The current Ebola outbreak in the Democratic Republic of Congo has proven devastating. Since the outbreak began in mid-May, more than 3,000 people have died.
Nearly half of all individuals infected with Ebola are expected to die, and the mortality rate is particularly high for young children. According to a commentary by Doctors Without Borders recently published in the medical journal The Lancet, the mortality rate for children under the age of 5 exceeds 60%.
However, this outcome often stems from a lack of appropriate medication and insufficient information on how to use it with young patients, rather than from the disease itself.
“Children must be centered in Ebola treatment and prevention research,” the aid organization wrote in early September.
At the heart of the debate is the EBO-PEP study, which began in mid-July. The study examines an experimental antiviral drug called obeldesivir, investigating its ability to protect people exposed to the Bundibugyo Ebola virus—the strain responsible for the current deadly outbreak.
Children weighing less than 30 kilograms (approximately 66 pounds) and roughly 12 years old or younger were not included in the original study. However, this could change soon, with new protocols being developed to include children weighing over 20 kilograms.
Children weighing less than 20 kilograms—roughly 6 years old or younger—will not be included in the treatment. An alternative treatment exists for them: another antiviral drug, remdesivir, given intravenously. However, as Doctors Without Borders argued, a 10-day course of infusions is difficult to administer during an outbreak, especially for young children.
According to Neal Russell, a pediatric doctor based in London who consults for Doctors Without Borders and who served as the lead author of the Lancet commentary, young children face particularly high risk from Ebola. This vulnerability may be due to their weakened immune systems, underlying health conditions, or the fact that treating them during an outbreak presents unique challenges.
For instance, children are often harder to diagnose than adults because early symptoms resemble other illnesses, and young children frequently struggle to describe their symptoms accurately. Additional complications arise from the fact that children cannot always be accompanied into an Ebola treatment center by their parents or caregivers—something especially important for their recovery. Younger Ebola patients also require closer monitoring and specially trained staff.
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Ebola in Berlin
In May, an American doctor received treatment at Berlin’s Charité hospital after contracting the Bundibugyo Ebola virus while caring for patients. His wife and their four children were also considered at high risk. The medical team in Germany decided to treat the entire family prophylactically with an experimental antibody drug called MBP134.
“Of course, a careful risk-benefit assessment had to be carried out,” said Han Ngoc Le, a doctor at the hospital who was involved in the treatments.
The available data about the drug’s impact on children was extremely limited. Simultaneously, the children faced a high risk of catching Ebola following close contact with their sick father.
Ultimately, the entire family remained healthy, and no apparent side effects were observed. It remains unclear whether the experimental treatment prevented infection in the children. Such a small sample cannot be applied to the broader population either.
Nonetheless, the test provided valuable insights. “The mere fact that the antibody was so well tolerated even in 1-year-olds and children under 12 is a valuable finding upon which future studies can build,” Le noted.
Why do such gaps in knowledge exist?
Le explained that, from a medical perspective, children cannot simply be treated as “small adults.”
Their metabolisms function differently, they react differently to medications, and their pharmacokinetics—how the body processes a drug—are inherently distinct. Similar cautions apply to pregnant women.
Consequently, medication dosages cannot simply be transferred from adults to children. New medications require separate studies so that specific dosages can be determined and specialized formulations can be developed. Children may need kid-friendly syrups rather than adult-sized tablets, for example.
DR Congo launches Ebola trial for high-risk contacts
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“All of this creates additional costs,” said Marc Biot, access coordinator for Europe at Doctors Without Borders, who works to ensure people in need can access affordable, high-quality medical products. He noted that research institutions and pharmaceutical companies often view investing in pediatric studies as a lower priority.
“It is faster and it can be cheaper if you only focus on adults,” Biot explained—which is why treating children and pregnant women typically becomes integrated into research only at later stages of drug development. “That is our plea—a plea not only to the scientists, to the pharmaceutical companies, but also to those who fund and authorize trials—to allow that to happen at the same speed for adults as for children and pregnant women.”
Biot expressed disappointment that external pressure is needed to drive this change. “Whenever you start a clinical trial, you should also include pregnant women or children,” he argued.
A difficult balance
None of this is entirely new. In 2020, the Global Accelerator for Pediatric Formulations network was founded—supported by the World Health Organization (WHO)—to accelerate the development and availability of child-friendly medicine worldwide.
This challenge extends beyond Ebola. Russell pointed to the 2024 mpox epidemic in the Democratic Republic of Congo, where children constituted a large proportion of those infected or killed.
Although a vaccine existed for mpox, it was not designed for children. The WHO advised it be used “off label” for minors, but children tended to receive it significantly later than adults. Experts have observed comparable trends with other diseases including HIV, tuberculosis, and during the COVID-19 pandemic.
“When you’re conducting a research study, which is not in an emergency, [it makes sense] to protect children and pregnant women from any potential harm of an investigational product,” Russell explained. “But when you’re in an emergency, the balance between protecting those people from any potential harm from research, and protecting them from a very fatal disease, shifts.”
Berlin-based doctor Le believes children and pregnant women should be considered from the very beginning of any new clinical trials. “They shouldn’t be excluded from participation just like that,” she said. “Instead, sub-studies or parallel studies should be established from the outset.”
Russell advocates for a similar approach. He wants to see all people benefit equally from scientific progress during a health crisis—especially in emergencies, when the most vulnerable should not be the last to benefit from that progress.
“No matter who you are, you should have the same opportunity to access these medical products,” he concluded.