Leading Edge

Commentary

Roots, Not Parachutes:

Research Collaborations Combat Outbreaks
Nathan L. Yozwiak,1,2,* Christian T. Happi,3,4 Donald S. Grant,5 John S. Schieffelin,6 Robert F. Garry,6 Pardis C. Sabeti,1,2,7
and Kristian G. Andersen2,8,9,*
1Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, MA 02138, USA
2Broad Institute of MIT and Harvard, Cambridge, MA 02142, USA
3Department of Biological Sciences, Redeemers University, Ede, Osun State, Nigeria
4African Center of Excellence for Genomics of Infectious Disease, Redeemers University, Ede, Osun State, Nigeria
5Kenema Government Hospital, Kenema, Sierra Leone
6Tulane University Medical Center, New Orleans, LA 70112, USA
7Howard Hughes Medical Institute, Chevy Chase, MD, USA
8The Scripps Research Institute, Department of Immunology and Microbial Science, La Jolla, CA 92037, USA
9Scripps Translational Science Institute, La Jolla, CA 92037, USA

*Correspondence: nyozwiak@broadinstitute.org (N.L.Y.), kristian@andersen-lab.com (K.G.A.)

http://dx.doi.org/10.1016/j.cell.2016.06.029

Recent infectious disease epidemics illustrate how health systems failures anywhere can create
disease vulnerabilities everywhere. We must therefore prioritize investments in health care infra-
structure in outbreak-prone regions of the world. We describe how rooted research collabora-
tions can establish capacity for pathogen surveillance and facilitate rapid outbreak responses.

International research collaborations are
essential in combating major public
health emergencies. Failure to collabo-
rate can delay critical findings, hamper
outbreak response, and erode trust be-
tween institutions and nations. In this
commentary, we expand on recent dis-
cussions on the lack of openness during
public health emergencies and perceived
exploitation of disease-stricken countries
by parachute researchers (Heymann more than a billion people call Africa
et al., 2016). We draw on our experience
establishing the Viral Hemorrhagic Fever
Consortium and the African Center of
Excellence for Genomics of Infectious
Disease in West Africa and show how
rooted collaborations can assist during 2013, but still comprise less than 1.5%
public health emergencies. Recognizing
that many successful infectious disease
research collaborations exist, we highlight
their critical and often unheralded role
in mitigating and preventing infectious
disease outbreaks.
Infectious disease outbreaks continue
to pose challenges to global health and
security, prompting reactive counter-
measures. Recently, severe outbreaks of
Ebola and Zika virus were designated by
the World Health Organization as Public
Health Emergencies of International
Concern. Other emerging viral patho-
gens have warranted similar attention,
including virus outbreaks from Lassa, Chi-
kungunya, avian influenza, Nipah, SARS,
and MERS. Additionally, endemic human
pathogens, such as dengue and West
Nile virus, have expanded to new regions
due to changing demographics and
increased urbanization.
Due in part to underinvestment in
health care infrastructure and scientific
research, Africa harbors a dispropor-
tionate infectious disease burden and
vulnerability to acute outbreaks. Though
and an increase in the ease of travel, in-
home, the continent produces only 5%
of the worlds gross domestic product
(UNESCO, 2015). Total investments in Af-
rican research and development (R&D)
rose more than 50% between 2007 and
vere pathogens, with unpredictable con-
of the worlds total R&D expenditure
(Marsh, 2016). This increase in invest-
ment, however, translated into an imme-
diate expansion of scientific output, with
a rise in publications of 60% from 2007
to 2013, compared to less than 15% in
Europe over the same period (Marsh,
2016).
Health care and disease surveillance
disparities can exacerbate local out-
breaks into global infectious threats. The
large imbalance between health care ca-
pacity in Africa and most western nations
means that serious infectious disease
outbreaks in Africa should be shared con-
cerns in the US, Europe, and elsewhere.
Controlling pathogens that lack effective
vaccines and therapeutics make early
detection, isolation, and contact tracing
critical. However, even when effective
vaccines are availablesuch as in the
recent outbreaks of yellow fever in Africa
and measles in the USbreakdown of
health care infrastructure and/or low
vaccination rates allow preventable infec-
tious diseases to spread. Combined with
an ever expanding human population
fectious disease outbreaks can therefore
no longer be considered local threats,
but rather represent international emer-
gencies. With these factors in mind, we
anticipate recurring interactions with se-
sequences to human health.
Rooted Research
The recent Ebola and Zika epidemics illus-
trate how vulnerable the world can be to
the threat from severe viruses. To effec-
tively combat such pathogens, the global
community must prioritize investments
in health care infrastructure in regions of
the world most susceptible to outbreaks,
and establish local capacity for pathogen
detection and containment before they
occur. This capacity building should not
only focus on the potential danger from
emerging pathogens, but rather should
address ongoing matters of local pub-
lic health importance. Well-established

Cell 166, June 30, 2016 2016 Elsevier Inc. 5

research collaborations are at commonly built on four pillars:
the center of creating such (1) co-creation, (2) capacity
capacity and can serve as a building, (3) sustainability,
major source of knowledge and (4) openness. Co-crea-
transfer and preparedness tion, through the mutual
before, during, and after an agreement on research goals,
outbreak. This is a much outcomes, and scientific pub-
more powerful and cost ef- lications among partners.
fective strategy than reacting Capacity building, through
once the outbreak has begun, frequent training and estab-
as in the 2013-2016 Ebola vi- lishment of scientific infra-
rus disease (EVD) epidemic. structure. Sustainability, by
What would become the providing short-term and
largest recorded EVD out- long-term research goals,
break began in December and continued technology
2013 in Guinea, yet was not transfer among partners. And
detected until March 2014 finally, openness, by immedi-
(Baize et al., 2014). Local ate public sharing of data,
outbreak responders contrib- analyses, findings, and, if
uted vital efforts during the feasible, resources and sam-
epidemictragically result- ples (Figure 1).
ing in more than 500 deaths We are not advocating sim-
of West African healthcare ply for the creation of addi-
workers (Currie et al., 2016). tional research consortia or
Ultimately, more than USD recognition of the general ben-
$7 billion were raised for the efits of scientific collaboration.
response, but despite this Research collaborations have
Figure 1. Pillars Underlying Rooted Infectious Disease Research
large injection of foreign become standard practice
Collaborations
capital, only once the local Rooted partnerships operating during public health emergencies are across all sciences; address-
response was sufficiently commonly built on four pillarsco-creation, capacity building, sustainability, ing big scientific challenges,
strengthened did the region and opennessthat enable immediate and long-term approaches for such as emerging infectious
outbreak response. Artwork by Sigrid Knemeyer.
control the outbreak. Collabo- disease surveillance and con-
rative clinical research played trol, unquestionably requires
a key role in facilitating this, by ensuring In several cases, international scientists large, multi-disciplinary teams. We also
comprehensive training of West African with no established collaborations in recognize that one size does not fit all for
outbreak responders. In addition, some West Africa allegedly transported sam- research collaborations and that there
of the diagnostic and surveillance labora- ples back to their home countries for exist many successful approaches to
tories established during the epidemic further research, in many cases without forming lasting and mutually beneficial
remain in place and continue to support permission or knowledge of the affected research partnerships. Rather, we seek
case investigations by local researchers nations (Heymann et al., 2016). Parachute to highlight the critical and often unher-
(Ariasa et al., 2016; Blackley et al., research can be detrimental to emer- alded role of rooted research collabora-
2016). These operations added critical gency response by preventing sharing tions in mitigating and preventing infec-
capacity to detect and investigate the of resources critical to public health and tious disease outbreaks. Sustainable
multiple flare-ups of EVD observed over fails to enhance the capacity of affected partnerships build trust and capacity
the last year and continue to be instru- regions to combat future outbreaks (Hey- upon which outbreak responses can be
mental in determining likely transmission mann et al., 2016). quickly mobilized.
chains originating from EVD survivors A more successful and sustainable
(Ariasa et al., 2016; Blackley et al., 2016). approach to outbreak response is built Collaboration, Education, and
Despite the ultimate containment of on collaborations that incorporate both Capacity Building in West Africa
EVD, however, collaborations during the immediate and long-term solutions for Our collective experience establishing
20132016 EVD epidemiclike many outbreak prevention into their infec- research consortia in West Africaone
other public health emergencies before tious disease research programs. We among many infectious disease collabo-
itwere often sub-optimal (Heymann term this rooted research to reflect rationsprovides insights into the value
et al., 2016). In some instances, re- the need for securing the research of rooted research partnerships. We
searchers parachuted into the affected with a firm foundation in the affected have tried to build and guide these collab-
countries, conducted research in isola- countries. As opposed to parachute orations adhering to the four pillars of co-
tion, and departed without creating sus- research, rooted partnerships operating creation, capacity building, sustainability,
tainable infrastructure or a lasting impact. during public health emergencies are and openness.

6 Cell 166, June 30, 2016

 Building on decades of research expe-
rience in West Africa, weresearchers
from West Africa and the USco-created
the Viral Hemorrhagic Fever Consortium
(VHFC; www.vhfc.org) in 2010 with the
goal of enabling research leading to better
diagnostics and treatments for Lassa
fevera virus that causes hemorrhagic
fever in thousands of people annually.
The VHFC unites the worlds only two
Lassa fever wards, at Kenema Govern-
ment Hospital (KGH), Sierra Leone, and
Irrua Specialist Teaching Hospital (ISTH),
Nigeria, with academic, government, and
industry partners. Investment by local
ministries of health and US governmental
agencies has supported clinical centers
capable of reliable diagnosis, clinical
care, and investigation of category-A level
pathogens in otherwise austere circum-
stances. Together, in 2014 we also
founded the African Center of Excellence
for Genomics of Infectious Disease
(ACEGID; acegid.org), centered at Re-
deemers University, Nigeria with support
from the World Bank and H3Africa.
ACEGID expands infectious disease
research and training among West African
researchers and has established genomic
sequencing capabilities for the study and
surveillance of human pathogens.
Capacity building and long-term sus-
tainability have both been central tenets
of ACEGID and VHFC. In addition to
investment in clinical, diagnostic, and
research infrastructure, both consortia
also have a significant focus on training
African researchers, combined with
frequent technology transfer to West Af-
rica. By creating ACEGID we sought to
expand the training part of our collabora-
tions, by creating long-term graduate-
level (M.S. and Ph.D.) programs for African
university students, as well as short-term
foundational training programs for African
educators and laboratory technicians. In
addition to training at host institutions
in West Africa, we have established two-
month training programs for African edu-
cators and researchers hosted each year
in the US. Now entering its third year, this
annual program has educated over two
dozen students in a training-of-trainers
model, covering molecular diagnostics,
microbiology, evolutionary genetics, and
teaching pedagogy. Ultimately, we aim
to modularize and extend this approach,
pairing laboratory enhancements and
education to create a critical mass of
well-trained African scientists to carry
out genomic infectious disease surveil-
lance in West Africa.
The establishment of VHFC and
ACEGID facilitated rooted collaborations
that not only allowed us to perform
research on Lassa fever directly in the
communities most affected by them, but
to be better prepared for the emergence
of another viral hemorrhagic fever virus.
As the EVD epidemic spread to Sierra
Leone and then Nigeria, the research
capacity and partnerships developed
in-country enabled early and critical
response and insights into the outbreak.
Within a week after Ebola virus was
confirmed in Guinea, together with the
Sierra Leone Ministry of Health and
Sanitation, we implemented PCR-based
diagnostic tests for Ebola virus at KGH to
supplement already available diagnostic
assays for other severe pathogens. This
enabled local staff to rapidly detect and
respond to the first Sierra Leonean EVD
patient who presented at KGH at the end
of May 2014 (Gire et al., 2014). The same
tests were introduced at Redeemers
University, which allowed Nigerian re-
searchers to quickly diagnose the first
case of EVD in Nigeria in July 2014. Over
the ensuing months, Sierra Leonean and
Nigerian researchers continued to play a
critical role in diagnosing EVD cases and
other febrile patients.
In addition to these diagnostic efforts,
our collaborations also made possible
several scientific studies that could be
shared rapidly and openly to ensure
maximum utility from the research. Open
sharing of data and analyses encourages
close collaborations, enables broad in-
vestigations, and can help correct or
corroborate analyses that the original in-
vestigators had posited. Our efforts al-
lowed us to investigate clinical features
of EVD (Schieffelin et al., 2014) and
dissect the molecular evolution and
spread of Ebola virus during the epidemic
(Gire et al., 2014; Park et al., 2015). We
immediately released all the generated
data into the public domain - a practice
many other groups also followed during
the epidemic. The rooted collaborations
in Sierra Leone and Nigeria also led to
the development and manufacturing of
an Ebola virus rapid bedside diagnostic
test (Corgenix ReEBOV), co-created by
Sierra Leonean and American partners.
A similar assay had previously been
developed for Lassa virus; both tests
were used in Sierra Leone during the
epidemic, and via new collaborations are
now expanding their reach into other
West African countries. Notably, much of
the research was performed and directed
by West African researchers with shared
co-first and co-senior authorships on
the resulting scientific publications. We
believe these advances would have
been delayed or impossible were it not
for existing commitments to long-term
rooted scientific projects in Sierra Leone
and Nigeria.
Future Responses
Nurturing rooted research requires
long-term investment and planning. The
benefits of collaboration may take many
years of commitment and cooperation
to appear, which requires dedicated
funding, even when wealthy countries
face no immediate outbreak threats.
Increasingly, global health funders are
facilitating rooted South-South (i.e.,
intra-African) research partnerships such
that low and middle income country re-
searchers independently set research
agendas and program direction. Pro-
grams supported by the US. National In-
stitutes of Health (H3Africa), World Bank
(African Centers of Excellence), the US.
Centers for Disease Control and Preven-
tion, Institut Pasteur, the Fogarty Founda-
tion, the UK Medical Research Council,
and the Wellcome Trust (DELTAS), seek
to establish long-term and equitable
science partnerships between African
nations and international partners. For
example, the H3Africa program advo-
cates access to funding, samples, and
data for African researchers and sets
a new standard for international collabo-
rative health research that involves Afri-
can research participants. An important
aspect of H3Africa research is that it is
under the leadership of scientists on the
African continent, with grants awarded
to, and managed by, African institutions.
North-South (i.e., international-African)
collaborations can continue to flourish
under such programs, perhaps even
more strongly, as collaborators prioritize
professional interests and research ques-
tions while encouraging long-term finan-
cial health and independence.
Cell 166, June 30, 2016 7
 Ultimately, rooted research consortia
can enable robust detection systems
to rapidly respond as outbreaks first
emerge. We envision networks of partner
laboratories equipped with diagnostic
and genome sequencing capacity and
know-how to characterize the range of
pathogens causing acute disease. Real-
igned training will keep pace with
advances in diagnostic technology and
regional public health needs. Going for-
ward, rooted collaborations are posi-
tioned as regional centers of excellence
at the forefront of infectious disease
research and surveillance.
ACKNOWLEDGMENTS
We honor and thank all the African outbreak re-
sponders who worked to control the 2013-2016
EVD epidemic, many of whom tragically died in
the process. We also thank all the members of the
Viral Hemorrhagic Fever Consortium and the Afri-
can Center of Excellence for Genomics of Infec-
tious Disease as well as Stephen Schaffner and
Jasmine Hanifi for helpful suggestions in preparing
8 Cell 166, June 30, 2016
this manuscript. C.H. is supported by the World
Bank project ACE019 and NIH H3Africa Award
1U01HG007480-03. R.F.G. is supported by NIH
grants and contracts including 1R01AI104621,
U19AI115589, and U19AI109762. P.C.S. is an
Howard Hughes Medical Institute Investigator,
and her work is supported in part by NIH
1R01AI114855-01 and U19AI110818. K.G.A. is a
PEW Biomedical Scholar, and his work is sup-
ported by an NIH National Center for Advancing
Translational Studies Clinical and Translational
Science Award UL1TR001114, and NIAID contract
HHSN272201400048C.
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