In a white paper from ICON in January 2023 the importance of preparing strong vaccines for future infectious diseases is explored. It emphasises the role that COVID-19 has played in drawing attention to the “importance of a strong vaccine response to emerging infectious diseases”. In fact, the paper suggests that COVID-19 has provided us with a “roadmap” for development. The strategies we implemented in the rapid process will have a “lasting” effect. So, what is ICON taking forward in the “fortifying” plan?
The paper states that “current standards of vaccine development are not sufficient to respond to rapidly spreading disease”. Although we made progress in the pandemic, we must continue to put the work in now to ensure that we can replicate or improve upon the rapid response. This is not a new message. In many of our interviews with vaccine specialists, we have heard of the importance of preparation. We know that behind the seemingly immediate mRNA success of COVID-19 was a wealth of research and investment.
Leaders of the future
ICON identifies several organisations and efforts that will help us make strides towards preparedness. For example, WHO identifies priority culprits of future diseases, offering an “excellent focal point”. CEPI stockpiles promising investigative candidates in order to accelerate trials when required. The paper also explores the potential in universal vaccines, such as those against influenza.
ICON also emphasises the “critical role” of early alert systems in allowing us to respond quickly to outbreaks.
“The earlier a disease is detected in a population, the sooner and more efficiently the response can be mobilised.”
The paper highlights the importance of surveillance of workers who are likely to be exposed to emerging pathogens. This is executed well by the Upper Midwest Agricultural Safety and Health Centre (UMASH) and the Minnesota Department of Health (MDH). They collaborate to monitor agricultural workers to identify and track infections, as well as characterising emerging zoonotic diseases. However, ICON suggests that this programme “may not quite be categorised as an early alert system”.
One example of an effort to establish early alert systems is the African Centre of Excellence for Genomics and Infectious Disease (ACEGID) and the Broad Insititute. They are working on the Sentinel project, which is focused on three pillars: Detect, Connect, Empower.
“For some diseases and places, clinical surveillance can be challenging, and does not always present an accurate representation of disease.”
ICON reminds us that it relies on the assumption that people affected by illness have access to and will seek out healthcare, as well as that health services have capacity to test. The paper explores the “promising alternate method” of wastewater surveillance. This allows us to identify diseases in a population before symptoms or large numbers of cases present themselves through monitoring pathogen DNA in stool and other waste.
The importance of data reporting is also underscored in the paper. Centralised data is “crucial to aggregating, analysing, and acting upon epidemiological information”. As an example, ICON refers to Global Initiative on Sharing All Influenza Data (GISAID), which was formed in response to the 2006 avian flu outbreak. “Widely accessible databases” enabled scientists to confidently share data and GISAID now has a significant role in vaccine recommendations.
On a local level, “effective” data reporting must be implemented. This means that local health systems need the resources for “robust data reporting”. ICON identifies “remote and rural” communities in LMICs. Their dependence on and involvement in livestock agriculture presents a higher risk for zoonotic disease, yet most “active surveillance in LMICs” happens in urban areas. Passive surveillance is more common in remote and rural areas but can exclude or “overlook” specific populations.
As well as the disease-centred approach, we need to work on our vaccine technology. Once again, mRNA COVID-19 vaccines were not developed overnight. Clinical trials, for example, have “unique considerations”. Before COVID-19, the typical vaccine timeline was up to 10 years, and costly. With the unpredictability of infectious disease spread, time is of the essence.
With the fast pace of infectious diseases, outbreaks can still take a couple of weeks to confirm. Thus, “traditional” patient enrolment strategies “may not be sufficient”. Responsive trial strategies, where the movement of disease is tracked, allow researchers to identify specific high-risk areas and respond in real time. This means that sites and enrolment can be “triggered by local transmission”. However, this is most effective with “fast acting vaccines” with prompt data collection.
Ring vaccination is responsive method that has become popular recently and was considered in the Ugandan outbreak of the Sudan ebolavirus. This approach was used for Ebola between 2014 and 2016, with the vaccine in question receiving approval in 2019.
Vaccine development “can be long and costly”. However, master protocols, or “core protocols” offer security. A master protocol involves several sub studies, allowing different candidates to be investigated at the same time. Adaptive trial design “provides a plan to modify elements of a trial depending on the data generated”. Critically, it does so without “compromising” the “validity or integrity” of a trial.
ICON identifies in COVID-19 the “implementation of a variety of valuable digital tools” which accelerated timelines and facilitated “decentralised and hybrid structures” to promote safety. For example, remote monitoring uses digital platforms to offer “agility in resource assignment”. Furthermore, it reduces cost and time. With the opportunity to monitor “around the clock” there is “increased motivation” for consistent data sharing. Thus, turnaround times and data submission are accelerated. Data collection and data cleaning also have benefited from new tools.
Although disease is unpredictable and fast-moving, we can do so much now to prepare for the future. Once vaccines have been developed, public health programmes must encourage vaccination and promote vaccine equity.
“There will be more epidemics in the future, whether caused by an unknown pathogen or a new strain of a familiar one. The medical community can take the lessons learned from COVID-19 to prepare and prevent future catastrophe.”