Genomic Surveillance
Lineage tree of Sars-CoV-2 strains according to genomic sequencing data.

British scientists have launched a new initiative to expand the sequencing of common seasonal respiratory viruses with the aim of developing an early warning system for new viral threats and help prevent future pandemics.  

At the height of the COVID-19 pandemic, labs around the world were sequencing tens of thousands of Sars-CoV-2 genomes a day. The data being shared from around the world allowed health authorities to keep pace with the evolution of the virus responsible for causing COVID-19, and identify where the next threat was coming from. 

The Respiratory Virus and Microbiome Initiative launched on Tuesday by researchers at the Wellcome Sanger Institute aims to build on these lessons. The project, run in collaboration with the UK Health Security Agency and other scientists, will track and sequence the evolution of respiratory virus pathogens like SARS-Cov-2, as well as other coronaviruses, flu families, and respiratory syncytial viruses (RSV) in order to establish a what it calls a “large-scale genomic surveillance system for respiratory viruses.” 

“It comes out of the simple idea that what we’ve done for Covid, we should now be doing for all respiratory viruses because if we can establish a better understanding of these viruses, we can be in a better place to understand their transmission and how to develop vaccines against them,” Dr Ewan Harrison, who is leading the initiative, told the Guardian.

Viral genome sequencing expanded significantly during the pandemic. The public release of the Sars-CoV-2 sequence by Chinese scientists in January 2020 allowed the world to start developing diagnostics and vaccines within days, saving millions of lives. To date, scientists have shared millions of Sars-CoV-2 sequences on public databases.

Influenza has attracted a lot of research interest over the years. However, many other respiratory bugs, like rhinovirus or adenovirus, are poorly monitored, leading to a gap in scientific understanding of their transmission dynamics.  By providing large amounts of data for academics and public health officials to use in their work, the program hopes to “supercharge” research efforts to fill these blind spots and improve scientific understanding of the particular characteristics of individual strains that make up respiratory virus families.

“Understanding which specific strains of each virus is causing disease in patients, and if there are multiple strains or multiple viruses present at any one time will hugely change our understanding of how viruses lead to disease, which viruses tend to coexist, and the severity of disease caused by each virus,” said Dr Catherine Hyams, an expert in respiratory viruses at the University of Bristol.

If the program succeeds, it could provide a blueprint for other countries to implement as part of their pandemic preparedness strategies – and become a cornerstone of global defenses against viral threats in the future.

Image Credits: MinMaj.

china
WHO’s director-general Dr Tedros Adhanom Ghebreyesus.

The World Health Organization (WHO) has called for more data on China’s COVID-19 situation to better understand the transmission dynamics of the virus on the ground and  flagged China’s under-reporting of COVID-related deaths. 

“There are some very important information gaps that we are working with China to fill. First and foremost is to have a really deeper understanding of the transmission dynamics of Covid across the country,” Dr Maria van Kerkhove, WHO’s COVID-19 technical lead, told a media briefing on Wednesday.

She added that the WHO has an open communication channel with the Chinese authorities and has offered technical advisory support to the country’s authorities. 

China’s management of COVID-19has been a cause for increased global concern in the recent past. Since the country lifted its ‘zero-COVID’ measures in December 2022, it has seen an unprecedented surge in infections and deaths.   

China recently narrowed its definition of COVID-related death to indicate only those with a positive COVID test and died of respiratory failure or pneumonia. By definition, this excludes deaths caused due to underlying conditions worsened by Covid-19. 

WHO’s Director-General, Dr Tedros Adhanom Ghebreyesus, told the briefing that the number of COVID-19 deaths across the world has remained constant at between 10,000 and 14,000 per week since mid-September.

Describing these deaths as “unacceptable” since there are tools to prevent it, Tedros added that “this number is almost certainly an underestimate given the underreporting of COVID-related death in China”.

Need for more sequencing

Recalling that the first gene sequence of SARS-CoV2 had been shared with the world three years ago, Tedros stated that the number of sequences that are being shared globally has decreased by more than 90% since the peak of the Omicron infection, while the number of countries sharing sequences has fallen by a third.  

“It’s understandable that countries cannot maintain the same levels of testing and sequencing they had during the Omicron peak. At the same time, the world cannot close its eyes and hope this virus will go away.”

He added that only 53 out of 194 countries provide data on Covid-19 deaths that are disaggregated by age and sex.

Since the early days of the pandemic, China has been accused of downplaying the number of COVID-19 infections and deaths. As of 12 January, China has reported a little over 17,000 deaths.

Dr Maria van Kherkhove, WHO’s Covid-19 technical lead.

The data from China will help WHO understand the breakdown, increases and decreases in the hospitalisations, ICU capacity and COVID-related deaths in urban and rural areas across the provinces in China, Van Kerkhove explained. 

While underlining that the agency has received some sequencing information from China, Van Kerkhove said that further information is necessary. “We have requested further information to have those sequences be shared publicly so that a deeper analysis and more phylogenetic analysis can be done so that we could look mutation by mutation to really assess what is circulating there.”

Reiterating that WHO believes that the “deaths are heavily underreported from China”, Dr Mike Ryan, executive director of health emergencies at WHO, said that the agency does not have enough information to do a comprehensive risk assessment. 

“We will continue to try to encourage access to that data but also recognize in the same breath that China has done a lot in the last number of weeks,” Ryan said, acknowledging the country’s efforts to strengthen its own internal capacities like increasing the number of hospitals, ICU beds and fever clinics, and prioritising vulnerable groups in treatment and using antivirals early in the course of the infection. 

Urging countries to maintain higher levels of sequencing and data sharing, Van Kerkhove said that this would greatly help WHO’s risk assessments.

“We need to maintain surveillance. We need to maintain sequencing and sharing of sequences from around the world so that risk assessments can take place, and we can ensure that any changes to our response, any changes to our advice is done in a timely manner.” 

Image Credits: Screengrab from Wednesday's presser. .

Health workers in Mubende, Uganda, to test suspected Ebola cases shortly after an outbreak of the Sudan virus strain was first declared there in September, 2022.

WHO’s Africa Region has declared the end to the recent outbreak of Sudan Ebolavirus – just a day before WHO convenes Ebola experts in a global consultation to explore a way forward on testing three candidate vaccines for the deadly Sudan strain of the virus.

The oubreak was declared over after the elapse of 44 days since the discovery of the last case.  That waiting period is double the 21-day period of time within which contacts of Ebola cases may become become ill with the deadly disease.

Uganda’s relatively rapid and effective campaign against the outbreak – which began on 20 September 2022 – was celebrated by health authorities, who fought the virus with classic measures like contact tracing, case isolation and treatment – in the absence of a vaccine against the Sudan strain of Ebolavirus.

At the same time, squashing the virus also has squashed the near-term prospects for a conventional clinical trial of three vaccine candidates that could prevent illness from the Sudan strain of the virus. WHO had originally planned to commence the randomized controlled trial last month in collaboration with Ugandan authorities. The trial was to be based on trials a convential demonstration of vaccine efficacy in a study group that would get the vaccine right away – as compared to a control group that would only get the vaccine after 21 days.  See related story:

Exclusive: Vaccine Trial Against Sudan Ebolavirus – With No Recent Infections in Uganda, What’s Plan B?

Similar trials were undertaken in Guinea for vaccine candidates against the Zaire form of the virus during the 2014-2016 West African Ebola epidemic.  The Merck vaccine candidate tested at the time, was eventually approved by United States regulatory authorities, after it helped bring an end to that tragic episode that killed over 11,000 people.  A second vaccine, by Johnson & Johnson, was later tested and aprpoved by the European Medicines Agency in 2020.

Is showing efficacy with animal models the best way forward?  

 

Microscopic image of an ebolavirus

Health Policy Watch conversations in late December with vaccine experts inside and outside of WHO, as well as with two of the three manufacturers of the Sudan Ebolavirus vaccine candidates, underline that a new strategy for testing the vaccines will now be needed.  And that is due to be discussed by WHO at Thursday’s meeting.

“Historically the number of cases of the Sudan Ebolavirus has been very limited,” one expert interviewed by Health Policy Watch also observed. Small outbreaks of only a handful of cases would deeply challenge any attempt to obtain statistically significant results from a randomized controlled trial of even one vaccine candidate, let alone three.

In the absence of any outbreak at all, experts have suggested that the most feasible pathway to regulatory approval might be throught the US Food and Drug Administration’s Animal Efficacy rule.  The approach could involve the testing of vaccine efficacy, per se, on non-human primates, along with more extensive testing of the vaccine’s safety and ability to produce an immune response, in healthy human volunteers.

The FDA’s animal efficacy rule is designed for just such situations, allowing initial regulatory approval of a vaccine for rare but deadly diseases based on animal model studies that replicate human disease, combined with evidence of safety and a strong immune response from clinical trials in healthy volunteers.

Such a model was used by Bavarian Nordic to gain US Food and Drug Administration approval of its MVA-BN® vaccine in 2018 against smallpox, which was then available for a rollout this year on a compassionate use basis in response to the global outbreak of monkeypox, which WHO now recommends calling mpox. Once mpox became widespread, clinical trials of vaccine efficacy in humans also commenced.

Developers of the vaccine candidates are quietly looking at such pathways to initial approval of Sudan ebolavirus vaccines. But it’s clear that the developers would also like the official, and proactive support of WHO for a new strategy, as the global health agency leading Africa’s Ebola response and the key partner of Uganda’s Ministry of Health as well as other countries on the continent in the Ebola battle.

“One would have to decide if it would be possible to test the vaccines clinically, or go for plan B, and accept the animal rule, whereby the vaccine is approved on the basis of experimental work, with non-human primates along with very robust safety and immunogenicity trials,” said an independent clinical trial expert with knowledge of the trial who spoke with Health Policy Watch.

Added another: “it would make a lot of sense to use the impetus of this outbreak, and the momentum that has been built, to do safety and immunogenicity trials, and then work in parallel on designing different Phase 3 trial [human] types that could be suitable for different types of outbreaks that might come in the future – trials of different intensity and so on, so that everything is ready to start the Phase 3 trials when the next outbreak comes.”

Ensuring adequate stockpiles of vaccine candidates

Swati Gupta, IAVI

Ensuring adequate stockpiles of the vaccine candidates in the field is another compelling concern – and on that point there appears to be broad agreement within WHO and beyond. Such stockpiles exist for approved Ebola vaccines – but not for candidates that also could and should be deployed quickly among volunteers should another outbreak emerge.

As the experience with the recent outbreak demonstrates, while the first Sudan ebolavirus vaccine candidates arrived in Kampala, Uganda in a record 79 days after the outbreak was first declared, that was still not fast enough – since by that time cases had dwindled, and most of the Ebola case contacts had already passed the 21-day virus incubation period without developing symptoms.

“When there is no outbreak, we need to ensure that we have adequate funding and resources are allocated so that people can produce the stockpiles, and then have a discussion about where you’re going to keep them, and how you would utilize them if there was a need,”  Swati Gupta, head of emerging infectious disease and scientific strategy at IAVI, a leading ebolavirus vaccine developer. “So we 100% support generating stockpiles and being prepared in advance.”

The WHO consultation from 14:00-18:45 p.m. CET is open to participation with registration in advance.  Registration link here:

Image Credits: @WHOAFRO, @WHOAFRO, Brittanica © jaddingt/Shutterstock.com.

WHO investigator into sexual abuse allegations.
“We are fast, we are rigorous,” said Lisa McLennon, Head of Investigations at WHO’s Office of Internal Oversight Services.

The World Health Organization (WHO) has rebutted allegations that the agency takes a soft approach to senior staffers accused of sexual misconduct following a report by the Associated Press that the same WHO official who allegedly harassed a British doctor at the World Health Summit (WHS) in Berlin last October had been accused of similar misconduct in 2017 – which top officials at the agency largely ignored. 

Meanwhile, the British doctor, Dr Rosie James, who alleged that a senior WHO staff member groped her during the World Health Summit, told Health Policy Watch that WHO’s investigation of her case, now nearly three months old, seemed to be taking too long and the process had been “scary and emotionally draining”.

Dr Temo Waqanivalu, who heads WHO’s work on integrated delivery of noncommunicable disease services, was named by AP as the staff member who is reportedly the focus of a WHO investigation into the Berlin incident.

But WHO also was well aware of a prior complaint against Waqanivalu, flagged to senior officials in 2018 – and did little about it, according to the AP account. That case involved physical approaches that he allegedly made to a female colleague during a 2017 WHO workshop in Japan.   

Investigation is ‘taking too long’

“In my humble opinion, I definitely think the investigation is taking too long,” said James in a written message to Health Policy Watch. “If they have a zero tolerance policy, why is he still working there and being considered for a promotion?” she asked. “The UN should have the highest standards and set a good example to other organizations.  I understand why many people fear the reporting process. It is scary and emotionally draining.”

On the day that the incident was reported, WHO Director-General Dr Tedros Adhanom Ghebreyesus tweeted that he was “sorry and horrified”, and WHO sources said that the staff member in question had been sent immediately back to Geneva.

But at least in terms of his public profile, Waqanivalu has remained active at his WHO post while the current WHO investigation took place, and was even mounting a candidacy to be appointed as head of the WHO’s Western Pacific Regional Office, with the support of officials in Fiji, his native country.   

Dr Temo K Waqanivalu
Dr Temo K Waqanivalu, a senior WHO staffer accused of sexual misconduct, is also campaigning to become Director of WHO’s Western Pacific Regional Office.

Former WHO ombudsman reportedly expressed frustration over handling of 2017 case

A former WHO ombudsman had expressed frustration about how the 2017 case involving Waqanivalu was handled – after the woman who alleged the harassment was advised by senior WHO officials to drop the case, AP also reported, citing internal emails and documents that it had obtained. 

In the 2017 instance, the WHO staff member reportedly alleged that Waqanivalu groped her between the legs during a workshop dinner, and then on her buttocks after he followed her to a train station. In the 2022 Berlin incident, James reported that Waqanivalu had groped her similarly while they were with a group having drinks one evening after a full day of summit events. 

Months after raising her concerns in 2017, the WHO staff member alleging the misconduct in Japan was informed by the WHO Ombudsman’s office that Waqanivalu was to be given a general “informal warning” that didn’t reference the alleged misconduct, according to AP. 

The WHO Ethics Office told her it would be difficult to prove a sexual harassment case, saying it might “compromise” her name and that she likely lacked “hard evidence,” according to the series of internal emails and documents that AP obtained.

WHO – ‘we are fast, we’re rigorous’

Speaking to the allegations at a WHO press conference on Wednesday, Lisa McClennon, head of investigations in WHO’s Office of Internal Oversight Services, denied that the agency had glossed over recent sexual misconduct cases. 

“We are fast, we’re rigorous, we’re thorough. We take a contemporary and survivor centric approach to the matters that are referred to us in this effort,” she said. “This increased effort and focus in increased resources towards this matter began over a year ago, and we have been able to clear up several cases that had perhaps languished in the past. 

“We are working these types of cases in real time,” she added. “We encourage people to report any instances of wrongdoing, particularly those involving sexual misconduct. And we work as hard as we possibly can to protect those who make such reports. There are multiple channels through which the reporting can be made and we encourage those who have information to use those channels.” 

In terms of the 2017 allegations, the alleged victim reportedly turned to WHO’s “integrity hotline” in July 2018, and then the case was “tossed around in (Geneva) for months” among officials tasked with misconduct claims, according to emails obtained by the AP.

“It seems our internal process is not efficient enough to address such cases,” AP quoted the former WHO ombudsman as saying, expressing frustration with the inconclusive results of the investigation into that case.

In the Berlin incident, James tweeted about the encounter just hours after it occurred, saying that she had been “sexually assaulted”.

At least one other colleague who said that he witnessed the unwelcome physical approaches, publicly supported her report on social media. According to WHO the investigation of that incident is still ongoing, but the results will not be made public.

New Global Advisory Committee: most members to be appointed by the WHO Director General

Meanwhile, a new 15-member WHO “Global Advisory Committee” to advise the WHO on policies around complaints of abusive conduct would include just five members elected by staff – while the other 10 members would be appointed by Dr Tedros, whose office already controls the entire internal WHO judiciary process.

On Wednesday, WHO circulated an internal memo to staff describing the formation of the new “Global Advisory Committee on formal complaints of abusive conduct.”

According to a copy of the memo obtained by Health Policy Watch, the new 15-member committee “GAC” would advise on WHO’s policies around preventing and addressing abusive conduct.

Elected staff members

It would be composed of five elected staff members, five staff members designated by the WHO Director-General in consultation with WHO’s six regional directors and five “senior staff members” also designated by the Director General “following consultation with the Regional Directors.

That means that like other internal judicial processes within WHO, control of the new advisory committee on complaints of abusive conduct would remain overwhelmingly in the hands of the Director-General himself.

 

Image Credits: Screengrab from WHO presser, WHO campaign brochure.

Child
7.1 Million Children, Adolescents and Youth Died in 2021: UN Estimates

An estimated 7.1 million children and teens up to the age of 24 years died in 2021, according to a United Nations (UN) report released on Tuesday. Sub-Saharan Africa, Central and South Asia bore higher burden of these deaths than other regions. 

This includes five million children under the age of five and 2.1 million children, adolescents and youth aged between five and 24 years’ old. 

The UN Inter-agency Group for Child Mortality Estimation (UN IGME), led by UNICEF, released two reports on 10 January 2023 with the latest data on child mortality and stillbirths. While one report consisted of data on child and youth mortality, the second report estimated that around 1.9 million babies are stillborn every year. According to the World Health Organization (WHO), a stillborn baby dies after 28 weeks of gestation, either before or during birth. 

The reports highlighted that equitable access to high-quality maternal, infant, child and adolescent health care could have prevented these deaths. 

Birthplace matters

The birth location of a child determines its life expectancy, both reports stated. 

More children and youth died in sub-Saharan Africa, and Central and South Asia than in other regions of the world. While the global average of under-five mortality rate in 2021 is 38 deaths per 1,000 live births, it is 74 deaths per 1,000 live births in sub-Saharan Africa.

“Children and youth older than five years old also face the highest probability of dying in sub-Saharan Africa.” 

“More than 80% of under-five deaths and over 70% of all deaths amongst five to 24-year-olds occurred in sub-Saharan Africa and Central and Southern Asia. This unjust burden must be recognised, prioritised and addressed,” the reports added.  

Respiratory diseases, diarrhoea, measles, malnutrition, malaria and newborn conditions are among the top causes of  deaths of newborns and children under the age of five. 

Similarly, the number of stillbirths across the world also differs vastly between regions. Of the 1.9 million estimated stillbirths, around 1.5 million took place in sub-Saharan Africa and southern Asia, according to the UN IGME report. 

“The major causes of stillbirth include pregnancy and childbirth-related complications, prolonged pregnancy, maternal infections such as malaria, syphilis and HIV, maternal conditions especially hypertension, and diabetes, and foetal growth restriction (when an unborn baby is unable to achieve its growth potential and therefore smaller than it should be),” says the WHO. 

Threat to SDGs 

The UN IGME report on child and youth mortality stated that without urgent action, several countries are on the line to miss the Sustainable Development Goals (SDG) 2030 that target ending preventable deaths of newborns and children under the age of five. Achieving this milestone will save 11 million lives across the world, over half of which in sub-Saharan Africa. 

“Without urgent action, 54 countries will not meet the under-five mortality target by 2030 and an even larger number – 63 countries – will miss the neonatal mortality target. Most countries that are off track to meet the SDG target on under-five mortality are in sub-Saharan Africa or classified as low- or lower-middle-income countries,” the report added. 

In 2014, the WHO’s 194 member states endorsed the Every Newborn Action Plan (ENAP), committing to reduce the rate of stillbirths to 12 or fewer per 1,000 total births by 2030. 

“If every country were to meet the ENAP target by 2030, the world would still lose an estimated 13.2 million babies to stillbirth – but, importantly, 2.6 million lives would be saved,” the report pointed out. It also stated that the countries will not meet ENAP’s targets by 2030 if the current pace is maintained.

“Among the 195 countries studied, 131 have already achieved the target and a further 8 are on track to meet it. But 56 countries will miss the target unless urgent and rapid changes to health care systems are made.” 

Immediate intervention crucial

The deaths across ages have decreased since 2000, the reports said. 

“The global under-five mortality rate fell by 50% since the start of the century, while mortality rates in older children and youth dropped by 36 per cent, and the stillbirth rate decreased by 35%. This can be attributed to more investments in strengthening primary health systems to benefit women, children and young people.” 

However, these gains have reduced since 2010 and only through sustained efforts and investments into health systems and services can the situation be improved.

“If swift action is not taken to improve health services, warn the agencies, almost 59 million children and youth will die before 2030, and nearly 16 million babies will be lost to stillbirth.”

To prevent stillbirths, the reports recommended that the evidence and knowledge around the topic be enhanced through better measurement and that every mother and child must be delivered the highest quality of healthcare. 

“Among the 195 countries for which stillbirth estimates are generated, 22 countries have no stillbirth data, and an additional 38 countries lack quality stillbirth data. Many countries with data issues are also high burden: 32% of those without data are in sub-Saharan Africa and 63% are from low- and lower-middle-income countries. Improved evidence and statistics are particularly critical in these settings, where stillbirth rates are likely to be amongst the world’s highest.”

Image Credits: Photo by Alex Pasarelu on Unsplash.

COVID-19 cases have surged in China after the country relaxed various travel and social restrictions.

European countries that plan to introduce “precautionary measures” in light of the huge COVID-19 surge in China should ensure these are “rooted in science, proportionate and non-discriminatory”, the World Health Organization’s (WHO) Europe director has urged.

However, Dr Hans Kluge added that, based on information available to WHO, “the SARS-CoV-2 virus variants circulating in China are those that have already been seen in Europe and elsewhere”.

“We share the current view of the European Centre for Disease Control that the ongoing surge in China is not anticipated to significantly impact the COVID-19 epidemiological situation in the WHO European region at this time,” Kluge told a media briefing on Tuesday.

Dr Hans Kluge

Morocco is the only country so far to have banned flights from China in the wake of its COVID-19 surge, while some other countries including Australia, France, Japan, South Korea and the US, require a negative COVID-19 test for Chinese travellers.

But while Kluge acknowledged that China has been sharing virus sequencing information, he called for “detailed and regular information, especially on local epidemiology and variants, to better ascertain the evolving situation”.

“It is not unreasonable for countries to take precautionary measures to protect their populations, while we are awaiting more detailed information that is shared via publicly accessible databases,” added Kluge.

There is concern that China is hiding the extent of its COVID infections death toll, particularly as it recently narrowed the definition to only cover people with a positive COVID test who died of respiratory failure or pneumonia.

Yet there are widespread reports on social media and elsewhere about the effects of COVID on hospitals, funeral homes and graveyards. 

Airfinity, the independent health modelling body, predicts that China’s outbreak will peak on 13 January with about 3.7 million daily cases, with a second peak in rural areas on 3 March with 4,2 million daily cases, resulting in 1.7 million deaths in the country by April.

Airfinity modelling on China’s COVID-19 cases released in December 2022

“There is likely to be over one million cases a day in China and over 5,000 deaths a day. This is in stark contrast to the official data which is reporting 1,800 cases and only seven official deaths over the past week,” according to an Airfinity statement in late December.

The WHO has long advised countries to use excess mortality data to assess the impact of COVID-19.

Spread of XBB.1.5

Meanwhile, the new XBB.1.5 recombinant virus that is spreading rapidly across the US, is starting to expand in Europe.

Kluge said that in some European countries that have maintained strong genomic surveillance, such as Denmark, France, Germany and the United Kingdom the new XBB.1.5 recombinant virus was being picked up in “small, but growing numbers” and the WHO was assessing its potential impact.

“After three long pandemic years – with many countries grappling with overstretched health systems, shortages in essential medicines, and an exhausted health workforce – we cannot afford more pressures on our health systems,” Kluge concluded.

South Africa’s health minister Dr Joe Phaahla also confirmed on Tuesday that the first XBB.1.5 case had been picked in his country in late December. 

South Africa’s health minister, Dr Joe Phaahla.

However, Phaahla assured a media briefing on Tuesday that there was no indication that XBB.1.5 was “more severe” or caused more hospitalisation.

“Even in the People’s Republic of China, there is no indication that these various sub-variants are more severe in terms of illness, but it’s just the sheer numbers in a huge population, where people are now travelling freely, both in the country and also able to travel out of the China. We believe that the dominant variant of concern in China and in the world remains the Omicron,” said Phaahla, adding that South Africa would not impose any travel restrictions on Chinese travellers.

Image Credits: Flickr.

Pakistan
The UN estimates over 20 million people still require immediate assistance in Pakistan.

World leaders, representatives of international development and humanitarian organizations, and UN delegations gathered in Geneva on Monday to rally financial support for Pakistan’s recovery from the devastating floods that hammered the country last year.

Pakistan has appealed for $16.3 billion to assist it to rebuild the country, and almost half this amount had been pledged by countries attending the International Conference on Climate Resilient Pakistan by Monday evening.

The United States committed an additional $100 million in recovery funding for flood-hit areas, while the European Union raised its total contribution to Pakistan to $500 million. The Islamic Development Bank’s pledge of $4.2 billion is the largest single donation to date.

At their height, the historic floodwaters submerged over a third of Pakistan, directly affecting over 33 million people and pushing nine million to the brink of poverty. Over 1,700 people, a third of whom were children, lost their lives to the torrential rains. More than two million homes were severely damaged or destroyed, along with 8,000 kilometres of roads and 3,100 kilometres of railway tracks. 

Of the eight million people displaced in early October 2022 by the floods that Pakistani Prime Minister Shehbaz Sharif described as a “tsunami from the sky”, 5.4 million remain displaced. The UN says money raised for flood victims is set to run out this month without fresh commitments, leaving millions at risk of disease, illness and malnutrition.

With millions still living near contaminated floodwaters, over 1,000 confirmed cholera cases and 76,000 dengue cases were recorded in 2022. Diarrhoea remains widespread and malnutrition in children continues to increase.

“No country deserves to endure what happened to Pakistan,” UN Secretary-General Antonio Guterres told reporters at a news conference with Sharif on the sidelines of the meeting. “If there is any doubt about loss and damage — go to Pakistan.  There is loss. There is damage. The devastation of climate change is real.”

Guterres: the global financial system is ‘morally bankrupt’

Pakistani Prime Minister Shehbaz Sharif described the flood waters that hit his country last year as “a tsunami from the sky.”

The funding push comes as Pakistan finds itself running out of avenues to turn to for the credit it needs to rebuild the country. Prior to the floods, Pakistan’s economy was already teetering on the brink of collapse, with dwindling foreign exchange reserves and debt default looming large over the country’s balance sheets.

With over 60% of developing nations in “critical” debt, according to the IMF, the conference is shaping up to be a litmus test for how rich countries will respond to the financial needs of the developing world as the impacts of climate change worsen.

Though a historic loss-and-damage fund was agreed to at COP27 in Egypt, it is not yet operational. Strong language on the reform of multilateral development banks was also included in the deal, but no changes have taken place to date.

Pakistan, which is one of the top 10 most affected countries by climate change, plays a negligible role in global warming, emitting less than 1% of global carbon dioxide annually. In the months prior to the floods, Pakistan was caught in a scorching heat wave that caused forest fires and aggravated droughts in the country’s western provinces. Some of the same areas on fire in the early spring were underwater by summer. 

Pakistani Prime Minister Shehbaz Sharif says that “Pakistan simply cannot do this alone”.

“Pakistan is doubly victimised by climate chaos and a morally bankrupt global financial system,” Guterres said. “That system routinely denies middle-income countries the debt relief and concessional funding needed to invest in resilience against natural disasters.”

In August, as the floods were in full swing, the Pakistani government agreed to new terms with the IMF on its foreign debt repayment. The $1.17 billion loan saved Pakistan from default – an outcome that would have made future borrowing more difficult, and likely sparked a recession – but forced the country to accept harsh austerity policies, passing the burden of debt on to ordinary Pakistanis. 

Amid overlapping food and energy crises arising from the Russian invasion of Ukraine and the destruction of Pakistan’s arable land in the floods, Prime Minister Sharif called the requirements imposed by the IMF to pass additional burdens on already struggling people “not in line with the norms of justice.” 

“How could you expect that, after the floods hit Pakistan and almost destroyed everything, we will pass on this imported inflation to the common man and he or she will accept it,” Sharif said.

“The rich can enjoy both worlds whether the price of oil touches $200 or $30 a barrel. And you expect a poor man who is able to meet these two ends with great difficulty will absorb this price hike without any protest? That is not normal.”

Pakistan offers a window into climate change future

Pakistan
The UN estimates 14.6 million people need food assistance, while over seven million children and women need immediate access to nutrition services.

While Pakistan’s situation is particularly acute, its overlapping crises are set to become a common occurrence in poor countries in the path of climate change. Multilateral development banks, Guterres said, need to make available concessional funding and rework their business models to allow countries to deal with extreme weather events without suffering from crippling debt loads. 

“We need first of all to recognize that we presently have a situation in the developing world in which countries are strangled by debt,” Guterres said. “We need to redesign our financial system in order to be able to take into account vulnerability and not only GDP when decisions are made about concessional funding to countries around the world.”

Citing a recent discussion with Kenyan President William Ruto, Guterres noted that his home country of Portugal – whose debt is 117.7% of GDP – is easily able to access loans at interest rates of 4%, while the lowest offer presented to Kenya was 14%. 

“It is very clear that the present system is biased. The system was conceived by a group of rich countries and naturally benefits rich countries,” he said. “It shows that there is a basic injustice in the system and that we need effective reform.”

Despite the painful conditions associated with the IMF loan, Sharif emphasized that Pakistan’s government “will do everything to comply with the terms and conditions” of the programme. Dialogues appealing to the IMF for “compassion” and “breathing space” are ongoing, he said.

“I hope that member states that control the boards of these institutions will be able to implement the kind of reforms that are needed to establish more justice,” Guterres concluded. 

Image Credits: UNDP, UNDP.

The 2022 World Health Assembly.

A high-level council to govern global health emergencies, made up of heads of state and other international leaders, is one of the proposals to be discussed by the World Health Organization (WHO) this year.

It is the first of 10 proposals to strengthen the WHO’s response to health emergencies put forward by WHO Director General, Dr Tedros Adhanom Ghebreyesus, in a document published late last week.

The proposals, distilled from the numerous inputs from member states and global health in light of COVID-19, will be considered by the body’s executive board meeting from 30 January to 7 February.

The executive board develops the agenda for the WHO’s annual World Health Assembly, the body’s highest decision-making forum.

The proposed global health emergency council would be guided by the principles of equity, inclusivity and coherence and “complement the Standing Committee of the Executive Board, and a main committee on emergencies of the World Health Assembly”, according to Tedros’s document.

Its three primary responsibilities would be to address “obstacles to equitable and effective health emergency preparedness, response and resilience (HEPR)”, foster compliance with, global health instruments including the International Health Regulations (2005), and “identify needs and gaps, swiftly mobilize resources, and ensure effective deployment and stewardship of these resources for HEPR”.

Balancing health and economic considerations

The second proposal aims to make targeted amendments to the International Health Regulations to address weaknesses exposed by the COVID-19 pandemic, particularly how to balance often contradictory health and economic considerations.

The third proposal is scaling up universal health and preparedness reviews and strengthening independent monitoring.

Proposal four addresses strengthening the health emergency workforce, while the fifth proposal is aimed at improving global coordination by standardising approaches to the “strategic planning, financing, operations and monitoring of health emergency preparedness and response”.

The other proposals address partnerships, better coordination between finance and health decision-makers and strengthening the Pandemic Fund set up by the World Bank.

The crucial ninth proposal calls for the expansion of funds available for a rapid, sustainable emergency response.

“Drawing on the experience of the ACT-Accelerator, the funding required for the rapid and equitable deployment of medical countermeasures against a pandemic pathogen is in the order of tens of billions of United States dollars,” according to the document.

It calls for the WHO Contingency Fund for Emergencies (CFE) to be expanded for immediate relief, but acknowledges that “an additional financing facility that is capable of disbursing large tranches of funding quickly should be triggered” following the CFE response.

“The triggers for activation of this draw-down facility should be pre-negotiated, transparent and based on the ‘no regrets’ precautionary principle,” it proposes. 

Strengthened WHO

The 10th proposal is for the WHO to be strengthened so that it can be at the centre of the global health emergency and preparedness architecture.

To achieve this, the WHO needs “the authority, sustainable financing and accountability to effectively fulfil its unique mandate as the directing and coordinating authority on international health work,” according to the document.

Should member states adopt a pandemic accord, this would “reinforce the legitimacy and authority of WHO and complement the steps that member states are already taking to ensure sustainable financing of the WHO”. 

The zero-sum conceptual draft of a pandemic accord was discussed by the WHO intergovernmental negotiating body at a meeting in December, with the final draft of the accord to be put forward at the World Health Assembly in 2024.

Explaining the need for the overhaul of the WHO, the document explains that “the fragmented nature of the current modes of health emergency governance, functional systems and financial mechanisms has given rise to a global health emergency preparedness, response and resilience architecture that is often less than the sum of its parts, and which fails to respond rapidly, predictably, equitably and inclusively to health emergencies”.

“It is vital that the world now seizes the chance to do things differently. The devastation caused by COVID-19 has brought a welcome sense of urgency to efforts to strengthen the way the world prepares for, prevents, detects and responds to health emergencies. It is equally vital, however, to ensure that the collective efforts of member states, the WHO Secretariat and partners at national, regional and global levels are coordinated, coherent and reflective of a broad and inclusive participation by all stakeholders.”

Tuberculosis
Baraka, one of ADOPO’s landmine detection rats born in Tanzania, is described as playful and curious. He has two sisters and a brother following in his footsteps.

For months, Sharifa Shomale suffered in silence from tuberculosis, not knowing what was wrong with her. Doctors suspected a viral infection. Then an unlikely hero made a life-saving discovery: a mischievous rat named Hamisi.

DAR ES SALAAM, Tanzania—Every evening, as the call to prayer from the mosque echoes in the twilight from Manzese—a tangled Dar es Salaam slum dotted with flimsily built homes, Shomale routinely swallows a dozen pills. That’s not easy for the 38-year-old mother of three children, but it’s much better than the disease itself.

“I had all TB symptoms such as a bad cough, chest pain, and I was spitting bloody mucus,” she told Health Policy Watch, describing what she later learned were common TB symptoms along with fever, loss of appetite, and weight loss.

When Shomale became pregnant with her fourth child, her symptoms worsened. Yet doctors at Palestina hospital in Dar es Salaam, where she was receiving treatment, suspected she had contracted a viral infection.

Distraught, the visibly sick Shomale started to lose weight. At some point, she feared her unborn baby wouldn’t survive given her ill health.

“The doctor asked me to take an X-ray, but the photo did not provide any clear diagnosis, “she said.

Luckily, a friend advised her to visit the “HeroRats” TB detection facility in Dar es Salaam to have her phlegm checked. To Shomale’s surprise, an African giant pouched rat with a highly developed sense of smell detected mycobacterium within hours of investigation.

“I was very relieved, knowing that doctors would prescribe proper medication and I would stick to the treatment plan,” she said.

Shomale is not alone. Tanzania is among the world’s 30 countries with the highest burden of TB. And yet here, like in other high-burden countries, many people remain undiagnosed due to a historic lack of access to diagnostics that will simply tell them that they have the disease.

A holy grail

Quick and accurate diagnosis of TB has long been an elusive holy grail for clinicians, who describe it as a major barrier to extending treatment to the estimated 10.6 million people infected with the disease in 2021, of which only 6.4 million (60%) were actually diagnosed.

The dearth of diagnostics means that one of the world’s oldest known diseases still ranks as its deadliest too, claiming some 1.6 million lives in 2021, including 187,000 HIV positive people, according to the World Health Organisation’s 2022 Global TB report.

Diagnosis of TB via the age-old technique of sputum smear microscopy, which analyzes a sputum sample under a microscope, is still only accurate about 65% of the time, despite improvements to low-cost LED smear microscopy.

More sophisticated molecular-level diagnosis with tools like GeneXpert have been expanded under initiatives by STOP TB and the Global Fund, but still remain costly and thus out of reach to people in many low- and middle-income communities worldwide.  

Rats have a hypersensitive capacity for detecting odors 

Cars pass through Sharifa Shomale’s Manzese neighbourhood in Dar es Salaam.

In the quest to stop the spread of tuberculosis, scientists in Tanzania are taking advantage of rats’ highly developed sense of smell to detect TB bacteria more rapidly and accurately.

While rats are ill-famed for stealing food in the kitchen, nibbling expensive clothes in the wardrobe, and even spreading diseases, in Tanzania they are now gaining new stature for saving lives.

The giant African poached rats, famous for their  role in detecting landmines due to their light weight, ability to sniff out chemical compounds of explosives and ignore scrap metal, are being trained by APOPO, a Belgian non-profit organisation, to detect TB bacteria and save lives.

At ‘HeroRats’ TB detection centre in Dar es Salaam, where Shomale was successfully diagnosed, a mischievous rat nicknamed Hamisi darted between six split phlegm samples placed in a glass-sided cage.

The rodent momentarily used its nose to hover above a potential TB infection, then scratched the cage’s bottom while rubbing its front paws to confirm a positive diagnosis.

Then a researcher in a white lab coat used a giant syringe to inject a mix of crushed avocado and peanut in a small hole — a treat for the rat’s job well done.

Within minutes of scuttling over the phlegm samples, the playful rat adeptly identified five potential TB cases, APOPO’s researchers said.

Since his birth in 2018, researchers say Hamisi the rat helped save the lives of many patients including Shomale. On a typical work day, Hamisi can examine up to 100 samples before going for a rest in an open-air play cage.

“Rats are very fast, they can examine many samples within a short period of time,” said Joseph Soka, APOPO’s program manager.

Rigorous training

‘HeroRats’ begin training in their infancy.

At the age of four weeks, when he was still learning to open his eyes, Hamisi was exposed to various stimuli, and was conditioned to socialise with humans before he underwent special training to identify TB bacteria, Soka said.

The trained rats were able to screen tuberculosis samples with an accuracy of up to 85%, according to Soka. In contrast, smear microscopy, which also uses mucus from the patient’s lower respiratory tract, has a lower rate of sensitivity, ranging from 20% to 60%, he said.

In combination, the rats can help improve the pace and accuracy of sputum smear diagnosis, he said, noting that “we use the rats to re-evaluate human sputum samples from our partner clinics. One rat can screen a hundred samples in just 20 minutes.”

While a lab technologist can take a few hours peeping through a microscope to detect tuberculosis strains on a cultured phlegm sample, a trained rat can screen dozens of sample in minutes at a cost of as little as two cents ($.02) a sample screen, Soka said.

Despite their skill in detecting tuberculosis, the rats have their limitations since they cannot distinguish between different types of TB strains or identify the particularly dangerous strains that respond to only a few medications, known as multi-drug resistant (MDR) or extremely drug resistant (XDR), APOPO scientists say.

More than 579,770 sputum samples from 337,737 suspected TB cases have been screened since the project started in 2011, APOPO officials told Health Policy Watch.

For Shomale, who finally gave birth to a healthy baby boy, the TB diagnosis motivated her to immediately start treatment and reduce chances to pass on the pathogen to the rest of her family members.

“When I started taking the pills, I was no longer worried about infecting others,” she said.

A heavy burden

Tanzania is among the 30 countries with the highest burden of tuberculosis in the world. According to WHO, 142,000 Tanzanians (253 per 100,000) fell ill with TB in 2018, including 40,000 (28%) that also were reportedly living with HIV/AIDS. 

Among those, however, just 75,828 people received a lab-confirmed diagnosis. This means that some 47% of those people living with TB remained untreated, at risk of dying or transmitting the disease to friends, family and neighbors.

Health authorities in Tanzania have for decades relied heavily on smear microscopy — an outdated diagnostic technique which involves collecting and examining human sputum samples under a microscope.

Critics say positive TB cases are repeatedly going undiagnosed due to the shortage of services in rural areas and the equipment’s high margin of error.

And given the deeply rooted cultural stereotypes and low awareness of chronic diseases afflicting people in rural areas, many TB patients are stigmatized even by members of their own families – who may perceive the patients as “bewitched” rather than ill, bringing a curse upon their local community. 

On the edge of death

Mathew Kaloli writhed in pain and agony. Too frail to get on his feet, the 66-year-old fisherman from the country’s northeastern Bagamoye district suffered from chronic drug-resistant tuberculosis.

Because his diagnosis was delayed, his chances of survival were slim. “My father has lost hope of living,” his son Karim told Health Policy Watch.

An old X-ray photo showed the disease’s devastation to Kaloli’s right lung. Nestling on the chest like a delicate balloon, the lung – which should normally appear white in the photo – looked dark. The X-ray showed the landscape of the chest cavity, scrambled beyond repair.

Unlike Shomale, whose TB diagnosis was positively confirmed quickly after she sought help, Kaloli suffered in silence for many months, to the point where the disease could outwit most antibiotics. 

In an interview with Health Policy Watch, Riziki Kisonga — a pulmonologist at Tanzania’s National Tuberculosis and Leprosy programme, said the fight against tuberculosis requires rapid, innovative, and affordable detecting techniques.

“As an infectious disease that primarily affects the lungs, TB can prove fatal in the absence of timely and comprehensive treatment,” he said.

Patients need to seek treatment

Microscopic view of mycobacterium tuberculosis in the lungs.

Powerful and effective drugs are freely available in public and private health facilities across Tanzania, but TB patients often fail to show up at health facilities to receive them.

While rapid diagnosis is one barrier, it is not the only one. It is common, for instance, for some TB patients to stop taking the drugs when they start to feel better, Kisonga said, even though they may not yet be fully cured.

“If a patient takes the right medication for the right duration as advised by doctors, chances are high he/she can get cured,” he said.

Kisonga urged TB patients to get comprehensive treatment – to the end of a  course, along with using proper cough etiquette to avoid infecting others.

“Early diagnosis and effective complete treatment is the key for cure,” Kisonga said.

For Shomale, the novelty of a life-saving discovery being made by a rat has made a lasting impression..

“I always trap and kill rats at home. I never thought they would someday help doctors find a disease in my own body.”

Image Credits: ADOPO, Rwebogora, Laëtitia Dudous, Roche .

Abortion pills are the most common method of pregnancy termination in the United States, used in more than half of abortion cases in 2020.

CVS and Walgreens, the two largest pharmacy chains in the United States, totaling nearly 18,000 locations nationwide, announced plans on Wednesday to carry the abortion medication mifepristone after the US Federal Drug Administration (FDA) relaxed rules for distributing the pill earlier this week.

The new rule updates FDA labeling to allow any pharmacy that undergoes FDA certification – from independent local stores, to national chains, to telehealth providers – to distribute the abortion pill to patients with a prescription. Since its approval for public use in 2000, mifepristone has been gated behind restrictions limiting its dispensing to a limited number of specially certified doctors and clinics. 

The FDA decision comes as the US continues to grapple with the fallout of the June ruling by the conservative-majority Supreme Court to revoke the federally-guaranteed right to abortion that had stood since the Court’s 1973 ruling on Roe versus Wade. Since the ruling, 12 states have banned abortion beginning from conception. 

The FDA rule does not supersede state laws, meaning its effect will be limited to states that already allow the pill’s use. Walgreens, in its announcement, stressed its distribution of the abortion medication will be “consistent with state and federal laws,” while CVS spokesperson Amy Thibault told USA Today that the company plans to provide mifepristone “where legally permissible.”

Expanding access in the post-Roe era 

Abortion
The US Supreme Court’s overturning of Roe v. Wade triggered major protests around the world.

Despite state-level limitations on the sale of mifepristone, the net result will be to make the medication more widely available for women in states where sales are permitted. The reduced barriers to accessing the drug may also make it easier for women in the 12 states where abortion bans are in place to cross state lines in order to buy the pills legally with a prescription at a pharmacy. 

The pill can be administered in the first 70 days (up to ten weeks) of pregnancy to stop the production of hormones that maintain the interior of the uterus. It is typically used in combination with misoprostol, which then induces muscle contractions that clear the uterus. Misoprostol has never been tightly regulated due to its use in treating a variety of other medical conditions.

Abortion pills are now the most common method of pregnancy termination in the United States, used in more than half of abortion cases in 2020. Following the overturning of Roe v. Wade last year, the medication is in even higher demand, and has become a focal point of the new front of the American abortion wars. 

The FDA decision is the latest in a series of administrative actions by the Biden administration to reduce barriers to accessing abortion services amid pressure from rights groups to shore-up federal protections for women’s bodily autonomy in the post-Roe era. 

The FDA first issued a temporary suspension of the in-person requirement for prescribing mifepristone during the Covid-19 pandemic in response to a lawsuit led by the American Civil Liberties Union (ACLU) – a change made permanent in December 2021. 

With Tuesday’s decision, the last remaining federal requirements to access the abortion pill are a certification process for health providers and their staff, and a consent form that patients complete to acknowledge they are taking the medication for the purpose of having an abortion.

A “common sense decision”

Mifepristone first received FDA approval in 2000.

Leading medical associations, rights groups, and the manufacturers of mifepristone’s brand-name and generic versions welcomed the FDA’s loosening of restrictions as long overdue.

Mifepristone has been used by more than 3.7 million people since the FDA approved the medication over 20 years ago, and while bleeding is a common side-effect, serious complications are exceedingly rare.

“Now, people in states where abortion is legal will be able to get medication abortion with a prescription through their local pharmacy or by mail—just like they can for other equally safe medications,” said Nancy Northup, president and CEO of the Center for Reproductive Rights, in a statement. “This is a commonsense decision that prioritizes science and safety over politics.”

Iffath Abbasi Hoskins, president of the American College of Obstetricians and Gynecologists, called the move “an important step forward in securing access to medication abortion,” saying the group has long advocated for the in-person dispensing requirement to be removed. 

“There is no clinical evidence that in-person dispensing improves the safety of this medication’s outcomes,” she said. “Instead, this requirement unnecessarily restricted patient access to a safe and effective medication.”

Rule change “will not provide equal access to all people”

Abortion
US abortion policies and access after Roe v. Wade. Data reflects situation as of as of January 1, 2023.

Mifepristone has been a focus of regulatory fights between pro-choice and anti-abortion rights groups ever since its approval in 2000, and its newfound centrality to the national abortion access picture is likely to trigger an array of lawsuits from state officials and activist organizations seeking to challenge the FDA’s ruling. 

“Twelve states have banned abortion, and this move will not change anything for the people in those states,” Nancy Northup, president and CEO of the Center for Reproductive Rights, said in a statement. “With abortion under attack in so many parts of the U.S., improving access to care is a public health imperative that can’t wait.”

Among the 12 states that ban most or all abortions, many have included specific provisions targeting mifepristone, including the criminal penalties for medical providers who prescribe the pill to patients. 

Evan Masingill, CEO of GenBioPro, the company which manufacturers the generic version of mifepristone, told Politico that while the FDA’s move was “a step in the right direction” to increase access to abortion care, the policy “will not provide equal access to all people.”

“These are medications that have been lawful for a long time. And it isn’t a question as to whether they’re safe and efficacious. It’s really just the politics,” Nicole Huberfeld, a health law professor at Boston University’s School of Public Health told Vice News. 

Larger companies will take longer to adjust to regulatory requirements 

Walgreens and CVS have not yet announced dates on when they expect to reach full compliance with regulations to distribute the abortion pill.

The first officially approved pharmacy under the new requirements to dispense abortion pills, HoneyBee Health, a telehealth provider based in California, began operating on Wednesday, just one day after the ruling. 

The speed of approval bodes well for small-scale operations like HoneyBee, but the sheer size of national chains like Walgreens and CVS means compliance is likely to take months. As a result, first adopters are likely to be independent pharmacies, physicians, and small- to medium-scale health and telehealth providers.  

A spokesperson for Danco, the company that manufactures the branded version of mifepristone known as Mifeprex, told the New York Times the biggest hurdle is likely to be the implementation of privacy rules that require pharmacies to keep the names of health providers and doctors prescribing mifepristone confidential to prevent retaliation from anti-abortion groups. 

In the polarized and increasingly violent arena of US abortion politics, non-compliance with confidentiality rules could have violent real-world consequences. According to the National Abortion Federation’s 2021 Violence and Disruption Report, bomb threats against abortion clinics jumped 80% from their 2020 levels, and a 54% increase in vandalism at facilities providing the procedure. 

Image Credits: Ajay Suresh, Matt Hrkac, Yuchacz, Guttmacher Institute, Anthony.