Neglected tropical diseases
A man with symptoms of the deadly NTD African trypanosomiasis (sleeping sickness), is examined by Dr Victor Kande in the Democratic Republic of Congo (DRC).

The number of people requiring treatment for Neglected Tropical Diseases (NTDs) decreased from 2.19 to 1.65 billion between 2010 and 2021 – an impressive 25 percent decline. However, interlinked challenges, including the COVID pandemic and, now, accelerating patterns of climate change are putting this progress at risk.  On World NTD Day, we need to recognise these  emerging challenges and look to more integrated approaches.

The impressive 25 percent decrease in the number of people requiring treatment for NTDs and the mounting number of countries that have eliminated at least one NTD are testimony to the progress being made to stamp out some of the world’s most deadly and debilitating diseases – which strike mostly at communities in developing countries and at people living in poverty. 

According to the World Health Organization (WHO), 47 countries have eliminated at least one NTD since 2010, and NTD programmes have performed better in the past year than in 2021.  

But while this progress is admirable, it is too slow for millions of people still living with, or at risk of infection from these 20 viral, parasitic and bacterial diseases considered NTDs which range from river blindness to leprosy, rabies and  more, and continue to defy national and global elimination plans in many parts of the world today. 

Storm clouds on the horizon

Moreover, new challenges like the COVID-19 pandemic and climate change are putting recent progress at risk, threatening to reverse the tremendous gains that have been made over the last few years.

During the pandemic, services for NTDs were the second most frequently disrupted set of health systems services. Looking ahead, changing temperature and rainfall patterns will exacerbate poverty and displace people, and climate change will influence the emergence and re-emergence of multiple NTDs in higher latitudes and altitudes and pose a major risk for communities.

This year’s World NTD Day is an opportunity to revitalise the way we tackle NTDs to not only maintain the progress we achieved so far, but to catalyse better, more efficient, bolder strategies for elimination in the future – harnessing the power of collective action.

The climate threat 

Water shortage in Ethiopia. Population exposure to heat is increasing due to climate change. Globally, extreme temperature events are observed to be increasing in their frequency, duration, and magnitude.

This is especially crucial in addressing the added challenges that climate change poses. 

NTDs are highly influenced by temperature, rainfall, humidity, and other climatic changes, and even small fluctuations can greatly increase transmission and spread, with potentially devastating effects. Climate change is thus threatening the re-emergence of NTDs in many parts of the world  and will likely result in negative health outcomes and disruptions to healthcare systems.

The threat to progress expands beyond NTDs to other infectious diseases. For malaria alone, studies show that climate change could lead to an additional 60,000 malaria deaths per year between 2030 and 2050.

Despite the risks, the world is paying little attention to the climate-health nexus and the impact it could have on the resurgence of NTDs and their transmission. 

Up until now, approaches to address health and climate emergencies have remained largely separate, perhaps partly due to the lack of knowledge and guidance surrounding the health impact of climate change.

The current literature on the intersection between climate and health also is insufficient to guide policy development. This is why countries, world leaders, and all stakeholders involved should prioritise research in this area. By exploring new and under-explored areas of the interface between climate and infectious disease, we can start to tackle the challenge and protect the gains and accelerate progress towards elimination. 

Removing NTDs from the disease control silo

Fulfilling the goal of elimination begins by taking NTDs prevention and control out of isolation and adopting a more integrated approach. At the Global Institute for Disease Elimination (GLIDE) we see the intrinsic value of promoting and adopting cross-disease, cross-border, multi-stakeholder and multi-sector, approaches to innovatively and effectively control, eliminate, and eradicate NTDs.

For this to work in global health, we must make way for more integrated healthcare systems that address preventable infectious diseases of poverty.

The COVID-19 pandemic has exposed the pre-existing cracks in our healthcare systems, spotlighting the dangerous link between NTDs, other communicable diseases, and health emergencies. It has also reinforced the need to address health issues in a more holistic manner. A stronger, more systems-wide approach to health will strengthen surveillance, early warning, and pandemic preparedness.

Mainstreaming NTDs within health systems and primary health care services, and promoting country ownership and accountability is an effective jumping off point, according to WHO’s NTD road map 2021-2023. In fact, this will contribute to sustainable and efficient NTD prevention and control, yielding better health outcomes and program management, and cost-effective solutions. But we must understand the economics of neglected diseases and elimination better in order to develop and refine investment cases in a more holistic way, using the health system and packages of essential health care as an important entry point to this mainstreaming.

Water, sanitation and hygiene as a starting point

Africa and Asia have the least access to basic sanitation facilities in the whole world

Another starting point is to consider cross-sector coordination such as with water, sanitation, and hygiene (WASH) for disease prevention. WHO’s roadmap lays out a plan for effective elimination efforts, citing WASH as one of the key interventions in tackling 18 of the 20 NTDs. Improved access to clean water and sanitation can reduce the transmission of many NTDs, such as schistosomiasis, trachoma and guinea worm which, according to the Centers for DIsease Control and Prevention (CDC), is caused by the parasite Dracunculus medinensis and contracted when people do not have access to safe water for drinking.

There is no vaccine or medicine available against guinea worm. However, eradication is being achieved by implementing WASH-related preventive measures. These include filtering drinking water to remove the water fleas that carry the parasite, providing improved water sources and preventing infected individuals from wading or swimming in drinking-water sources. The measures – supplemented by active surveillance and case containment, vector control and provision of improved water sources – have led to great progress toward eliminating guinea worm, with the number of human cases annually falling from 3.5 million in the mid-1980s to just 13 cases in 2022, poising it to become the second disease in human history that could be eradicated altogether, according to a report last week by the Carter Center. 

Breaking down silos

The elimination of NTDs is feasible, but we need new approaches. 

The upcoming 28th Conference of the Parties (COP28) to the United Nations Framework Convention on Climate Change (UNFCCC), hosted by the United Arab Emirates (UAE) between 30 November and 12 December 2023, will be an opportunity for world leaders to both recognise and commit to addressing the health impacts of climate change.

The World Health Assembly’s NTD road map 2021-2030, meanwhile, emphasizes the importance of integrating NTD programs and establishing links with other sectors such as education, nutrition, WASH, animal, and environmental health. We also must increase spending on NTD control and elimination, strengthening the case for investment. 

There is an intimate connection between the health of individuals and the interlinked, cross-boundary events across the globe. 

Recognizing this, we need an approach that engages  all sectors and geographies  in ways that facilitate collaboration, stimulate innovation and continued investment and, finally, by staying committed to delivering a world free of NTDs. 

____________________________________

 

Simon Bland is the CEO of the Global Institute for Disease Elimination (GLIDE), based in the United Arab Emirates (UAE) and focused on accelerating the elimination of four preventable infectious diseases –  malaria, polio, lymphatic filariasis, and river blindness – by 2030 and beyond. Founded in 2019 as the result of a collaboration between UAE President, His Highness Sheikh Mohamed bin Zayed Al Nahyan, and the Bill & Melinda Gates Foundation, GLIDE works to elevate awareness and engagement, advance elimination strategies, and foster and scale innovation for disease elimination and eradication.

 

Image Credits: DNDi, Oxfam East Africa, Deep Knowledge Group.

Last year’s World Health Assembly mandated the secretariat to look into a replenishment fund.

An influential sub-committee of the World Health Organisation (WHO)’s Executive Board (EB) has greenlighted a proposal by the cash-strapped global body’s Secretariat to seek additional funds via a replenishment fund, that would be filled by voluntary donations from both member states and philanthropies recruited at high-profile events.

In its report published on Monday just as the WHO’s Executive Board’s began a week-long meeting, the Programme, Budget and Administration Committee (PBAC), accepted that a replenishment fund could provide an avenue for flexible funding that the WHO so desperately needs.

“The committee acknowledged WHO’s need for more flexible, predictable and sustainable financing and considered that a replenishment mechanism provided a possible solution, especially for chronically underfunded areas of the organization’s programme budget,” according to the report, which concluded the deliberations of the three-day meeting of the PBAC last week.

The Global Fund to fight AIDS, Tuberculosis and Malaria raised $15.7 billion in its ‘replenishment drive’ last year, while Gavi, The Vaccine Alliance as well as the World Bank and other UN-backed global organisations also run replenishment fundraising drives to attract additional funds from donors. 

Last year’s World Health Assembly mandated the WHO Secretariat to explore a replenishment fund based on six principles, including that it is driven by member states, allows flexibility in allocation, covers the base budget, and aligns with the WHO’s resolutions.  

Funding crisis

The Executive Board is now expected to consider the proposal further this week in a series of discussions on improving WHO’s financial sustainability.  A nod by the EB would pave the way for a full-fledged vote by the World Health Assembly in May.  

At the EB’s opening session on Monday, Director General Dr Tedros Adhanom Ghebreyesus confirmed that he expected that the proposal for a replenishment process would be submitted to member states for consideration.

“We recognize that with increased flexibility and sustainability come increased expectations for transparency, efficiency, compliance and accountability. All of this leading to results,” said Tedros.

Only around one-fifth of the WHO’s budget comes from members’ countries’ “assessed contributors” (calculated on their GDP), with the rest being made up from donations. But the donations are usually tied to particular programmes, inflexible and can be withdrawn at any time.

At last year’s World Health Assembly, member states agreed to increase their contributions to cover half of the WHO’s budget. This year, members’ annual contributions are slated to be increased by around 20%.

However, even when member states increase their contributions, there will still be a gaping shortfall, obviously undesirable given disease outbreaks and other demands.

Developing the replenishment option

Recommending that the executive board accepts the replenishment mechanism, the PBAC has advised the secretariat to develop the proposal further by examining “replenishment mechanisms established by other global health organizations and [analysing] the advantages and disadvantages of the various systems”.

It also recommended that the “funding envelope for a replenishment mechanism should be based on the base segment of the programme budget, minus approved assessed contributions”. 

Still up for discussion is whether the fund will be based on the budget over one (two-year) budget cycle or two (four-year).

More money for country offices

PBAC has also recommended that the WHO secretariat consider further increases to its country operations rather than head office and regional structures. However, while the secretariat confirmed its commitment to strengthen country offices, it said that this would only be possible “gradually over time”.

The WHO secretariat told PBAC that the main reason for the uneven financing of its programmes was “the extremely tight earmarking of the funds it received”. Director-General Dr Tedros Adhanom Ghebreyesus told the committee that member states’ agreement to an increase in assessed contributions would “make all the difference”.

In response, the committee proposed that the Secretariat should “improve the persistent uneven financing across programmes, major offices and levels of the organization, including by distributing undistributed funds”.

As far as the 2024/25 WHO budget is concerned, PBAC has recommended that  member states should have until 10 February “to study and provide feedback on the programme budget digital platform” to allow proper consideration of the proposed budget ahead of the World Health Assembly in May.

Pandemic
A healthcare worker wearing PPE disinfecting a street in the early days of the COVID-19 pandemic.

The World Health Organization’s Emergency Committee on the COVID-19 pandemic and Director General Dr Tedros Adhanom Ghebreyesus both agree: the event continues to constitute a public health emergency of international concern (PHEIC).

The UN health agency agreed on Monday that ending the state of international public health emergency over the coronavirus would be premature even after three long years since its appearance upended the world of normality as we knew it three years ago.

Tedros said in a statement that he concurs with the advice offered by committee in its report based on a closed videoconference on Friday. He acknowledged the committee’s views that the COVID-19 pandemic is “probably at a transition point” that must be navigated carefully while ensuring the world is able to mitigate the potential negative consequences.

“Achieving higher levels of population immunity globally, either through infection and/or vaccination, may limit the impact of SARS-CoV-2 on morbidity and mortality, but there is little doubt that this virus will remain a permanently established pathogen in humans and animals for the foreseeable future,” the committee reported.

“As such, long-term public health action is critically needed,” it said. “While eliminating this virus from human and animal reservoirs is highly unlikely, mitigation of its devastating impact on morbidity and mortality is achievable and should continue to be a prioritized goal.”

pandemic
Personal protective equipment was essential to protect healthcare workers during the pandemic

Seven pandemic recommendations

As a result of his decision, Tedros advised nations to:

  1. Maintain momentum for COVID-19 vaccination to achieve 100% coverage of high-priority groups.
  2. Improve reporting of SARS-CoV-2 surveillance data to WHO
  3. Increase uptake and ensure long-term availability of medical countermeasures.
  4. Maintain strong national response capacity and prepare for future events
  5. Continue working with communities and their leaders to address the infodemic
  6. Continue to adjust any remaining international travel-related measures and do not require proof of vaccination for international travel
  7. Continue to support research for improved vaccines that reduce transmission and have broad applicability

The committee said moving forward past the PHEIC will require a focused commitment by WHO and its 194 member nations, along with other international organizations, put in place “systematic, long-term prevention, surveillance, and control action plans.”

The committee members, whose statement comes on the three-year anniversary of the determination of the COVID-19 PHEIC in January 2020, said it agreed the world is in a better position than it was during the peak of the Omicron transmission a year ago, yet more than 170,000 COVID-19-related deaths have been reported globally in the past eight weeks.

It agreed surveillance and genetic sequencing declined globally, making it more harder to track known variants and detect new ones, while health systems are struggling with COVID-19 and caring for patients with influenza and respiratory syncytial virus (RSV), health workforce shortages, and fatigued health workers.

pandemic
Investment in strong health systems is key to pandemic=proofing the world.

WHO asked to study impact of ending pandemic

Vaccines, therapeutics, and diagnostics have been and remain critical in preventing severe disease, saving lives and taking the pressure off health systems and health workers globally, it said, but “the COVID-19 response remains hobbled in too many countries unable to provide these tools to the populations most in need, older people and health workers.”

Some 13.1 billion doses of COVID-19 vaccines have been administered, with 89% of health workers and 81% of adults older than 60 years completing the primary series, WHO said.

“COVID-19 remains a dangerous infectious disease with the capacity to cause substantial damage to health and health systems,” the committee said, adding that has asked the WHO Secretariat to provide an assessment of the regulatory implications for developing and authorizing vaccines, diagnostics, and therapeutics if the PHEIC were ended sometime “in the coming months.”

Image Credits: Photo by Maksym Kaharlytskyi on Unsplash, Tehran Heart Centre .

WHO Director General Dr Tedros Adhanom Gehebreyesus (left) and Didier Houssin, chair of the WHO Emergency Committee. on 30 January 2020, when the COVID International Health Emergency was first declared.

The World Health Organization’s Emergency Committee on the COVID-19 pandemic was meeting Friday evening – with mixed signals emerging about whether the expert advisory group would recommend that the global health agency end the state of international public health emergency over the virus whose emergence stunned the world a little more than three years ago.

At a press conference in December 2022, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed hopes that the emergency that he first declared on 30 January, 2020, under WHO’s International Health Regulations, could finally be concluded sometime in 2023.

But in his remarks to the Emergency Committee’s 14th meeting, the WHO Director General hinted for a second time this week that the time may not yet be ripe – as cases of new infection increased again worldwide only recently and a new wave of the virus continues to rip through China shortly after strict lockdown policies were finally relaxed.

“As we enter the fourth year of the pandemic, we are certainly in a much better position now than we were a year ago, when the Omicron wave was at its peak, and more than 70,000 deaths were being reported to WHO each week,” said Tedros in his remarks at the closed meeting, reported by WHO in a press release.

“When you last met in October, the number of weekly reported deaths was near the lowest since the pandemic began – less than 10,000 a week,” he added.  “However, since the beginning of December, the number of weekly reported deaths globally has been rising.”

China trends create a second level of concerns

Following a massive wave of protests in autumn 2022, China lifted most of its COVID restrictions – which had been among the strictest in the world.

In addition, Tedros noted, the lifting of COVID restrictions in China has led to a spike in deaths in the world’s most populous nation, whose citizens were poorly protected by vaccinations as well as having low natural immunity thanks to months of social isolation.

“Last week, almost 40 thousand deaths were reported to WHO, more than half of them from China,” Tedros said. “In total, over the past eight weeks, more than 170,000 deaths have been reported. The actual number is certainly much higher.”

Earlier this week, Tedros also expressed his mixed feelings about declaring an end to the pandemic even more bluntly, saying: “While I will not preempt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” he said, speaking at WHO’s weekly press briefing.

“While we’re clearly in better shape than three years ago when this pandemic first hit, the global collective response is once again under strain.”

In fact, after reaching a peak in mid-December, the wave of new cases in China and worldwide have been declining for the past month – both according to WHO data and other data monitoring platforms. However, in light of the reduced amount of COVID testing worldwide, the confirmed case count is an increasingly unreliable measure of true cases.

“Surveillance and genetic sequencing have declined dramatically around the world, making it more difficult to track known variants and detect new ones,” Tedros told the committee at the outset of Friday’s meeting.

Revolution in vaccines, treatments and diagnostics has not reached everyone

Related to that, the global response to COVID remains “hobbled” because “powerful, life-saving tools are still not getting to the population that need them most – especially older people and health workers, Tedros said.

“Many health systems around the world are struggling to cope with COVID-19, on top of caring for patients with other diseases including influenza and RSV, and with work shortages and fatigued health workers.

“And public trust in the safe and effective tools for controlling COVID-19 is being undermined by a continuous torrent of mis- and disinformation.”

It was unclear as to whether the committee’s deliberations would continue into the weekend, or when their conclusions will finally be announced.

However, there was speculation that their report might only be published on Monday, when the WHO Executive Board, WHO’s governing body, begins its first annual round of meetings for 2023.  Among the nearly 50 items on the week-long agenda are a raft of reports and recommendations on strengthening global preparedness and response to health emergencies.

The WHO Public Health Emergency of International Concern (PHEIC) was declared in the framework of the 2005 International Health Regulations, which constitute a legally binding agreement between WHO member states regarding emergency outbreak and response. In March 2020, Tedros also declared that the emergency also constituted a “pandemic” – although there is in fact no legal provision for a pandemic declaration in the IHR.

However, the weaknesses in the IHR system of outbreak alerts, notification and resonses, highlighted by the faltering and inconsistent reponse to the COVID pandemic, have paved the way for major reconsideration of global pandemic response frameworks, with debates over a new pandemic treaty, as well as IHR revisions, set to continue throughout 2023 and into 2024.  See related story here:

Governing Pandemics Snapshot

 

Image Credits: Twitter: @WHO.

nuclear
A Nuclear powerplant in Belgium.

The World Health Organization (WHO) on Friday  released an updated list of medicines that should be stockpiled in the event of a radiological and nuclear emergency, along with new policy advice in the event of such an incident.

“Preparedness for radiation emergencies is consistently reported as the weakest area of preparedness in many countries,” the 66-page report said.

This newest report updates the one released over 15 years ago, in 2007, and thus includes a host of new pharmaceutical developments. 

“In radiation emergencies, people may be exposed to radiation at doses ranging from negligible to life-threatening. Governments need to make treatments available for those in need – fast,” said Dr Maria Neira, WHO Acting Assistant Director-General of the Healthier Populations Division. 

“It is essential that governments are prepared to protect the health of populations and respond immediately to emergencies. This includes having ready supplies of lifesaving medicines that will reduce risks and treat injuries from radiation.”

Added Dr Mike Ryan, Executive Director of WHO’s Health Emergencies Programme: “This updated critical medicines list will be a vital preparedness and readiness tool for our partners to identify, procure, stockpile and deliver effective countermeasures in a timely fashion to those at risk or exposed in these events.”

Radiological or nuclear emergencies could occur at nuclear power plants, medical or research facilities or be the result of accidents during transport of radioactive materials, WHO explained. In addition, these emergencies could be the result of a malicious event, such as a nuclear bombing.

To date, there were two massive nuclear incidents: The 1945 atomic bombings of Hiroshima and Nagasaki by the United States, the consequences of which have been continually studied. There was also the 1986 accident at the Chernobyl nuclear plant in Ukraine – the largest uncontrolled radioactive release in history.

Former Russian President Dmitry Medvedev warned this month in yet another Telegram post that a defeat of Russia in Ukraine could trigger a nuclear war.

“The defeat of a nuclear power in a conventional war may trigger a nuclear war,” Medvedev wrote. 

Exposure to high doses of radiation can have severe consequences on a person’s long-term health or lead to immediate or early death. As such, aside from generic supplies and materials used for any type of emergencies, stockpiles should include medicines that either prevent or reduce exposure to radiation, WHO explained. 

Only a handful of recommended medicines 

There are only a handful of specific drugs that have been proven effective in the treatment of over-exposure to radiation and these are included in the report. They include: stable iodine; chelating sand (decorporating agents); cytokines used for mitigation of damage to the bone marrow; and medicines to treat vomiting, diarrhea and infections.

“One of the most serious outcomes of over-exposure to radiation is acute radiation syndrome (ARS), which manifests as a haematopoietic syndrome”. The latter, also called bone marrow syndrome, impacts blood cell production and in cases of acute poisoning, can lead to death through infection or hemorrhage.  

“Depending on the severity of the exposure may further progress as gastrointestinal, cardiovascular and neurological syndromes,” the report states. However, the WHO recommendations only include treatments of haematopoietic and gastrointestinal syndromes, “as cardiovascular and neurological syndromes are considered non-salvageable and require only palliative care.”

Blocking agents such as stable iodine, could be used to block the uptake of radionuclides in the body, the WHO report added. Other agents like Prussian blue are applied to remove radioactive ceasium from the body. Calcium or zinc diethylenetriaminepentaacetic acid can treat internal contamination with transuranium radionuclides.

“These and other elements of such stockpiles should be made rapidly available in case of radiation emergencies,” wrote WHO. 

Bone marrow syndrome – emerging treatments

In the case of haematopoietic, or bone marrow syndrome, radiation attacks all three blood lineages – white and red blood cells and platelets. 

Low white blood cell count weakens the immune system, making an individual vulnerable to infection. Red blood cells carry oxygen to the body and platelets are responsible for coagulation, which prevents bleeding, explained Yaky Yanay, CEO and president of Pluri – an Israeli-based biotech firm developing an injection of placenta cells for the treatment of ARS. 

The treatment has been approved by the United States Food and Drug Administration as an “Investigational New Drug” (IND) for use in the event of a nuclear incident – although it is not yet mature enough to be considered for the WHO list of recommended medicines. 

The WHO report notes, however, that researchers are making progress on developing novel treatments, although none of them have been approved by the global health agency for use in a nuclear emergency. 

WHO: Stockpile based on population size

WHO stressed that a country’s nuclear medicines stockpile should be based on reliable data for national risk profiles, the size of the population and available resources and capabilities of their health system. 

Finally, WHO called on national health authorities, health-care facilities, pharmaceutical suppliers and logistics, civil defense and emergency services to be leveraged in the event of an emergency. These teams should be coordinated in advance to be able to function effectively in the event of a nuclear incident. 

Image Credits: Photo by Frédéric Paulussen on Unsplash.

Standing ovation at the close of the special World Health Assembly session 1 December 2021, in which member states agreed to negotiate a new pandemic accord.

A briefing series on the status of moves to reform the global system of pandemic preparedness and response launches today, just ahead of the WHO Executive Board review of progress next week. Looking back at 2022 and forward into 2023, this series by the Global Health Center of the Geneva Graduate Institute, published in collaboration with Health Policy Watch, provides an update on the progress so far in the WHO-led negotiations over a new pandemic treaty.  It also looks at the progress in revisions to the existing emergency rules of the International Health Regulations (IHR) – while considering what could happen next. The complete “Governing Pandemics Snapshot”, also includes briefings on reforms being considered in the financing of pandemics as well as the rules around pathogen access and benefit-sharing. 

Pandemic treaty: tough political negotiations ahead 

By Daniela Morich

Following a milestone World Health Assembly decision in late 2021, WHO Member States have been negotiating an international agreement on pandemic prevention, preparedness and response to strengthen global capacities and resilience for future pandemics.

The year 2022 was the year for the advance of these pandemic treaty talks with the establishment of a formal process, a strict timeline, and initial discussions on principles. In 2023, negotiations will shift from broad consultations to tough politics.

The Covid-19 pandemic brought to the surface the shortcomings of global health governance for emergencies and accelerated discussions to reform it. At a special WHA session in late 2021,  the second-ever convened by the World Health Assembly, WHO Member States agreed to establish an intergovernmental negotiating body (INB) to negotiate a new “instrument” to strengthen pandemic prevention, preparedness and response – or, a pandemic treaty.

The INB initiated its work in early 2022 and is to present the outcome of the negotiations to the 77th World Health Assembly (WHA) in May 2024. This is an ambitious timeline for a complex international rule-making process, especially as it will run in parallel to the process to revise the International Health Regulations (IHR), a pre-existing WHO instrument that governs the cross-border spread of infectious disease.

Nonetheless, the INB is moving forward and achieved two mid-term milestones in 2022. In July, at the second INB meeting, Member States agreed that the instrument should be legally binding, which suggests countries are ready to accept new international obligations to improve pandemic prevention and response. In addition, the INB engaged in intensive intersessional consultations to seek input not only from governments or well-established experts – the traditional protagonists of international rulemaking – but also from civil society organizations and the public. Despite these efforts, commentators have argued that the process is still not as inclusive as it should be. As work on the instrument progresses, negotiators should expect more demands to expand meaningful participation of stakeholders beyond governments.

The INB’s Bureau (six countries elected to lead the process) released the ‘conceptual zero draft’ (CZD) ahead of the third meeting of the INB, which took place in December 2022. The CZD –which can be seen as the first rough draft of the accord – brought to the negotiating table a broad set of issues and highlighted a collective willingness to ensure a more equitable response to future threats. It also reflected tough divisions on several issues, in particular, intellectual property (IP), pathogen- and benefit- sharing, One Health, financing and accountability, which will likely become more visible and contentious as negotiations move to the next phase.

At the conclusion of the gathering, Member States directed the INB Bureau to develop the ‘zero draft’. Delegates strongly encouraged the Bureau to move away from the vague and aspirational language of the CZD and to present clear legal provisions and definitions, including one for ‘pandemic’, for Member States to negotiate in earnest.

The INB Bureau is expected to circulate the zero draft in early February 2023. At this stage, the negotiation process will likely shift from a consultation and information gathering process to become a more politicized, polarized and consequential debate. The time available to negotiators is constrained. The 2023-2024 agenda includes 6 additional INB meetings scheduled over 14 months in addition to meetings of the drafting groups, with the IHR revision process unfolding in parallel. Considering the complexity of the issues on the table, the existing divisions between Member States, and the limited time available to negotiators, achieving meaningful progress in this new highly-political phase is the tall order for 2023. 

An existential moment for the International Health Regulations

Dr Hiroki Nakatani, chairman of the May World Health Assembly, applauds the WHA decision to revise the International Health Regulations.

By Gian Luca Burci

While negotiations on a new pandemic instrument continue in 2023-24,  the International Health Regulations (IHR) remain  the sole global legally-binding instrument devoted to the prevention and control of the international spread of disease – and revisions to those are already underway.  Can the two parallel processes complement each other or will they add new layers of confusion?  That is the challenge negotiators and member states will face. 

Although considered an essential component of the global health security toolbox, the IHR attracted severe criticism and allegedly low compliance during the COVID-19 pandemic. The momentum towards a new “pandemic treaty”, beginning in late 2020, was in part a reaction to the perceived weaknesses and limitations of the IHR. 

The difficult and sometimes confusing discussions in the Working Group on strengthening WHO preparedness and response to health emergencies created by the 74th World Health Assembly in 2021 to discuss reforms, ultimately led to a WHA decision in December 2021 to launch negotiations on a new legal instrument (“pandemic treaty”) to be adopted by 2024. 

Then, in 2022, attention turned back to the IHR as member states sought faster solutions for the most burning issues that had surfaced during the pandemic – particularly around outbreak reporting and IHR compliance. As a result, a complex IHR amendment process is also now underway. The two processes (IHR revisions and pandemic accord) are thus now proceeding in parallel, with hard decisions still to be made on the issues that the revised IHR will tackle – as compared to the new pandemic accord.  

Negotiations to amend the IHR in 2023/2024 raise an existential question about their raison d’etre: should they retain their technical, operational character, or expand significantly to address highly political questions such as those on international assistance, equity and access to technologies for disease outbreaks?

The US broke the ice by proposing its own substantial set of amendments in January 2022, and successfully winning agreement at the 75th WHA in May 2022, to both adopt a set of limited technical IHR amendments and to open up a broader process for further amendments. 

The WHA thus launched negotiations towards “targeted amendments” of the IHR with the same 2024 deadline for WHA adoption as the new pandemic accord. Member States submitted their proposed amendments by 30 September 2022 and an expert “review committee” analyzed them and presented its recommendations to the Director-General in January 2023.

A Working Group open to all Member States will work from February 2023 towards a negotiated package. The process is unusual compared to other intergovernmental negotiations, in that states hardly ever place on the table all their proposed amendments at the outset; the initial US disclosure of all its amendments, however, required a similar treatment for other states and made that approach inevitable.

Wildly diverse amendments but a few trends emerge

A patchwork of national rules around international travel, vaccines and border controls were a feature of the COVID pandemic, highlighting the inconsistent application of key IHR provisions aimed at ensuring international trade and travel during health emergencies.

The outcome of the first phase of this process is a massive aggregation of wildly diverse amendments (available here) proposed or supported by almost 100 states. They range from focused technical amendments to far-reaching changes. Despite their diversity, a few trends emerge dividing Global South and Global North countries. The most political proposals, coming in particular from the African Region, Bangladesh and India, aim at ensuring equitable access to vaccines, distributed manufacturing capacities, technology transfer, limitations on patenting and sustainable financing of national capacities. 

These proposals reflect the North-South divide that we have been witnessing in the recent treaty conferences on climate change and biodiversity and are clearly also a consequence of the inequities in access to life-saving medical countermeasures displayed during the COVID-19 pandemic. 

Other proposals, in particular from the European Union, the Eurasian Economic Union (submitted by the Russian Federation) and the United States, aim at strengthening the IHR within their current approach, e.g. by tightening compliance and accountability for information sharing, encouraging the sharing of genetic sequence data and through the use of digital technologies.

Two negotiating processes unfolding at the same time

The challenge in reaching an agreed package in time for the 2024 WHA is increased by the unprecedented parallel unfolding of two negotiating processes with the same timeline, where countries will probably submit the same types of proposals for both instruments to secure an overall favorable outcome.  An important point in this respect that is often overlooked is that amendments to the IHR will in principle enter into force at the same time for all its 196 parties, whereas the pandemic instrument – since it will likely be an international treaty – will enter into force once a critical mass of countries has ratified it and only for them, with new countries joining once they ratify. 

The broad range of proposals for the pandemic instrument and the likelihood that the US will eventually not ratify it may actually lead Global South countries to prioritize the IHR for some of the most ambitious proposals. This possibility raises one final issue. Currently, the IHR is  essentially an operational instrument to coordinate outbreak prevention and control and depoliticize WHO’s role in managing them. There is no emphasis on equity, assistance or international cooperation. Amendments proposed by Global South countries would transform it into a regulatory and transactional instrument with a more political role for WHO and differential treatment for developing countries to improve equity in the availability of health technologies. Fundamentally, negotiators will have to decide what they want the IHR to be – and if the IHR is expanded to encompass the issues of health equity then what role would the new pandemic instrument play? 

For essays on financing pandemics and pathogen and benefit sharing, see the full Governing Pandemics Snapshot here. This is the first in a periodic series of updates to be published during the year. 

About the authors

Pandemic
Daniela Morich is Manager and Adviser of the Governing Pandemics initiative at the Global Health Centre, and a lawyer with experience in multilateral negotiations. 
Pandemic
Dr Gian Luca Burci is Adjunct Professor of International Law at the Geneva Graduate Institute. He was a member of the IHR Review Committee that completed its expert analysis of the proposed IHR amendments in January 2023. He co-leads the Governing Pandemics initiative.
Pandemic
Dr Suerie Moon is Professor of Practice and Co-Director of the Global Health Centre, and co-leads the Governing Pandemics initiative. 
Pandemic
Adam Strobeyko is a Hauser Global Fellow at NYU Law and was a Doctoral Researcher for the Governing Pandemics initiative. 
Pandemic
Moeen Hosseinalipour is a master’s student in global health and international affairs at the University of Geneva and Geneva Graduate Institute, and a research assistant for the Governing Pandemics initiative. 

Image Credits: Geneva Graduate Institute.

WHO only published the guidelines for COVID-19 self-tests in March 2022.

Most Africans could not get a COVID-19 test unless they were hospitalised or could afford to pay a private laboratory for a pricey test – yet rapid tests were being dished out free in the US and Europe.

High prices, slow regulatory approval, and outdated ideas about self-testing were some of the barriers that prevented low and middle income countries, particularly in Africa, from getting COVID-19 tests, according to a forthcoming report from the People’s Vaccine Alliance.

And these problems will repeat themselves in the next pandemic unless there are systematic global and regional efforts to ensure better access to diagnostics, according to Dr Fifa Rahman, lead author of the report.

“Most African countries were reliant on Cepheid’s GeneXpert machines to run PCR tests, but some of the patents, for example for the expensive cassettes, run until 2037,” said Rahman, the principal consultant at Matahari Global and the civil society representative at the ACT Accelerator.

“Then there are different patents for the doors, and other things. If we have a pandemic before 2037, and we know that space between pandemics is shrinking, then African countries are going to be reliant on Cepheid again,’ said Rahman.

Dr FIfa Rahman

WHO diagnostics resolution

Eswatini, on behalf of the Africa region, has proposed a resolution on diagnostics that will be presented to next week’s World Health Organization (WHO) executive board (EB) meeting. It proposes a range of measures to boost access to diagnostics, including support for the local manufacturing of tests, and is likely to be put forward by the EB for discussion at the World Health Assembly in May.

“The reliance [on imported diagnostic machines] is something that really needs to sorted, but there also need to be African-made, automated PCR machines, in conjunction with automatic [patent] waivers during pandemics,” said Rahman.

The initial cost of each rapid test was $2.50, and barriers to African companies producing the tests including a lack of the basics to construct these tests – the plastic, the extraction tubes, the cassettes  – 

The report, due for imminent release on the People’s Vaccine Alliance website, proposes increased investment for the local production of diagnostics along the entire pipeline, to reduce reliance on foreign supplies, diversification of molecular platforms to reduce reliance on patented technologies and monopolies, and the expansion of the WTO June 2022 TRIPS ministerial decision to include diagnostics.

But Rahman is also wary of country dependence on WHO processes, pointing out that the regulatory process within the global body had delayed access to COVID tests because it required guidelines to be published before manufacturers could apply for emergency use listing. In addition, some WHO officials also wanted a feasibility study on self-tests.

“The WHO finally published the [self-test] guidelines in March of 2022, which is of course too late, as manufacturers could only apply for regulatory approval after that, and that takes a long time,” said Rahman.

Three steps to fast-track tests

The report proposes three key steps to fast-track diagnostics ahead of the next pandemic.

First, regions need to ensure that they improve their regulatory expertise to lessen their dependence on the WHO.

“Africa CDC buffing up regulatory capacity is essential, so that they don’t have to wait for WHO. Essentially, if WHO doesn’t have the resources to expedite the processes, regions need to do that themselves. They need to ensure that they can take decisions regionally. So they need to fund the degrees and training to create that regulatory expertise before the next pandemic,” says Rahman.

Second, countries also need national diagnostic plans to come into force as soon as possible, and technical experts are on hand to assist to draft those implementations plans. 

The third measure is one that Rahman describes as “more philosophical” as it involves a shift away from seeing diagnostics simply in terms of PCR tests for the sake of surveillance and data, to factoring in all kinds to ensure wider access nd equity – including rapid tests that can be easily distributed by community health workers.

“A lot of leaders see PCR tests as the gold standard in terms of surveillance and data, but if a PCR lab is 60 kilometres away from a village, tand a person doesn’t have time to come to the lab to get a PCR test, a self test is really the best solution,” says Rahman.

Diagnostics to prevent antimicrobial resistance

There is an urgent need for investment in diagnostics to prevent antimicrobial resistance.

Earlier in the week, a report published by Health Action International (HAI) has appealed for urgent investment in the development of effective diagnostics to fight antimicrobial resistance (AMR).

“Currently, treatment decisions are often made without diagnostic tests, increasing the chance that an ineffective therapy could be prescribed, for example, an antibiotic to treat a viral infection, or a bacterial infection resistant to that drug,” according to the ‘Diagnostics to treat AMR’ report.  

“In the UK, for example, 70-80% of all antibiotics are prescribed in the community and 60% are for respiratory tract infections (RTI). Twenty percent of RTI prescriptions are thought to be unnecessary or inappropriate as RTIs are often viral so antibiotics are not required.”

HAI proposes the development of diagnostic tests to determine the broad type of infection – bacterial, viral, or fungal; identify the specific pathogen causing an infection and to identify the antimicrobial susceptibility of a pathogen.

A number of such tests already exist, according to HAI. For example, Abbott’s Afinion test can detect an inflammatory biomarker CRP in the blood to indicate if a bacterial infection is likely, which has a turnaround time of four minutes.

“For health systems to manage the challenge of AMR and enhance antimicrobial stewardship, the development of more accurate and rapid diagnostics for a range of clinical indications remains a priority,” argues the report.

Image Credits: Maxpixel, DNDi.

Outbreak
Africa is making progress against COVID-19, but Dr Matshidiso Moeti, WHO Regional Director for Africa, urged countries to remain on alert.

The first three weeks of 2023 were encouraging for the African continent’s fight against COVID-19. With cases down 97% year-on-year since the same period in 2022, hospitalizations for severe illness and deaths from the virus decreased significantly, the World Health Organization’s African Regional Office said.

“For the first time since COVID-19 shook our lives, January is not synonymous with a surge,” said Dr Matshidiso Moeti, WHO Regional Director for Africa, adding the continent hopes to transition out of “emergency response mode” as the fourth year of the pandemic kicks off.

But with an ever-growing crop of variants circulating, an uptick in cases in South Africa, Tunisia and Zambia, and the overall drop in reported COVID-19 cases partially attributable to low testing rates, Moeti urged African states to remain on guard against the virus.

“It is important that countries stay alert and have measures in place to effectively detect and tackle any upsurge in infection,” she said.

As the threat of COVID-19 comes under control, new dangers have emerged from a diphtheria outbreak in Nigeria and a cholera epidemic with Malawi as its epicenter. The outbreaks have already taken 38 lives in Nigeria, and 583 in Malawi.

Diphtheria and a mystery flu hit Nigeria

Africa CDC acting director Dr. Ahmed Ogwell Ouma said the cholera outbreak must be stopped.

At its weekly press briefing on Thursday, Africa CDC said the diphtheria outbreak had spread to four Nigerian states that do not share borders. Vaccines and treatments exist for the virus, but officials said the rapid spread of the disease constitutes a major public health concern for the African continent.

Diphtheria is a serious bacterial infection that primarily affects the nose and throat. Infection leads to a thick grey or white coating of the tonsils, throat, and nose, making it difficult for infected patients to breathe or swallow. Left untreated, diphtheria causes severe complications such as heart conditions, nerve damage, and death.

Out of 123 confirmed cases, the virus has killed 13% of the people it has infected.

Africa CDC also revealed it is working with its Chinese counterpart and health authorities in Nigeria to investigate the outbreak of an unknown flu-like disease that has infected at least ten Nigerians.

Officials also reported 59 confirmed cases and 23 deaths from Mpox in the first three weeks of 2023. New cases have been reported in the Democratic Republic of Congo, Ghana, Liberia, and Nigeria.

The 2022 cholera outbreak continues

Several African countries continue to suffer the fallout of a cholera outbreak that began on the continent in March 2022.

Africa CDC has pinpointed Malawi as the epicenter of the 2023 outbreak, which accounts for nearly 20,000 new cases and 583 deaths. Burundi, the Democratic Republic of Congo, Kenya and Mozambique have also reported new cases.

Cholera cases in Malawi have increased seven-fold since the same period in 2022. Africa CDC’s acting director Dr. Ahmed Ogwell Ouma said there are heightened concerns about the spread of the outbreak to Mozambique, a neighboring country that has only reported a few cases.

“The outbreak has affected most of the districts in Malawi, and this resurgence of cases in districts where cholera was being controlled is a very big concern for us and the government,” Ouma told journalists.

The mortality rate of Malawi’s outbreak is currently 3.4%.

Omicron remains the dominant variant in Africa

Experts say the presence of XBB1.5 in Africa has not led to increased hospitalisations or deaths.

Omicron remains the dominant variant driving Africa’s COVID-19 caseloads. While recent sequences from South Africa and Botswana revealed the presence of the XBB.1.5 variant on the continent, it represents just 23 of the 150,000 genomes sequenced in Africa.

“Despite the detection of new variants, the system for genomic surveillance is still working well and there is currently no concern for an increase in hospitalizations,” said Tulio de Olivera, professor at the Center for Epidemic Response & Innovation at South Africa’s Stellenbosch University.

XB.1.55 has only been detected in Southern Africa — four cases in Botswana and 19 in South Africa. The presence of the variant has not resulted in an increase in infections, hospitalizations or deaths especially in the last two weeks, Olivera said.

Instead, recent data from South Africa showed that transmission levels are decreasing, with an 18.1% drop in the number of cases detected in the third epidemiological week. This decrease, Oliveira said, is not related to lower testing, but rather a high level of population immunity.

Africa CDC reported that 44% of the target population on the continent have been vaccinated, with four countries having surpassed the 70% COVID-19 vaccination target. Of the nearly 1.1 billion doses of vaccines received by public health authorities, 83% – over 895 million doses – have been administered, including 45 million booster shots.

As the continent continues to make progress on immunization rates, Africa CDC encouraged its member states to continue targeted and public vaccination campaigns.

“We really are encouraging our member states to continue with targeted and public campaigns for vaccination, whether it is amongst youths, health workers or those with comorbidities, even the general public. If we do it in a targeted and sustained way, then we can get even more people vaccinated,” Ouma said.

Dr Samukeliso Dube, FP2030 executive director.

In the past year alone, women’s use of contraception in 82 low- and lower-middle-income countries has averted more than 141 million unintended pregnancies, 29 million unsafe abortions and almost 150,000 maternal deaths.

This is according to the global family planning partnership, FP2030, which released its 2022 Measurement Report on Wednesday.

Today, 371 million women of reproductive age are using modern contraception – an increase of 87 million over the past decade, according to the report.

The biggest increase in contraceptive use is in sub-Saharan Africa, where there has been an increase of over 6% in the past decade, to cover 23% of women and girls of reproductive age. 

“The past ten years have been full of obstacles for country health systems – wars, political upheavals, natural disasters, deadly disease outbreaks, and lately the COVID-19 pandemic – yet through it all, women everywhere have continued to seek out and use modern contraception in ever-growing numbers,” said Dr Samukeliso Dube, FP2030 executive director. 

“What our latest report shows is just how unstoppable the demand for modern contraception is,” she added. “Women want to control whether and when to have children, and how many children to have.”

in sub-Saharan Africa, young married women aged 15-24 relied on methods such as injections and pills obtained from government facilities, while most unmarried sexually active women in the same age group relied on condoms from private health sources. 

Globally, there has been “a steady shift towards long-acting and reversible contraception”, according to  FP2030’s Jason Bremner.

Today, implants are the most common method in 10 sub-Saharan African countries and the second most common method in another 14. 

Between 2012 and 2018, the use of implants in Benin, Guinea, and Mali more than doubled among unmarried sexually active women aged 15-24, and today more than one in five unmarried sexually active contraceptive users in these countries are using implants. 

Funding flatlining

However, the report shows that donor funding for family planning is not keeping up with the growing demand for modern contraception. In 2021, donor government funding totalled approximately US$1.4 billion, which was substantially lower US$1.52 billion received in 2019. 

The US remains by far the biggest funder of family planning, making up over 41% of the $1.39 billion in bilateral disbursements in 2021. The UK has reduced its contribution the most, and now contributions little over 11%. The Netehrlands is now the second biggest donor, contributing 13,7%.

“Failing to adequately fund family planning efforts would be a missed opportunity for millions of women,” said Dr Dube. “We need not only to hold the line but also to secure new funding to accommodate the surge in demand for family planning. The hard-won gains of the last 10 years could slip away if we don’t act now.”

“There are still 50 million women who report using a traditional method, such as rhythm and withdrawal,” according to Bremner, adding that they should be offered the opportunity to use a more modern and reliable form of contraception.

A resident of Ifakara tucked into a mosquito net.

IFAKARA, Tanzania – When you think of malaria, a swarm of mosquitoes flying against an orange sunset is a dangerous sight.

As part of their mating ritual, the dreaded bloodsuckers brazenly hover for 30 minutes, males adroitly flapping their slender wings to produce a sound that lures female partners to join them.

The mosquito proliferation that results from this harmonic mating song ensures a grim reality for farmers in Tanzania’s Mchombe Village, who struggle with bouts of malaria.

Locals in this impoverished village use all the ammunition at their disposal to fight the deadly insects, whose population keep rising. At dusk, they routinely shut down windows, burn piles of fresh eucalyptus leaves to produce scented smoke to chase away the mosquitoes and, most importantly, get under their bed nets to sleep.

“Malaria is a big problem here. The mosquitoes reproduce themselves in large numbers,” said Amina Jaka, a paddy farmer at Mchombe Village.

The 28-year-old mother of four children, says mosquitoes are ubiquitous due to the presence of stagnant ponds of water, and her children struggle to sleep through the night because of them.

Clever insects

Jaka, who has witnessed two malaria deaths in the village in the past few weeks, is increasingly worried about her children and makes sure they are tucked under mosquito nets even they sleep in the afternoon.

“Mosquitoes are very clever insects. You simply don’t know when they will bite you,” she said.

Msombwa villagers, who had considered themselves exempt from malaria after a mammoth government-led anti-malaria campaign in the village two years ago, are baffled by the rising number of mosquitoes in recent months.

Nestled on the lower echelons of the Kilombero River, the village is a hotspot for the Anopheles mosquito, which transmits the plasmodium parasite that causes malaria.

Although malaria infections have declined in most parts of Tanzania since 2000 thanks to multiple vector control interventions, including insecticide-treated bed nets, residual spraying and improved diagnostics, the struggle is far from over.

Constant innovation

Scientists in Tanzania are constantly devising new ways to control the mosquito population. At a research institute run by the Ifakara Health Institute dubbed ‘Mosquito City’ as it’s home to the world’s largest captive colony of mosquitoes, researchers are studying the mating behaviour of mosquitos.

Fedros Okumu, a senior entomologist and director of science at the centre, said his team uses cutting-edge approaches to trap, repel and kill mosquitoes when mating.

“One of the most interesting experiments we have done is to study the mating behaviour of malaria mosquitoes,” he told Health Policy Watch.

“Male mosquitoes usually fly to their favourite mating places to begin a ritualistic flight dance [at sunset], drawing in females,” Okumu said, adding that a male would then identify and pursue a flying female by detecting her flight sound.

 “If the male can’t properly hear the female then the chase fails and they don’t mate,” he said.

Although mosquitoes’ romances sound like a trivial matter, researchers say it is a rare opportunity to kill the malaria-causing insects.

A doctor at Ifakara district hospital treating a malaria patient

In 2021 there were approximately 247 million cases of malaria worldwide with about 619,000 deaths, according to World Health Organisation (WHO).

The  WHO Africa region carries the heaviest global malaria burden. In 2021 the continent was home to 95% of malaria cases and 96% of deaths, with children under five accounting for about 80% of the deaths.

At Mosquito City, scientists are studying the Anopheles funestus mosquito, which is responsible for 90% of malaria cases in the region.   

“This is a least understood species of mosquitoes because it is extremely difficult to raise in a laboratory environment,” Okumu said.

There are 3500 known species of mosquitoes of which 400 belong to Anopheles family, and only 50 to 70 of them can transmit malaria to humans, he said. In Africa, malaria parasites are transmitted by the Anopheles gambiae, funestus, arabiensis and colluzzi species.

“Effective malaria control can be achieved when we identify, understand and target just one or two anopheles species instead of trying to kill all mosquitoes,” he said.

Recent gains in the fight against malaria have been attributed particularly to the use of insecticide-treated bed nets . Since 2000, over two billion insecticide-treated nets have been delivered to malaria-endemic countries including Tanzania. This rapid scale-up has been by far the largest contributor to the impressive drops seen in malaria incidence since the turn of the century, according to WHO.

But in the last two decades, analysts say their effectiveness is increasingly being compromised by the emergence and spread of insecticide resistance and increasing outside exposure to mosquito bites.

Genetically modified mosquitos

Scientists globally are now working to better understand the overall ecology of mosquitoes as the malaria vector and how the changing landscape will affect the mosquito population in the future.

One such innovation is to create genetically modified mosquitoes under lab conditions, which, upon mating with wild mosquitoes, produce offspring that are incapable of further reproduction or transmitting malaria to humans.

However, malaria researcher Zul Premji said past efforts to ensure the genetic control of mosquitoes using the sterile-insect technique have been less successful than expected due to low competitiveness between sterile and wild males.

“Many mosquito species can be cultured in large numbers under controlled conditions, but due to genetic selection and loss of natural traits, such insects may behave differently from their wild siblings,” Premji told Health Policy Watch.

However, the seasoned researcher is confident that laboratory cultures and subsequent genetic transformation of target mosquito species may result in insects with widely different mating behaviours compared to their wild siblings.

But Jaka and fellow villagers are sceptical about whether a genetically modified species will make any difference.

To them, what matters to prevent malaria is the provision of free insecticide bed nets, and repellents, quality diagnostics at local hospitals and the availability of antimalarial drugs.

Image Credits: Peter Mgongo.