Africa only produces 1% of the vaccines it uses.

Gavi, the global vaccine alliance, has undertaken to adapt its approach to procuring vaccines in order to support African vaccine manufacturing.

In a plan released on Thursday, Gavi has committed to placing “a higher value on the benefits of diversification to supply security, with a focus on Africa”.

The 10-point plan, developed in consultation with the African Union and other key partners, also allocates responsibilities to other key players – G7 Development Ministers, African countries, international partners including development financial institutions, and the private sector – to support sustainable African manufacturing capacity.

However, Gavi will drive and coordinate the plan, given its enormous clout as the world’s biggest buyer of vaccines.

“For 22 years, as the largest buyer of vaccines in the world, Gavi has worked closely with African countries and manufacturers to favourably shape the market for essential routine and outbreak vaccines,” said Gavi CEO Dr Seth Berkley. 

“Gavi is committed to contributing to the AU’s vision. The plan published today provides a pathway to ensuring vaccine supply security for Africa during pandemics and expanding access to other life-saving vaccines at sustainable, affordable prices.”

The COVID-19 pandemic exposed Africa’s vulnerability when the entire continent was unable to get vaccines for months as wealthy countries had bought up all the doses made by Pfizer and Moderna and India stopped the export of generic vaccines made by the Serum Institute of India destined for the continent.

Stung by the COVID-19 experience, the AU has set a target to produce and supply more than 60% of its vaccine doses on the continent by 2040 – it currently supplies 1%. 

Although Africa consumes vaccines valued at over $1 billion every year, the cost of much of this is carried by Gavi, UNICEF and donors.

At present, Gavi chooses vaccine suppliers on price, and “does not systematically permit the accommodation of higher prices in the name of geographical diversity and supply security”, it acknowledged. 

“New accommodations in the way Gavi assesses products against supply security as a new market health objective, could have a substantial impact,” it acknowledges. 

The risk of supporting more expensive African-made vaccines could be mitigated by countries committing upfront to vaccines which would enable “predictable pooled procurement volumes”. 

African countries themselves also need to “send clear demand signals to the market on willingness to select and procure from African suppliers”.

“In the last 18 months alone, more than 30 new African manufacturing projects have been announced and estimates indicate that the African vaccine market across all existing and projected novel products could range between US$ 2.8 billion and US$ 5.6 billion by 2040, demonstrating the potential for a thriving regional industry to emerge,” according to Gavi.

However, the report also acknowledges that “a disorderly expansion risks unhealthy competition, potentially undermining the impact of market-shaping initiatives that have delivered low vaccine prices to lower-income nations, while also failing to realise Africa’s manufacturing aspirations”. 

It calls for a  “business model” that “actively shapes markets in support of the AU’s vision: meeting the mutually reinforcing objectives of continued global market health, and a sustainable regional manufacturing sector”.

Nonetheless, the price of setting up new manufacturing facilities in Africa may mean that their products are way too expensive to be viable.

“Modelling indicates that price differentials for new entrants may be in excess of levels that could be accommodated during standard Gavi/UNICEF competitive tenders, without impact on programme coverage,” Gavi warns.

“Ways must be found to support new entrants, whilst at the same time, avoiding a situation in which incumbent manufacturers increase their prices for vaccines due to lost volumes. This carries a potential risk of increasing the costs of immunisation worldwide.”

To address the high cost for new entrants, the plan proposes “a time-limited financial instrument that can help mitigate the high cost of vaccine production at market entry”. 

It also advocates that this financial instrument supports African manufacturers to make the most commercially viable antigen-based vaccines – starting with cholera and Ebola.

For their part, African countries are tasked with accelerating investment in the enabling environment, including “strong regulatory authorities, robust supply chains, skilled human capital, reduced trade barriers and empowered regional coordination”.

Image Credits: Gavi/Karel Prinsloo 2017.

Roast chicken vendors prepare their meals in Dar es Salaam                                                             

DAR ES SALAAM, Tanzania—At a smoky kitchen in the port city of Dar es Salaam, none of the customers jostling to place their orders knows that the irresistibly tasty roast chicken may be harbouring bacteria that could make them sick.

“I don’t think poultry farmers would do anything likely to cause harm,” said 34-year-old Lilian Kiswale a regular customer at this popular fast-food joint.

However, what is not clear to Kiswale, is that strains of bacteria that are resistant to antibiotics have repeatedly been found in chickens at farms where city’s street kitchens source their poultry products.

“None of our customers has ever complained about the smell of antibiotics in the food we have prepared,” said Kelvin Massawe who works as a chef at the chicken restaurant that is a culinary delight in the neighbourhood. 

But it’s not about antibiotics ruining the taste of roast chicken. The antibiotic-laced food that poultry farmers in Tanzania give to their birds, ostensibly to increase muscle weight quickly and keep infections at bay, poses a threat to humans as well.

According to a recent study by Tanzania’s Muhimbili University of Health and Allied Sciences (MUHAS), excessive amounts of antibiotic residue had been found in broiler chicken tissues – a perfect condition for antimicrobial resistance (AMR).

Using the liver samples of 84 commercial broiler chickens, the researchers found that 100% had the antibiotic tetracycline – and 90% at levels that exceeded acceptable daily limits. In addition, 21.4% of the samples also had sulphonamide, although this was within the maximum limit, according to the study, which was published in the journal, Antibiotics.

Worse still, researchers say that poultry farmers have unrestricted access to prescription-only antibiotics including tetracycline, sulphonamides, penicillin, aminoglycosides and macrolides.

Shop owner Jesca Anthony confirms that she sells antibiotics to farmers without prescription

This was confirmed by shop owner Jesca Anthony, who said that she sells antibiotics, without prescriptions to farmers.

“Random use of antibiotics in animal feeds heighten the risk of drug resistance not just to animals but in humans as well,” Professor Mecky Matee, head of microbiology at MUHAS and the study’s lead author, told Health Policy Watch.

“The use of antibiotics as growth promoters for chicken should be banned,” Matee stressed.

Antibiotics are losing their power

When an antibiotic is used, it wipes out susceptible bacteria, leaving behind resistant ones. These resistant bacteria can grow and become dominant, and pass from chicken products to humans who eat or handle the meat. Once inside a person, these resistant bacteria can take over the colon, which is then unable to fight infections.

Antibiotics are increasingly losing their efficacy due to indiscriminate use in humans and for stimulating animal and birds’ growth.

The rise in drug-resistant bacteria has the potential to inflict a devastating human and economic toll globally, according to the United Nations.

According to the most comprehensive estimate of the global impact of antimicrobial resistance (AMR), published in The Lancet in January 2022, an estimated 1.2 million people died in 2019 from antibiotic-resistant bacterial infections – more deaths than those from HIV/AIDS or malaria.

“Many types of common antibiotics are no longer effective enough to treat bacteria, in many cases patients need hospitalisation,” said Hellen Sabuka, a senior epidemiologist at Shree Hindul Mandal Hospital in Dar es Salaam.

Sabuka urged Tanzania’s health authorities to adopt strict regulations and control on the use of antibiotics in animal production.

A customer at the Tegeta slaughter house

Although Tanzania has policies and guidelines for the use of antibiotics in animal feed, such policies are poorly enforced due to weak systems for food and agricultural productions.

In Dar es Salaam, one of Africa’s fastest-growing cities and home to 5.8 million inhabitants, poultry farmers routinely mix an array of human antibiotics into chicken feed to try to ensure they grow faster and don’t get sick.

It is a humid Sunday evening at Kibamba, a suburb in the western part of Dar es Salaam, and Salma Libuhi is busy mixing a concoction of medicines into rice husks to feed her caged chickens.

Amid smouldering heat, she methodically mixes in a cocktail of three antibiotics— oxytetracycline, doxycycline and enrofloxacin – and sets the food in cans.

“When they eat this food, they grow faster,” she told Health Policy Watch. For the 38-year-old mother of four, poultry farming is her livelihood. In 2017, quit her job as a teacher and ventured into entrepreneurship.

“Raising chicken is very profitable,” she said.

To educate herself about animal husbandry, Libuhi joined a whatsapp groups where she gets all the information about diseases and antibiotics.

“I never consulted a vet. The information I get from the group is enough,” she said.

 At Libuhi’s farm, broiler chickens usually take six weeks to reach market weight. Once they’ve reached the proper size and weight she catches each chicken by hand and transfers them to holding cages ready to be sold.

Unlike wild chickens that traverse a range of habitats as they forage for seeds, insects and fresh leaves, broiler chicken are often kept in overcrowded, poorly ventilated and unhygienic shacks.

Lack of controls in Africa

Across Africa, antibiotics are heavily in the farming of cows, pigs and chickens to fight infections and promote growth. With the indiscriminate use of antibiotics, particularly in agriculture for stimulating animal and birds’ growth, these essential medicines are losing their efficacy.

“Many types of common antibiotics are no longer effective enough to treat bacteria, in many cases patients need hospitalisation,” said Hellen Sabuka, a senior epidemiologist at Shree Hindul Mandal Hospital in Dar es Salaam.

Sabuka urged Tanzania’s health authorities to adopt strict regulations and control on the use of antibiotics in animal production.

While over-use of antibiotics as growth promoters is not a new phenomenon, global experts think preventing drug-resistant bacteria that kill millions of people every year, requires a coordinated approach.

Mohan P. Joshi, technical lead for antimicrobial resistance and global health security at the non-profit, Management Sciences for Health, said the overuse of antimicrobials in animals, especially as growth-promoters in food-producing animals, is common in many countries.

 “In some countries, the proportion [of antibiotics] used in the animal sector is as high as 80% of the total antimicrobials consumed. Alternatives such as good animal husbandry, vaccinations, and biosecurity measures including hygienic practices are critical farming approaches that can help reduce antimicrobial use in animals raised for food,” he said.

While 144 countries have national plans to combat AMR, according to a 2021 World Health Organization (WHO)  report, Joshi says sectors differ in the amount of progress they’ve made, with the human health sector generally making the most progress and the animal sector lagging.

“We need collaborative, multisectoral coordination to address public health threats at the intersection of humans, animals, and the environment. A One Health-focused approach is the only way to effectively address this widespread issue,” Joshi said.

According to him, the fight against AMR needs coordinating bodies with adequate funding, political support and authority to act.

“Countries need to establish functional multi-sectoral task forces to contain AMR that include high-level government officials and stakeholders from both human and animal health, along with the agricultural, environmental and food sectors, and ensure that such bodies are effectively facilitating One Health coordination, helping build capacities of local stakeholders, and mobilising diversified funding,” he said

In 2019, five million human infections were associated with bacterial antimicrobial resistance worldwide, including more than 1.2 million human deaths attributable to bacterial AMR. The burden was highest in sub-Saharan Africa and South Asia, with children below five years of age the most affected.

Pushed by the rising demand for cheap poultry products, the broiler value chain in Tanzania, is a big user of antibiotics. Most poultry farmers in Tanzania treat chicken with a concoction of antibiotics often without consulting veterinary doctors.

Despite the growing adversity, global experts are cautiously optimistic about prescription-only system where veterinarians will have the upper hand in dispensing drugs used in animal production.

Chicken dealers waiting for customers at Tegeta slaughter house.

Thomas Van Boeckel, from the public research university, Zurich ETH, said the best way to curb antibiotic use in animals is to move to a prescription only –system where only trained veterinarian would be authorized to sell the antibiotics rather than retail shop owners.

“However, even in Switzerland where such a system is in place, this does not resolve all problems because vets may still have a financial conflict of interest in prescribing for profit,” Boeckel said.

He says that a better solution would be to “remove the profit margin from vets on drug prescription,” as is the case in Sweden.

Meanwhile, Emma Berntman, senior engagement specialist at FAIRR initiative, said low and middle-income countries, including Tanzania have the largest share of global antimicrobial consumption in animals and agriculture, due to the routine use of antimicrobials in farming for growth promotion and prophylaxis.

She blamed the countries’ lack of checks and balances and low awareness on overuse of antibiotics.

“Tanzania is no exception to this. The country lacks regulation that is sufficient to adequately address the issue of excessive antimicrobial use and antibiotic are cheap and widely available,” said Berntman. FAIRR is an investor-run initiative to address threats to the global food supply.

According to her, even when regulation exists in the emerging market, it can be hard to enforce when there is a lack of access to veterinarians and poor awareness of the impacts of overusing antibiotics.

“On-the-ground initiatives are needed to help support farmers to reduce their dependence on these drugs,” she stressed.

Growing appeal of organic products

Although Switzerland launched an AMR strategy in 2015, FAIRR experts say the highest priority critically important antibiotics (HPCIAs) including fluoroquinolones, are still excessively used in farms, notably in broiler production, with authorities warning of high levels of resistance.

“These antibiotics are deemed ‘the last line of defence’ in human medicine and are the only antibiotics available to treat certain bacterial infection. If they become ineffective, it poses a significant threat to human health,” Berntman said.

“Resistant bacteria developed in broilers can spread to humans through direct contact with the birds, eating chicken or via the environment. There is also a risk to flock health due to the reduced efficacy of antimicrobials used to treat them.”

Despite the growing threat, experts see glimmer of hope in reducing the use of antibiotics in broiler farms and other antibiotics used in human medicines.

“The government can support reductions by further restricting the use of antibiotics in animals in line with the latest EU regulations, so that antibiotics can only be used to treat infections and routine use is prevented,” Berntman said.

Moreover, Berntman said the government can facilitate antibiotic stewardship activities to support the adoption of alternatives to antimicrobials including vaccination programmes and improved nutrition.

According to Berntman the rising awareness of the risk of AMR in Europe and North America has triggered a surge in demand for products associated with or lower antibiotic use.

“Many consumers are willing to pay a price premium to purchase organic chicken or chicken raised without antibiotics,” she said.

Approximately 60% of broilers in the US are now raised without antibiotics, according to Berntman. Moreover, the number of broiler chicks receiving antibiotics in the hatchery has dropped by 90% to nearly zero.

 “It is important that poultry producers improve animal welfare, vaccinate their flocks, and implement routine health monitoring programmes to meet consumer demand for broilers raised with less or no antibiotics while simultaneously creating environments where healthy flocks can be raised no antimicrobials required without impacting animal welfare,” Berntman said.

But for chicken lovers in Dar es Salaam, antibiotic-free roast chicken meat is probably a distant dream.

Image Credits: Peter Mgongo.

Severe air pollution in Anyang, China in January 2022.

Ahead of the global climate talks in Egypt, the World Health Organization (WHO) has urged governments to expedite fossil fuel phase out and transition into clean energy. 

“Climate change is already impacting health in many ways, through more frequent and extreme weather events, more disease outbreaks, and more mental health issues,” Dr Tedros Adhanom Ghebreysus, the director-general of WHO said in a press briefing on Wednesday. 

Flagging the impact of climate change on various aspects of human life, including diseases and malnutrition, Dr Tedros called for governments “to lead a just, equitable and fast phase-out of fossil fuels and transition to a clean energy future”.

The 27th United Nations Climate Change Conference (COP27) will take place in Sharm el-Sheikh, Egypt from 6 to 18 November. At the conference, world leaders are expected to assess the progress in limiting global warming to 1.5 º Celsius above the pre-industrial levels. 

“Meeting that target will have massive benefits for human health. Failing to meet it comes with massive risks,” Dr Tedros warned. 

Impact of climate change on food security

Martin Griffiths, the UN Office for the Coordination of Humanitarian Affairs (OCHA), told the briefing that the world is in the grip of hunger crisis and that the pandemic and vast inequality are partly to blame.  

Listing the different crises happening across the world – the drought in the Horn of Africa, Somalia and Kenya, the floods in Pakistan, the civil war in Tigray, Ethiopia – the OCHA chief called for immediate action to control global warming. 

“This is the world at 1.2º Celsius [above pre-industrial levels]. But we’re on track to double that. And unless we act now, we’re heading for a future full of droughts, diseases and climate disasters across the whole world,” he added. 

In 2009 at the Copenhagen Summit, G20 countries pledged that they will channel $100 billion a year to less wealthy countries to mitigate the effects of climate change. Referring to this promise, Griffiths pointed out that the wealthy countries have not kept their word. “We need to come out of COP27 with clarity [about the missing money] and ability [to ensure the promise is kept].” 

He also referred to the UN Secretary General Antonio Guterres´ proposal to impose a windfall tax on the profits earned by fossil fuel and gas companies, saying that 18 days’ worth of such profits can cover the entire sum of UN’s humanitarian appeal for the year. 

“COP27 is going to be a major test for all of us to see if those commitments made so boldly in years gone past finally made land for the people who are staring climate [change impact] in the face,” Griffiths said. 

Adopt WHO 2021 air quality guidelines

In line with the theme in the coming weeks, spotlight was also put on the role air pollution plays in public health and climate change. Around 1.1 million people in Africa died from diseases related to air-pollution in 2019. 

The WHO estimates that seven million people across the world stand to lose their lives to air pollution in a year. 

But Rosamund Kissi-Debrah, founder and trustee of the Ella Roberta Family Foundation,  says that need not be the case. “Cleaning up the air will save lives and it will also reduce health healthcare costs to increase productivity, and it will save trillions of dollars from governments,” she said. 

Kissi-Debrah called for all the countries participating in COP27 to immediately adopt WHO’s air quality guidelines 2021, describing them as “achievable” and life-saving.

She further said that governments must invest in solutions to tackle air pollution and raise public awareness about the adverse effects of rising air pollution on health. 

Pointing to the example of global cooperation to develop and deliver COVID-19 vaccines, Kissi-Debrah called for a similar level of cooperation to tackle air pollution. “We definitely believe seven to 9 million people every year are definitely worth saving. I urge everybody who goes into COP27 to not forget about public health.” 

Image Credits: Chris LeBoutillier, V.T. Polywoda.

WHO Assistant Director-General Dr Ren Minghui

Two of the World Health Organisation’s top leadership team in Geneva – Dr Soumya Swaminathan and Dr Ren Minghui – are on the brink of leaving as Director-General Dr Tedros Adhanom Ghebreyesus’s long-anticipated leadership shake-up starts to take shape.

Swaminathan is WHO’s Chief Scientist, while Ren serves as assistant Director-General for Universal Health Coverage, Communicable and Noncommunicable Diseases.

Meanwhile, Stéphanie Seydoux has been appointed as the WHO Director-General’s Envoy for Multilateral Affairs, replacing Dr Agnès Buzyn, who was appointed executive director of the WHO Academy in Lyon recently and remains on the leadership team in her new role.

Seydoux is the former French Global Health Ambassador. France has been a firm supporter of WHO and is the major investor in the new academy, which is expected to open in 2024, which will offer health workers around the world access to “the latest evidence-based health guidance, state-of-the-art learning technologies and advancements in the science of adult learning”, according to WHO.

WHO Deputy Director Dr Zsuzsanna Jakab is also expected to leave soon. The 71-year-old Hungarian is well over the WHO mandatory retirement age of 65 – which can usually only be extended by three years. 

As Health Policy Watch previously reported, 63-year-old Swaminathan is still two years short of WHO’s mandatory age of retirement, but there have been hints that her style was too independent for the director-general. 

However, a source close to Swaminathan said that she was leaving voluntarily after five years in senior WHO leadership to reunite with her husband and elderly parents who remained in her hometown of Chennai, India, while she served in Geneva.

Prior to WHO, Ren was director-general for international cooperation at the National Health and Family Planning Commission of China.

Conversely, Dr Mike Ryan, executive director of WHO’s Health Emergencies Programme, who had earlier been expected to leave the organization, appears set to remain, several WHO insiders with knowledge of the pending reshuffle confirmed.

 

Causa Justa activists outside Colombia’s Constitutional Court

In February, Colombia introduced one of the most liberal abortion laws in the world after activists took to the courts – but now their challenge lies in ensuring the health system is in a position to offer terminations

Not long ago, abortion in Colombia was a taboo topic that could not be mentioned during dinners or family gatherings, according to Florence Thomas, one of Colombia’s feminism most influential voices.

“It was considered such a difficult subject that people would stand up and leave my lectures when I touched upon it,” Thomas told Health Policy Watch.

 Some 16 years ago, in 2006, Colombian lawyer Mónica Roa challenged the country’s complete ban on abortion in the Constitutional Court and achieved the decriminalization of abortion on three grounds: when the pregnancy was the result of rape or incest; when there was a severe malformation of the fetus; and when the pregnancy constituted a risk to the woman’s health. 

“That ruling changed the course of history,” Thomas explains because it made it evident that the legal way to fight for safe abortions was not the Congress, but the Constitutional Court, the highest court in Colombia.

Since then, feminist movements and pro-choice lawyers like Roa have fought to extend the decriminalization of abortion in Colombia.

Lawsuit against barriers

In 2020, Causa Justa (“Just Cause”), a movement made up of over 100 organisations and 140 activists united to legalise abortion, filed a lawsuit against the criminalization of the early termination of pregnancy. 

Instead of proposing a whole new scheme of laws that would have to go through Congress, they sought a regulate abortion within the rules that were already in place and thus would not rely on politicians. 

Causa Justa showed that, despite the 2006 reforms, abortion remained a crime in the Penal Code, putting it out of reach for most women.  Causa Justa’s lawsuit, supported by more than 100 national and international experts, also showed that almost 400 women were convicted every year for having or seeking an abortion, with sentences ranging from 16 to 54 months in prison. Between 2006 and 2019, more than 5,700 women were charged for abortion.

Causa Justa’s lawyers also showed the judges that criminalization forced women to seek unsanitary and dangerous underground abortion clinics. According to Colombia’s Public Health and Epidemiology Observatory, one of the main causes of  the deaths of over 400 women from haemorrhaging in 2020 was unsafe, illegal abortions.

Between 59% and 70% of the complaints laid against the women seeking abortions had come from health workers, explains Mariana Ardila, a lawyer with Women’s Link, one of the organizations that are part of Causa Justa. 

Abortion providers could also face charges, which made most health professionals refuse to perform abortions.

Nail-bitingly close judgement

That sad reality changed with the new ruling in February this year, which established that abortion will only be an offence after the 24th week of pregnancy. 

“Women won,” said the plaintiffs after learning of the decision, surrounded by chants claiming: “It is a law! It is a law! It is a law.”

The ruling is historic because successive Colombian governments have never legislated on an issue that they consider neither a priority nor find beneficial because of the controversy it generates in the street. 

Colombia is a secular but deeply religious country. A 2017 survey revealed that 97% of citizens believe in God and the different churches, predominantly Catholic and Evangelical, have enormous power over believers, pushing them into an all-out fight against abortion.

In its final stage, the Constitutional Court judges voted on the lawsuit, and the vote was nail-bitingly close: five judges were in favor, and four against. With this final say, the court proved that Colombia is changing. Today, only 20% of the population approves that women go to jail if they get an abortion.

Health services not prepared

The Court also ruled that the government would have to implement a comprehensive public policy regarding access to safe and legal abortions in the “shortest possible time.” However, to date, such a policy hasn’t been fully defined and executed.

 Colombia’s Ministry of Health recognizes that barriers to abortion persist and are mainly associated with the denial of services – mainly due to ignorance of the changed legal framework and improper exercise of conscientious objection by medical personnel. 

On 28 September, it issued a document with instructions about how to strengthen sexual and reproductive health care, including abortion, that was addressed to all entities that are part of the health system.

Colombia is part of a “green wave” of countries in the region that have decided to expand their abortion freedoms, but it allows abortion much later than its regional counterparts.

 

Mexico’s Supreme Court ruled late last year that was unconstitutional to criminalize abortion. However, each state has to regulate the decision of the Supreme Court. 

In Argentina, Congress approved abortion’s legality up to 14 weeks, and, as in Colombia, lifted the restrictions that only allowed for abortion in cases of rape or where the mother’s health is at risk.

On the other hand, Ecuador’s National Assembly approved a bill that allows abortions if they result from rape up to the 12th week, but President Guillermo Lasso vetoed it, saying that he respects “life from conception.”

Colombia’s ruling, however, is a historic victory for the Colombian women’s movement that has fought for decades for their rights to be recognized in a traditional and ultra-catholic country. The next step is for the public policy to be fully deployed across the country and to serve as a model for the region.

Mesa por la Vida y la Salud de las Mujeres, a feminist collective that defends women’s sexual and reproductive rights, stated that during the first few months of 2022, they helped more than 90 women to overcome barriers while seeking an abortion within the new law’s parameters.

Alejandra* (not her real name) is one example. She asked for an abortion in her sixth week of pregnancy but only finally got one in her 11th week. She states that the procedure was slow and painful and that the doctors did not provide clear information about the process.

The numbers show that the path is still long for women in Colombia and that the famous feminist march slogan, “we want sex education to decide, contraceptives to avoid abortion, and legal abortion not to die,” will still echo in the streets, the mountains, the buildings, and law-making entities until Colombian women can feel free to decide, unchallenged, about their bodies.

The Rosa Luxemburg Foundation provided support for this article.

Image Credits: Causa Justa.

Alcohol is related to more than 60 different conditions, including cancers, heart and liver disease.

A $15 million initiative to address the harms of alcohol consumption through policy change was launched Tuesday, roughly doubling the total global spending on mitigating the effects of alcohol.

Alcohol is one of the top-ten drivers of death, illness and injury, with wide-ranging social and economic harms, many disproportionately affecting young adults, according to Vital Strategies, which heads the RESET Alcohol consortium.

“RESET Alcohol is an initiative that brings together national governments, civil society, research organizations, and global leaders in public health and alcohol policy to develop and implement evidence-based alcohol policies from the World Health Organization’s WHO) SAFER technical package,” according to Vital Strategies. 

The initiative will focus on Latin America, Africa and Asia, with partners Movendi International; the University of Illinois Chicago; the Global Alcohol Policy Alliance (GAPA); the Non-Communicable Disease (NCD) Alliance; and the WHO, with GiveWell as the donor.

RESET’s primary policy focus will be on increasing alcohol taxation and other pricing policies which it describes as being “among the most effective interventions for reducing consumption”. It also aims to regulate the availability of alcohol, and restrict its marketing.

Over three years, the initiative will support 15 or more countries to develop policies including raising the price of alcohol via taxation, regulating availability, and restricting alcohol marketing.

Policies to protect kids

“Every year, alcohol use cuts millions of lives short and causes even more widespread suffering,” said Adam Karpati, senior vice president at Vital Strategies. 

“The onus can’t be on individuals. We must reset from an environment where the alcohol industry is empowered to push alcohol into nearly every aspect of our lives, including schools, sports, and media. We need policies that protect kids, make healthy choices, the easy choices, and check the industry’s influence. RESET Alcohol will do just that through strong partnerships with government and civil society leaders who are committed to action.” 

Alcohol consumption has increased in nearly all regions of the world consistently since 2005, and accelerated during the COVID-19 pandemic. It is related to more than 60 different conditions, including cancers, heart disease, liver disease, tuberculosis and HIV/AIDS; injuries and trauma including suicide, homicide, assault, falls, intimate partner violence, and vehicle crashes. Alcohol consumption is also associated with adverse economic impacts, from medical care costs to lost productivity.

RESET Alcohol’s approach builds on its partners’ successes in similar consortiums that have addressed tobacco and other harmful commodities, including contributing to 18.5% reduction in tobacco use in Bangladesh between 2009 and 2017 and a 17% reduction in India between 2010 and 2017.

“Failure to act has led to millions of preventable deaths and suffering from alcohol,” said Jacqui Drope, the new director of RESET Alcohol. “It’s time governments treat it like the public health crisis that it is. When governments take up policies proven to reduce alcohol-related harms, population health and economies will benefit.”

 RESET Alcohol will provide technical support to governments, improve national research and data collection, resource advocacy for policy change, and mount communications campaigns.

 “For governments, tax increases on alcohol are a win-win, especially given the sluggish global economy,” said Jeffrey Drope, Research Professor at UIC.

“Effective alcohol taxation reduces affordability, consumption and alcohol-related disease and premature death. This means lower healthcare costs and increased productivity from a healthier population. Taxes also create revenue for governments to fund health programs or other social priorities.

Image Credits: U.S. Air Force/Samuel King Jr. .

The World Health Organization (WHO) and World Meteorological Organization (WMO) launched the first global knowledge platform dedicated to climate and health on Monday called climahealth.info.

The global open-access platform is envisaged as being the “go-to technical reference point for users of interdisciplinary health, environmental, and climate science”, according to the WHO in a media release. 

“The use of tailored climate and environmental science and tools for public health, such as disease forecasting and heat health early warning systems, have enormous life-saving potential. These tools and resources can enhance our understanding of the connections between climate and health, help us reach at-risk populations, and anticipate and reduce impacts,” according to the media release.

“Climate change is killing people right now,” said Diarmid Campbell-Lendrum, coordinator of WHO’s climate change and health programme. “It is affecting the basics we need to survive – clean air, safe water, food and shelter – with the worst impacts being felt by the most vulnerable. Unmitigated climate change has the potential to undermine decades of progress in global health. Reducing its impacts requires evidence-based policy backed by the best available science and tools.”

Joy Shumake-Guillemot, who leads the WMO-WHO Climate and Health Joint Office, said that public health practitioners who are concerned about the environmental impacts on health “lack access to training and tailored climate information needed to address these growing issues” while  “climate experts (are) sitting on troves of research and resources that could be applied to support public health goals, but just aren’t reaching the right people”.

The initiative is supported by the Wellcome Trust.

“Collaboration between climate, health and technical specialists is crucial for helping us understand and tackle the health effects of climate change,” said Madeleine Thomson, Head of Climate Impacts and Adaptation for the Wellcome Trust. “But right now, experts can’t always partner and share information as effectively as we know they’d like to. We hope this portal will help fulfill the potential of different disciplines to work together on research and gain new insights into how climate change is affecting health around the world.”

Cities’ Malaria Framework launched

On the occasion of World Cities Day 2022 on Monday, the WHO and UN Habitat launched the Global framework for the response to malaria in urban areas, which provides guidance to city government officials, health professionals and urban planners on how to develop a  comprehensive malaria response specifically in urban areas, “where the dynamics of transmission and burden of vector-borne diseases can be different from that of rural areas”.

By 2050, nearly 70% of people globally will live in cities and other urban settings and the WHO predicts that unplanned urbanization is likely to result in a malaria disease burden that is “disproportionately high among the urban poor”.

Speakers at the launch also anticipated that climate change will see malaria in places that were previously too cold for the disease that is carried by mosquitos.

The framework provides guidance for city leaders, health programmes and urban planners to respond to the challenges of rapid urbanization in a targeted way that helps to build resilience against the threat of malaria and other vector-borne diseases.

Omicron
Experts have described the array of subvariants as a “swarm”.

The SARS-CoV2 virus just won’t give up. As the northern hemisphere heads into its third pandemic winter, experts say the continued evolution of Omicron’s sub-variants indicates a fresh wave is coming, but no one knows which variant will fuel it.

Scientists have catalogued 390 Omicron lineages and 48 recombinants of the virus – which occur when at least two variants co-infect the same person, allowing them to ‘exchange notes’ and evolve. The sheer number of Omicron strains circulating makes predictions complicated.

“We’re having trouble isolating which of the omicron sub-variants will have a growth advantage and will take over in dominating the spread,” WHO Senior Emergency Officer Dr Catherine Smallwood explained at a press conference last week. “Some variants like BQ.1 have been noted as potentially accelerated, but we’re not sure yet how this is going to pan out in the longer term.”

The variety of offshoots also creates the possibility of a ‘double wave’ in some places if two successive variants with different immune-dodging characteristics succeed each other.

“Looking at all the data, it seems a sizable new infection wave is certain to come,” Tom Wenseleers, an evolutionary biologist at the Catholic University of Leuven told Nature.

Subvariant surges not causing hospitalization spikes – for now

Omicron
Ranking of the immune evasion for the new variants

There is some good news: early signs show that though the BA.4, BA.5, BQ.1.1 and XBB subvariants are able to break through immune protections and resist certain treatments, they do not appear to be causing increases in hospitalizations.

“An encouraging sign for one of – if not the most – immune evasive new variants XBB: it is dominant in India and Bangladesh without a rise in cases or deaths to date,” said Eric Topol, founder and director of Scripps Research.

Despite the dominance of the highly infectious XBB variant, deaths and cases in India and Bengladesh have remained stable.

Similar findings have come out of South Africa, where the Africa Health Research Institute in Durban conducted studies on the BA.4 and BA.5 sub-lineages. The team, led by virologist Alex Sigal, found that while these Omicron families possess strong enough immune-dodging mechanisms to lead to an infection wave, they are “not likely to cause much more severe disease than the previous waves, especially in vaccinated people.”

The World Health Organization’s (WHO) Technical Advisory Group on SARS-CoV-2 Virus Evolution (TAG-VE), which released a statement singling out BQ.1 and XBB as key variants of concern on Thursday, issued a similar analysis.

“While we are looking at a vast genetic diversity of Omicron sublineages, they currently display similar clinical outcomes, but with differences in immune escape potential,” TAG-VE’s expert panel found. “So far there is no epidemiological evidence that these sublineages will be of substantially greater risk compared to other Omicron sublineages.”

World trending in the right direction – but surprises could be around the corner

WHO
WHO data as of the October 26 SARS-CoV2 weekly situation report.

The question lingering on the mind of many experts is whether the varying properties of subvariants mean infection by one will provide immunity from others – a key determinant of whether double waves will hit.

A team at Peking University in Beijing, led by Yunglong Richard Cao, has been studying the variants’ immune-evading capacities. “I have a feeling that if you’re infected with BQ.1, you might have some protection against XBB,” he told Nature. “We don’t have data yet.”

Experts warn not to rule out more surprises from the virus. With Delta still circulating in the background, the deadlier variant could return to the fore. 

“The virus has surprised us more than once,” said Dr Hans Kluge, WHO Europe Regional Director. “We are much better prepared, and the fall surge has not led to previous ICU admission or severe disease levels, but forecasting remains tricky.” 

Russia’s invasion of Ukraine – denoted by the red line above – caused the country’s ability to report cases and deaths to fall.

Reports emerged this week of yet another subvariant, BA.5.2.6 taking hold in Ukraine. The dire conditions occasioned by Russia’s invasion of the country have made it conducive ground for viral spread, and reporting since the start of the conflict has dropped off a cliff. 

Little is known about the true state of play on the ground – nor which subvariant will take over next. 

Image Credits: Nature, Stuart Turville.

A woman getting medicine at a shop in India.

NEW DELHI – Govind Ram is still waiting to get justice for the death of his daughter in 2019 – who allegedly died from contaminated cough syrup.

In December 2019, Ram’s two-year-old, Surabhi, had a fever and chest congestion. Ram, a labourer in the Udhampur district of India’s Jammu and Kashmir region, took his daughter to a local doctor who prescribed a cough syrup. 

But her condition deteriorated further, and she was taken to a sub-district hospital then to a district hospital. Doctors there told her father to take her home as there was no chance of her survival, and she died a short while later.

Ram does not know whether he will ever get justice for the death of his daughter, who authorities believed died from ingesting a contaminated cough syrup.

Earlier this month, the deaths of 66 Gambian children were linked to contaminated cough syrup manufactured by Indian company, Maiden Pharmaceuticals. The Maiden-made cough syrups were contaminated with diethylene glycol (DEG), commonly used in anti-freeze, and ethylene glycol (EG).

The Indian government has stopped production at the company’s facility in Haryana at the request of the World Health Organization (WHO).

Cough mixture exported to Gambia by Maiden Pharmaceuticals has been implicated in the deaths of 66 children. The company has a large export base.

Not the first time 

This is not the first time that such contamination has been alleged in Indian pharmaceutical products where substandard and contaminated medicines remain a widespread problem. 

Between 2019 and 2020, 13 children died after reportedly being administered a cough syrup adulterated with DEG in the northern state of Himachal Pradesh.  The deaths of another 12 children in Jammu, including Surabhi, were also alleged to have been tied to their consumption of cough syrup tainted with DEG.  

Both of the syrups were reportedly manufactured by Digital Vision, which is based in Himachal Pradesh. Two years later, the Himachal Pradesh’s Drugs Control Administration (DCA) has yet to complete its probe of the cases, which would allow charges to be filed. 

“The company’s manufacturing license was suspended, but later restored, first partially and then fully,” said Assistant Drugs Controller Garima Sharma, but did not explain how this had happened when the probe was not complete.

Lax regulatory authorities 

These are not isolated cases. The manufacture of sub-standard – and in some cases dangerous – drugs in India is rampant and the lax implementation of regulations enables manufacturers to escape any consequences.

While the sale of inferior quality drugs is a serious offence under Indian law with minimum prison term of a year and fines for the manufacturers, the provisions of the law are rarely enforced against the errant drug manufacturers. In most cases, the regulators simply suspend the drug maker’s license for a few days.

Take Digital Vision, which is supposedly being investigated for Surabhi’s death. It has 19 violations of quality standards since 2009 yet regulators have taken no significant action against it.

The October monthly alert from India’s Central Drugs Standard Control Organization (CDSCO) identifies 59 medicines that failed safety standards, including painkillers and calcium. 

“Due to repeated failure of samples of these medicines, action has been taken against them,” said Himachal Pradesh Drug Controller Navneet Marwah, explaining that these medicines had been withdrawn.

“Monitoring is needed from the time the medicine is made till it reaches the patient because it is a matter of life and death,” said Amulya Nidhi, national co-convener of People’s Health Movement of India. 

“After giving permission to manufacture a medicine it should be seen if the procedure and the guidelines related to it are being followed or not. These are regulatory failures.

“It is also important to see what action they have taken after the death of so many children. They have done nothing. Issuing notices to drug manufacturers can’t be called an action when innocent lives are lost,” added Nidhi.

According to Nidhi, a 2012 parliamentary report from the Standing Committee on Health and Family Welfare on the functioning of the Central Drug Standard Control Organization (CDSCO), had found some instances of collusion between the manufacturers, doctors and regulatory agency and had made a large number of recommendations for drastic revamping of the CDSCO.

“It is a regulatory failure and the monitoring process is very weak in our country which is responsible for such a condition,” he added.

Expired medicines and fake COVID-19 treatments 

Many other cases of the manufacture or sale of substandard drugs have been reported in the recent past. In February, a firm in Agra in the northern state of Uttar Pradesh was found to be buying expired medicine at low cost, repackaging and reselling it.

The Authentication Solution Providers’ Association (ASPA), an organization working against counterfeiting activities, said that fake COVID-19 medicines had been found in most Indian states over the last two years, especially at a time when there was severe shortage of COVID-19 products. 

India lacks suitable regulations for the pharma industry and the regulations and legal structures are not well defined, according to ASPA. 

Exports of substandard Indian drugs 

India is the world’s largest manufacturer of generic drugs, with sales of more than $2.4 billion in March 2022 alone. 

But some experts estimate that probably between 12% and 25% of the active pharmaceutical ingredients and finished medical products supplied globally from India are contaminated, substandard or counterfeit.

In the case of deaths of the contaminated medicines sold in The Gambia, Indian regulators allowed a habitual offender firm to export substandard drugs, public health activists Dinesh Thakur and T Prashant Reddy told India Today. Thakur is the co-author of a book entitled ‘The Truth Pill’, on substandard medicines in India’s pharma industry.

“A Certificate of a Pharmaceutical Product (CoPP) is needed by the importing country when the product in question is intended for registration, with the scope of commercialisation or distribution in that country,” they said.

The CoPPs, effectively export permits, are issued by the CDSCO which operates under the central government’s  Ministry of Health, they added. 

“Therefore, it was not correct to suggest that Haryana’s state regulator gave the approval to this drug and that the central body had nothing to do with the approvals,” they said, adding that the same cough syrups were also authorized for sale in India –  contrary to government statements to the effect that they were only marketed for export. 

WHO’s investigation raises the stakes 

While problems with poor quality medicines have flown under the radar for years, the recent alarm sounded by WHO on the four types substandard cough syrups made by Maiden Pharmaceutical has raised attention about the issues at play. 

India’s Ministry of Health and Family Welfare said that the Central Drugs Standard Control Organisation took up the issue with the regulatory authorities in Haryana, under whose jurisdiction the drug manufacturing unit of Maiden is located. The Indian government and the Haryana government imposed a ban on Maiden Pharmaceuticals. 

External Affairs Minister Dr S Jaishankar told his counterpart in Gambia, Dr Mamadou Tangara, that the matter was being seriously investigated by appropriate authorities.

Despite the accumulating claims and evidence, India’s mainstream medical community has been slow to react. 

“It is too early to say that the syrup has caused deaths in Gambia. Syrup sells a lot, but it has to be seen that the children had not eaten anything else that could have caused their death,” said Sahajanand Prasad Singh, president of the Indian Medical Association.

Brushing aside the WHO reports that syrups used by the children had been adulterated, he added: “I do not think that consuming syrup alone would have such fatal consequences.”

However, the WHO has said clearly that syrups sold in the Gambia and used by the children had definitely been adulterated by a toxic compound that can lead to death. Although the global health agency has been clear that the exact cause of death has not yet been determined.  

Weak or substandard medicines are also a major driver of antimicrobial resistance – which is reaching epidemic proportions in India as well. Experts say India is one of the nations worst hit by antimicrobial resistance. Antibiotic-resistant neonatal infections alone are killing about 60,000 newborns each year. A new government report says things are getting worse, with tests conducted at a hospital revealing that a number of key drugs were barely effective.

Image Credits: Bijay chaurasia, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons, Maiden Phrama.

A Somali boy struggles to find water

The global cholera vaccines shortage relates to the unpredictability of the disease, and the fact that it unattractive to manufacturers as it is a disease of poverty – but if preventive vaccines are part of a routine vaccine package where cholera is endemic, this could stabilise demand and outbreaks

There is no short-term solution to the global cholera vaccine shortage as “the current manufacturers are producing to their maximum capacity, and one is increasing its production capacity but this increase is limited by technical constraints”, according to Dr Philippe Barbosa, the World Health Organization’s (WHO) technical lead on cholera.

Faced with at least 29 global cholera outbreaks – Haiti, Malawi and Syria battling particularly big outbreaks – and a diminishing supply of vaccines in the international stockpile, the WHO recently recommended that affected countries administer only one vaccine dose instead of the usual two. 

 Cholera is an acute diarrhoeal infection caused when people consume food or water contaminated with Vibrio cholera bacteria, and it usually affects those with inadequate access to clean water and proper sanitation.

As the disease primarily affects “the poorest and most vulnerable”, vaccine manufacturers have “no prospect of selling to rich countries”, so production is limited, Barbosa told Health Policy Watch.

“As the demand appears limited, this makes it unappealing for new manufacture to engage in this market,” said Barbosa, adding that the challenge of limited cholera data also made it difficult to forecast of future needs.

But Gavi, the global vaccine alliance, believes that it may be possible to stabilise vaccine production and supply by introducing preventative vaccines in cholera “hot spots”.

“We’re trying to get some preventive vaccination going in regions where cholera is endemic and that will help obviously to prevent outbreaks from a public health perspective,” says Gavi special adviser Aurelia Nguyen.

“It will also help with this ‘peaks and troughs’ view. As you can imagine from a manufacturing perspective, it is difficult to be able to just turn production on and off at very short notice,” added Nguyen, who has over a decade of experience in vaccine supply, most recently as managing director of COVAX, the international COVID-19 vaccine platform.

Gavi advisor Aurelia Nguyen

Only two suppliers

At present, only two suppliers make cholera vaccines available for mass vaccinations. Shanchol is produced by Shanta Biotechnics, a Sanofi subsidiary in India, and Euvichol-Plus, made by EuBiologics in South Korea.

Both companies supply the international cholera vaccine stockpile managed by the International Coordinating Group (ICG), a mechanism that coordinates the provision of emergency vaccines and antibiotics to countries during major outbreaks. The ICG is made up of members from the WHO, UNICEF, Médecins Sans Frontières, and the International Federation of Red Cross and Red Crescent Societies.

All countries that need cholera vaccines apply to the ICG, and those that qualify for Gavi financing get free vaccines while the others need to reimburse the stockpile.

“What we’ve done with Gavi financing is show manufacturers that there is a certainty of regular funding for vaccines, and the minimum stockpile that we want to have at any point in time for outbreak is five million doses,” says Nguyen.

But Shanta Biotechnics announced a while back that it will stop making Shanchol next year, while production at EuBiologics is currently constrained as the company is expanding its facilities. The expansion will ultimately enable it to produce 50 million vaccines a year. 

Nguyen said that “production economics” were behind Shanta Biotechnics’ decision to quit the field, and Gavi has been working “very closely” with EuBiologics “and their volumes are going to keep increasing over the course of next year”.

Neither company responded to questions Health Policy Watch sent to them.

However, Gavi has also “been in very active discussions” with other manufacturers to enter the market in the next two to three year to ensure “resilience in the market”.

“We’ve been discussing with potential new entrants what it would take in terms of their developments, and it also links to another conversation in terms of regional manufacturing on the African continent,” said Nguyen.

Gavi has been in discussions with the African Union, and in the past week with the G7 and G20, about having “a stronger and more sustainable manufacturing base in Africa, and this is one of the vaccines that would be perhaps suitable for a new entrant coming from the continent”, she added.

Unpredictable demand

Typically, the international stockpile has about five to seven million vaccine doses which get replenished as it is used – but the unpredictability of outbreaks has made it hard to ensure regular supply.

“In 2020, we used five million doses for outbreak response. This year, so far we’ve already shipped 18 million doses and we have just seven million doses on hand at the moment and we plan to buy another five million through to the end of the year.”

However, what is more predictable is that climate change will drive more cholera outbreaks. The recent floods in 33 of Nigeria’s 36 states  – the worst in a decade – are expected to increase cholera cases, while Pakistan has been bracing itself for more cases after its recent devastating floods.

“The consequences of a humanitarian crisis – such as disruption of water and sanitation systems, or the displacement of populations to inadequate and overcrowded camps – can increase the risk of cholera transmission, should the bacteria be present or introduced,” the WHO warns.

Meanwhile, earlier this week UNICEF described the cholera outbreaks in Syria and Lebanon as “alarming”.

“The acute epidemic in Syria has left over 20,000 suspected cases with acute watery diarrhoea and 75 cholera-associated deaths since its start. In Lebanon, confirmed cholera cases reached 448 in just two weeks, with 10 associated deaths,”  UNICEF warned in a media release.

“Malnourished children are more vulnerable to developing severe cholera disease, and the cholera outbreak is yet another blow to already overstretched health systems in the region.”

Image Credits: CNN, UNICEF.