The global health community faces a critical challenge in ensuring equitable access to life-saving treatments, especially during outbreaks affecting vulnerable populations like children. A recent outbreak of Bundibugyo virus disease, a type of Ebola, in the Democratic Republic of Congo (DRC) has starkly highlighted this disparity. Médecins Sans Frontières (MSF) is sounding the alarm, emphasizing that children, who are particularly susceptible to severe outcomes from this infection, are being left behind in vital research efforts for treatment and prevention. ### Understanding Bundibugyo Virus Disease Bundibugyo virus disease (BVD) is one of six recognized species of the Ebola virus, infamous for causing severe, often fatal, hemorrhagic fever in humans. Like other Ebola strains, it is transmitted through direct contact with blood, body fluids, or tissues of infected animals or people, not through the air. Symptoms typically include a sudden onset of fever, intense weakness, muscle pain, headache, and sore throat, followed by vomiting, diarrhea, rash, impaired kidney and liver function, and in some cases, both internal and external bleeding. The fatality rate for BVD can be high, making rapid diagnosis, isolation, and effective medical countermeasures crucial during an outbreak. The Democratic Republic of Congo has a history of facing multiple Ebola outbreaks, adding to the complex public health landscape in the region. ### Why Children Are Uniquely Vulnerable Children, especially those under five years old, are often disproportionately affected during disease outbreaks, and the current Bundibugyo outbreak in the DRC is no exception. Reports indicate that among confirmed cases where age was recorded, children under five years old diagnosed with BVD experienced significantly higher mortality rates compared to adults. Several factors contribute to this heightened vulnerability. Young children have developing immune systems, making them less equipped to fight off severe infections. Diagnosing Ebola in infants and toddlers can also be challenging, as initial symptoms can mimic common childhood illnesses like malaria or typhoid, leading to delays in crucial care. Furthermore, children in outbreak settings may face unique exposure risks, such as proximity to sick family members or participation in traditional burial rituals. The psychological and social impact on children affected by an outbreak, including potential orphanhood or isolation, also adds to their burden. ### The Challenge of Including Children in Research Despite children's particular vulnerability, they are frequently excluded from clinical trials for new medical interventions during public health emergencies. This exclusion often stems from a combination of ethical, logistical, and scientific hurdles. Ethically, children cannot provide informed consent for participation in trials, requiring parental or guardian permission and, where appropriate, the child's assent. Scientifically, developing pediatric formulations of drugs – such as palatable syrups or smaller, easily administered tablets – is complex and costly. Children's bodies metabolize drugs differently than adults', necessitating specific dosage guidance based on age and weight, which requires dedicated research. The absence of this specific data often leads to their exclusion from adult-focused trials. Logistically, administering treatments like intravenous (IV) medications to young children, especially in resource-limited outbreak settings, presents significant operational difficulties, including maintaining sterile environments and ensuring skilled medical staff are available for continuous care. ### Current Treatment and Prevention Efforts: The EBO-PEP Study In response to the current Bundibugyo outbreak, an important clinical trial known as the EBO-PEP study commenced on July 14, 2026. This study is evaluating the effectiveness of an oral antiviral drug called obeldesivir as a post-exposure prophylaxis (PEP). PEP involves administering medication to individuals who have been exposed to a disease but have not yet developed symptoms, with the aim of preventing infection or mitigating its severity. If proven effective, an oral PEP could revolutionize outbreak response, offering a practical and scalable way to protect high-risk contacts. However, the EBO-PEP study’s original design excluded children weighing less than 30 kilograms, roughly equivalent to children aged 12 years or younger. While a protocol amendment to include children over 20 kg (around 6 years old) is anticipated, children under this weight threshold remain excluded. This is primarily due to the lack of an available pediatric formulation of obeldesivir and insufficient data supporting the safe crushing or dissolution of adult tablets for younger children. ### The Role of Antivirals like Obeldesivir and Remdesivir Antiviral medications play a crucial role in combating viral infections by targeting specific stages of the virus's life cycle. Obeldesivir and remdesivir are both antivirals that have shown promise against various viral pathogens. Remdesivir, for instance, has been used to treat Zaire Ebola virus disease and was also investigated for COVID-19. It works by interfering with the virus's ability to replicate its genetic material. Obeldesivir is also designed to inhibit viral replication. While the EBO-PEP trial primarily focuses on oral obeldesivir, a sub-protocol for excluded children involves intravenous (IV) remdesivir. However, a daily IV treatment course over 10 days poses significant logistical hurdles in outbreak settings, especially for very young children. Such an intensive regimen requires consistent venous access, trained personnel, and a stable, sterile environment, all of which are challenging to maintain amidst an emergency. ### MSF's Urgent Call to Action for Equitable Access MSF, through its Pediatric Advisor Dr. Neal Russell, is unequivocally calling for urgent action from researchers, donors, and pharmaceutical manufacturers. Dr. Russell emphasizes that the inclusion of children in the development of medical countermeasures should not be an afterthought but a paramount consideration, especially when they are at disproportionately high risk of dying. MSF is urging stakeholders to actively support a pediatric obeldesivir sub-study, leverage existing dosing guidance, and accelerate the evaluation of other potential oral antivirals and monoclonal antibodies for post-exposure prophylaxis. The goal is to generate robust evidence now, ensuring that children can access effective preventive treatments alongside adults, rather than facing delays until an outbreak has waned. Furthermore, MSF is directly appealing to Gilead, the pharmaceutical company manufacturing obeldesivir, to provide a clear and expedited timeline for making pediatric formulations available. The hope is that with these formulations, or even with modified adult tablets where appropriate, studies can commence quickly to determine the most practical, timely, and effective post-exposure prophylaxis options for all children at risk. This collaborative effort is vital to closing the research gap and ensuring that no child is excluded from life-saving interventions during future public health emergencies. ### Moving Forward: Ensuring No Child is Left Behind The current Bundibugyo outbreak in the DRC serves as a poignant reminder of the ethical imperative to prioritize the health and well-being of all individuals, particularly the most vulnerable. Addressing the exclusion of children from critical research and access to essential medical countermeasures requires a concerted, multi-stakeholder approach. This includes proactive planning for pediatric clinical trials, dedicated funding for pediatric formulation development, adaptable regulatory pathways, and a commitment from pharmaceutical companies to prioritize these needs. By ensuring that research and access strategies are inclusive from the outset, the global health community can build more resilient and equitable responses to future outbreaks, safeguarding the health of every child. The time for action is now to ensure that children are not just considered, but actively included in the fight against deadly diseases like Bundibugyo virus disease.