After early development testing of the vaccine at USAMRIID, at the request of the DTRA, the Walter Reed Army Institute of Research conducted the first human trials of VSV-EBOV in mid-October 2014. According to Col. Stephen Thomas, M.D., WRAIR’s deputy commander for operations and the leader of its Ebola Response Management Team, this first trial, conducted in coordination with the National Institute of Allergy and Infectious Diseases, was aimed at demonstrating that the vaccine was safe and produced the desired immune response.

In August 2015, WRAIR began a second clinical trial of two experimental Ebola vaccines in Uganda, and will conduct further trials of one of these candidates at 10 sites in Nigeria later this year. In late July 2015, a trial of VSV-EBOV among 4,000 subjects in Guinea funded by the World Health Organization (WHO) demonstrated 100 percent efficacy among patients who received the vaccine immediately after exposure to Ebola. The WHO authorized the immediate immunization of anyone currently at risk, and is currently helping to lead a Phase III study of VSV-EBOV among more than 7,500 residents of Guinea, Liberia, and Sierra Leone.

“Nigeria dodged a bullet,” he said, “in large part because there was a Navy infectious disease physician who was liaison to the WHO . . . he’s the guy who held down the fort in Nigeria, and probably saved that country a lot of pain and suffering.”

 

Lessons Learned

At the end of January 2015, WHO reported that for the first time in eight months, there were fewer than 100 new weekly cases in the three most-affected countries. Liberia was officially declared Ebola-free in May 2015, but a few new cases were later reported in June and July.

While Operation United Assistance played an important role in building the capacity of health systems and providing expertise, military infectious disease experts – including Coleman and Thomas – view the overall response to have been a mixture of successes and failures.

To Thomas, one of the operation’s greatest successes was the fact that none of the deployed service members got malaria, let alone Ebola. Many of the U.S. Marines deployed to Liberia in 2003 to help stabilize the country during its civil war suffered from malaria, and the prospect of sending 3,000 people into the same area worried many leaders, said Thomas. “I can tell you,” he said, “we were more concerned about malaria and diarrhea than we were about Ebola.”

Thomas also pointed out that one of the region’s most populous countries, Nigeria, suffered only 20 Ebola cases during the outbreak, a circumstance, he said, due in part to U.S. military expertise. “Nigeria dodged a bullet,” he said, “in large part because there was a Navy infectious disease physician who was liaison to the WHO . . . he’s the guy who held down the fort in Nigeria, and probably saved that country a lot of pain and suffering.”

Though new Ebola cases are increasingly few and far between, there has been pain and suffering enough in West Africa: As of August 2015, nearly 28,000 people had been infected with the virus (a number the CDC believes to be underreported), and nearly 11,300 of them had died.

Humanitarian assistance isn’t a new mission for the U.S. military, but it’s a mission in which it plays an increasingly significant supporting role, partnering with the U.S. government and the international community. Several JFC leaders, in their own review of Operation United Assistance, published in the July-August 2015 edition of Military Review magazine, called for a more refined doctrine, better training, and a common operating picture for the DOD and these partners, to ensure the timeliness, efficiency, and effectiveness of future responses.

Two circumstances, in particular, point to room for improvement in the military’s global health engagement:

• First, Guinea’s government reported the Ebola outbreak in March 2014, but it was later determined that the first confirmed case of Ebola virus disease was in December 2013, in the remote village of Meliandou. “The Army has worked with its partners to develop pretty advanced tools to support infectious disease surveillance, to support data collection, data consolidation and data reporting, and putting that data in a format that’s easily analyzable,” said Thomas. But such systems rely on computerized recordkeeping, which renders them useless in places such as rural Guinea. “I think what we saw with Liberia and Sierra Leone and Guinea revealed a huge blind spot in that network, and that if people are really serious about avoiding this scenario again,” Thomas said, “there’s going to have to be a lot more coordination and collaboration.”
• Second, despite the promise of VSV-EBOV, the “short game” in product development – fielding drugs or vaccines during an outbreak to treat or prevent infection – failed to help anyone within the given time frame: “By the time they got the vaccines over there and everything set up,” Thomas said, “the epidemic was on the downward slope.”

Part of the problem, Coleman said, is that, “Our business model is terrible. We don’t buy a lot. We don’t know when these products are going to be used – we actually hope they’ll never be used. But then we suddenly want [companies] to surge and potentially provide millions of doses all at once.”

Still, Coleman said, many companies stepped up at the height of the Ebola crisis. “Some companies that had been working on Ebola vaccines or therapeutics diverted resources from other projects to more aggressively respond to this Ebola outbreak,” Coleman said. “And that was tremendous. But you don’t want to wait for an emergency to start thinking about it. In the U.S. government, we’re thinking continuously about this, but we have difficulty attracting the right partners in the absence of an outbreak like this one. So it’s worth asking: Can that model be changed?”

Despite remaining challenges, the comparison of West Africa before and after Operation United Assistance is stark: In September 2014, the CDC’s worst-case projection was for 1.4 million total Ebola cases by Jan. 20, 2015. In an October speech, Dr. Margaret Chan, WHO’s director-general, said: “I have never seen a health event threaten the very survival of societies and governments in already very poor countries. I have never seen an infectious disease contribute so strongly to potential state failure.”

About six weeks later, with Operation United Assistance well underway, the Liberian government and WHO reported the number of new Ebola cases was falling. U.S. military leaders won’t claim credit for this result, but they understand the unique capabilities they bring to infectious disease response, and they know they had something to do with it.

“We’ve always been very good at expeditionary medicine,” said Thomas. “We’ve also been uniquely good at the expeditionary research and development of products, going back to the time of Walter Reed and his team in Central America. Our overseas Army and Navy laboratories have 50- and 60-year-old relationships that have produced an incredible amount of knowledge that has supported the large-scale testing of vaccines and drugs that were later licensed. It’s part of our DNA. It’s what we do.”