Liver tissue specimen displaying acute hepatitis features – but as a result of drug-induced liver disease

Just days after the World Health Organization (WHO) announced that 650 total cases – and another 99 suspected cases – of mysterious acute hepatitis have been discovered in 33 countries worldwide, a top virologist has told Health Policy Watch that doctors and scientists may fail to ever find the root cause of the illness.

“There are a number of investigations that are ongoing and a number of hypotheses,” William Irving, a professor of virology at the University of Nottingham said. “I cannot guarantee that we are going to find a cause in a week, a month or even a year. We are looking, but thus far, we have not found exactly what is going on… I think we might not find out the cause at all.”

Hepatitis is an inflammation of the liver, and acute hepatitis is a sudden onset of hepatitis. The inflammation is usually caused by viral hepatitis infections A, B, C or E. The disease usually passes without the need for special treatment. However, according to WHO, in rare cases, it can result in severe liver failure or even death.

As the number of children, mostly young children under the age of 5, suffering from acute hepatitis has grown in recent weeks, WHO on Friday labelled the risk at the global level as “moderate.”

The 650 cases were found between 5 April and 26 May, and WHO said that the cause of the cases is under investigation. However, Irving stressed that finding the root “could be difficult” because there are not too many cases and the cases appear to be declining – at least in the United Kingdom, where Irving lives and where the highest number of children have been reported.

“The problem researchers are going to have will be declining cases,” Irving explained. “Some of the studies will need relatively large numbers to have statistical significance.”

Moreover, there are so many potential and overlapping causes for these cases of acute hepatitis that “it is like you are in a dark room and you are trying to find a needle, but you have no idea where you are going,” said Prof Cyrille Cohen, head of the Immunotherapy Lab at Bar-Ilan University in Israel.

Classification of reported probable cases per country since 1 October 2021, as of 26 May 2022.
Classification of reported probable cases per country since 1 October 2021, as of 26 May 2022.

Majority of cases discovered in European region

WHO broke down the origins of the cases, with the majority (58%) emanating from 22 countries in the WHO European region, with 34% of cases from the United Kingdom and Northern Ireland alone. The next largest group (216 cases) was reported in the United States, followed by the South-East Asia region and Eastern Mediterranean region.

In Europe, three-quarters (75.4%) of the cases were individuals under the age of five. Some 156 were reportedly hospitalised due to hepatitis and 12% of patients received a liver transplant. Out of the 650 patients, only 6% required transplants.

Overall, said WHO, 110 (61%) of the 180 children in the European region tested for adenovirus had it. Another 12% of 188 cases tested for COVID-19 were infected at the time they developed hepatitis, and 73% of the 26 individuals who underwent serological tests showed they had been infected with SARS-CoV-2 in the past. The majority (53 out of 63 cases with data) were unvaccinated.

Nine deaths out of the collective 650 infected children have been reported to WHO.

“Laboratory testing has excluded hepatitis A-E viruses in these children,” WHO said. “Further detailed epidemiological, clinical, laboratory, histopathological and toxicological investigations of the possible cause(s) of these cases are underway by several national authorities, research networks and across different working groups in WHO and with partners. Additional investigations are also planned to ascertain whether and where the detected cases are above-expected baseline levels.”

A child receives a vaccine through the Maccabi Health Fund in Israel in December 2021.
A child receives a vaccine through the Maccabi Health Fund in Israel in December 2021 (Credit: Maccabi)

WHO: ‘Hypotheses related to side effects from COVID-19 vaccines are currently not supported’

But while those tests are ongoing, scientists have developed a number of hypotheses for the inflammation. At the forefront is infection with Type 41 adenovirus.

Irving said that doctors have known about Type 41 adenovirus for decades and “it is a good lead,” but cannot explain the recent phenomenon on its own because “this strain of adenovirus has not previously been linked to such a clinical presentation in otherwise healthy children.”

He said that either the virus has mutated, though he believes this to be unlikely, or the host has changed.

“It could be that these children were infected recently with SARS-CoV2, and the combination of SARS and adenovirus in some way is resulting in liver damage,” Irving hypothesised. “But if so, there is not going to be any way to prove that because probably most children under five had had a SARS infection.”

Alternatively, he said, it is possible that lockdown and lifestyle changes that were implemented during the height of the pandemic have made children more susceptible to acute infection. Many countries, for example, saw a decline in influenza and respiratory syncytial virus (RSV) when public health measures were in place and then a rapid and unseasonal spike in those viruses when the public returned to routine.

If this is the case, the effect will gradually decrease over time “because we are now mixing and children are getting all the normal coughs and colds that children normally get,” Irving said.

The WHO also suggested that it could be the result of a super antigen-mediated immune cell activation caused by COVID-19 but stressed that “hypotheses related to side effects from COVID-19 vaccines are currently not supported as most of the affected children did not receive these vaccines.”

WHO asked that doctors take whole blood, serum, urine, stool, respiratory and liver biopsy samples for all cases meeting the case definition to help the agency develop interim guidance and to aid researchers in figuring out a cause.

Micrograph of human liver tissue infected with the ebola virus
Micrograph of human liver tissue infected with the ebola virus

Expert advises parents to keep threat in perspective

But even as these cases of hepatitis continue to cause concern, Irving reminded parents to keep the situation in perspective. In the UK, for example, there are five million children under the age of five and only 180 cases of mysterious hepatitis.

“Although it is much more common than it usually is, it is still very rare,” he said. “It is a significant event if you are a child or parent of a child that is affected. But the risk to the general population is extremely small.”

Additionally, only about 10% of cases require any serious intervention, and in the UK, no one has died. Most children experience vomiting, diarrhoea, abdominal pain, jaundice and pale stools as a result of hepatitis.

WHO offered a handful of ways to help keep children safe while cases continue to spread. These include practising good hygiene, avoiding crowded spaces, ensuring good ventilation, using safe water for drinking, following safe food handling practices and regularly cleaning surfaces you often touch with your hands.

“There are a lot of questions,” Cohen concluded. “Right now, we just don’t have enough information.”

Meanwhile, the US Food and Drug Administration (FDA) are investigating the link between a hepatitis outbreak in 17 children in the US and Canada and organic strawberries sold under the FreshKampo and HEB brands.

Image Credits: National Institutes of Health , World Health Organization, Maccabi Health Services, PIXNIO.

EB 151 delegates Loyce Pace, US and Søren Brostrøm, Denmark defend including the terms such as sexual orientation in the WHA Strategy on HIV, Hepatitis B and STIs as evidence-based.

In another one of a series of recent pandemic reform moves, the WHO Executive Board Monday approved the creation of a new Standing Committee on Health Emergencies, which could convene within 24 hours after the declaration of a global public health emergency – and liaise between the WHO Director-General and member states about modes of response. 

The creation of the EB committee was recommended by a number of review bodies last year as a key reform to better link the scientific work of the WHO with the political work of member states in real-time, as new health threats unroll.   

It took months for the EB to convene virtually following the March 2020 declaration of the COVID-19 pandemic by Dr Tedros Adhanom Ghebreyesus – a delay that member states and independent critics later said harmed collaboration and the smooth flow of information between the agency and member states in the darkest months of the unfolding crisis. 

The EB decision follows a World Health Assembly resolution and companion decision last week aimed at kick-starting a process of reforming the International Health Regulations, the binding rules that govern member states’ response to health emergencies.   

In a last-minute move on Monday, EB delegates, at the request of Botswana, amended the terms of reference of the new EB Standing Committee, to state that the new EB Committee also would consider the “information and needs expressed by member states in whose territory and event arises” – a clear nod to countries’ sovereignty concerns during outbreak alerts.

Board revisits painful WHA debates on HIV language, Ukraine and WHO internal justice flaws  

Saudi Arabia led the charge during a late night Saturday debate, trying to get references to “men who have sex with men” and other sexual health phrases removed from the WHO’s new Global Strategy on HIV, Hepatitis-B and STIs

The day-long EB session, following on the heels of last week’s WHA, also saw a member states debrief on key moments of last week’s Assembly. In particular, EB members expressed deep concerns over the assembly’s failure to reach a consensus vote late Saturday on a new Global Health Strategy for HIV, Hepatitis B and Sexually Transmitted Infections. This was due to disputes over terms used in the strategy to refer to peoples’ sexual health and sexual orientation despite months of negotiations and numerous compromises.

Member states, led by Saudi Arabia, led a wave of objections to the strategy’s reference to “men who have sex with men” as an HIV prevention and treatment target group, “sexual orientation” and other references to sexual rights and sexuality. The dispute delayed the closure of the World Health Assembly closure until nearly midnight on Saturday evening.

In a compromise offered by Mexico, a glossary of terms was finally deleted from the strategy although the reference to men who have sex with men remained. Although the strategy was approved by a vote of 60, 120 member states either abstained or were absent, including Russia, China, India and Indonesia, all the WHO Eastern Mediterranean Region and most of the African Region of WHO.   

HIV vote – dismay over lack of consensus and lack of attention to evidence   

Micronesia’s Marcus Samo says consensus is critical for technical documents.

EB members expressed dismay over the “dangerous precedent” set by the long series of roll-call votes on an essentially technical document.  However, they diverged about whether the more fundamental problem was a lack of consensus or lack of agreement on evidence.  

Member states that had supported the strategy lamented the fact that the WHA could not agree on the terms used in an “evidence-based” technical document that aims to ensure that often-marginalized groups at risk are marginalised. 

Loyce Pace, US Assistant Secretary of State for Global Public Affairs, appealed for a balance between “science, respect for human rights and dignity, as well as national laws and context’

On Saturday night Pace had also made a spirited defense of the sexual health terms used, saying, “We should not need to hold a vote on the existence of entire communities of people.” 

Denmark’s Søren Brostrøm, Director-General of the Danish Health Authority, told the EB: “It’s very unfortunate that we had a discussion on Friday and Saturday that was very political, on established evidence and technical issues.  I think we need to reflect going forward, how we can balance the legitimate geopolitical differences that we have in our world, while at the same time protecting the technical authority of the WHO. I don’t have a solution. I think we need to reflect very carefully.” 

However, member states from countries that had opposed some of the language said that more efforts needed to be invested in consensus-building.   

“Botswana strongly believes that consensus should always be pursued in order to ensure our collective action and cooperation for a successful outcome,” said Dr Edwin Dikoloti, Minister of Health and Wellness, speaking on behalf of the 47 member state African group, which had largely abstained from voting on the strategy, with the exception of South Africa which supported the strategy. 

“It is important that the adoption does not set a precedent for consideration and adoption of technical documents by the Health Assembly.” 

Added Micronesia’s delegate, Marcus Samo, Secretary, Department of Health and Social Affairs. “I align myself with the sentiment raised earlier by honorable colleagues, particularly on the importance of compromise and consensus, rather than taking the floor for vote counts.”

WHO Staff Association Calls for Reshaping Internal Justice Board 

WHO’s Staff Associations representative speaks at the EB on equity, inclusion and internal justice.

The Executive Board also saw a lengthy debate on WHO follow-up over the ongoing investigation of sexual exploitation and abuse charges against WHO staff and consultants during the 2018-2020 Ebola outbreak in the Democratic Republic of Congo. 

In a related move, a written statement by the WHO Staff Associations, representing over 9,000 staff, called for a seven-point plan for staff reform, to ensure more diversity, equity and inclusion, as well as a remake of WHO’s internal justice system so that it operates more at arms length from the Director General’s Office. 

In particular, the Staff Associations proposed a remake of WHO’s Global Board of Appeals (GBA) body which renders judgment on cases of staff misconduct of any kind, brought by staff or managers.

Under the current system, the GBA is housed in the Office of the Director-General and its three board members are effectively appointed by a GBA Chair, a high-ranking career professional reporting directly or indirectly to the WHO Director-General, who also makes a final decision on GBA cases reviewed. This makes WHO’s key internal justice mechanism more of an administrative rubber stamp than an independent body. 

“The panel of the Global Board of Appeal (GBA) should have five-members,” stated the WHO Staff Association written statement. “A three-member panel – the current practice – is simply not reassuring staff that GBA deliberations are sufficiently robust. 

“Furthermore, the staff representatives on each of the GBA panels should be selected by the respective staff association rather than selected by the GBA Chair or Deputy-Chair.”

More ‘fairness’ needed in administrative leave processes  

In addition, the Staff Association statement called out the need for more “fairness” – regarding who is placed on administrative leave for abuses of power, misconduct, egregious behaviour etc. 

“We have noticed that whilst investigations take place, some staff are placed on administrative leave while other, often senior, staff members are allowed to continue to work.” 

The risk of being placed on administrative leave, or worse yet, terminated, is a deterrent to potential whistle-blowers against speaking out against misdeeds. It also inflicts permanent professional and financial damage on staff, who are wrongly charged as a result of political reprisals from more powerful managers or senior officials, WHO insiders have told Health Policy Watch. 

Speaking again on behalf of the US, Pace expressed discomfort that the head of investigations into sexual exploitation and abuse charges against staff and consultants during the DRC 2018-2020 Ebola outbreak reported directly to Tedros. This was the standard WHO internal justice process even though the exception had been sanctioned by the EB.

Pace acknowledged that “extraordinary factors” had led to the EB’s agreement to this chain of command. However, the “altered reporting lines” still “conflict with well-established communication and reporting lines of other UN system internal oversight offices”, said Pace.

In particular, “provisions allowing the head of an investigative unit to circumvent the leadership of the Oversight Office in which the unit sits, such as this decision has done, removes an ordinarily important level of oversight and quality control of the investigation function… 

“We believe that the current arrangement would benefit from further reflection and analysis as we consider what structures are required in the medium to long term,” she stated. 

WHA resolution on Russia’s invasion of Ukraine – about health not geopolitics  

The Russian Federation’s representative speaks protests WHA’s resolution on Ukraine at EB 151

Last Thursday’s WHA resolution co-sponsored by Ukraine, most of the EU, Turkey, Canada, and the USA condemning Russia’s invasion of Ukraine also briefly emerged again as an issue at Monday’s EB meeting. The resolution was adopted by a vote of 88-12, with 53 abstentions, mostly among African and Asian nations. 

“Resolution 75/6, this resolution was not unanimous,” said a Russian Federation delegate, speaking near the close of the day-long EB. “The Russian Federation thinks this is unacceptable, and it doesn’t take into account the true situation that has occurred, something that’s gone back to 2014. We hope that in the future, WHO will avoid polarization of issues.”

His remarks brought a strong response from Pace who stated that “the resolution … was not about politicization or global power struggles. 

“It really was about the health and welfare of millions, and the need to hold actors accountable for the devastation they’ve caused. And so this humanitarian crisis and aggression are in the minds of those who supported the resolution,” said Pace referring to the “indefensible destroyed infrastructure and disrupted chains of medical supplies. 

“And food now poses a grave threat to millions of people within, and well beyond, Ukraine. So over 80 million people are internally displaced and the number of people who have fled to neighbouring countries is now six million. 

“We thank the WHO and other humanitarian agencies and partners who are working tirelessly to provide protection and access to life saving supplies and services for affected communities and health workers.”

Traffic jam in Dhaka (Bangladesh) – Fossil fuel burning, including for transport, leads to deadly air pollution emissions that kill millions every year.

To save lives and accelerate climate action we need concerted international collaboration on air pollution – and it’s time for the health community to join the fight for clean air.

Air pollution isn’t a new problem. In the UK, citizens have been imploring authorities to act on London smog since the 17th century. But industrialization and urbanization have made air pollution a global health emergency. Today, death rates from air pollution are four times higher in low and lower-middle income countries than high income countries. India is home to 21 of the 30 most polluted cities in the world. Worldwide, deaths and disability caused by dirty air are the highest they have ever been.

‘We are going backwards’

Pollution in Delhi peaks in late autumn when drifting smoke from crop burning exacerbates pollution from urban household, traffic and industrial sources.

The Lancet’s recent progress update on pollution and health declares: “We cannot continue to ignore pollution. We are going backwards.” Air pollution caused 6.7 million deaths in 2019, equivalent to the populations of Mongolia, Botswana and Eswatini put together.

Since then, the COVID-19 pandemic has ripped through the world’s most polluted places, preying on people who were already suffering from pollution-related lung and cardiovascular health conditions. The toll of air pollution on health globally is on par with tobacco and was recognized by the UN General Assembly in 2018 as a major risk factor for noncommunicable diseases (NCDs).

But recognition has yet to galvanize urgently needed action. The World Health Organization’s (WHO) plan for a roadmap to tackle NCDs, approved by Ministers of Health at the World Health Assembly last week, is silent on one of the world’s major killers.

Clean air is a human right

Students walk to school in air pollution episode in Anyang, China, January 2022.

One hundred countries recognise the right to a healthy environment in their constitutions. In Chile and South Africa, the highest courts have recently reiterated that governments have a duty to ensure clean air as a constitutionally protected human right.

The messages of the UN Special Rapporteur to the Human Rights Council have become louder and more urgent during the pandemic: governments must do better to protect the most vulnerable from deadly air pollution, including our youngest and oldest and people living with NCDs, especially people living in poorer and marginalized communities.

Winning indoors but worsening outdoor air quality

Transitioning to cleaner cookstoves and fuels in Uganda.

The Lancet’s pollution and health progress update provides insights into how governments and the global health community can come together to solve this problem. The statistics show that deaths from indoor air pollution, caused by the burning of solid fuels in homes, are decreasing thanks to the adoption of cleaner fuels worldwide.

Although there is still a long way to go before harmful household air pollution is a thing of the past, the progress made so far is a testament to what can be achieved with concerted collaboration and dedicated funding.

An example of this is the Pradhan Mantri Ujjwala Yojana (PMUY) clean cooking initiative in India and the organisations brought together internationally by the Clean Cooking Alliance, which has mobilised partners, expertise and resources around a clear mission to clear the air inside homes.

The downward trend in mortality rate from traditional pollution (including household air pollution, water, sanitation and hygiene) in Africa 2000–19 (left) contrasts with the upward trend in mortality from modern pollution (outdoor air pollution and chemicals), particularly in south Asia and southeast Asia, 2000–19. (Lancet Planetary Health update, 2022)

The same cannot be said for outdoor air pollution and indeed greenhouse gases, both driven by fossil fuels in energy and transport, waste burning and agricultural pollution. In 2000, outdoor air pollution was responsible for 2.9 million deaths, but this shot up to 4.5 million deaths in 2019 and continues to rise as more people move to growing cities. The massive jump in the number of deaths due to outdoor air pollution has more than offset the gains from cleaner indoor air, water and sanitation.

While The Lancet report shares stories of progress in China, Mexico, Santiago de Chile and Bogota in Colombia, it raises particular concern about accelerating trends in African cities, related to urbanisation, traffic growth and waste burning. 

It also highlights the devastating economic impacts of air pollution, which is already costing over 10% of GDP in South Asia and 9% in east Asia and the Pacific.

Clean air gap in health action and funding

Indian students at a December 2019 protest over Delhi’s poor air quality.

Initiatives like the Convention for Long-Range Transboundary Air Pollution and the Climate and Clean Air Coalition have worked tirelessly to address outdoor air pollution, but without a focus on health. And there is a ‘clean air gap’ in funding and political commitment in the international landscape. Only 1% of development finance goes towards clean air projects, while philanthropic funding for clean air is even lower, contrasting with a backdrop of continued, self-destructive investment in fossil fuels.

Air pollution continues to fall through the cracks of health and climate plans, despite offering immense potential for win-win solutions. Only 7% of countries’ climate commitments consider short-lived climate pollutants such as black carbon, which harm both people and the planet. 

Even fewer governments have made air pollution an explicit priority in their climate action. Despite unprecedented attention to health during the COP26 climate conference in Glasgow last year, the final negotiated outcome doesn’t mention air pollution at all.

From deadly air to clear skies ahead

Blue skies in Delhi during COVID lockdown highlight human causes of air pollution.

Rapid urbanisation in cities worldwide continues, particularly in the global south, where polluting infrastructure for energy and transport risks harming health for generations to come. A global emergency requires a global response, where cities, regions, states, governments and the global health community all play a role. To protect people and planet, we need coordinated, well-resourced action for clean air that meets the challenge with proven solutions.

National leaders should create a Global Air Quality Convention to catalyse fresh international collaboration on the issue. Considering the human and economic toll of air pollution, Ministries of Health and Finance should lead the charge. 

Governments should agree and report against global targets informed by the WHO’s ambient air pollution guidelines. Regional cross-border approaches are needed, with stronger pollution monitoring holding leaders accountable for their clean air actions. 

A world where everyone can enjoy their right to clean air is within reach. With robust international cooperation and funding, action on outdoor air pollution, especially in low- and middle-income countries, can reverse the trends caused by deadly air, and make populations healthier and more resilient against future epidemics. A global convention makes a future where everyone breathes clean air possible, but we have to act now.

Jane Burston is the Executive Director of the Clean Air Fund. Nina Renshaw is the Clean Air Fund’s Head of Health.

Image Credits: Flickr – joiseyshowaa, Flickr, V.T. Polywoda, Climate and Clean Air Coalition , @DYFIDELHI.

Rosamund Lewis and Sylvie Briand at WHO sponsored webinar Monday on Monkeypox

Monkeypox can be spread by an infected person through salive and droplets, including mouth lesions, as well as via bedding.  A mother can also pass the virus to her baby across the placenta.

In addition, untreated HIV might increase the risk of more serious infection.

So warned Dr Rosamund Lewis, the WHO’s monkeypox expert, at a WHO briefing on Monday where she described the current monkeypox outbreak in people with no contact with areas where the disease is endemic continues as “atypical”.

“What we don’t know is whether there is aerosol transmission – aerosolized transmission from talking and breathing,” said Lewis, speaking at a WHO webinar on Monday.

“We also don’t yet know whether there is asymptomatic transmission of monkeypox,” added Lewis.  “The indications in the past have been that this is not a major feature, but this remains to be determined.”

Public health risks “moderate” says WHO as virus spread farther than in the past

In a statement on Sunday, WHO said it had recorded 257 cases of the disease since 26 May, outside of the 12 central and west African countries where the disease is endemic. All of the cases have been diagnosed with the West African clade of monkeypox, which is less deadly than the central African one.

In contrast, only nine cases have been identified outside these regions over the past five years and all those cases involved people who were linked to these regions by travel.

“Currently, the overall public health risk at global level is assessed as moderate considering this is the first time that monkeypox cases and clusters are reported concurrently in widely disparate WHO geographical areas, and without known epidemiological links to non-endemic countries in West or Central Africa,” the WHO statement said.

“Cases have been mainly reported amongst MSM. Additionally, the sudden appearance and wide geographic scope of many sporadic cases indicates that widespread human-to-human transmission is already underway, and the virus may have been circulating unrecognized for several weeks or longer.”

Transmission rates generally have not been that high in the past

Transmission rates have not generally been that high in the past, and “it is a large DNA virus, one of the largest viruses known, and it would change or mutate much more slowly than RNA viruses”, Lewis said.

“There is not much information right now. We are just seeing the first genomes being put up and don’t have a lot of information on what the genomes of the viruses being detected in this current multi-country outbreak are telling us,” added Lewis. 

However, she said that it was not yet known whether people immunised against smallpox 40 or 50 years ago would still have immunity.

“We are concerned that the global population is not immune to orthopox viruses since the end of the small pox eradication.. The virus may attempt to exploit a niche and spread more easily between people.”

Congo Basin clade more severe

The Congo Basin clade appears to cause severe disease more frequently with case fatality ratio (CFR) previously reported of up to around 10%, said the WHO statement, adding that nonetheless, the Democratic Republic of the Congo, where the disease is most prevalent,  is reporting a CFR among suspected cases of around 3%.

“The West African clade has in the past been associated with an overall lower CFR of around 1% in a generally younger population in the African setting. Since 2017, the few deaths of persons with monkeypox in West Africa have been associated with young age or an untreated HIV infection.”

WHO’s Dr Sylvie Briand said that unlike COVID-19, monkeypox was a known disease with symptoms, including ever, muscle aches and swelling of the lymph nodes – with skin eruptions within three days of the onset of fever.

 

Image Credits: US Centers for Disease Control.

 

Pakistan is one of two countries where polio remains endemic.

World Health Organization (WHO) member states endorsed a new polio eradication strategy 2022-2026 last week that aims to permanently interrupt all poliovirus transmission – both of the wild poliovirus and vaccine-derived cases. 

Meanwhile, WHO Director-General Dr Tedros Adhanom Ghebreyesus said that the discovery of a second wild poliovirus case in Africa, confirmed on 18 May in Mozambique, was “not unexpected” in light of the case previously reported in Malawi. 

But Tedros maintained that member states still have a real opportunity to end polio in the coming years if they “reach every child,” and countries free of the virus build resilient health systems.”

Tedros was speaking at a session on poliovirus eradication shortly before the World Health Assembly’s closure on Saturday.  

Along with the earlier reported case in Malawi, the reported case in Mozambique raises questions over the continued status of the WHO African Region as “wild poliovirus free”.

The wild virus is still endemic in just two countries, Afghanistan and Pakistan. 

But the appearance of the two new wild poliovirus cases in southern Africa, as well as six  new cases in Pakistan in April and May this year, after 15  months in which no cases were reported, underscores the fragility of recent gains.

A WHO spokesperson told Health Policy Watch that Africa’s current wild poliovirus eradication status is not affected at the moment, because these cases are not endemic to Africa, but are linked to virus from Pakistan.  

“We’ve seen this time and again in the past, in other regions as well, where poliovirus was imported into the region, but because it is not endemic to that region, it would not affect the certification status,” said the WHO official.

“That does not make it any less tragic of course, particularly for the children affected and their families, nor does it make the outbreak any less of a public health emergency.  That is why Mozambique immediately declared detection of this outbreak to be a national public health emergency, and the country continues to participate in the multi-country outbreak response with Malawi and other neighbouring countries to urgently stop this outbreak again.”

Vaccine-derived outbreaks increased 

Type II vaccine-derived polio cases continue to be reported in about 20 other countries,  including recent cases in developed countries such as Ukraine and Israel, where the first vaccine-derived polio case in over 30 years was found in March in an ultra-Orthodox Jewish community with low rates of childhood vaccination.  

Overall, a WHO Progress report found a sharp increase in the number of circulating vaccine-derived poliovirus outbreaks between 2018–2021 and “continued vastly insufficient inactivated polio vaccine and oral polio vaccine coverage rates across many polio transition priority countries. 

Even so, the most recent WHO report also found that “compared to 2020, the epidemiological situation improved in 2021, with a 96% decline in cases of poliomyelitis due to wild poliovirus type 1 and a 47% decline in cases due to circulating vaccine-derived poliovirus, globally.

“In endemic areas, five cases due to wild poliovirus type 1 were reported in 2021. This favourable situation must not give rise to complacency; it is a unique opportunity that should be capitalized on through strengthened engagement and support by all partners in the public and civil society sectors,” it adds. 

Civil insecurity, and vaccine hesitancy 

At the same time, the report warns that “the polio eradication programme continues to face both ongoing and emerging challenges, such as the need to catch up with and vaccinate children in endemic reservoir areas who are persistently missed by programmes; insecurity and uncertainty in Afghanistan; the continuing COVID-19 pandemic, which affects polio surveillance and campaigns; and a precarious financial situation adversely affecting the global effort.” 

Member states expressed particular concerns about the resurgence in southern Africa, where wild poliovirus cases have been reported recently in Mozambique as well as Malawi, sparking a massive, five-country vaccination campaign targeting some 23 million children.

As with Malawi, the wildpolio virus strain that has been reported in Mozambique originated  in Pakistan, members said.  However, the appearance of the two cases underscores the fact that the virus is now circulating locally – insofar as neither of the two children had become infected had a travel history.  

The USA said “It strongly supports the WHO efforts for eradicating polio and proposes effective field campaigns in Pakistan, Afghanistan, Malawi and Mozambique. It also expressed concerns about the importation of polio cases in southern Africa”.

Build capacity for countries to produce their own vaccines 

Western African nation republic of Benin speaking on behalf of 47 African states said asked for the capacity building in the health systems including producing local vaccines to end polio. 

It said member states are committed to eradicating polio till 2023 but results so far are fragile, adding that governments have to build strong policies and sustainable financial programs to maintain the success against polio. 

Regional Director of the WHO Africa region, Dr Matshidiso Moeti, said member states need to prioritize the commitments to end polio with political commitment and increased domestic funding. 

She urged a strengthened surveillance system to be the best defence against wild and vaccine-derived polio cases.

Moeti said that the Mozambique case, like that in Malawi, was “genetically linked to Pakistan,” and  “does not affect the WHO African region wild polio-free certification for now. 

However, she acknowledged that the continued appearance of cases would in fact pose an obvious  threat to Africa’s polio-free status, saying, “the governments of Malawi and Mozambique are taking determined and swift action with the support of GPEI partners and action of their neighbours to address a setback which threatens decades-long hard work and region’s certification status.”

Dr Ahmed Ali Mandhari, regional director of WHO’s Eastern Mediterranean Region to which Pakistan and Afghanistan belong, said that fragile campaigns have given a chance to survive the wild poliovirus in Pakistan and Afghanistan. However, the health systems and polio workers are doing impressive work in difficult regions where they face deadly attacks. 

He further said that added investments in polio eradication programs can help wipe out the vaccine-derived cases “on the fast track” from conflict zones, such as Somalia, Yemen, and Sudan. 

In its statement, Gavi, the Vaccine Alliance, said full implementation of the eradication plan for 2022-26 means reaching 1.71 million more children, mostly in the AFRO and EMRO regions,  who have not yet been vaccinated at all.

Gavi said the COVID-19 pandemic disrupted immunization activities across the world and widened the vaccine equity gaps as well. 

Wildvirus re-emergence due to fragile anti-polio drives

At the same time, Rotary International, a WHO and GAVI partner said although the lowest numbers of polio ever were reported in 2021, the virus re-emerged in 2022 because of fragile anti-polio drives. 

 “The fragility in 2022 of anti polio drives led to the emergence of cases in Malawi and Mozambique,” said the Rotary delegate to the WHA. He  and called countries to address gaps in their immunization programs”.

Rotary asked the member states to address immunization gaps in their respective polio programs. 

Pakistan also re-affirmed its commitment to ending polio.  The country has proposed five years program with the financial assistance of above 10 million dollars to end polio from the country.

The African nation Malawi said the country has 2.9 million population of children and it has submitted a budget proposal to increase efforts against polio which resurge after years. 

It said the polio response program and Emergency Operations Center are working and the plan is to achieve zero polio cases in Malawi.   

Ten recommendations – including global polio integration into health systems 

Another WHO evaluation of progress on poliomyelitis presented ten recommendations to member states for accelerating eradication efforts. 

These include developing a global plan to integrate polio eradication and vaccination efforts into national health systems. 

Traditionally polio eradication has been funded separately by a massive donor driven effort under the auspices of the Global Polio Eradication Initiative (GPEI), and managed vertically – although behind the scenes, better-funded polio teams sometimes also were used by national health systems to administer other vaccine efforts in tandem. 

The WHO plan aims to better include polio activities in relation to other WHO investments in primary health care, vaccine-preventable diseases, and emergency response, as well as broader, global polio and polio transition efforts.

Member states have a real opportunity to end polio by 2023, adding that 50 countries have the support of GPEI and each has challenges ahead. 

“Countries still fighting with the virus must reach every child, and countries free of the virus must build resilient health systems,” said Dr Tedros. 

Image Credits: Sanofi Pastuer/Flickr.

Saudi delegate in heated WHA debate Saturday over sexual rights and terminology

On its final day of a session dominated by discussions of sexual health and the war in Ukraine, the World Health Assembly (WHA) voted 61-2 to adopt a new global strategy on HIV, hepatitis B and Sexually Transmitted Infections 2022-2030 (GHSS) 30 absentions and 90 delegations skipping the vote altogether. 

The vote Saturday evening, after hours of painful debate, was the final act of the WHA before it closed a rollercoaster week of unprecedented debates over issues ranging from pandemic reform to the war in Ukraine.

But the absence of 120 delegates – 90 delegations skipped the vote and 30 abstained from the final vote was almost unprecedented on a technical matter. Cumulatively, the two days of time taken in debate was even more than the hours expended discussing a resolution condemning Russia’s invasion of Ukraine, approved by another roll call vote on Thursday.

In closing the WHA just after the vote and shortly before midnight, WHO Director General Dr Tedros Adhanom Ghebreyesus said he wished the Assembly could have reached consensus on the strategy. “But in my view we should not be afraid of voting when needed to press ahead with global health strategies.” 

Approval of the strategy came over strenuous objections by socially conservative countries, led by Saudi Arabia to terms used in the strategy and in its annexed glossary on sexual health and target populations for HIV treatment – language regarded by many experts as standard for HIV treatment and care.  

Speaking on behalf of WHO’s 22-member state Eastern Mediterranean Region (EMRO), the Saudi delegate and other EMRO nations catalogued the terms that they found objectionable, including references to: “sexuality”, “sexual orientation”, “”sexual rights”. There also were objections to the strategy’s reference to “men who have sex with men” as a target population for HIV treatment.

And, member states objected to definitions of terms contained in an annexed glossary, such as one saying that “for sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.” 

Glossary of terms removed in last-minute compromise 

WHO legal counsel explain voting choices regarding ammendments proposed by member states from the draft WHO strategy on HIV, hepatitis B and STIs.

In a compromise that was approved shortly before the final vote, Mexico’s delegation offered to remove the glossary of terms altogether, as it included much of the language that had become a flashpoint for many of the conservative member states’ objections.

The measure was accepted in a 58-0 vote, but with 95 delegations absent and 30 abstaining. The compromise also added language specifying that “national context should be considered” in relation to strategy and called upon WHO’s director-general to report back to the Assembly over the next decade. 

Ultimately, however, the Mexican-brokered concession didn’t go far enough for Saudi Arabia, Egypt, Nigeria and other leading critics. Along with deleting the glossary, they demanded the removal of sexual rights terms from the strategy, per se, as well as a reference to an International Technical Guidance on Sexuality Education, which makes use of the same terminology. 

In the final rollcall vote, shortly before midnight, not only the entire EMRO region, but also most sub-Saharan African nations abstained or were absent from the vote – with the notable exception of South Africa, which voted in favor.

Similarly, the Russian Federation, Ukraine, as well as India and Indonesia abstained from the vote on the strategy, supported by most countries in Europe, as well as the United Kingdom, Ireland and Israel, along with North America, Latin America, and parts of Asia and the Western Pacific Region.

Dismay among many member states over the lack of consensus

Nigeria disassociated itself from language in the strategy after the final vote.

After the final vote, some member states, including Egypt and Nigeria disassociated themselves once again from the language around sexual health and rights, contained in the strategy.

But member states on both sides of the divide also expressed dismay that the WHA had not managed to reach consensus on such an important technical document. Countries that had vigorously objected to terms used just a few hours earlier, including Egypt, Djibouti and Syria, saying that they would support the strategy’s implementation – but on their own terms.

“Process and procedures should be more inclusive,” said the delegate from Djibouti, adding that it would implement the strategy “with full respect for the religious and ethical values, and cultural background of its people, and in comformity with universally recognized international human rights.”

Countries voting in favour also expressed regrets about the failure to find consensus, and the need to resort to a roll call vote on a technical document covering diseases that continue to represent a huge burden of disease for so many countries worldwide. Said Monaco, “We consider this deeply disappointing. And we think this will have consequences in the future because of the precedent created.”

US makes spirited defense

sexual health
Loyce Pace, Assistant Secretary of State for Global Public Affairs in the US Department of Health and Human Services

But Loyce Pace, US Assistant Secretary of State for Global Public Affairs in the US Department of Health and Human Services, defended the decision by the prevailing group of member states to leave references to “sexuality,” and “sexual education” intact in the final Strategy document, along with a reference to the International Technical Guidance on Sexuality Education, as well as mention of a key target population of HIV work as “men who have sex with men.”

“We appreciated those member states acted in good faith as part of these deliberations. Unfortunately this has served as a painful reminder of the need to reinforce our focus on evidence, human dignity and decency.

“We should not need to hold a vote on the existence of entire communities of people,” Pace asserted. “We have a strategy on critically important global health issues, yes. But at what cost to those we risk leaving behind? So to gay, lesbian, bisexual, queer, intersex, transgender and gender non-conforming people around the world, the United States government sees you, and will continue to support you.  Stay strong.”

Clock ran down as debate dragged on

As the debate on sexual health dragged on into the evening hours, Dr Hiroki Nakatani, presiding over the Assembly committee discussing the issue, puzzled over whether to push for consensus, break to confer with capitals or give delegates more time to negotiate a compromise. He decided breaking for informal consultations, resumed and then broke again for more consultations on the Assembly floor, before resorting to a vote.

Earlier in the afternoon, he had seemed more hopeful. “I heard there is a very rich discussion,” Nakatani told the committee. “Proposals are being generated.”

WHA in final hours Saturday – Committee A breaks twice in effort to hammer out agreement.

Conservative WHA members backed another Saudi-led proposal to delete all sexual rights language or references

Diplomats from the UK, Monaco, Argentina, Canada, Chile, Dominican Republic, Uruguay, Peru, France, Slovakia, Denmark, Australia, US, Norway, Germany, Brazil, Italy, Ireland and Netherlands all favored Mexico’s compromise proposal.

The Saudi delegation’s proposal, however, wanted to go further, with the insertion of footnotes in the strategy expressing reservations about the use of terms like “sexual orientation” other sexual health and sexual rights terms used there and in the International Technical Guidance on Sexuality Education. That proposal, however, was defeated in a show of hands. 

Some diplomats argued for more time to study the proposals. Regardless of which proposal they favored, however, most diplomats seemed to agree that further delay on the draft strategy would only bring harm to global efforts to eliminate HIV/AIDs and other sexually transmitted diseases. 

Untenable we don’t reach agreement

“It is an untenable prospect that we don’t reach agreement on the strategy,” a UK diplomat said earlier in the day when hopes of a consensus were higher.

“I hope we will be able to conclude our discussions and WHA session on a positive note and at the end of these consultations and discussions to have consensus,” a Djibouti diplomat agreed, saying. “How can we combine the two proposals so that we would have a less divided room?.”

“We have to take a decision today because the WHA is closing today and we need a decision on this strategy … hopefully by consensus,” said a French diplomat. “If not, then we have to make a decision.”

A  German diplomat echoed the French view: “We are running out of time and given the views expressed, it seems the Mexican proposal is the best opportunity for consensus.”

A day earlier, Suriname on behalf of 56 countries including South Africa, Thailand, the UK and US stressed that health strategies had to be based on data and evidence. The US pointed out that a number of concessions had been made to the GHSS in the interest of reaching consensus. 

“Important subjects central to addressing these diseases have been removed from the document or caveat, including comprehensive sexuality education, gender identity, gender-responsive approaches, intimate partner violence that’s not limited to heterosexual partnerships and gender-based violence,” said Loyce Pace, a top U.S. health official.

The International Federation of Medical Students Associations, International Federation on Ageing, International Planned Parenthood Federation, and Women in Global Health have all told the Assembly that they “deeply regret the removal of terms like comprehensive sexuality education (CSE) and intimate partner violence (IPV) from the text.”

Dr Hiroki Nakatani joins in the applause after the resolution’s passage

Diplomats approve the complex process they will use to update the legally binding rules among nations for responding to global health emergencies like the coronavirus pandemic.

GENEVA – The 194-nation World Health Assembly approved a resolution on Friday that halves the two-year period for amendments to the International Health Regulations (IHR) to take effect down to just one year.

The move is part of a highly technical package of US-proposed measures that picked up support as the most practical way of kickstarting the reform process in pandemic response. Broad applause broke out just after one of the Assembly’s main committees adopted the resolution.

“I’m so excited,” said the committee’s president and veteran public health specialist Dr Hiroki Nakatani, “that we could adapt this very important resolution by consensus.”

Just before the respolution’s adoption, Colin McIff, deputy director of the US Department of Health and Human Services’ Office of Global Affairs, explained a series of technical changes that had been reached to ease passage of the resolution. Those included giving nations “additional time for consideration” – up to 10 months, rather than nine, to reject or voice reservations over any future amendments that would be adopted. Nations also would have up to 12 months – double the previous suggestion of six months – to ensure they implement any IHR amendments that newly enter into force of law.

A paragraph also was added, he said, that urges nations “to collaborate with each other in the provision or facilitation of technical cooperation and logistical support, particularly in the development, strengthening and maintenance of the public health capacities required under the International Health Regulations.”

Resolution reflects “our produtive work together”: Colin McIff, Deputy Director of the Office of Global Affairs at the U.S. Department of Health and Human Services.

The entire resolution reflects “our productive work together over the past several days here at the Health Assembly and reflects the consensus of member states,” said McIff. “We would like again to thank member States for working together on this historic effort to strengthen the IHRs.”

The Biden administration, supported by countries as diverse as Colombia and Thailand, has long contended that changes to IHR would complement, rather than be a substitute for a pandemic treaty. The changes to IHR would be targeted to topics already covered in the global health rules like procedures around outbreak notification, and could take effect within three years. A treaty would likely address a broader set of issues, but also take far longer to negotiate, approve and be ratified by individual member states.

IHR revisions urgently needed  

More than a year ago the Independent Panel on Pandemic Preparedness and Response concluded the IHR badly needed updating from the “analogue” to “digital” era of information sharing to ensure that WHO and its member nations more quickly react to global health risks. 

Under current IHR rules, for example, there is no clear deadline for countries to report suspected outbreaks to WHO or for WHO, in turn, to report them to member nations. In a recent wild poliovirus outbreak in Malawi, it took months for a report on it to be published.

While such concerns weren’t directly addressed by this Assembly, the decisions made this week set in motion a process for updating the vague and often indirect 2005-era IHR rules, while negotiations proceed over a broader pandemic treaty.

Earlier in the week, that procedurally-oriented resolution ran into unexpected resistance from some nations, including the African Group, which was concerned that changes might be introduced to the IHR without sufficient study or input.  

Working Group on IHR reform paved the way  

McIff told the committee that those concerns were addressed during intensive discussions as part of a Working Group that paved the way for the resolution’s adoption by consensus. One key breakthrough, diplomats said, was the Assembly’s approval late Tuesday of the companion WHA decision that sets in motion a two-year process for substantive rule changes that are the ultimate goal. 

The aim is to have a package of reforms ready for the World Health Assembly 77 in 2024 and for any new rules that are approved to take effect as of May 2025. The task of collecting and assessing nations’ proposals for amending the IHR will be managed by a new member state “Working Group on IHR reform (WGIHR)” that replaces the  “Working Group on Pandemic Reform” that operated over the past year.  

In tandem, WHO’s Director-General Dr Tedros Adhanom Ghebreyesus has been asked to convene an IHR expert review committee to provide more studied inputs into the WGIHR about the most needed and useful reforms.

According to the timeline agreed to on Tuesday, any and all member states may submit their proposals for revising the IHRs to the new WGIHR group by 30 September 2022. The WGIHR group will sift through the proposals and draft a report to be reviewed by the WHO Executive Board in January 2023. In parallel, the expert IHR Review Committee will make its own recommendations by then.  

“The rebranding of the WGPR to the WGIHR gives all member states an equal opportunity to put their ideas forward,” a senior US official, said of the process, in an interview with Health Policy Watch.

The fact that an IHR expert review committee will also provide input means that “there’s going to be a member state political component that’s backed up by an expert level review commissed by the DG,” the official said.

Interface with the pandemic convention negotiations 

One key concern has been the potential overlap of the IHR reform process and the parallel process already underway of negotiations on a potential new pandemic convention, treaty or other instrument – which can potentially address  a broader set of issues and concerns, such as medicines and vaccines equity and related to that, support for better emergency preparedness and response in low and middle-income countries.  

The negotiations on the pandemic instrument are already underway under the guidance of an Intergovernmental Negotiation Board (INB), mandated by a special session of the World Health Assembly in November 2021.

Diplomats hope that by the time the negotiations over IHR reform get underway in serious in early 2023, the INB will have made some progress – and specific pandemic reform issues can be allocated to one or the other of the processes without too much overlap.

The aim is to make the two processes complementary, the senior US official said, with the IHR revisions starting later, but also concluding more rapidly – while the pandemic convention or treaty process continues.

“There’s been very strong engagement with the African group, and also with the Europeans and others, a lot of back and forth around this discussion of should there be a treaty or an international instrument,” the official said.

That dialogue contributed to “a lot of consensus-building over the course of this year, starting with the Executive Board in January, which endorsed in Decision 150(3), the concept of targeted, limited [IHR] amendments, without opening up the whole IHR for renegotiation. So that’s what we’ve been building on, and that’s what was adopted.”

Timeline for moving ahead on IHR reform

According to the timeline set out in the the decision on Tuesday, any and all member states may submit their proposals for revising the IHRs to the new WGIHR group by 30 September 2022.

The WGIHR group will sift through the proposals and draft a report, to be reviewed by the WHO Executive Board in their meeting of in January 2023. 

In parallel, the expert IHR Review Committee of experts will also complete its work – and make recommendations by early 2023. 

The aim, the senior US official told Health Policy Watch, is to then “put all that into the mix, and then the member state negotiation process can really begin in earnest.”

While the IHR negotiations will still take at least two years, not including the year for any new amendments to take force, there is a delicate balancing act that must be observed, the official said, referring to concerns that had emerged in talks with the African Group and other nations over the past week:

“We have to move with a sense of urgency and a sense of purpose. But frankly, these are also technically complex issues, relating to a lot of implementation challenges, not only in the executive branch, but legislative branches of governments.  So we have to give due consideration to the topics as well.” 

Nigeria objected to the inclusion of ‘sexual orientation, transgender and men who have sex with men’.

Despite significant compromises to a draft strategy on HIV, hepatitis B and STIs, conservative World Health Organization (WHO) member states used a debate at the World Health Assembly on Friday to object to the inclusion of such as “sexual orientation”, “sexuality” and “men who have sex with men”.

The objections were led by Nigeria, Egypt, Pakistan, Jordan and Saudi Arabia, who claimed that some of the sexual health and rights terms referred to in the Global Health Sector Strategies (GHSS) on HIV, viral hepatitis and sexually transmitted infections 2022-2030 – terms standard for many years in HIV treatment and care – was an affront to their culture.

This led to a delay in WHA approval of the GHSS – whose finalization also was delayed by disputes over references to comprehensive sexuality education and gender identity, despite the expiration of a previous strategy in 2021.

A last-minute compromise was proposed on Friday night by Saudi Arabia. This involves deleting the entire GHSS glossary and inserting two footnotes. One footnote would record that some countries have reservations about the term “sexual orientation”. The other would note objections to a reference to the International Technical Guidance on Sexuality Education.

But a number of member states said that they needed to first check with their principals before accepting the last-minute compromise. While none of the member states voiced objections to Saudi Arabia’s compromise, Monaco’s delegate expressed disquiet at the delay, which she said was unprecedented in her many years at the WHO.

The Africa region did not object to the text, with Namibia and Senegal expressing support for science-based approaches. Neither did Russia which is renowned for leading the anti-LGBTQ charge at international forums, but in this case described the GHSS text as “balanced”.

Saudi Arabia proposes a compromise.

Science-based policies

Earlier in the debate, Suriname on behalf of 56 countries including South Africa, Thailand, the UK and US, stressed that while consensus was important, health strategies had to be based on data and evidence.

“We recognise that achieving consensus at the World Health Assembly depends on compromise balancing national priorities and contexts with the global epidemiological context, but it is the WHO’s role to put forward normative guidance that follows and aligns with the most current science-based knowledge,” Suriname asserted.

“We must continually adjust and replace outdated or ineffective interventions with those that can reach key populations and vulnerable populations,” added Suriname. “Effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all.”

Loyce Pace, Assistant Secretary for Global Affairs at the United States Department of Health and Human Services (HHS).

The US, represented by Loyce Pace, Assistent Secretary for Global Affairs at the US Department of Health and Human Services, praised the “comprehensive and transparent consultation process” that took place over the strategy throughout 2021 and 2022. 

“The US would like to underscore the important role WHO plays in developing strategies,” said Pace.

“These strategies are used widely across all regions to guide the provision of health services and interventions. To ensure the greatest impact they must be based on the most current science responding to the diverse needs of different populations, especially those who are excluded from health services due to stigma and discrimination.”

Pace added that “effective approaches must promote equity, gender equality, and protect and fulfil the human rights and dignity of all”. 

Concessions

She also pointed out that a number of concessions had been made to the GHSS in the interest of reaching consensus. 

“Important subjects central to addressing these diseases have been removed from the document or caveat, including comprehensive sexuality education, gender identity, gender-responsive approaches, intimate partner violence that’s not limited to heterosexual partnerships and gender-based violence,” said Pace.

“The current scientific evidence clearly supports the inclusion of these terms and effective strategies to address HIV, viral hepatitis and STIs,” said Pace, but added that the US “remain satisfied that the strategy is preserved the importance of core interventions and populations of focus”. 

France on behalf of the European Union (EU) noted that, “despite the scientific nature of the work on the strategy, some states are reluctant to recognise some realities on which this guidance is based, even though they could adapt them to their national situation”.

“We underscore the importance of ensuring universal access to complete education and good information on health connected with sex, your sexual health and complete sexual and reproductive health support,” added France.

Cultural objections

Among African nations, Nigeria was most vocal in its complaints about terminology used in the strategy documents.

“Spirited efforts were made by the delegation of Nigeria to engage the Secretariat where these concerns can be addressed. Nevertheless, and despite the demonstration of openness and best intentions by Nigeria, it is disappointing and most unfortunate that some of these terms and phrases – which are totally objectionable, and inimical to our cultural and social well being as a sovereign state – are still broadly reflected in the text,” said the Nigerian delegate.

“Nigeria hereby without ambivalence and or intended ambiguity, objects and dissociate itself from the following terms and phrases in the text: ‘sexual orientation, transgender, men who have sex with men’.”

Nigeria also objected to the reference to the International Technical Guidance on Sexuality Education and the definition of sexual health in the glossary.

“Let it be placed on record that Nigeria has not accepted these terms and phrases in the past. I will not accept them today,” he declared.

Jordan said that “some of the expressions and some of the language used in the text does not conform to the culture and tradition in our country and the countries of the region” and “remain unacceptable to us”. 

Pakistan objected to  “non-consensual terminologies about gender, sexual orientation, sexual rights, comprehensive sexuality education, among others”. 

Egypt, Indonesia, Bahrain and Bangladesh also raised objections.

Science not ideology

The International Federation of Medical Students Associations, International Federation on Ageing, International Planned Parenthood Federation, and Women in Global Health told the assembly that they “deeply regret the removal of terms like comprehensive sexuality education (CSE) and intimate partner violence (IPV) from the text”.

“We emphasise the need for WHO to adopt strategies that are evidence-based, rather than based on politics and ideology. The objective and functions of WHO as defined in its constitution are very clear. We call on the director-general of WHO to stand firm behind science and not ideology.”

Meanwhile, Cedric Nininahazwe, the advocacy manager of the Global Network of People Living with HIV, praised the new strategy, saying that it gave hope to communities.

 

Dr Tedros urges implementation of NCD policies.

While the World Health Assembly adopted a raft of roadmaps, strategies and resolutions to address non-communicable diseases (NCDs) on Friday, what was important was their implementation, said Dr Tedros Adhanom Ghebreyesus.

“It is impossible to overstate the importance of concerted action against non-communicable diseases, which account for 85% of all premature mortality in low and middle-income countries,” said Tedros,  Director-General of the World Health Organisation (WHO).

“The package of strategies, roadmaps, action plans, work plans and recommendations you’re about to adopt provide important evidence-based tools that could save many lives. But what matters is not adopting them, but implementing them. What happens in this room is important only in as much as it translates into concrete change,” Tedros challenged.

“The growing burden of NCDs highlights the many threats to health in the food people eat, the water they drink, the air they breathe and the conditions in which they live and work,” said Tedros.

While diabetes and obesity are rising globally, tobacco use has declined in 150 countries and 58 countries had policies to eliminate trans fat from food, he added.

“Tobacco use remains too, high physical activities too low and 99% of the world’s population raises air that exceeds WHO air quality limits,” he said.

“The great tragedy of NCDs is that many of these diseases are preventable and treatable when people have access to the services they need. That’s why it’s so crucial that all member states prioritise resources to integrate services for NCDs and their risk factors into primary health care as part of their journey towards universal health coverage.”

Huge treatment gap for epilepsy

Dr Zsuzsanna Jakab, WHO Deputy Director-General.

Dr Zsuzsanna Jakab, WHO Deputy Director-General, pointed out that more than 50 million people with epilepsy live in low and lower middle-income countries, but the treatment gap is over 75% in most low-income countries and 50% in most middle-income countries.

Jakab said that the neurological manifestations of COVID 19 infection had also highlighted the importance of addressing neurological conditions such as epilepsy.

“COVID-19 condition, disruption of services, medication inaccessibility, interruption in vaccination programmes and increased mental health issues have added to the burden of those with neurological disorders,” said Jakab, adding that the action plan represents an unprecedented opportunity to address the impact of neurological disorders.

“Meanwhile, the alcohol-attributable disease burden continues to be unacceptably high and there is a need to accelerate action on reducing the harmful use of alcohol,” she added.

Dr Ren Minghui, WHO Assistant Director-General of communicable and non-communicable diseases within universal health coverage, highlighted that disorders of the nervous systems are “the leading cause of disability-adjusted life course and the second leading cause of deaths globally”, accounting for 9 million deaths per year. 

“In addition, every 10 seconds a person died from alcohol-related causes.”

“People living with neurology disorders continue to experience stigma, discrimination and human rights violation,” he added.

With regard to alcohol, some member states had asked for guidance on how to protect alcohol policy from commercial interests and this would be provided by the WHO Secretariat, Minghui added.

monkeypox
Sylvie Briand fielding questions about COVID-19 cases in healthcare workers.

GENEVA — The monkeypox outbreak has spread to almost 200 cases reported by more than 20 nations outside of Africa, where the disease is endemic. But the epidemic can be contained through a quick response, World Health Organization (WHO) officials told a public briefing for member nations on Friday.

With few vaccines and drugs available globally to fight monkeypox, a zoonotic disease transmitted from animals, WHO officials proposed creating a stockpile to equitably share existing resources. They said there is no evidence the virus has changed but acknowledged many questions remain about how this epidemic emerged, and what role animal hosts played in tranmission.

Dr Sylvie Briand, WHO’s director of pandemic and epidemic diseases, said “it’s an unusual situation” because the first case was only reported on 7 May, and since then there have been a high number of cases among non-endemic countries. Most of the cases result in symptoms such as body aches, chills, fatigue and fever, but some people may also develop a rash and lesions on their face and hands that can then spread to other parts of the body.

Monkeypox endemic in nine countries

“We know that it’s endemic in a bit more than nine countries in Africa where we have seen outbreaks in the recent years. This virus is an autopox virus. It’s a virus from the same family as smallpox and also other cowpox viruses,” Briand said.

“What is important is just to see that this event is unusual,” she said. “Usually, we have no cases or very sporadic cases that are exported to non-endemic countries. But now we have more and more cases.”

Briand said WHO doesn’t know “if this unusual situation is due to a virus change. It doesn’t seem so, because the first sequencing of the virus shows that the strain is not different from the strains we can find in endemic countries, and it’s probably more due to a change in human behavior.”

“But we are also investigating this and trying to understand the origin of this sudden outbreak of monkeypox in non-endemic countries,” she continued. “There are so many uncertainties about the future and this disease, about the future, because we don’t know if this transmission will stop.”

Briand said WHO believes there is “a good window of opportunity to stop the transmission now” because of existing medical countermeasures, vaccines and therapeutics. “We are afraid that there will be spread in communities, but currently it’s very hard to assess this risk. We think that if we put in place the right measures now, we probably can contain this easily,” she said.

No need for mass monkeypox vaccination

Dr Rosamund Lewis, head of WHO’s smallpox department, said a vaccine for monkeypox has only been approved in the US and Canada, but there is no need for mass vaccinations because the virus is usually only transmitted only through skin-to-skin contact. But she suggested those few nations that have the vaccines could use them for vulnerable populations, such as health workers or families of patients.

“And as far as we know, smallpox countermeasures may be protective against monkeypox. But you can imagine that there’s not been time to do a lot of research, certainly nothing on smallpox in the last 40 years in terms of human studies, clinical trials and field studies,” Lewis said. “What we have been advised so far is that there is no need for mass vaccination, there is no need for large immunization campaigns.”

Dr Mike Ryan, WHO’s emergencies chief, said the global body will work with member nations on creating a stockpile to share the limited number of smallpox vaccines with other nations that lack the resources to purchase them.

“We would like to see a coordinated mechanism whereby countries can access vaccines and therapeutics through a mechanism that’s efficient, that’s fair, that’s equitable, but also recognizes that mass vaccination is not the target here,” he said.

“We’re talking about providing vaccines for a targeted vaccination campaign, for targeted therapeutics. So the volumes don’t necessarily need to be big, but every country may need access to a small amount of vaccine.”

Ryan said such vaccines would be distributed on the basis of need, not the ability to pay, and a number of countries already “have very wisely invested in stockpiles in case of smallpox” and could make available vaccines and therapeutics that are licensed for monkeypox.

“We will and are and will be working with those countries to see if we can make good on many informal arrangements over the years for the sharing of those products,” he said. “And we would very much thank those countries who do have stockpiles, who have engaged with us previously over the years, and are engaging with us right now to try and find solutions for this issue.”

Image Credits: WHO.