Preventing Ebola: The power of proactive vaccination

So still and vast, Lake Kivu is the sixth largest lake in Africa, separating Rwanda from its neighbor, the Democratic Republic of Congo, and acting not only as a partial border but as a divider between a population that has experienced Ebola and one that has been lucky enough to only fear it.

“They talk about how Ebola spreads and how it kills. We would hear that and be traumatized,” said Acquila Ange Mukandengo, a 32-year-old mother of four living in Rubavu district in north-western Rwanda. Sitting in Gisenyi Hospital’s maternity clinic, located 2.5 kilometers (1.5 miles) away from the DRC border, she cradles her sleeping 2-year-old child while sharing how Ebola brings to mind harrowing images of bleeding from body parts.

While Rwanda has never had an outbreak, the DRC, a five-minute drive away, has endured 14 since the disease was identified in 1976. The most recent began in August 2022 and while it was officially declared over by September, the threat of another outbreak lingers. Uganda, another neighbor to Rwanda, recently grappled with an outbreak of the Sudan strain of the virus.

The J&J vaccine induces long-term immune responses among communities, explained Jos Noben, former senior director for capacity development in J&J’s global public health research and development team. “This [vaccine] means that the population gets protected even before the virus can spread to this area,” CFHR’s Dr. Karita added. In contrast, other vaccines are designed only for those who come into contact with an affected person amid an outbreak.

Clinical trials of the vaccine in the United States, Europe, and Africa indicated “durable immune responses” to the Zaire strain, which has been behind all Ebola outbreaks in the DRC to date.

From 2018 to 2020, the DRC experienced the second-largest Ebola outbreak and J&J pledged 500,000 regimens of its vaccine to assist in prevention. Seeing the outbreak over the border, Rwanda took action to prevent the potential for spread. 

“The Ministry of Health decided not to wait until cases crossed the border,” said Karita. “They knew that there was an Ebola vaccine that was available that could potentially prevent the transmission of the virus.”

In 2019, under the project name Umurinzi, the Rwanda Biomedical Center, CFHR, Rwandan health promotion organization Rinda Ubuzima, and J&J began distributing the J&J vaccine at 14 different sites, including Gisenyi Hospital, among the border districts of Rubavu and Rusizi. More than 216,000 people were vaccinated and of those, 94% of people received both doses.

The high adherence rate demonstrates that "with support from political leaders, local communities, [and] other stakeholders in the community, it's possible to launch a large, multidose vaccination campaign like the one we launched here in Rwanda,” said Karita, who was the principal investigator of Umurinzi.

An extension of the program which targets pregnant women, called “Ingabo,” is currently underway in two district hospitals. Mukandengo was vaccinated at seven months pregnant and says she is “no longer afraid of Ebola.”

Pregnant women were excluded from the first phase of Umurinzi, but it’s important they get vaccinated because during pregnancy the immunity is lowered, said Mirimo, who is the Ingabo trial’s study physician. Ingabo aims to evaluate the safety profile among pregnant women, a group specifically vulnerable to high morbidity and mortality from Ebola.

Mirimo, who sees numerous pregnant women a day, explained that half of the 2,000 women in the trial received the vaccine while pregnant and a control group received it after giving birth.

Mukandengo was approached during one of her prenatal checkups, but initially had reservations. A night of talking it over with her husband meant she had questions, not least about the risk it would pose to her baby. “We thought there would be other side effects of the vaccine,” she said. But after continued discussions with the doctor, she felt reassured and now believes every pregnant woman should get vaccinated.

While recruitment of participants for the Ingabo trial wasn’t necessarily difficult, Brigitte Ndandali, Ingabo clinical trial site coordinator for Rubavu district, said such concerns weren’t uncommon. Some felt it was a lot of vaccines to receive while pregnant, as rollout began around the time people were being vaccinated against COVID-19. Others were put off by rumors and misinformation, she said.

Rebecca Ntakirutimana, a 20-year-old mother of one who lives in the nearby village of Nyabagoro, said she heard a lot of rumors when considering whether to take part. “Some told me ‘You will lose your child if you go through this.’ Others said ‘Your baby will turn into a snake,’” she said.

Some people in the community believe vaccines are a form of black magic, Ndandali explained. Vaccine hesitancy amid fear of adverse effects has been on the rise in general since COVID-19.

“The next steps are to reach out to other places in the world, other regions where Ebola is endemic,” Noben said. “We want to be sure that we can build capacity for healthy community immunization in areas where Ebola is possible to arise so preventative vaccines can be deployed without losing time and also without too [many] impacts on the people.”

This is doable, said Karita. Already, J&J has pledged up to 206,000 doses of the Ebola vaccine regimen to health care workers in Guinea. “What we’ve learned from this Umurinzi vaccination campaign … is that really it's not magic, it's doable. … If this program was successfully implemented in Rwanda, I do not see any reason why the program cannot be replicated in other contexts,” he said.

The main barrier to this, according to Noben, is shifting the mindset on Ebola to preventative rather than reactive strategies.

“It’s important for governments, multilaterals, and funders to see with their own eyes that a reactive approach is always more disturbing to the health system. In an outbreak, you have to fly in people from abroad, you have to rely very much on outside players to help you out,” Noben said. “It’s much better to have strengthened local systems and people, developed through a preventative proactive approach, so should an outbreak occur, resilience is already established. Governments can maneuver into the right direction step by step, with their own capabilities, not flown in from afar.”

Karita and Noben believe that through Umurinzi and the ongoing Ingabo campaigns Rwanda has demonstrated how the status quo on Ebola can evolve. “Once you have people aligned, working in the right direction, and see the potential healthy community campaigns offer, like preventing one of the worst infectious diseases, you can go from a plan to a reality fast,” said Noben.