G-FINDER 2022 Landscape of Emerging Infectious Disease Research & Development report: From Pandemic Response to Pandemic Resilience

This is our second report analysing global investment into research and development for emerging infectious diseases. Funding for emerging infectious disease R&D is overwhelmingly driven by outbreaks. Since 2016, there has been growth in EID funding largely driven by Ebola and Zika outbreaks.

In 2019, the Coalition for Epidemic Preparedness Innovations (CEPI) began ramping up funding for several of its priority diseases. We also saw a rise in 2019 because of a big jump in global funding targeting more than one EID – which we capture under the broad heading of ‘Disease X’. The Disease X label was coined by the WHO’s R&D Blueprint team to account for the now familiar idea of preparing for an unknown disease with pandemic potential. Research designed to tackle multiple and/or mysterious diseases has become much more popular, growing from just $43m to $244m in 2018 and then rising by another $113m in 2019, when it received more funding than any individual disease. By the start of 2020, global EID funding had already begun to shift from outbreak response to research designed to protect against multiple, lesser-known or entirely novel pathogens. This would prove to be an excellent choice.

Thanks to the seven years of investment in Ebola R&D since the beginning of the West African epidemic in 2014, we now have two registered Ebola vaccines, two approved biologics and an approved rapid diagnostic test. Additional products might be cheaper, better meet the needs of particular populations or provide improved protection against secondary strains and related pathogens.

Reported global funding for COVID R&D in 2020 was $4.7bn, of which $3.9bn was disbursed to product developers. Even these figures likely understate the true total, thanks to big gaps in industry’s reporting, but they still dwarf funding for previous epidemics. The full amount of COVID R&D funding is likely more than the $4.8bn funders provided for all EID-related R&D over the preceding six years.

Speed is vital and failures are inevitable. The exponential growth of outbreaks like COVID means that small increases in the speed of product development can save many lives. Dexamethasone, the first widely-administered pharmaceutical intervention for COVID, reduces mortality among mechanically ventilated patients by 36% and is estimated to have saved 650,000 lives over the second half of 2020. Completing the RECOVERY trial, which identified dexamethasone as an effective therapy, even a week earlier would have saved tens of thousands of lives in the pandemic’s first wave. Even in smaller outbreaks, where the lives lost to delays are fewer, the initial wave of a pandemic may also prove to be the only window for product development. When the West African Ebola epidemic ended, so did the still ongoing product trials it had enabled, slamming shut the window on product development and leaving candidates at best frozen, or at worst needing to restart trials during the next outbreak. So while research and development can only form part of the global response to a novel pathogen, every part of that response must be optimised for speed. For R&D funding, that means immediate, credible commitments, ideally drawing on pre-existing relationships and pre-existing platforms. Funders’ reserves of credibility and cash-on-hand can function as a kind of platform to accelerate product development, giving developers the means to begin work immediately.

As in the early years of previous epidemics, well over half the 2020 R&D funding for COVID went to vaccines (58% of the total). About a quarter went to therapeutics, split more-or-less evenly between drugs (13%) and biologics (12%), with 10% for basic research and 5.2% to diagnostics. While vaccines have proved incredibly effective at reducing the lethality of COVID and, gradually, bringing the pandemic under control, even with record levels of funding their development and large-scale deployment takes time. The speed of an initial response directly determines number of cases and number of deaths, and drug trials require an order of magnitude fewer participants than those for vaccines. So supplementing the vital project of vaccine discovery and testing with earlier, better coordinated trials of repurposed therapeutics could have saved hundreds of thousands of lives.

While CEPI played a key role in the response to COVID, its pre-pandemic funding to other, less recognised pathogens is arguably even more significant. CEPI identifies six priority diseases, in addition to vaccine platforms for use against Disease X. Along with its contributions to consortiumled Ebola R&D, it has made independent calls for proposals in relation to five of them: Lassa fever, Nipah, MERS, Rift Valley fever and Chikungunya – a non-WHO-priority pathogen not captured in our headline figures and therefore excluded from this analysis. Since 2019, when its disbursements began in earnest, CEPI has provided 22% of global MERS R&D funding, 46% of Lassa fever, 57% of Rift Valley Fever and 60% of Nipah funding. Together with the US NIH – either the largest or second largest funder of each of these areas – these two organisations are responsible for 89% of global funding across these four pathogens.

As we deal with the ongoing effects of COVID-19, we must remember that the next pandemic may arrive from an unexpected source, and the distribution of R&D funding should reflect that uncertainty. This means ensuring a broad funding and funder base, especially for basic research and for smaller pathogens, and nimble product developers with immediate access to platforms and funding. By these standards, it is not ideal that basic research funding is down 40% from its 2017 peak for the priority areas without recent outbreaks. But, thanks in part to CEPI, overall funding for these pathogens has risen sharply since 2016, rising by $71m to $203m in 2019 before remaining relatively stable (down $3.5m) in 2020.

While funding for most multi-pathogen research dropped, almost all individual priority pathogens have seen increased funding since 2016 – SARS being the sole exception. Funders seem to have recognised the importance of preparing for outbreaks of unknown or little-known pathogens in concert with the immediate threat of COVID-19.

To maintain an R&D sector that can absorb the kinds of funding spikes generated by Ebola, Zika and COVID, it is important that funders maintain their support even when the threat of infectious disease no longer seems quite so immediate. Boom-bust funding cycles, like those that characterised our response to epidemic coronaviruses, are an inefficient way to support R&D.

We are undoubtedly much more prepared for a pandemic than we were at the beginning of 2014, and more prepared than we were at the beginning of 2020. But we are also, by any reasonable standard, not ready enough. Will we, the people who collectively spent two years washing our hands and disinfecting hard surfaces in response to an airborne coronavirus, learn the broad lessons of pandemic resilience, or just go back to fighting the last war?