More R&D into already known emerging disease threats, from Mpox to Lassa fever would go a long way to both bolster developing countries’ preparedness as well as protecting the world, experts argue.

Member state negotiations resume next week over a draft WHO convention on pandemic prevention, preparedness and response – which is supposed to be ready by the May 2024 World Health Assembly. 

While parties prepare to debate the latest draft text published, distilled from a 208 page “compilation draft” of 34 different country and regional proposals, the lessons learned from recent or ongoing outbreaks can  provide concrete insights on how to make the world better prepared.

A group of high level experts from Africa, Europe, the Middle East and Latin America provided their insights at a recent seminar on “How Can Global Action Really Meet Local Needs in Emerging Outbreaks, hosted by the Graduate Institute’s Global Health Centre on the margins of the recent World Health Assembly.  

The event was co-sponsored by the International Geneva Global Health Platform, and PANTHER Health, an NGO dedicated to supporting rapid responses to emerging infectious diseases in Africa.

Insights from Mpox, Lassa fever are indications of preparedness 

Speaking at the event, Bernhards Ogutu, Chief Research Officer of the Kenya Medical Research Institute (KEMRI), said insights from current Mpox, Lassa fever and other “endemic pandemics in the south” are among the best indications of countries’ current level of preparedness for future outbreaks.

“Even when we think there are no pandemics there’s lots of them that we need to address and possibly need to see how well to do this as we get prepared for the next pandemic,” Ogutu said.

The INB text echoes the importance of research and development. Article 9 of the current draft states that: 

“The Parties shall cooperate to build, strengthen and sustain capacities and institutions for research and development for pandemic-related products, particularly in developing countries, including for related clinical trials and information-sharing through open science approaches for rapid sharing of scientific findings and research results.”

More research in endemic countries is needed

But those high notes of ambition are far from today’s reality said Jean-Jacques Muyembe-Tamfun, director of the Democratic Republic of Congo’s Institut National de la Recherche Biomédicale. He noted, for instance, that more research in endemic countries on the connection between smallpox and Mpox could have contributed to the more rapid roll out of countermeasures when the Mpox global health emergency hit countries worldwide last year. 

With knowledge about how the smallpox vaccine provides some protection against Mpox, more adequate research a decade ago into Mpox vaccines and treatments could have informed better policy guidance on priority countermeasures and target groups for their use, during the recent emergency. This might have yielded recommendations for continued smallpox vaccination in countries where Mpox is endemic, he suggested.

Instead, when the emergency hit, it was unclear how wide a net needed to be cast with the vaccines, which turned out to be in short supply, and were rarely put to use.  As for medicines, just one small study in the Central African Republic of the new treatment, Tecovirimat (TPOXX™), was only just beginning when the virus emerged.

Aligning with the INB’s draft text on supporting research in developing countries, Muyembe argued that his country remains critical for clinical trials on Mpox, the findings of which could help in developing tools that would protect the rest of the world against the new variants of an old disease. 

“DRC is the most affected country. We will not lack cases of Mpox to continue our studies and clinical trials in the field,” he said.

‘No regrets’ funding

Funding has always been a subject of debate in global health and the INB’s June negotiations are no exception. In the working document, financing was captured in Article 19 and it describes sustainable financial resources as playing an important role in achieving the objective of the instrument. It pegged financing as the primary financial responsibility of national governments in protecting and promoting the health of their populations. 

The parties, however, are yet to agree on whether to include a proposed Paragraph 6 in Article 19 on Financing, stating that funding models “would take into account national financial capacity and capabilities.” Two options are being considered, one which would elaborate the principle in detail – and one which would not reference it at all:

Option 19.A6. The Parties agree that the funding models for pandemic prevention, preparedness and response need to take into account national financial capacity and capabilities, and to this extent shall: (a) establish programmes that convert debt repayment into pandemic prevention, preparedness, response and recovery investments in health, to be attained under individually negotiated “debt swap” agreements; and (b) commit to expanding partnerships with development finance institutions for providing additional funding to developing countries, through prioritized debt relief, debt restructuring and the provision of grants rather than loans that will guarantee that programmes protect essential health and related spending from encroachment, as well as to take advantage of the economic benefits of frontloading finance for prevention and preparedness or support investments. 

Option 19.B: not to include a paragraph.

At the Graduate School event, Veronika von Messling, Director-General for Life Sciences at the German Federal Ministry of Education and Research also stressed the importance of a ‘no regrets’ funding approach that permits flexible use of both national resources and donor-based funding that allows recipients to dynamically adapt plans in times of crisis. She described this as essential to long-term capacity strengthening in low and middle income countries.

“These are central elements for a global pandemic preparedness and response,” she said. “Continuous investment in national and international initiatives even before a pandemic. underline the importance of acting not only in times of crisis, but also in between.”

The formidable INB task ahead 

The Intergovernmental Negotiating Body (INB) will resume in its fifth meeting on the draft accord next week. 

The INB is the name of the group that is drafting and negotiating the WHO “convention, agreement or other international instrument on pandemic prevention, preparedness and response,” with a view to its adoption under Article 19 of the WHO Constitution, which allows the World Health Assembly to adopt “legally binding conventions or agreements” by a two-thirds vote. It is open to all Member States and Associate Members (and regional economic integration organizations)

From 12 June, the board, starting with Member States and followed by relevant stakeholders, will provide general comments on the Bureau’s most recent draft text, published on 2 June. At the 76th World Health Assembly, the INB said it has made progress in developing a framework for the accord, although negotiations are expected to continue steadily until May 2024. 

One Health – a key principle of the accord – or not?    

In a briefing last week, the “Bureau” of six member states guiding the negotiations, provided a mapping of the draft text and its proposed amendments by member states, reflecting the many choices still to be made.  

Those range from semantic choices between “but” or “and”, to the critical question of whether “One Health” will be included as a fundamental principle of the accord. Other challenges include how prescriptive to be regarding tasks that parties would fulfil, particularly with regard to prevention and surveillance. For instance, word choices like “are encouraged to” suggest voluntary action while “shall” conveys a mandatory meaning. 

While there appears to be agreement on referencing the importance of strengthening R&D and information sharing about research agendas and plans in the text, changes are being proposed to the section on preparedness monitoring and functional reviews (Article 8). Some member states oppose the establishment of a peer review mechanism for monitoring preparedness in which countries would review the plans and performances of other member states.

While there appears to be agreement on references in the text to the healthcare workforce, changes are being proposed to the section on preparedness monitoring, with some member states opposing the establishment of a peer review mechanism for monitoring preparedness, whereby countries themselves would review the preparedness plans and performance of other member states. 

The review instrument, fashioned on a similar mechanism used by the Human Rights Council, is called the “Universal Health and Preparedness Review’. It has already been piloted on a voluntary basis by some member states.

For the preparedness review and about 16 other controversial provisions touch on sensitive topics from the inclusion of “One Health” as a key accord principle (Article 8) to the sharing of genetic sequence data in exchange for rights to the benefits from drugs and vaccines developed (Article 12), the bureau draft contains 2-3 options for each key paragraph to allow member states to choose a direction.

For the more controversial provisions of the accord, which touch on sensitive topics ranging from the sharing of genetic sequence data to notification requirements during emergencies, the “Bureau” draft contains 2-3 options for each of about 16 key paragraphs – so that member states can concretely choose a direction.

Two options are presented for principle 8. Option 8.A: One Health – Multisectoral and transdisciplinary actions should recognize the interconnection between people, animals, plants and their shared environment, for which a coherent, integrated and unifying approach should be strengthened and applied with the aim of sustainably balancing and optimizing the health of people, animals and ecosystems, including through, but not limited to, by giving attention to the prevention of epidemics due to pathogens that are resistant to antimicrobial agents and zoonotic diseases. 

Option 8.B: not to include as a principle.

The journey ahead

Following the June meeting, the INB will host its sixth meeting in July 2023. Further meetings or drafting group sessions could be held in September, November, and December. The board is expected to submit its outcome for consideration by the 77th World Health Assembly in May 2024.

The six members of the INB Bureau include Ms Precious Matsoso (South Africa), former Director General of the National Health Department of South Africa and INB Bureau co-chair, representing Africa and Mr Roland Driece (Netherlands) Director of International Affairs at the Ministry of Health, Welfare and Sport, and INB Bureau co-chair, representing Europe. 

Other members are Ambassador Tovar da Silva Nunes (Brazil) Permanent Representative of Brazil to the UN in Geneva, representing the Americas; Dr Viroj Tangcharoensathien (Thailand) Advisor to the Ministry of Public Health, representing South-East Asia; Mr Ahmed Salama Soliman (Egypt) representing the Eastern Mediterranean region; and Mr Kazuho Taguchi (Japan) representing the Western Pacific region.

The full panel on how global action can meet local needs in emerging outbreaks can be viewed here.

• Additional reporting by Elaine Fletcher.