Join us today for an interview hosted by Avast CEO, Ondrej Vlcek with Dr Nick Cammack, Wellcome

Hi Andre, very nice to meet you and to join you today for this discussion. So yeah, I joined Welcome last October actually to lead a large 80 million pound program to improve snakebite treatments around the world with a particular focus on sub-Saharan Africa. There are over a hundred thousand deaths a year around the world from snakebite and half a million disabilities, and it's a massive problem that is actually solvable. So that's why I joined Welcome. My background is actually in infectious diseases, firstly in academia and then many years in pharmaceutical companies involved in the discovery and development of medicines for HIV, for hepatitis C, hepatitis B, malaria, tuberculosis. So I joined Welcome as I said last October, and then of course after Christmas and in March time, COVID certainly over here in the UK hit, and I think my background sort of set me up really to lead this therapeutic accelerator that Welcome's set up with the Gates Foundation.

Yeah, so I think the private sector is hugely important in tackling COVID-19 for two reasons really. Those in the private sector that have expertise in the discovery and development of medicines, that expertise is really important to help in the overall global efforts. But I think just as importantly, even perhaps more importantly, private organizations, private companies who see the challenge, see the problem, and want - maybe don't have the expertise - but want to offer support from a funding perspective to help us deliver what we need to do, which is treatments and vaccines for COVID-19. So that latter group, of which Avast of course is one, is hugely important because it gets the world, helps get the world back on its feet and business back to normal.

Yeah, so I think the biggest challenge of course is that COVID-19 is a new virus. It's not a new family of viruses, we've had experience of members of this family of viruses moving from animals to humans in the last sort of 20 years - SARS back in 2003, and then the Middle Eastern respiratory syndrome in 2011-12. They're not new from a family, but COVID-19 is a different virus again from that family. So the biggest challenge is trying to understand everything about that virus, both from how it infects humans, how the immune response of humans is developed to that virus, whilst at the same time trying to make treatments and vaccines in parallel. I think ordinarily, with other viruses as I was mentioning previously, HIV or with bacteria like TB, we know an awful lot about those, and that helps us in the design of our treatments and vaccines. In this case, everything's at pace. We're in July now, and it's all been happening in this first half of the year. And I think the biggest challenge is again understanding the virus but also assimilating the massive amount of information that's coming out to the benefit of the programs that we're trying to deliver. I think the other piece, and we touched on it previously, is this is a pandemic. This is not like Ebola that was in Africa and many of us could sit back and watch from a distance. This is happening everywhere, and we really do need the global community who understand these diseases to come together, and that's public and private sector. There's no point - as it's quite obvious but say it anyway - no point to eliminate COVID-19 in our countries if it's existing everywhere else because we're still in a period of very little air travel, and so as soon as that kicks back up, we will see for example what's been happening in Australia in this last week or so, folk flying in reintroducing COVID-19 and a new outbreak taking off. So big challenges around the speed with which we develop and assimilate the information.

Yeah, so I would like to describe it in three buckets. When this first came about, when we first understood about COVID-19, the quickest way for a treatment for COVID-19 is to use a medicine that already exists now. That's not a medicine that exists for COVID-19, but there are infectious disease medicines out there that we could test to see if they can make some difference. Some difference might be the difference between life and death because you just suppress the infection enough for the body to be able to respond appropriately, or even at another level, the difference might be individual doesn't need to go into hospital and we save hospital beds and that sort of massive stress on health systems. And of course we're particularly focused in low- and middle-income countries where the infrastructure for health systems is not always as we would like. So the first sort of medicines we've been looking at are what we call repurposed medicines, these that were developed for other conditions. The advantages there are that they have been in humans, many - the safety is well known, we know how to dose them and so on. The disadvantage of course is they're not specific for COVID-19. And you, Andre, I know you've seen there's huge numbers of clinical trials of all of these repurposed medicines going on, and frankly very little coming out. Remdesivir is one drug that we've seen benefit, it's injectable, so as a potential treatment for everybody around the world that will be a real challenge. And then most recently we saw an old drug, dexamethasone, an anti-inflammatory drug, actually have a mortality benefit - in other words, one in eight people would not die where ordinarily they would. So it's a start, it's not the solution by any stretch, but it shows that some of those repurposed medicines can make a difference, and we'll keep looking at those. So that's one bucket.

So that is - for a virologist like me, that is a great question, Andre, because you'd like to think that similar viruses, many of these drugs for one should work against the other one, and they don't. They don't. There's just subtle differences that mean you'd think it should but it doesn't. There are examples in HIV and hepatitis B where the same drugs work - same drugs for HIV will work, some of them will work for hepatitis B. But there are other good examples like dengue, which is a very similar virus to hepatitis C, and there are many hepatitis C drugs and none of them work against dengue. So it's back to your comment, which is we need a little bit of luck on this one.

So monoclonal antibodies - I'll tell you very simply, and I know you know this, but basically they are individual antibodies known to inhibit the virus, so stop it entering cells where it needs to grow, and they've been sort of scaled up into huge amounts that you can then use as treatments. So it's just like any one antibody you would make yourself if you were infected with COVID-19, taken out and grown up in a manufacturing sort of scale to then be able to give to people. So you can sort of envisage that this sort of treatment is fast forwarding your immune response, really helping the body get the upper hand in dealing with the virus. So monoclonal antibodies are now being developed by large companies, by academic institutions and organizations, and there's a sort of race now of determining their safety. I have to say, for a monoclonal antibody, they are actually human antibodies, so in principle the safety is going to be good. So that's a great thing because for many medicines, the big thing you need to find out early on is whether they're safe before you can even test the efficacy. So these will be safe, and then I think it's the level of efficacy that we'll be able to see. We want for around the world obviously very potent, low dose, so that we can manufacture the quantities we need, and a strong preference for either subcutaneous or intramuscular injection, not intravenous, which would make it much more of a challenge to deliver particularly in low- and middle-income countries. So this is what we're going to see over the next months - you'll see it in all the press, all the data. But again, there will be a lag between this early data and producing the amounts at scale that we need. So that's the second and the most immediate new area coming through. And if I just very quickly, I think after that we will see what we call small molecules, small chemicals that are really specific for this virus. It might be for the machinery that replicates the virus, that makes it grow. We'll see those start to come through during this year and beyond, but they will be a lot more safety to do there because they are chemical and we don't know anything about them. But the reason why I mentioned those and that's more for the longer term is that we're dealing with COVID-19 now. If we find a small chemical that works against COVID-19's basic replication machinery, if COVID-25 comes along - back to an early question of yours - this will work. We know this will work because it's directed against key aspects of this family of viruses. So for us, I think it's really important that we drive through to finding those types of medicines so that we don't end up in the position we're in today. So that applies only to the small molecule, to the third one you spoke about, because the monoclonal antibodies are very specific for COVID-19, for the protein on its surface that helps it get into cells. That changes for different viruses even within the same family, and so if COVID-25 comes along, the monoclonal antibodies may do something, but it will be a bit more like repurposing.

So for me, COVID-20 or 21 is this same virus resurging, new waves of it. I'm talking about, you know, COVID-30 in 10 years time, another coronavirus jumped into humans. I think we'll be in a much better space. It would be a real crime not to have these medicines and indeed vaccines ready.

I think again, great question. I think we really, really, really need treatment that will be used in either people who feel that they've got the infection, get the test and they actually have it, so mild before they get to the hospital. We want to keep people out of the hospital because as you've rightly said, you can go into hospital and go home in seven days, or be on a ventilator in seven days, and we don't really know who will go in which direction. So we've got to keep people out of the hospital. So I think the focus for us for treatments are the mild patients, or even where there's an outbreak, prophylaxis - so giving something to people, an antibody for example, a quick subcutaneous antibody that we've been talking about would last for two, three, four weeks depending on its properties. So imagine where there's an outbreak in an area, you could quickly give people - it's not a vaccine, it's a treatment that lasts in the body for that period of time - you could quickly kill off that small outbreak by treating everybody with an antibody that would last for a period of time, and the virus will die out. The virus fortunately for us has to live in humans. We hear all this stuff about it lives on plastic for whatever length of time, but at the end of the day to grow and replicate, it's got to be in humans. So if you can prevent that in the short term with those sort of treatments, clearly with a vaccine for a much longer term.

Yeah, so we through the therapeutic accelerator, actually we've supported clinical studies of repurposed medicines as we were talking about earlier. One big study in pre-exposure prophylaxis for healthcare workers - this is basically giving a drug to healthy healthcare workers who are having to deal with COVID-19 patients, and looking to see if it will protect them because they need all the help as well as the PPE that they wear, they need all the help they can get. So that's ongoing. An interesting study we've just supported is actually going out into the community with the treatment to people's homes or to care homes and treating them there rather than bringing them into the hospitals, because we've seen particularly for elderly folk, they're better off treated at home quickly so that they can recover in that sort of environment. So it's called the hospital at home, and it involves expert physicians in respiratory disease and they actually go to the homes. And the reason why we've supported that is it's a model that is very transferable to low- and middle-income countries, whereas we were discussing, hospital infrastructure is perhaps not everything we want. So that's another example of something we've supported, and again through the Gates Foundation, similar studies of other types of medicines, and we'll continue to do that.

Yeah, so at this stage in development of a vaccine, so this early testing in humans, it probably has - the numbers are debated - but a 15 to 20 percent chance of being successful. So we need many vaccines in development so that one or more come through in the end as successful vaccines. And I think particularly with COVID-19, there's also the fact that many new technologies are being tested as well, so there's an extra risk on top. So hopefully out of all of these 115 different vaccines being evaluated, we get - we need more than one, simply because as we've discussed, we need to reach the whole world in this pandemic, and scaling different ones up in different places will be useful. We need a vaccine ultimately for this virus to die out. I think we need therapeutics as well; it's not one or the other. There are many folk, for example, immunocompromised, the very old, who frankly will not make a good immune response to a vaccine, so there'll always be a need for treatments for those people. And there will always be areas of the world that still haven't had the vaccination program, and therefore if those folk are either moving around the world or interacting with others, then there'll be a need for treatment there. So for today, while we're in a pandemic, we need both. And I think there's a lot still to be learned about how the immune response is developed. You know, we're all reading in the publications and in the press that the antibodies disappear very quickly, but that could be a normal thing and that you have another arm of the immunity preserved with a memory so that if you were infected again you would be fine. So still lots to learn there, but I can't emphasize enough the need for both treatments and vaccines.

So I'm not going to give you the answer you want here, Andre, but I think for treatments, if we see in the next - it could be next week, next month, rest of this year - if we see one of these repurposed medicines or two together maybe making a real difference, that could move very quickly. But before the end of this year, we could have something that is being distributed at scale around the world. If it's monoclonal antibodies as we're discussing, an exciting approach, I would say early next year is when we'll see those really being rolled out. So there'll be clinical studies during this year. And for vaccine as well, a real roll out globally will happen next year, but could start as early as the end of the year for some parts of the world. But that's the earliest.

Thank you very humbly.