identified, post-trial access is key. We also need to make sure they can be manufactured at scale, and equitably distributed and accessible to affected communities, particularly those who took part in trials. For diagnostics and therapeutics, coordination to ensure access is particularly pressing.
Vaccines have benefited from years of sustained investment, with organisations like CEPI and Gavi established to fund and purchase at speed. Therapeutics and diagnostics have no equivalent: no dedicated financing body, no established pathway from a promising candidate to something manufactured at scale and available where it is needed. That gap needs to be closed. Unitaid has taken a first step, committing up to US$3.4 million to support rapid access to promising Bundibugyo diagnostics and treatments, but this alone is not sufficient to meet the investment needs.
Looking beyond Day 100, we must consider what is needed in the long term, so that the next time a health emergency like this is declared, diagnostics, therapeutics and vaccines are already prepared, ready to scale up and reach people fast. What we do to prepare in “peacetime”, the quiet years between outbreaks, matters just as much as what we do during the response itself.
This speed was only possible because of investment made before the outbreak began. If we want to move even faster next time, and there will be a next time, that investment in therapeutics, diagnostics and vaccines has to be sustained even when there is no outbreak in the headlines, and no political urgency to compel it.
That means predictable, long-term financing for end-to-end research and development for tests, treatments and vaccines; building regionally distributed manufacturing and clinical-trial capacity so trials can continue to be undertaken in affected regions; and accelerating access to products once they succeed. It also means resourcing the regional institutions that sustain preparedness and response. Access must be treated as a design requirement from the outset, not an afterthought once the science succeeds.
A hundred days into this outbreak, we have shown we can move fast. If we invest now in the infrastructure, coordination and commitments this pace demands, we could reach a point where diagnostics, therapeutics and vaccines are ready within 100 days of the next outbreak, or as close to that ambition as possible.
The question is whether we will make the investments needed now, or wait once again for the next emergency to remind us.