Nipah@20 Nipah Virus International Conference - CEPI

DAY 1OPENING CEREMONYCo-chairs: Professor Linfa Wang, Duke-NUS / Dr. Raúl Gómez Román, CEPIA warm welcome to everybodyfor joining the Nipah VirusInternational Conference(Nipah@20). This conference isthe result of an initiative takenby the Coalition for EpidemicPreparedness Innovations (CEPI)in March 2019, and it was puttogether in a relatively short time.The conference has 215 participantsfrom 24 countries, which exceededthe organisers’ expectations byabout 50 %! Impressively, mostof the people who were invited tothe conference, on relatively shortnotice, are now present.As organisers, we are grateful forthe contributions made by thescientific community in preparingthe conference. Scientists fromnine different countries have takenpart in the preparations, and theconference programme is the resultof their experience and input. Wewould also like to thank our hosts,organisers, partners, and sponsors,who have entrusted us with theresponsibility and privilege ofpreparing the conference. On behalfof the international organisingcommittee, we would like to wishyou a productive and scientificallystimulating Nipah@20.Message from Ministry of Health, SingaporeSMS Dr. Lam Pin Min, Senior Minister of State for Health and TransportNipah@20 marks the 20thanniversary of the discovery ofNipah virus (NiV). There wasalso a conference marking the10th anniversary, but hopefullythere will not be a need for a30th anniversary conference – bythen, an effective vaccine shouldideally have been discovered. It isimportant to come together at aconference like this, to take stockof the latest developments in globalhealth, and discuss how we maybetter address emerging infectiousdiseases (EIDs).EIDs remain a threat to countriesaround the world, Singaporeincluded. In addition to Nipah,Singapore has experiencedrecent outbreaks of Severe AcuteRespiratory Syndrome (SARS),endemic Influenza (H1N1), andZika. We are not able to predictwhere and when the next EID mayemerge, but we are able to preparefor its emergence and mitigate its8impact. Our defence against EIDsinclude three elements: Publichealth capabilities, cooperation,and commitment to research.Strong public health capabilitiesand -systems are important formanaging and responding topublic health crises. Singaporeadopts an integrated and dedicatedapproach to the management ofEIDs, with capability to deliverclinical services as well as publichealth functions to detect, respondto, and contain EIDs. The NationalCentre for Infectious Diseases(NCID) was opened this year, tostrengthen Singapore’s capabilitiesin public health preparedness andinfectious disease managementand prevention. In the event ofan epidemic, the capabilities ofour healthcare professionals arecritical. Recognising this, Singaporecontinues to invest in training forhealthcare professionals and publichealth practitioners.The responsibility for addressingEIDs does not rest with oneinstitution, one sector, or onecountry alone. This brings inthe aspect of cooperation – orrather, cooperation, collaboration,and coordination. Managementof zoonotic diseases, such asNipah, underscores the needfor coordination across sectors.Singapore has adopted aninterdisciplinary “one health”approach, integrating human,animal, and environmental healthsurveillance and response. Robustanimal and human surveillance,combined with infrastructurecapabilities, are critical inproviding early warnings tothe animal and human healthauthorities. The Ministry of Healthworks closely together with anumber of other agencies todevelop capabilities and strengthensurveillance.Nipah Virus International Conference, 9th and 10th December 2019

DAY 1During the 1998-1999 Malaysiaand Singapore Nipah outbreak,international collaboration wasinstrumental to the identificationof pigs as an intermediateamplifying host for NiV infection.Fostering partnerships acrossregional and national borders isnecessary to deal with infectiousagents that are not constrainedby such borders. In addition, theemergence of new infectiousdiseases stresses the importance ofresearch investments.CEPI was established in Davosin 2017, as a private-publicpartnership with the ambitionto accelerate the developmentof vaccines against EIDs. Thisconference is yet another exampleof how different players can cometogether to support work andresearch concerning EIDs. Our hopeis that the conference may lead tonew partnerships and innovationsthat may boost the fight againstNipah virus.Message from the Ministry of Health, MalaysiaDatuk Dr. Christopher Lee Kwok Choong, Deputy Director General of Health(Research & Technical Support)Thank you to the organisers andSingapore for hosting this event.Nipah virus was named after theMalaysian village Sungai Nipah. Tomany Malaysians, the word Nipahevokes memories of the devastatingzoonotic outbreak in 1998, wherethe pig farming industry was hithard. A total of 283 cases wereconfirmed infected, resulting in110 fatalities. The outbreak alsoreached Singapore, reminding usthat borders are unable to stopinfectious diseases.Since the 1998 NiV outbreak, theministry of health (MoH) has putin place a number of measuresto protect the people of Malaysiafrom future zoonotic outbreaks.This includes strengthening ofthe surveillance systems in bothhuman and animal health sectors,and in particular a structured andcontinuous engagement platformwhere information may be sharedand analysed, and decisions aremade collectively. The platform,corresponding to Singapore’s “onehealth” approach, has been in placesince 1999.While the Nipah outbreak in 1998would ideally have been a one-offevent, the last 20 years have proventhe opposite. Although Malaysiahas not had another outbreak, NiV9outbreaks have occurred a numberof times in Bangladesh and India.These outbreaks have been tracedto food contaminated by fruit bats,which are now known to be thenatural host of NiV. Transmissionfrom human-to-human has beenconfirmed in South India, primarilyaffecting family members orhealthcare personnel. Fatality ratesrange from 40 to 75 %, yet interestin NiV has been more or lessconfined to the countries affected.To this day, there is no cure,vaccine, or specific treatment forNipah, and affected individualsreceive only supportive care. Inthe 20 years that have passed,WHO estimates that there has beenabout 600 Nipah cases worldwide,limited to countries in SoutheastAsia. There are, however, concernsregarding the devastating zoonoticpotential of NiV, as stated by theWorld Organisation for AnimalHealth (OIE). The WHO considersthe risk of geographical spread ofNipah to be low, yet the migrationpatterns and distribution of fruitbats are extensive. Evidence fromBangladesh shows that viralspillovers from bats to humanshappen regularly, providingopportunities for a more highlytransmissible strain to infect andadapt in humans.For effective countermeasuresto Nipah, a broader and morecomprehensive approach, withinvestments in therapeutics,diagnostics, and vaccines as wellas surveillance infrastructure, isurgently needed. Furthermore,strengthened capabilities arewarranted in rapidly detecting andverifying cases, conducting detailedcontact tracing, investigatingspillovers, and gaining a betterunderstanding of NiV andits mode(s) of transmission.Equally important is the need forbehavioural change, and improvedsupport to local communities forprevention and control measures.The goal is to reduce transmission,especially in the healthcare setting.Nipah@20 is a timely opportunityfor assessing the many gaps thatstill remain in our understandingof NiV and, hence, our ability toprevent and treat Nipah infection.Malaysia is grateful to be involvedin this meeting, and looksforward to learn from the manyexperts gathered at the event, aswell as to engage with the otherstakeholders present in the interestof moving towards more effectivemanagement of NiV infection.Nipah Virus International Conference, 9th and 10th December 2019

DAY 1Message from the WHODr. Michael Ryan, Executive Director, WHO Health Emergencies ProgrammeNipah virus and the relatedhenipaviruses are severe emergingdiseases with the potential toimpact vulnerable populations,generating public healthemergencies. Many aspects of themanagement and treatment ofthe henipaviral diseases remainunknown, and they have thereforebeen included on the list of WHOpriority diseases, as well as on theWHO research and developmentBlueprint for action to preventepidemics (WHO R&D Blueprint).The WHO R&D Blueprint is a globalstrategy to ensure implementationof critical research findings onhighly infectious diseases in asafe, effective and timely way. Incollaboration with leading experts,WHO R&D Blueprint allows forfast-tracking of effective medicaltechnologies in the context of anepidemic.The Nipah virus has a significantepidemic potential. Its bat reservoirhas been found in a number ofcountries, and it has the abilityto amplify in livestock, which isa source of exposure to humans.Human infection results insevere neurological disease andrespiratory symptoms, causingsignificant long-term sequelae,and high mortality.Our current knowledge of thehenipaviruses results fromremarkable collaborative, longterm efforts of the scientificcommunity, including many of theparticipants at Nipah@20. WHOR&D Blueprint has contributed todeveloping the key R&D prioritiesin the fight against Nipah, bybuilding on these collaborationsand bringing together experts fromaround the world.During the third Nipah outbreakin India, in May 2018, the WHOR&D Blueprint’s coordinatedapproach led to quick identificationof the most promising availabletherapeutic agent (the monoclonalantibody m102.4), and access tothe agent within 48 hours. Thiscase study demonstrates thatproactive research planning beforean outbreak allows for a quickeroutbreak response, allowingfor prompt implementation ofpotentially life-saving medicalinterventions.Epidemic risk can only beaddressed by acceleratingglobal preparedness, with anintegration of research into all ofour preparedness and responseactivities. This conferencerepresents a unique opportunityto share knowledge, and to laythe groundwork for a clear andcoordinated research agenda forNipah, at the regional and nationallevels.Message from NIAIDDr. Cristina Cassetti, Deputy Director, Division of Microbiology and Infectious Diseases, NIAID, NIHEmerging infectious diseaseshave been an important researchpriority at the U.S. NationalInstitute of Allergy and InfectiousDiseases (NIAID) for years.The aim is to gain a betterunderstanding of these pathogensand why they emerge, and todevelop countermeasures suchas diagnostics, therapeutics,and vaccines. With substantialbiodefence funding from U.S.Congress, the institute has beenable to support Nipah research10since the early 2000s, contributingto important advances such asidentification of the receptor usedby NiV for cellular entry and thedevelopment of animal modelsto be used in the evaluation ofvaccines and therapeutics.NIAID has been involved in thedevelopment of therapeutic andvaccine candidates, some ofwhich have now been transferredto CEPI and other partnersfor further development. TheNipah programme of NIAIDremains very active, with about17 currently ongoing extramuralprogrammes and a number ofinternal programmes focusingon the development of vaccinecandidates, as well as studies onthe pathogenesis of NiV usingnon-human primates (NHP).At Nipah@20, NIAID hopes toreconnect with old friends andpartners, as well as to learn aboutnew advances in the field of NiVresearch.Nipah Virus International Conference, 9th and 10th December 2019

DAY 1Welcome AddressProfessor Thomas Coffman, Dean of Duke-NUS Medical SchoolEmerging infectious diseasesconstitute an important part ofthe research portfolio of DukeNUS, and Professor Linfa Wang,who is the co-chair of Nipah@20,runs the Duke-NUS’ EmergingInfectious Diseases programme.Duke-NUS is very excited to bringthis conference to Singapore,partly because this was where thefirst Nipah outbreak happened.At the conference venue, there isa storyboard with news clippingsfrom the first outbreak, clearlydepicting the terror the diseasecaused when it first emerged.Another reason why Singaporeis a suitable location for such aconference, is the many travellersthat come through its airport,as well as its large volume ofshipping. Singapore was verysignificantly affected by SARS,and emerging diseases representa topic for concern to authoritiesas well as the public. Nipah@20brings together experts from allover the world, and highlights theimportance of facilitating globalcommunication between expertsfrom different disciplines such asepidemiology, surveillance, basicscience, vaccine development, andclinical treatment. Nothing canreplace face-to-face discussionsamong experts in bringing the fieldforward.Inaugural AddressDr. Richard Hatchett, CEO of CEPINipah virus and the relatedhenipaviruses are some of theworld’s most frightening causes ofdisease. WHO has included theseas one of 10 pathogens on its listof priority pathogens, since theepidemic potential of henipavirusesposes a grave risk to public health,and because there are no effectivecountermeasures.It is highly appropriate thatNipah@20 convenes in Singapore,a beacon for globalism and acity that embodies the moderneconomic order. When Nipah firstemerged in Malaysia, it rapidlyspread to Singapore. In the lastfew decades, other frighteningdiseases like SARS, Ebola, andMERS have fared similarly,spreading from rural areas todensely populated cities, where thedamage they can cause is amplifiedimmensely. No city is more globallyinterconnected, and thus at greaterrisk, than Singapore.Nipah has demonstrated its globalpotential, with recent outbreaks inKerala, India – more than 3,000kilometres (km) from Singapore,and more than 2,000 km fromBangladesh and Eastern India,where other recent outbreaks haveoccurred. As a result, more than 211billion people live in areas at riskfor Nipah. Unless something isdone, Nipah will continue to reemerge in smaller outbreaks, untilit finds the perfect combination ofcircumstance and opportunity toexplode again, as it did some 20years ago.CEPI is delighted to co-hostNipah@20 with the Duke-NUSMedical School, WHO, and NIAID.Meetings like this are important,not only because of the opportunityto share knowledge, but becauseof the momentum created inaddressing the threat of Nipah, sothat it does not become the nextEbola. In addition to being the20th anniversary of Nipah, 2019marks 50 years since the discoveryof Lassa fever, and one of theinspirations for Nipah@20 wasfound in a similar meeting on Lassafever in Abuja, Nigeria, in January2019.Lassa fever has haunted physiciansin West Africa for half a century,occasionally flaring up in explosiveoutbreaks, and likely causingthousands of deaths. The burden ofdisease has not been known, due topoor or non-existent surveillancesystems. In recent years, however,the Nigeria Centre for DiseaseControl, in collaboration withWHO and other internationalpartners, has been able to drawmore attention to the diseaseand establish Nigeria’s researchpriorities for Lassa fever. Throughthe Lassa meeting in January 2019,where several hundred physicians,scientists, and public healthofficials participated, concertedand coordinated action againstthe disease was established.Subsequently, CEPI and WHO havehelped Nigeria and other affectedcountries establish a network tosupport important epidemiologystudies, which will lead to thedesign of better and more efficientclinical trials of vaccines. CEPIhas also helped move the two firstLassa fever vaccines into clinicaltrials, with more to follow. Theworld has woken up to Lassa, andbegun to move to take this threatoff the table.CEPI embraces the notion that thecountries at greatest risk of theWHO priority diseases should bethe ones to set the research agendafor these diseases. Thankfully,more than 100 scientists, publichealth officials, and policy makersfrom countries at risk of Nipahhave registered for Nipah@20.Nipah Virus International Conference, 9th and 10th December 2019

DAY 1Another inspiration for thisconference was the majorprogress the world has madeagainst Ebola over the lastyear. While Ebola remains afrightening and disruptive threat,a clinical trial conducted inthe Democratic Republic of theCongo for a therapeutic againstEbola was recently terminatedearly due to positive results.Even more recently, Merckreceived conditional marketingauthorisation from the EuropeanMedicines Agency (EMA) for itsvaccine. Within the last weekbefore Nipah@20, GAVI announcedthat they will open a new fundingwindow to establish a globalemergency stockpile of Ebolavaccines. Low- and middle incomecountries will be able to access thevaccine free of charge, and willreceive support for the operationalcosts of vaccination campaigns. Asa result, we are approaching theday when Ebola is no longer theterrifying disease that it has beenfor the last 40 years.12It has taken tremendous effortby countless people to get theresults seen with Ebola, but thedemonstration that we can movefrom outbreak response to a globalR&D effort that results in a fullyaccessible stockpile of licensedvaccine is a major victory forglobal health. This experienceprovides a roadmap for emerginginfectious disease preparedness,where CEPI and the other partnerspresent at Nipah@20 will play acritical role. Beginning today, wecan do the same thing for Nipah.We can defeat Nipah, but only ifwe come together as a communityand coordinate our efforts.The triumvirate of capabilities,cooperation, and commitmentmentioned by Dr. Lam will beessential to any progress againstNipah. Fostering these was theintention with Nipah@20, and CEPIis confident that the participantswill rise to the challenge.Nipah Virus International Conference, 9th and 10th December 2019

SESSION 1 – HISTORIC REVIEWOF NIPAH OUTBREAKSDAY 1Chair: Dr. Marie-Pierre Preziosi, WHOOverview of outbreaksProfessor John Mackenzie, PathWest & Curtin University, PerthOutbreaks of henipaviruses,notably Hendra virus (HeV) andNiV, have affected Australia andseveral countries of SoutheastAsia over the past two to threedecades (see Figure 1). Outbreaksof HeV have been limited to theeast coast of Australia, whereasNiV outbreaks have been found inMalaysia, Singapore, Bangladesh,India (West Bengal and Kerala),and the Philippines. Whereas HeVuses horses as intermediate host,NiV infects pigs. One exceptionwas in the 2014 outbreak in thePhilippines, where ten horses werefound to be infected by NiV, andculled.communication between cliniciansand veterinarians – an aspect thatis now considered very importantto the management of zoonoticdiseases, as is clear from thewidely used One Health approach.Other lessons learned were: 1) apreviously unknown pathogencould emerge from a wildlife sourceat any time, in any place, andwithout warning, to threaten thehealth, well-being, and economyof a country – or even globally; 2)there is a clear need for countriesto have the capability and capacityto maintain an effective alertand response system to detectand quickly react to outbreaks ofinternational concern, andto share information aboutsuch out

Nipah Virus International Conference 9th and 10th December 2019 Singapore Meeting report prepared by: Christine Berge and Eirik Torheim Life Science Team AS, Gaustadalléen 21, N-0349 Oslo Contact@lifescienceteam.com, 47 905 88 644 Pending partner logo 2 Nipah Virus International Conference, 9th and 10th December 2019 Acronyms and Abbreviations5