In 2019, global support was mobilised to tackle a major Ebola outbreak in the Democratic Republic of the Congo (DRC). Towards the end of the year, people in China began to fall ill from an unusual form of pneumonia, later shown to be caused by a novel coronavirus (SARS-CoV-2) and destined to become a devastating global pandemic (COVID-19). These two examples vividly illustrate the hugely damaging health and economic impact of infectious disease outbreaks.

The 2014–16 West Africa Ebola epidemic, which claimed the lives of more than 11,000 people directly and at least as many indirectly through its impact on health systems, highlighted the threat posed by emerging and re-emerging infections in sub-Saharan Africa. As well as struggling to meet clinical challenges, the countries affected were poorly prepared to carry out research that could have improved responses to the epidemic and to future outbreaks.

EDCTP has also funded a range of smaller projects through a special emergency call for proposals in 2018 triggered by the DRC Ebola outbreak and to boost outbreak response capacity. These Ebola-specific projects have included work on a sensitive new diagnostic for Ebola and related viruses (AdjustEBOVGP-Dx), surveillance in Republic of Congo (EPIRISK-Ebov), drug testing and surveillance in Uganda (Capa-CT 2, which built on a related earlier grant, see below), Ebola patient care in the DRC (PEAU-EBOV-RDC) and introduction of a mobile ‘laboratory in a suitcase’ into the DRC for rapid diagnosis (MobEBO-DRC).

These projects complemented other Ebola-specific projects awarded in 2016, which have helped to build research capacity in countries affected by the 2014–16 West Africa Ebola epidemic, such as Sierra Leone (RECAP-SL, ID-CLINICAL-CAPACITY) and Liberia (SELeCT), countries neighbouring the DRC, such as Uganda (Capa-CT), and countries and regions at risk of outbreaks, including Gabon (SECC) and northern Uganda (ENDORSE).

ALERRT is a multidisciplinary consortium building a patient-centred clinical research network to respond to epidemics across nine countries sub-Saharan Africa, supported by institutions in four European countries. It is creating platforms to build capacity for laboratory and clinical research and for data sharing, able to respond rapidly to new regional threats.

PANDORA-ID-NET, spanning 22 institutions in nine African and four European countries, is strengthening outbreak response capabilities across Africa, in partnership with national governments and other key stakeholders in Africa and Europe. It has adopted a ‘one health’ perspective, recognising the importance of animal-to-human transmission of novel infectious agents.

The two consortia have also established collaborative links, for example working jointly to develop a set of principles to guide data-sharing practice. Importantly, the presence of these networks has enabled them to take a lead in regional responses to COVID-19, as well as responses to other emerging and re-emerging threats, such as Lassa fever, chikungunya, plague and monkeypox.

The MobEBO-DRC project is introducing a mobile ‘laboratory in a suitcase’ into the Democratic Republic of the Congo (DRC) for rapid diagnosis of Ebola. How does this approach work? What is the expected impact?

In principle we are trying to deploy differential testing for Ebola virus disease into the field. Ninety percent of cases tested in the West African Ebola outbreak were Ebola virus negative, so the cause of symptoms was unknown in nine out of ten patients. Following our experiences with a suitcase laboratory using an isothermal amplification method, we are now equipping and training five teams from the DRC to use mobile differential testing for a range of pathogens, including Plasmodium falciparum, Salmonella Typhi, yellow fever virus, dengue virus and chikungunya virus. If we can show that this approach works, it will enable the DRC teams to respond in a flexible way to infectious disease outbreaks.

What comes next?

We had to introduce some optimisations to two tests, and once these issues have been fixed we would like to deploy the teams in regions experiencing Ebola cases to test the system in an outbreak situation. Currently we are suffering from delays in the supply chain since worldwide diagnostic activities due to the COVID-19 pandemic are draining the market of reagents. However, we hope to obtain all reagents we need to deploy later in 2020.

What progress was made in 2019?

We have shown in principle that all developed assays work and we have assembled and delivered the mobile laboratories and trained teams from the DRC. Some preliminary testing of the assays was done in the Kivu region of the DRC. We are hoping to launch our deployments once the restrictions due to the COVID-19 pandemic are lifted.

What were the main challenges of strengthening health research capacity in Sierra Leone? How did the project objectives address them? 

The Ebola disease outbreak highlighted the need for responsive and resilient health systems within and beyond Sierra Leone, with health systems strengthening efforts informed by policies based on context-specific evidence. However, at that time, health research capacity in Sierra Leone to inform policy and practice was limited.

Accordingly, there was a need for sustainable approaches to build capacity for multidisciplinary health research in support of wider health systems-strengthening efforts. The 2-year RECAP-SL project was funded by EDCTP and WHO/TDR and led by the College of Medicine and Allied Health Sciences (COMAHS), University of Sierra Leone, in partnership with Liverpool School of Tropical Medicine. It supported sustainable institutional capacity development at COMAHS, building on its existing strengths – knowledge, experience, expertise and links to national networks – for multidisciplinary health research to deliver credible, relevant research for effective policy making and practice.

What was the (short- and long-term) impact of the project?

The project carried out an institutional research capacity assessment report, which highlighted the capacity gaps in health research and research management and support systems at COMAHS and presented a number of recommendations for addressing them. COMAHS has been working to address these gaps, to ensure a continuing upward trajectory in both individual and institutional research capacity. The project also helped to develop a 4-year research strategy for COMAHS.

Student engagement to develop a research culture at COMAHS was another successful area. Robust research methodology training was provided and the project fostered student interest and knowledge in health research through the student engagement programme, which is open to students from all years with an interest in research.

In addition, the project has supported the development of four research fellows with the potential to be future health systems research leaders in Sierra Leone. Two are now completing their PhD studies with new project partners, along with a third student, which will address an identified capacity gap with regards to faculty members trained to PhD level.

The project is building the capacity of the Democratic Republic of the Congo to evaluate new diagnostics and to support clinical activities for Ebola. What are the main challenges? How is the project addressing them?

The DRC was faced with the most serious Ebola epidemic in its history, with 3,470 cases. The epidemic spread to an area where implementing interventions was very complicated.

Concerning the diagnostic, it was important to identify transmission chains, which next-generation sequencing (NGS) allows. In addition, serological tests can also help assess the spread of the virus in the population. For these two aspects, the project provided support to the Institut National de Recherche Biomedicale (INRB).

On a clinical level, several aspects were planned, in particular a follow-up of the survivors in order to evaluate long-term effects in patients who received a treatment based on either monoclonal antibodies or antiviral drugs.

What progress was made in 2019?

Despite the very difficult conditions, in a collaboration between the INRB and the national survivor program, a cohort study was initiated that includes 800 survivors out of the 1,190 recorded.

What comes next? ?

The health crisis linked to COVID-19 has delayed certain activities, in particular strengthening of clinical research. Restrictions meant that several planned training activities were postponed. Even so, cohort monitoring of survivors has been established and will continue for a total period of 18 months.