As Ebola threatens mega-cities, vaccine stockpile needs grow

FILE PHOTO: Healthcare workers carry the coffin of a baby believed to have died of Ebola, in Beni, North Kivu Province of Democratic Republic of Congo, December 15, 2018. REUTERS/Goran Tomasevic/File Photo

By Kate Kelland

LONDON, Dec 20 (Reuters) – Doubts are growing about whether the world’s emergency stockpile of 300,000 Ebola vaccine doses is enough to control future epidemics as the deadly disease moves out of rural forest areas and into urban mega-cities.

Outbreak response experts at the World Health Organization (WHO) and at the vaccines alliance GAVI are already talking to the leading Ebola vaccine manufacturer, Merck, to reassess just how much larger global stocks need to be.

“We’re actively engaged with the World Health Organization and with groups like GAVI, the U.S. government and others to try to understand what will be an appropriate sized stockpile in the future,” Merck’s head of vaccines clinical research, Beth-Ann Coller, said in a telephone interview.

Supply of the Merck shot, which is currently being used to fight a large and spreading outbreak of Ebola in the eastern Democratic Republic of Congo, is not a problem right now, according to the WHO’s deputy director-general of emergency preparedness and response, Peter Salama.

But the nature of Ebola outbreaks is changing, he told Reuters. As the virus finds its way out of rural villages into populous urban settings, plans for how to contain it in future must change too.

“What I’m concerned about is the medium- to long-term stockpile. The figure of 300,000 was very much based on previous Ebola outbreaks where you never really had huge numbers of cases because they were in isolated, rural, populations. But now, we increasingly see Ebola in mega-cities and towns.”

“We need to view it now as an urban disease as well as a rural one – and therefore one requiring a different order of magnitude of preparations, including vaccines,” he said.

Merck’s experimental Ebola vaccine, known as rVSV-ZEBOV, is the furthest ahead in development. Another potential vaccine being developed by Johnson & Johnson could also eventually become part of the stockpile, global health officials say.

Congo’s two Ebola outbreaks this year illustrate the shifting nature of the threat.

The first was relatively contained, infecting up to 54 people and killing 33 of them in an area of DRC’s Equateur Province that is remote and sparsely populated.

Several of the eight outbreaks before this one in Congo – including one in 2014 and another in 2017 both also in Equateur – were also quickly contained and limited in size.

But this year’s second outbreak in Congo – and the country’s tenth since the virus was first identified there in 1976 – is concentrated not in rural villages but in urban areas of the North Kivu and Ituri provinces.

It has already infected more than 450 people, killed more than 270, and last month spread to Butembo, a densely populated city of about one million.

This kind of prospect means global health emergency responders must “review our assumptions around Ebola”, Salama said. “If it were to take off in Butembo, or Goma, or, even worse, Kinshasa, we’d be talking about a totally different issue in terms of … vaccine supplies required.”

Seth Berkley, chief executive of the GAVI vaccines alliance which has an agreement with Merck to ensure a current stockpile of 300,000 rVSV-ZEBOV doses, told Reuters that around 40,000 doses had been used so far in the Congo outbreak.

The emergency response is based on “ring vaccination” which aims to control an outbreak by identifying and offering the vaccine to contacts of anyone likely to be infected. This method uses relatively small numbers of vaccine doses and forms a human buffer of immunity to try to prevent spread of the disease.

For now, in Congo, Berkley said, there is no immediate need to boost the stockpile. But looking towards future inevitable outbreaks, the numbers would likely need to change.

“The challenge we would have – and this has been under discussion – is if we started to do community-based vaccination in urban and semi-urban areas. That’s when the numbers would start to get quite big quite quickly,” he told Reuters.

Merck’s shot has proven safe and effective in trials in West Africa but has yet to be approved for a license by U.S. and European regulators, so is being used in the Congo outbreak under special emergency rules for experimental products.

When it gets approval, which Coller hopes would be in 2019, it will be made at a newly built manufacturing plant in Germany.

Coller said Merck is not yet clear how many doses a year, or a month, the German facility could churn out once it is in production, but she stressed the company would “work collaboratively with the public health agencies to do our best to support their needs”.

(Reporting by Kate Kelland; Editing by Giles Elgood)

Vaccines group plots path through conflict, instability, epidemics

FILE PHOTO: A Rohingya refugee boy who crossed the border from Myanmar a day before, gets an oral cholera vaccine, distributed by UNICEF workers as he waits to receive permission from the Bangladeshi army to continue his way to the refugee camps, in Palang Khali, near Cox's Bazar, Bangladesh October 17, 2017. REUTERS/ Zohra Bensemra/File Photo

By Kate Kelland

LONDON, (Reuters) – – More children worldwide are now immunized against killer diseases but the task has become harder due to conflicts, epidemics, urbanization and migration, the head of a global vaccine group said.

Seth Berkley, chief executive of the GAVI vaccines alliance, said his agency was now focusing on how to get vaccines to people in rural areas, those isolated by war and refugees.

GAVI uses its funding by private philanthropies and government donors to negotiate down vaccine prices for poorer nations, buying them in bulk to supply countries most in need.

Since its launch in 2000, the alliance has helped save the lives of about 10 million children and immunized 700 million children with new and generic vaccines against everything from measles to diarrhea to cervical cancer.

“Ninety percent of children in the world are now reached by routine immunizations, but there are 10 percent that aren’t,” Berkley told Reuters by telephone from a GAVI meeting in the United Arab Emirates.

“And there are more and more (disease) outbreaks around the world – partly because of climate change, partly because of instability – and we have the largest number of refugees in history,” he said.

He cited U.N. data showing there were now almost 70 million displaced people worldwide.

“So to deal with those challenges, GAVI has to adapt its model to work more flexibly,” Berkley said.

The alliance has traditionally worked with governments to raise routine vaccine coverage rates in poor countries.

More recently it has also worked on emergency projects, including getting oral cholera shots to Rohingya refugees in Bangladesh, stockpiling an experimental Ebola vaccine for use in an epidemic in Democratic Republic of Congo, and trying to help prevent infectious disease flare-ups in Syria.

Berkley said GAVI was also now finding new partners.

In Uganda, it is working with the delivery firms UPS and Freight in Time Ltd, and with Parsyl, a data start-up, to use customized apps, data and wireless temperature monitoring to overcome vaccine supply chain issues.

GAVI is also working with the German development bank KfW to explore using blockchain technology in its cash support and supply chain management.

Payments firm Mastercard has said it would offer advice and technology to help provide digital immunization record cards in poorer countries.

“It’s about understanding where people are being missed,” Berkley said, adding that this was increasingly in “urban slums, isolated rural areas and conflict areas in fragile countries”.

(Reporting by Kate Kelland; Editing by Edmund Blair)

Yemen’s ex-president Saleh shot dead after switching sides in civil war

A supporter of Yemen's then President Ali Abdullah Saleh waves a poster featuring him during a rally to show support for him in Sanaa September 9, 2011.

By Noah Browning and Sami Aboudi

SANAA/DUBAI (Reuters) – Veteran former president Ali Abdullah Saleh was killed in a roadside attack on Monday after switching sides in Yemen’s civil war, abandoning his Iran-aligned Houthi allies in favor of a Saudi-led coalition, foes and supporters said.

Sources in the Houthi militia said its fighters stopped Saleh’s armored vehicle with an RPG rocket outside the embattled capital Sanaa and then shot him dead. Sources in Saleh’s party confirmed he died in an attack on his convoy.

Unverified footage of his bloodied body lolling in a blanket circulated just days after he tore up his alliance with the Houthis following nearly three years in which they had jointly battled the Saudi-led coalition that intervened to try to reinstate Yemen’s internationally recognized government.

Saleh’s death, close watchers of Yemen say, will be a huge moral boost for the Houthis and a major blow to the Saudi-led coalition. Any hope of the coalition that Saleh could have been bought off to help them against the Houthis has now been dashed and the Houthis have destroyed a powerful new adversary.

The coalition must either continue its long war in Yemen or offer compromises to bring the Houthis to the negotiating table.

In a televised speech on Monday, Houthi leader Abdul Malik al-Houthi congratulated the Yemeni people for what he described as a victory against a “conspiracy of treason” engineered by the group’s Gulf Arab enemies. He did not mention Saleh’s death.

Supporters of the Houthis drove through city streets blasting celebratory war songs.

Saleh, 75, had said in a speech on Saturday that he was ready for a “new page” in ties with the coalition and called the Houthis a “coup militia”, leading them to accuse him of betrayal.

Warfare between the former allies has torn densely populated Sanaa for days as Houthi fighters seized control of much of the capital and on Monday blew up Saleh’s house while coalition jets bombed their own positions.

A Houthi militant mans a checkpoint as clashes with forces loyal to Yemen's former president Ali Abdullah Saleh continue in Sanaa, Yemen December 4, 2017.

A Houthi militant mans a checkpoint as clashes with forces loyal to Yemen’s former president Ali Abdullah Saleh continue in Sanaa, Yemen December 4, 2017. REUTERS/Khaled Abdullah

The end of their alliance could transform the course of war in the Arabian Peninsula country after two years of attrition along mostly static front lines, which gave the Saudi-led coalition a new advantage over the Houthis.

Stalemate in Yemen has contributed to a human catastrophe as a Saudi-led blockade and internal fighting has thrust millions of people to the brink of famine and accelerated the spread of deadly epidemics.

Eyes will now turn to Saleh’s political allies and military commanders, whom analysts credited with aiding the Houthi march southwards in 2014 to dominate swathes of western Yemen.

“What happens now and whether his family and political allies fight on is not yet clear,” said Adam Baron, a Yemen expert at the European Council on Foreign Relations.

“His people will be angry, and many will certainly be out for blood, but there are many in the middle especially among the tribes who will fall with whoever appears stronger,” he said.

“The (Saudi-led) coalition may have put a lot of their eggs in Saleh’s basket, only for it to fall over now. They appeared to strongly support his attempt to confront the Houthis and now that bid may have failed.”

 

HEADS OF SNAKES

A Western diplomat told Reuters: “Brutal revenge could be the only way forward for the Saleh clan.”

The Saudi-led coalition, the diplomat added, could aim for a lightning attack on key urban centers that have eluded their grasp in years of war.

“Let’s see if they take advantage of the fog of war and try to take Sanaa or (the Red Sea port) of Hodeidah.”

Saleh once compared his 33-year rule over Yemen to “dancing on the heads of snakes”, a period that included unification of conservative north and Marxist south Yemen, civil war, uprisings, Islamist militant campaigns and tribal feuds.

But he was forced from power in 2012 after an Arab Spring uprising that left him wounded by an attempted assassination, leading to a Saudi-brokered political transition.

He fled to Saudi Arabia, his former ally, for treatment of his injuries and the princes in Riyadh allowed him to return to Yemen months later – something they came to bitterly regret as he undermined the transition plan and later joined the Houthis.

That set the stage for his final role – that of ally to the Houthi movement which he had previously fought six times during his own presidency, and to Iran, the Houthis’ political backer.

But Houthi and Saleh loyalist forces jostled for supremacy over the territory they ran together, including Sanaa, which the Houthis seized in September 2014, and their feud burst into open combat on Nov. 29.

The maneuvering ended on Monday, as footage circulating on social media appeared to show his corpse, a deep wound in the side of its head, wrapped in a red blanket and being loaded onto a pick-up truck as tribal fighters waved their weapons.

“Praise God!” and “Hey Ali Affash!” (another name for Saleh) they were shouting.

Officials in his own General People’s Congress party said Saleh was killed outside Sanaa in an RPG and gun assault on his convoy along with the GPC’s assistant secretary general Yasser al-Awadi.

His death was confirmed by Saleh’s nephew and former chief of Yemen’s security forces, Yahya Mohammed Abdullah Saleh, who hailed him as a martyr on his official Facebook page.

 

STREET BATTLES EASE IN SANAA

Residents reported that the situation in Sanaa had calmed. Most people were indoors, and streets were deserted amid a state of fear as the Houthis asserted full control. Saudi-led aircraft continued to fly overhead.

Houthi spokesman Mohammed Abdul Salam claimed significant gains in the battle for Sanaa on Monday.

“With the aid and approval of God, the security forces backed up by wide popular support were able last night to cleanse the areas in which the militias of treason and betrayal were deployed,” he said in a statement.

The Houthi movement’s TV channel al-Masirah and witnesses said Houthi fighters had seized the downtown home of Saleh’s nephew Tareq, an army general.

Residents said the warring sides traded heavy automatic and artillery fire as the Houthis advanced in the central Political District, which is a redoubt of Saleh and his family.

“We lived through days of terror. Houthi tanks have been firing and the shells were falling on our neighborhood,” said Mohammed al-Madhaji, who lives in the frontline district.

“The fighting has been so violent we feel we could die at any moment. We can’t get out of our homes.”

Houthi media and political sources also reported the Houthis advancing towards Saleh’s birthplace in a village outside Sanaa where he maintained a fortified palace.

Saleh cultivated Yemen’s national army for decades and put key units under the command of relatives, but the speed of the Houthis’ apparent gains over his partisans indicates they have a strong upper hand in the lands they once held together.

Nearly three years of Houthi control over key ministries and state media has helped convert much of Yemeni society toward their brand of religiously-inspired militarism while key tribal and military commanders did not flock to Saleh’s uprising.

This may mean that Houthi positions in nationwide battlefronts against pro-Saudi forces will remain robust with the overall stalemate dragging on.

 

(Additional reporting by Stephanie Nebehay in Geneva; Writing by Noah Browning, Angus McDowall and Samia Nakhoul; editing by Mark Heinrich)