hepatitis e
Medicins Sans Frontieres and the South Sudan Ministry of Health vaccinate people in Bentiu, the largest internally displaced persons camp in South Sudan.

In a global first – over 25,000 people in South Sudan have been vaccinated in the world’s first mass vaccination campaign to contain an outbreak of hepatitis E, a disease especially fatal for pregnant women.

The outbreak occurred in Bentiu, the largest internally displaced persons camp in South Sudan. Outbreaks of hepatitis E have been seen there since 2015, due to appalling living conditions, including inadequate water, sanitation, and hygiene. 

The most recent outbreak has seen 759 patients with confirmed hepatitis E, 17 of whom have died. 

Hepatitis E is the most common cause of acute viral hepatitis, causing approximately 20 million infections and 44,000 deaths every year. It is transmitted through faecal contamination of food and water. Large scale outbreaks typically occur in mass displacement camps, where water and sanitation are inadequate. 

While hepatitis E has a fatality rate of up to 25% among pregnant women, as well as an increased risk of spontaneous abortions and stillbirths, there is no specific treatment for the disease, so preventing its spread is critical.  

“The fight against hepatitis E has been long and frustrating,” said Dr Monica Rull, Medical Director, Médecins Sans Frontières (MSF). 

First time vaccine has been used in a public health emergency

In response to the outbreak, Médecins Sans Frontières (MSF) and South Sudan’s Ministry of Health jointly carried out the first two rounds of a hepatitis E vaccination campaign in Bentiu in March and April 2022. 

Around 25,000 people, including pregnant women, received Hecolin, the only available hepatitis E vaccine, developed and tested in China, where it is licensed and used primarily to vaccinate travellers. While the World Health Organization has recommended that it be used in outbreak response since 2015, the campaign in Bentiu was the first time the vaccine had been used at scale, in response to a public health emergency.

A third and final round of vaccinations will be conducted in October 2022. South Sudan’s Ministry of Health and MSF are monitoring and reporting on the results of the vaccination campaign.

Hepatitis E vaccination campaign considered a success

Hepatitis E factors in South Sudan’s high maternal death toll.

Both MSF and the South Sudan Ministry of Health have praised the ‘successful’ response to the vaccination campaign, saying it can be a model replicated in future outbreaks. 

“Given the successful implementation and the community’s enthusiastic response in the first two rounds, this innovative vaccination campaign can serve as an example and be replicated in similar settings managing hepatitis E outbreaks,” said Dr John Rumunu, Director General for Preventive Health Services, South Sudan Ministry of Health. 

“I hope the vaccine will help reduce infections and deaths from hepatitis E in Bentiu and beyond.”

“Over the last two decades, MSF has been responding to hepatitis E outbreaks in a wide range of displacement camps, trying to control the disease in challenging conditions and seeing the devastating impact on extremely vulnerable communities,” said Rull. 

“With the experience of this vaccination campaign, we hope to change the way we tackle hepatitis E in the future.”

WHO has called the campaign a “significant milestone” in the fight against hepatitis E. Melanie Marti, a WHO Medical Officer for the Department of Immunization, Vaccines & Biologicals, said, “It is the first time a vaccine has been used to combat the effects of this potentially devastating disease.”

Image Credits: MSF Innovation/Twitter , Stephen Rynkiewicz/Twitter .

covid-19 amr
Doctors at Continental Hospital in Hyderabad, India, were alarmed at the number of drug resistant bacteria they found in patient samples as the COVID-19 pandemic took hold.

(DELHI, India via The New Humanitarian) – As medical professionals across the globe grappled with COVID-19 infections, microbiologist Dr. Bhavani Eshwaragari was confronting a quieter – though no less dangerous – pandemic. Reviewing patient samples in her laboratory in Continental Hospital in the southern India city of Hyderabad, she began to notice an alarming trend as the pandemic wore on: Almost all of the cases of Klebsiella pneumoniae, a bacteria that causes infections such as pneumonia, were resistant to antibiotics.

“Especially during the COVID time there has been multi-drug resistance,” she told The New Humanitarian at her lab in February. Eshwaragari estimated that of the 40 to 50 samples of patient bacteria the hospital tested each day, around 10 percent were drug resistant.

Rising antimicrobial resistance (AMR) had been ringing alarm bells across the world long before COVID-19 emerged. A report published in the Lancet earlier this year – the first to estimate the global burden – calculated that antimicrobial resistance was directly responsible for almost 1.3 million deaths in 2019 – more than HIV or malaria.

While this will result in longer hospital stays and higher costs of treatment for patients across the globe, the impact in low resource settings such as conflict zones may be particularly devastating.

“The supply of antibiotics in those regions is very limited,” said Dr. Bhishmaraj Srivastava, strategic medical lead (South Asia) at Médecins Sans Frontières (MSF). Specialised equipment and experienced doctors, essential for accurate and speedy diagnosis, are also often in short supply, he said. “Getting those kinds of facilities available in resource-limited or conflict settings is a very major challenge.”

Antimicrobial resistance is becoming a leading cause of death, surpassing AIDS/HIV, and malaria

The result of drug-resistant infections in such areas is that “illnesses become more prolonged, death rates become more severe,” said Srivastava. “What becomes even more frustrating is that it’s preventable,” he added. “It’s a problem that could have been avoided in the first place.”

Now, experts worry that the coronavirus pandemic may have exacerbated the problem by accelerating antibiotic misuse, compromising infection control in hospitals, and curtailing vaccination and sanitation programmes. While concrete data has been difficult to collect during the pandemic (some countries, like India, halted data collection for much of the pandemic), anecdotal evidence like Eshwaragari’s as well as emerging reports suggest a steep rise.

Last week, the US Centers for Disease Control and Prevention released a report noting a rise of at least 15 percent in “resistant hospital-onset infections and deaths” in the first year of the pandemic – undoing much of the progress in the US battle against antimicrobial resistance. In addition, the World Health Organization issued an “urgent” call last week to ramp up research and development of vaccines to fight AMR.

‘A socio-economic problem’

In India, drug-resistant pathogens such as the ones seen in Eshwaragari’s lab have been becoming increasingly commonplace in recent years, pinpointing the country as central to the battle against emerging resistance.

The country’s high population density and rate of infectious diseases, combined with a chronically underfunded healthcare system, create the ideal breeding ground for drug-resistant infections. (India spends just 1.25 percent of its GDP on public healthcare, according to a 2020 Oxfam report, ranking the country 154th, or fifth from bottom of the countries studied.) The highest number of multi-drug-resistant tuberculosis cases in the world, according to 2021 WHO research, occur in India, accounting for around one quarter of the global total.

Part of the problem in India and elsewhere lies in an overdependence on antimicrobials – drugs such as antibiotics and antifungals which target infections in the human body. India has one of the highest out-of-pocket healthcare expenditures in the world, likely a result of its low spending on public healthcare. It is often cheaper to buy antibiotics over the counter than it is to visit a private healthcare provider. Regulations to limit access to antimicrobials – where they exist – are rarely enforced. One study conducted in 2018 in a city in southern India found that 78 percent of pharmacies dispensed antibiotics without a prescription.

See related Health Policy Watch story:

Breeding Superbugs – Veterinary Drugs, More than Human Ones, Drive AMR 

“This is truly a socio-economic problem,” said Dr. Guru N. Reddy, founder and managing director of Continental Hospital. He blames the overuse of antibiotics on “a lack of adequate regulations compounded with [a lack of] proper healthcare-dispensing systems.”

Antibiotic resistance occurs naturally as bacteria evolve, but antibiotic misuse can dramatically accelerate the process. When patients take incorrect or unnecessary antibiotics, bacteria that are sensitive to the drug are killed off, leaving behind only the drug-resistant strains. These propagate, accelerating the growth of AMR.

“Especially during the COVID time there has been multi-drug resistance,” Dr. Bhavani Eshwaragari of Continental Hospital in Hyderabad said.

The COVID-19 pandemic exacerbated the problem around the globe. As cases began to ramp up in early 2020, patient demand for certain drugs – even those not scientifically proven to treat the coronavirus – skyrocketed. In India, sales of the antibiotic azithromycin increased drastically, although antibiotics have no impact on viral infections such as coronaviruses.

“The highest sold medication in India is azithromycin antibiotic,” said Reddy. “You know why? Because of COVID. Patients just went to the pharmacy, got hold of this azithromycin and started taking.”

One study, which collected monthly data from 2018 until the end of 2020, estimated that an excess 216 million doses of antibiotics were consumed in India between June and September 2020 — during the first wave of the pandemic — alone.

In India and around the world, antibiotic misuse also increased inside hospitals. As admissions rose, overcrowding and overstretched hospital workers meant less attention was paid to basic infection control measures, such as hand washing and disinfecting equipment. An increase in secondary infections, such as pneumonia and sepsis, resulted, which many doctors attempted to pre-empt by administering precautionary antibiotics. When patients did contract secondary infections, there was a lack of diagnostic equipment to determine which ones, forcing doctors to administer broad-spectrum antibiotics instead of targeting specific pathogens.

“Compromised infection control and lack of diagnostic support are definitely the reasons why a lot of drug prescriptions happen,” said Dr. Kamini Walia, senior scientist at the Indian Council of Medical Research (ICMR). “And that’s something that was exacerbated during this time.”

In an attempt to combat growing antimicrobial resistance in India, the ICMR in 2018 introduced national Antimicrobial Stewardship guidelines, which lays out best practices for hospitals and trains doctors on the importance of targeted prescriptions and tracking antibiotic usage. The guidelines encourage doctors to use a mobile app to check the sensitivity of the antimicrobial susceptibility of any given microorganism to a particular drug, as well as current antibiotic policies before prescribing.

The initiative also aims to improve access to rapid diagnostic tools and drug-sensitivity testing. Advanced laboratory tests can rapidly diagnose both the pathogens present in a sample and their antimicrobial susceptibility. That helps to determine the most appropriate drugs for a patient, resulting in quicker and more effective treatment, and also allows the ICMR to track antimicrobial resistance patterns across the country. This is important, explained Walia, because “unless we have evidence, we can’t push for change.”

Turning to technology as a solution

While India’s population density and overburdened healthcare infrastructure make it an area of concern for the emergence of antimicrobial resistance, the problem is hardly unique to India. Drug-resistant infections increased during the pandemic in a number of countries in the Americas, Dr. Carissa F. Etienne, director of the Pan American Health Organization (PAHO), noted in a media briefing last November. PAHO data since the beginning of the COVID-19 pandemic shows that while 90 percent of COVID-19 patients in hospitals in the region were given an antimicrobial, only an estimated 7 percent actually required these drugs to treat a secondary infection.

See related Health Policy Watch story:

Four Priority Actions to Slow the Silent Pandemic of Antimicrobial Resistance

Vaccination and sanitation programmes, which aim to decrease the number of overall infections, were curtailed in many places during lockdowns or as resources were diverted to fighting the pandemic, further exacerbating the rise of drug resistance. Globally, 23 million children missed out on basic vaccines in 2020, according to WHO and UNICEF.

In environments with high levels of displacement, such as Ukraine and other conflict zones, drug resistance can become a challenge. At a March press conference, the WHO warned that the conflict in Ukraine could increase the country’s cases of drug-resistant tuberculosis – already one of the highest in the world. In conflict settings, “decades of progress in important public health areas like tuberculosis are lost, sometimes in days or weeks – and that threatens everybody,” said Dr. Mike Ryan, the executive director for WHO’s Health Emergencies Programme.

In conflicts, other humanitarian crises (including pandemics) or situations where healthcare is underfunded, technology can step in to fill the gap left by a shortage of medical professionals, said Srivastava of MSF. Basic equipment and apps can connect healthcare workers in remote areas to specialists, which “helps improve the decision-making as well as the prescription practices,” he said.

Artificial intelligence has the potential to take this one step further, by helping to improve diagnostic accuracy and providing an automated interpretation of test results, he noted. Artificial intelligence in such settings is “more cost effective, it’s more mobile” than getting trained medical professionals on the ground, said Srivastava.

Back in Hyderabad, the patients at Continental Hospital are some of the privileged few: they have access to one of the city’s best private hospitals, with state-of-the-art diagnostic technology and an in-house laboratory. Doctors there diagnose and test the drug-sensitivity of most infections within 30 minutes, the hospital’s founder and managing director, Reddy said.

“The faster we do this, the faster we get the right antibiotic to the patient,” he added. “Which should be the norm in taking care of sick patients.”

While that technology is still out of reach for many in public hospitals across India, the COVID-19 pandemic may offer one silver lining, as it “brought a lot of focus and concern around antimicrobial resistance, globally as well as in India,” said ICMR’s Walia. “So now, physicians are more concerned about increasing levels of drug resistance than they were pre-COVID.”

Edited by Abby Seiff

______________________________________________________

This article was first published by The New Humanitarian, a non-profit newsroom reporting on humanitarian crises around the globe

Image Credits: Catherine Davison/TNH, The New Humanitarian .

hepatitis
A study by Glasgow’s Center for Virus Research and others has found that the recent hepatitis outbreak in children may have been caused by a failure to build up the usual immunity due to COVID-19 lockdowns.

The mystery around the rash of acute, serious hepatitis cases that have afflicted over 1000 children under the age of 16 may have been unravelled by a group of Scottish researchers who say that the interaction of two common adenoviruses, or related herpes viruses, may have caused the condition in genetically susceptible children who failed to build up the usual immunity due to COVID lockdowns – and then fell seriously ill after they began to mix socially again.

Their study, led by a team from the University of Glasgow’s Center for Virus Research, and supported by others from University College London and Public Health Scotland, was published on the preprint server medrxiv.org last week.

Over 1000 children in 35 countries, many under the age of 5, have fallen victim to the acute severe acute hepatitis of unknown aetiology, as WHO has termed it.  The most seriously ill have required liver transplants.

Distribution of probable cases of severe acute hepatitis of unknown aetiology in children by WHO Region since 1 October 2021, as of 8 July 2022. 

In a detailed investigation of nine Scottish children who had become acutely ill, researchers found that all of them were co-infected both with adeno-associated virus (AAV2), as compared with zero of healthy, aged matched child controls.

But the nine acutely ill children also were co-infected either with adenovirus (HAdV-41 or HAdV-C), which causes common colds or gastro-intestinal illness, or herpesvirus 6B (HHV6B), the research team found.

The nine children investigated also displayed a higher-than-usual frequency of a genetic variant of the human leukocyte antigen (HLA), known as HLA-DRB1.  The HLA genetic anomaly, which is associated with a range of other immune disorders, which may have made them more vulnerable to such diseases, the researchers said.

Serious illness link to lack of immunity

Child receiving hepatitis B vaccine

Typically, AAV2 is asymptomatic and it requires the presence of either either HAdV or a herpes virus to replicate.

But the co-infections may have occurred, and then caused the genetically susceptible children to become seriously ill, because they had not built up the required immunity to such infections more gradually during the period of COVID lockdowns, the researchers said.

“The recent clustering of cases may have arisen in part because of changes in exposure patterns to HAdV, AAV2 and HHV6B as a result of the COVID-19 pandemic,” the researchers concluded in their preprint, which has not yet been peer-reviewed.  “Faecal HAdV usually follows seasonal trends with maximal rates of detection in younger age groups. However, the circulation of respiratory viruses was interrupted in 2020 by the implementation of non-pharmaceutical interventions, including physical distancing and travel restrictions, instituted to mitigate SARS-CoV-2 transmission.

“These measures may have created a pool of susceptible younger children, resulting in much higher rates of HAdV and potentially AAV2 circulation in this population of naïve children when the COVID-19 restrictions were relaxed.”

Scientists studying the mysterious issue reacted with glee to the publication of the initial findings.  “It explains a LOT,” said CJ Houldcroft of Cambridge University’s Department of Medicine, in a Twitter string.

“This would explain A. the timing of the surge in cases in children, B. why not all children develop this rare complication and C. why the risk isn’t evenly distributed around the world (because of both pathogen exposure factors AND differences in genetic background),” she added, also noting that, AAV2 is part of a class of enteric adenoviruses that are “really common worldwide, including on people’s hands if they don’t wash them properly…11% of hands, yuck!.”

The University of Glasgow’s Professor Emma Thomson, who led the research, said, however, that there were still many unanswered questions. “Larger studies are urgently needed to investigate the role of AAV2 in paediatric hepatitis cases,” she told the BBC.

“We also need to understand more about seasonal circulation of AAV2, a virus that is not routinely monitored – it may be that a peak of adenovirus infection has coincided with a peak in AAV2 exposure, leading to an unusual manifestation of hepatitis in susceptible young children.”

Image Credits: Paul Owere/Twitter , WHO, Dilemma Online/Twitter .

drowning prevention
Swimming lessons

The World Health Organization has issued a call for people around the world to “do one thing” to prevent drowning, on the occasion of World Drowning Prevention Day. 

Drowning tragically claims more than 236,000 lives each year, and is one of the leading causes of death globally for young children and young people aged 1 – 24, and the third leading cause of injury-related death overall.

More than 90% of drowning related deaths occur in low- and middle-income countries, with children under 5 at the highest risk. These deaths are frequently linked to  daily, routine activities, such as bathing, collecting water for domestic use, traveling over water on boats or ferries, and fishing. 

Children travelling by boat

Seasonal or extreme weather events, including monsoons, also are a frequent cause of drowning. 

These deaths are highly preventable through a series of interventions, says WHO. 

“Every year, around the world, hundreds of thousands of people drown. Most of these deaths are preventable through evidence-based, low-cost solutions,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. 

“In many cases, we know what works to prevent drowning. We’ve developed tools and guidance to help governments implement solutions – and if we do more together, we really can save thousands of lives,” said Michael Bloomberg, founder of Bloomberg Philanthropies and WHO Global Ambassador for Noncommunicable Diseases and Injuries

Low-cost prevention strategies 

Resuscitation classes

With the theme of this year’s World Drowning Prevention Day to “do one thing” to prevent drowning, WHO invited the global community – individuals, groups, and governments – to engage in at least one of several prevention strategies: 

Individuals can share drowning prevention and water safety advice with their families, friends and colleagues, sign up for swimming or water safety lessons, or support local drowning prevention charities and groups.

Groups can host public events to share water safety information, launch water safety campaigns, or commit to developing or delivering new drowning prevention programmes using recommended best practice interventions.

Governments can develop or announce new drowning prevention policies, strategies, legislation or investment, convene discussions on drowning burden and solutions, and introduce or commit to supporting drowning prevention programming domestically or internationally.

WHO also recommends six engineering and environmental measures to prevent drowning, including: installing barriers controlling access to water; training bystanders in safe rescue and resuscitation; teaching school-aged children basic swimming and water safety skills; providing supervised day care for children; setting and enforcing safe boating, shipping and ferry regulations; and improving flood risk management.

In May 2022, WHO has also published its latest guidance on best practice recommendations for three of these interventions: the provision of daycare for children, basic swimming and water safety skills, and safe rescue and resuscitation training.  

Bangladesh, Uganda and others commit to drowning prevention programmes 

Community Swimming Instructor training held at Tiakhali, Kolapara in Bangladesh

Many countries have already committed to drowning prevention programmes.

Bangladesh has started a 3-year program to reduce drowning among children throughout the country. As part of the program, the government will take over the 2,500 daycares established and funded by Bloomberg Philanthropies, and will expand the program by adding an additional 5,5000 daycares, providing supervision to 200000 children aged 1 – 5 years. 

Uganda and Vietnam also conduct drowning-prevention activities such as supervision of children in daycare, survival swimming instruction to children ages 6 – 15, and enhanced data collection. Uganda and Ghana are also receiving support to study the circumstances of drowning.  

Lighting up Geneva’s Jet d’Eau and other monuments blue to galvanize action 

To galvanize action towards drowning prevention, Geneva’s “Jet d’Eau,” which sprays a powerful shower of water from Lake Leman over the skyline of Geneva, Switzerland, will be illuminated blue this evening, accompanied by similar actions in other cities around the world. 

“Today, cities around the world are lighting up their monuments in blue light as a call to action for each of us to do our part to prevent drowning. Let’s put a stop to drowning,” said Tedros. 

Image Credits: WHO, WHO, WHO, WHO.

Tedros Adhanom Ghebreyesus, WHO Director General

WHO has declared a new global public health emergency over the Monkeypox outbreak which has now spread to more than 16,000 people in over 75 countries and territories – in what some public health experts described as a “bold decision” by Director General Dr Tedros Adhanom Ghebreyesus, overriding a divided group of expert advisors.

The WHO Director General announced his decision after a two-day meeting by a 15-member International Health Emergency committee failed to come up with a consensus recommendation.

Speaking at an extraordinary WHO press conference convened on Saturday, Dr Tedros said that took the decision in line with his authority to do so, deciding that the outbreak meets the criteria for a “public health emergency of international concern” (PHEIC) under the the terms of WHO’s binding International Health Regulations.

“There are now more than 16,000 reported cases from 75 countries and territories, and five deaths,” said Tedros. “Information provided by countries…. in this case shows that this virus has spread rapidly to many countries that have not seen it before,” he added.  “We have an outbreak that has spread around the world rapidly, through new modes of transmission, about which we understand too little, and which meets the criteria in the International Health Regulations.”

monkeypox
WHO monkeypox dashboard as of 23 July. Dark blue shows highest concentrations of confirmed cases. Not including several thousand suspected cases also seen since the beginning of 2022 in the African Region.

He said he took that decision despite the fact that the Expert Committee was 6-9 against declaring a PHEIC at this time – which he described as “very close” for a group that typically decides by consensus.

He said that he took the decision despite the fact that currently, WHO’s determination is that the global risk of Monkeypox to public health remains “moderate” except for in the European region, where risks are “high.”

Acted as a tie-breaker

“Under the International Health Regulations, I am required to consider five elements in deciding whether an outbreak constitutes a public health emergency of international concern,” he added, citing those as country reports, the Emergency Committee’s views, other scientific evidence, and WHO’s own assessment of the risks of international spread.

“I had then to act as a tie breaker,” Tedros said of the split Emergency Committee’s views.

“There was no consensus by them.  We believe that it’s time to declare a PHEIC, considering their advice and considering how it has spread since the last meeting of the Emergency Committee in late June, at a time when the infection was only being seen in 37 countries.

“We believe this will mobilize the world to act together, it needs coordination, solidarity, especially [for] the use of vaccines and treatments,” said Tedros.

Access to vaccines and treatments uneven – with many unknowns

Tim Nguyen, WHO Unit Head High Impact Events Preparedness

Currently vaccines and anti-viral treatments are only available in about half of the countries that are seeing cases, said WHO’s Tim Nguyen, who described the current state of play. In the other half, WHO officials have inadequate information about countries’ access to treatments and vaccines, which are being prioritized to at-risk groups.

“We know that from the countries that are having reporting cases at the moment, roughly half of them have already secured access …. For those other half we don’t know,” Nguyen said. “At the same time WHO continues to discuss with member states holding larger stockpiles about sharing and donating vaccines to those that have don’t have access at the moment.”

Nguyen said that there are three “third generation” smallpox vaccines that have been recommended by WHO for use against monkeypox, totaling over 116 million doses, and scattered among various national stockpiles. They include about 100 million doses of the ACAM2000® vaccine, about 16.4 million doses of the MVA-BN, vaccine, most of which are held by the USA, and an unreported quantity of the LC16, vaccine produced by Japan’s KM Biologics and held in Japan’s national stockpile.

However, Nguyen admitted that there are “uncertainties” around the effectiveness of the three vaccines “because they haven’t been used in this context and at this scale before.”

The US Centers for Disease Control, for instance, is rolling out the MVA-BN vaccine produced by Bavarian Nordic and marketed in the United States under the trade name JYNNEOSTM to the broader at-risk population, while reserving the ACAM2000, which can create severe complications, only for researchers and military personnel. On Friday, the European Medicines Agency also has moved recently to approve the same Bavarian Nordic vaccine for use against monkeypox.  The vaccine is marketed in Europe under the trade name Imvanex.

Big concern is sustained person-to-person transmission

Rosamund Lewis Technical lead for monkeypox, WHO Health Emergencies Programme

Meanwhile, the “big concern” with this outbreak is that sustained person-to-person transmission is now occurring in so many parts of the world, added Rosamund Lewis, Monkeypox technical lead.

She noted that traditionally, monkeypox outbreaks that were first observed among human communities in the 1970s, were small and self-contained. They typically occured in West and Central Africa as a result of contact with infected animals or food – and those infected might go on to infect other family members with onward transmission of two or three chains, before it died out.

However, more recently, the “chains of transmission have become longer – possibly 6 possibly 9 sequential chains” she added.  And more recently, the virus also began infecting some foreign travelers and groups of people who had frequent, close, intimate contact, particularly men who have sex with men.

It remains unclear if the more sustained transmission is also a result of mutations in the endemic clades of the virus – or the decline in immunity from smallpox vaccination  – which ceased on a mass scale in the 1970s.

Tedros’ ‘bold decision’ welcomed – but could it already be too late?

Mike Ryan, Executive Director, WHO Health Emergencies Programme

Tedros’ decision to declare a PHEIC, despite the hung jury of his expert committee, was welcomed as a “bold decision” by leading global health experts like Lawrence Gostin of Georgetown University, who earlier had said the outbreak was “spinning out of control.”

Over the past week, not only Gostin but a long list of other prominent global health experts were expressing rising concerns that it might be too late to contain the outbreak.

“Now that WHO has declared monkeypox a global emergency it’s vital to publish a global action plan with ample funding,” Gostin added, shortly after the WHO announcement was made. “There’s no time to lose.”

At the same time, emergency declarations cannot be taken too frequently, if WHO wants to mobilize action effectively when they are declared, stressed Stephen Morse, an epidemiologist at Columbia University.

“There are many concerns that have to be balanced with the decision to declare a PHEIC,” he told Health Policy Watch. “Doing it too often can be desensitizing, and we just had the COVID-19 (SARS-CoV-2) PHEIC.

Stigmatization and different transmission patterns in Europe and Africa also pose challenges

“There are also political and social concerns (in this case, stigmatization),” he added, referring to the fact that most of the cases seen outside of central and west Africa are occurring among men who have sex with men. At the same time,  Morse added, “Certainly the monkeypox epidemic is international and requires a coordinated response and resources.  Don’t forget Nigeria, which has had an ongoing epidemic of West African clade human monkeypox since 2017 and the current epidemic may be “spillover” from that epidemic.  They should get assistance in dealing with human monkeypox.

Smallpox vaccine protects against monkeypox. But questions remain if it can now be deployed rapidly and widely enough – with supplies still limited and concentrated in only a few countries.

“There is another issue, he added.  “Historically, human monkeypox is not self-sustaining in the human population.  Classically, it might transmit person to person for a few cycles (a few links in a chain of transmission) but then usually dies out. This has been going on for several months now, and on an unprecedented scale.

“So we don’t know if cases would essentially drop or if, as has sometimes been suggested, that the virus is now more human-adapted.  Either way, for a variety of reasons it’s important to contain and stop the outbreak as quickly as possible.  Unlike the beginning of the SARS-CoV-2/COVID-19 pandemic (which is manyfold more transmissible than monkeypox), we have tools – vaccine and an antiviral – if we can produce and effectively deploy them.”

Question remains if PHEIC will mobilize sufficient action to halt transmission trends

Speaking at the briefing, Lewis said she was still personally unsure if the world would be able to control the outbreak at this stage – although she expressed hopes that it might be possible.

“We don’t have a crystal ball,” she said, ” So we don’t know for sure if we’re going to be able to support countries enough and communities enough to stop this outbreak.  We think it is still possible precisely because it remains primarily in one group – who are very active in health-seeking behaviour.

“So we are very much appealing communities and community leaders who have many years of experience in managing HIV/AIDs or sexually transmitted infections to work with more mainstream… public health officials and agencies…..if we all pull together, this is how we will get to the end  of this outbreak.”

She noted that in the African regions where the disease is endemic, about 30% of the cases seen have been in women and children – reflecting the broader risks communities around the world face.

While 98% of the cases seen abroad have been in communities of men who have sex with men, as the virus becomes more deeply embedded elsewhere, it will also spread much more broadly in communities, including women and children, she and other WHO experts have warned.

Further transmission will also lead to the disease becoming embedded itself in animal populations – which will then continue to transmit the disease back to humans.

“If we don’t assist the affected community, there is the risk it will become broader,” said Dr Mike Ryan, WHO executive director of Health Emergencies, “So this is about enlightened self interest.

For more about communities at risk and preventive measures see below:

https://youtu.be/Zjy0wR1pQgw

Image Credits: WHO .

Midwife vaccinates a man during a COVID-19 vaccine campaign in Madagascar.

After missing the target to vaccinate 70% of people in every country against COVID by July 2022, WHO’s new vaccine strategy prioritises 100% coverage for health workers and older people – but admits that every country will have to decide for itself. 

The World Health Organization has published an update to the Global COVID-19 Vaccination Strategy that preserves its 70% global vaccination target and 100% vaccination targets for health care workers and older populations, but acknowledges that countries will still need to determine their ‘context-specific targets’ for their own COVID-19 national vaccination programmes. 

The language walks back previous WHO statements about achieving vaccine coverage of 70% of the population of each country by mid-2022, a target that was clearly missed. Now, that 70% goal is described as “aspirational” without any new date set for when it might be achieved.  While WHO called for 100% of health workers and older people to be covered, it also acknowledged that each country will have to set its own targets in line with local conditions and priorities:   

“This acknowledges that countries will determine the breadth of their COVID-19 national vaccination programmes considering factors such as: local COVID-19 epidemiology, demographics,
opportunities to leverage COVID-19 to strengthen primary health care systems, other health priorities, socio-economic risks from future waves of disease, population demand for breadth of vaccination, and sustainability of vaccination efforts,” the strategy states.

The update, published Friday, stresses that many of the people who are most at risk remain unprotected despite the biggest and fastest global vaccination rollout in history — with over 12 billion doses of COVID-19 vaccines administered globally across nearly every country in the world, resulting 60% global coverage.

Only 37% of older people in low-income countries got jabs

Only 28% of older people and 37% of health care workers in low-income countries have received a primary course of vaccines, and most have not received booster doses, according to a WHO statement. For the general population, only 16% of eligible adults in low-income countries and 21% in Africa have received a full two-course initial dose according to Oxford University’s “Our World in Data” vaccine tracker.  Twenty-seven of WHO’s member nations, including 11 low-income countries, have not yet started a booster or additional dose program. Controversy still swirls over who is fundamentally responsible for the continuing low rates of COVID vaccination in Africa, in particular, with fingers pointed at the pharma industry, WHO, and widespread vaccine hesitancy, alternately. 

WHO emphasized the need to vaccinate those most at risk for COVID-19. 

“Even where 70% vaccination coverage is achieved, if significant numbers of health workers, older people and other at-risk groups remain unvaccinated, deaths will continue, health systems will remain under pressure and the global recovery will be at risk,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, in announcing the strategy. 

“Vaccinating all those most at risk is the single best way to save lives, protect health systems and keep societies and economies open,” he said.

The strategy uses both primary and booster doses to reduce deaths and severe disease. The aim is to protect health systems, societies, and economies, as well as to facilitate the research, development, and equitable distribution of new vaccine products. 

vaccination
COVID-19 Vaccination Strategy prioritizes using existing vaccines to reach high priority groups and then accelerating access to improved ones to achieve protective immunity

Using local data and engaging communities

To ensure vaccines reach the highest priority groups, the strategy emphasizes the need to measure progress in vaccinating these groups and developing targeted approaches to reach them.

These approaches include using local data and engaging communities to sustain demand for vaccines and reach more displaced people through humanitarian response.

Coordinated action is needed to achieve global COVID-19 vaccination targets.

Call for more equitable distribution of new vaccines

The strategy also calls for the equitable distribution of new COVID-19 vaccines with “improved attributes” that increase “depth and breadth” of protection and ease delivery.

But it also stresses that supply agreements should aim at “targeting availability of vaccine products with improved attributes, for all countries.”

Omicron BA.5 and other subvariants have reduced the efficacy of vaccines, prompting the need for new vaccines that can protect against these variants of concern.

While current vaccines were designed to and have largely succeeded in preventing serious illness and death, they have not substantially reduced transmission rates. Global weekly COVID-19 cases almost doubled in the past six weeks, according to WHO’s press briefing on Wednesday. The surge has been driven by the Omicron BA.5 subvariant. 

“It is fundamental to continue investing in research and development to make more effective, easier to administer vaccines, such as nasal spray products,” WHO says, while also noting that ensuring the sustainability of the COVID-19 vaccination effort is an operational priority that will “require urgent attention and reorientation before the end of 2022.”

Image Credits: Samy Rakotoniaina/MSH, WHO.

A healthcare worker gives a child a dose of the malaria vaccine, RTS,S.

“It’s better to reduce the number of children affected than not to do anything at all”

The World Health Organization (WHO) and Gavi, the Vaccine Alliance are planning to go ahead with the mass rollout of the RTS,S/AS01 (RTS,S) malaria vaccine, starting with three countries in Africa — Ghana, Kenya and Malawi — despite the Bill and Melinda Gates Foundation’s withdrawal of more direct support for increased malaria vaccinations because its efficacy was limited.

In a June interview with Health Policy Watch, Philip Welkhoff, who directs the foundation’s malaria program, said the foundation preferred to invest in classical malaria control measures, like bednets, rather than the vaccine.

According to WHO, however, researchers observed a 30% reduction in severe malaria infections, a 21% reduction in hospitalizations, and a 10% reduction in mortality, in the areas of Ghana, Kenya and Malawi where the vaccine recently was piloted on some 800,000 infants and children aged 5–17 months  And those reductions are significant. 

In October 2021, the vaccine was approved by WHO in a historic first, shortly after the results of the three-country pilot were reported.  

Thabani Maphosa, managing director of country programmes at Gavi, the Vaccine Alliance

Thabani Maphosa, managing director of country programmes at Gavi, told a WHO press briefing on Thursday the malaria vaccine’s ability to protect some children justifies the investment in its rollout even though there are debates regarding the degree of its benefits.

“It is better to be protected and to reduce the number of children that are affected than not to do anything at all,” he said.

Maphosa said Gavi and WHO would make US$ 160 million in funds available to support the wider rollout of the vaccine between this year and 2025, first targeting children in the three African nations that began piloting the vaccine three years ago. He said the rollout would then expand to other eligible endemic countries.

 The two organizations also are working with others to improve the vaccine supply, since that is the real problem, not the funding.

A ‘Lifesaving’ Vaccine

Dr Matshidiso Moeti, WHO’s Regional Director for Africa, described the vaccine as “lifesaving.” Rose Leke, a malaria disease expert and professor at Cameroon’s University of Yaounde, said the vaccine is needed now more than ever.

After recent decades of progress, we now see that malaria is getting worse in many places, and this threatens our well being and future potential. And, really, this is unacceptable,” Leke, a co-chair of the expert group that advised WHO on a framework to allocate the currently limited malaria vaccine supply, told the press briefing. She described the vaccine as an opportunity to strengthen malaria control.

Rose Leke, a malaria disease expert and professor at Cameroon’s University of Yaounde

Welkhoff said during the June 2021 interview that the foundation would not prioritize the rollout of the malaria vaccine in its 2022 call to countries for proposals to fund malaria control projects.

Instead, he said, the foundation’s US$140 million contribution will go to country projects that prioritize traditional infection control measures, such as mosquito nets, access to antimalarial drugs, and improvements in diagnostics and health systems. The malaria vaccines’s limited effectiveness highlights a gap that still needs to be filled by researchers, according to Welkhoff.

“It is a remarkable technical accomplishment but is only partially effective and the effect goes away after a period of time,” he said.

Moet, on the other hand, noted that in the pilot countries where more than 1.3 million children have been vaccinated, there has been an almost 30% drop in hospitalizations of children with severe malaria. 

“They’ve also seen, after two years in areas where the vaccine was piloted, an almost 10% reduction in child deaths in the age group that is eligible for the vaccine,” she said.

Welkhoff, however, told Health Policy Watch the foundation wants to prioritize new measures like research and development and mass introduction of new generation drugs and insecticide treated nets (ITNs) that can beat fast-developing mosquito and parasite resistance to the drugs and chemicals currently in use.

“We want to start introducing and scaling up these [new] nets,” he said.  “We are [also] starting to see the beginnings of drug resistance in parts of Africa to the Artemisinin combination therapies (ACTs). So this is going to need funding, to make sure that we don’t lose these drugs that each year save so many lives.”

Image Credits: WHO/M. Nieuwenhof.

Genetic
WIPO concludes General Assembly with agreement to negotiate new accord on genetic resources and traditional knowledge

Overcoming years of stalemate, the World Intellectual Property Organization (WIPO) agreed to negotiate a proposed treaty on genetic resources and related traditional knowledge (TK) that are key components in both traditional and new medicines.

Delegates to WIPO’s General Assembly decided that the negotiations both to begin the draft international instrument and to conclude the talks must occur no later than 2024.

The breakthrough is highly significant because talks over proposals to require patent applicants to declare their use of indigenous resources and knowledge, among other measures, have been languishing in a WIPO committee for decades.

Indigenous genetic resources, including plants, animals and microorganisms, and related “traditional knowledge” are scientifically valuable to life sciences research and have been the basis for many modern drugs, from artemisinin-based anti-malarials like Coartem® to anti-parasitics that treat onchocerciasis, known as river blindness.

In a meeting from 30 May to 3 June, the WIPO Intergovernmental Committee on Intellectual Property and Genetic Resources considered a draft working document, developed by WIPO’s secretariat.

It would have called for patent applicants to declare any such resources that are used in new patent applications to be registered in WIPO’s global registry, but the discussions were inconclusive.

Genetic resources
Delegates in discussions at the IGC

Negotiators would, however, now consider a mandatory “patent disclosure requirement” when patent applications are made for inventions that involve the use of genetic resources, along with addressing questions of access, use and benefit-sharing, according to a statement Friday.

WIPO says proponents of such a treaty argue it would “harmonize diverse national systems, foster the sustainable development of Indigenous and local communities, provide legal certainty and predictability for businesses, and improve the quality, effectiveness and transparency of the patent system.”

‘Difficult decisions’ on genetic resources

WIPO Director General Daren Tang hailed the breakthrough as an “important step” and said the UN agency’s secretariat would provide “full support” to delegates as they try to overcome the significant gaps that remain among nations over some of the key issues.

“Today is a triumph of multilateralism, of us as a General Assembly, moving together as a community to make a difference for people everywhere,”  Tang said. “Of course there are disagreements, there will be divergences. This is just the beginning of a whole new set of conversations.”

Tang described the proposed treaties as more than “mere pieces of paper” because they would provide concrete help to people around the world. WIPO acts as a global forum for intellectual property policy, services, information and cooperation.

Moldova’s UN Ambassador in Geneva, Tatiana Molcean, chaired the WIPO Assembly, which concluded Friday. Around 900 delegates from among WIPO’s 193 member nations attended the July 14-22 assembly.

Molcean said she was proud of the “difficult decisions” it made in agreeing to move ahead with the proposed treaties.

“After years of negotiations,” she tweeted, it was mere reverence to see, as Chair of #wipoGA, member states come together to take their negotiations towards a final resolution.” 

WIPO to streamline IP registration for designers

The WIPO Assembly also approved a decision to commence intergovernmental negotiations over a second proposed international legal accord on design law.

This is intended to offer designers  easier, faster and cheaper means of registering IP, and ensuring its recognition, in home markets and abroad, according to WIPO.

Work to simplify procedures for the IP protection of industrial designs was initiated in a WIPO standing committee on the law of trademarks, industrial designs and geographical Indications as far back as 2006.

The new accord, if approved, could also have implications for new health technologies, from diagnostics to cancer treatment.

Three years ago WIPO was part of a symposium with the World Health Organization and World Trade Organization on cutting-edge health technologies, such as gene editing therapies for cancer, that focused on ways of improving the international IP system to drive innovation and bring people needed therapies.

The proposed treaty on design law aims to eliminate bureaucratic red tape in ways that would particularly help smaller-scale designers in low- and medium-income countries who have less access to legal support for registering their designs overseas.

WIPO says data show the design industry accounts for 18% of employment and 13% of GDP in Europe, indicating the benefits such a treaty could have in developing economies where less or no similar data is available.

“The benefits of a vibrant design sector go far wider than GDP,” WIPO said. “Design can support efforts in education and sustainability, and can support community building.”

Image Credits: @Tatiana_Molcean, Photo: WIPO/Berrod.

Afghan women health workers.

The COVID-19 pandemic was a stress test for the health sector, which is one of the fastest growing economic sectors in the world, and also one of the largest employers of women. Women are 70% of the health and social care workforce and 90% of nurses but they are clustered into jobs that are lower paid, often unpaid, and given lower social status.                   

In a recent report by Women in Global Health, Subsidizing Global Health, we calculated that six million workers worldwide are in fact propping up health systems with their unpaid and grossly underpaid labor. This is cause for concern in the context of the WHO’s recent estimation that there is a projected shortfall of 10 million health workers by 2030.

Cause for further concern is the fact that though the default health worker may be female, women hold only 25% of senior decision-making roles in health and that pattern has continued in the pandemic.

In a previous survey by Women in Global Health, it was calculated that 85% of national COVID-19 task forces had majority male membership. Despite their exceptional contribution in responding to COVID-19, women do not have an equal place in decision-making in health systems and there is evidence that they have lost ground in health leadership and governance since the start of the pandemic. 

This is a loss to women, but also to health systems that lose out on the professional knowledge, talent and perspectives of the women who are experts in the health systems they largely deliver.

Women excluded throughout history 

While women have had roles in healing and birth, they were often excluded in the health sector.

If leadership jobs were awarded on merit, we would see more women leaders in the sector. Why then are women the minority of health leaders? History matters. For millennia women were traditional healers, makers of herbal remedies and birth attendants. 

Despite this, when medicine was formalized as a profession in Europe and North America, it was established by men as a profession for men, and women were formally excluded from training and practice.  

That practice spread throughout the world as modern medicine and medical schools were established, again excluding women. Women fought their way into medicine but in some countries, it took until the 1940s before the first woman was able to graduate and practice as a doctor. 

The barriers were very different for women in different countries, with women from minority races, ethnicities, castes and other disadvantaged social groups still fighting to overcome the gendered obstacles to entering medicine and higher status occupations such as surgery.  

Legacy of exclusion remains 

The legacy of the formal exclusion of women is reflected today in women’s place in the sector.  Even in countries where women first broke into medicine, the legacy remains. 

In the US, only 18% of hospital CEOs are women and only 17% are full Professors of Medicine. In Canada, 63%  of medical students are women, 41%of doctors but only 12% of Deans of Medicine. 

Women still face ‘glass ceilings’ in their career progression while the small minority of men in nursing are said to have ‘glass escalators’ that take them to the top quickly, leaving their women counterparts on the ground floor.

COVID-19 exposes gender inequity 

Women continue to work on the frontlines of the pandemic unprotected by vaccines.

COVID-19 has been a major shock to health systems, economies and societies. It has exposed the deep inequalities within and between countries. 

Although many people in high-income countries speak as though the pandemic is over, the Africa Centres for Disease Control reported in May 2022 that only 17%  of people in Africa were fully vaccinated. Significant numbers of health workers in Africa, mostly women, are still working on the pandemic frontlines unprotected by vaccines. 

A recent Women in Global Health report also noted that over six million women health workers are working unpaid or grossly underpaid.  A systemic shock as big as COVID-19 must prompt us all to consider the value of health and the value of the women who largely deliver health services.

We know how to close the gaps

In the health sector, a majority of health workers are women.

The gender gaps in leadership, pay and career progression in the health sector are wide, but we know how to close them. In some science, technology, engineering and mathematics (STEM) sectors the issue is to attract women into the sector. 

This is not the case in health since women are already the majority of health workers, especially in younger age groups. A study by the World Health Organization found that in 104 countries, the majority of doctors, nurses, midwives, pharmacists and dentists under 40 years of age were women. 

These trends show that women are keen to enter the health sector and their numbers are increasing everywhere. The gender imbalance in leadership clearly, however, will not just come into balance over time. 

‘Action, not evolution’ 

Women make up 75% of the global health workforce, but hold only 25% of senior positions.

It will take intentional action, not evolution, to ensure women have an equal place in health leadership.  We can enable women to succeed in leadership by focusing on four areas:

First, by building the legal and policy foundations for equality: Governments must create the legal foundation to enable women to engage equally with men at work. 

This will include laws to support women’s rights to equal pay and decent work, protection of women from violence and harassment at work and the removal of all barriers to women’s participation in work. Minimum wage legislation and support for collective bargaining will enable over six million women working unpaid and grossly underpaid in health systems, to enter formal labor market jobs where they can progress in their careers.  

Governments must enable girls to finish second education and more.

In many low-income countries, governments must enable girls to finish secondary education at the same rate as boys so they can enter tertiary education and professional training. Poverty and low levels of education limit women’s access to formal sector jobs in health. 

The pandemic has blighted the education of a generation of girls in some countries. We must create routes back into education for girls whose schooling has been interrupted.

Second, we must address the social norms and stereotypes that drive gendered segregation in the health workforce and place lower value on professions that are majority female. Gendered stereotypes of occupations and of leadership as a “man’s role” take hold long before people join the workforce. 

These stereotypes encourage men and women to enter different occupations in the health sector, with women typically entering nursing and more men entering surgery; and they also disadvantage women in leadership. 

A 2020 United Nations Development Program survey in 75 countries found around 50% of men and women believed men make better political leaders than women, while more than 40% felt that men made better business executives.  The same study found that bias against gender equality is rising, especially amongst younger men, with a backlash recorded in Sweden, India, South Africa and Romania. 

We must pay attention to the education of our young men and women if we are to build equal and strong societies as we emerge from the pandemic.

Women do not need to be fixed, they need to be supported and given opportunities to enter leadership roles.

Third, we must address workplace systems and organizational culture. Interventions in the past have focused on ‘fixing women’ by training them in self-esteem or self-presentation, on the assumption that women needed to change to compete with men. It is the workplace cultures and policies that exclude women that need to be fixed, not women. 

Women face systemic inequality, bias and the exercise of power that favors men for leadership roles. Quotas and targets for women in senior roles have proved highly effective at increasing women in leadership roles, even as an interim measure until parity is achieved. 

In addition, visible and accountable support by senior leaders of all genders and adopting an equal and family-friendly policy framework are essential to enabling women’s progression into leadership.

Fourth, we must enable women to achieve. Women do not need to be ‘fixed’ but they can be supported with measures including peer support and mentoring for women, developing formal and informal networks for women’s leadership and increasing the visibility of women’s leadership. 

Global networks, such as Women in Global Health, along with partnerships like Every Woman Every Child and the Partnership for Maternal, Newborn and Child Health, enable women to work together to share experiences and campaign together for change on a local and global scale.

New social contract for women in health 

The pandemic has exposed the weaknesses, inequalities and gender gaps in our health, social and economic systems.  A systemic shock as big as COVID-19 must prompt us all to consider the value of health and the value of the women who deliver health and care services. 

We cannot expect women to continue to support a system of gender inequality as we emerge from this pandemic. We are asking for a new social contract for women in health that closes the gender gaps, recognises their contribution and enables them to lead on an equal basis. 

This is not a marginal women’s issue, it is central to strong health systems and global health security, and it is everybody’s business.

Magda Robalo is the Global Managing Director of Women in Global Health and H.E. Kersti Kaljulaid is  Former President of Estonia and the UN Secretary-General’s Global Advocate for Every Woman Every Child

Image Credits: WHO, WHO Eastern Mediterranean Regional Office , PAHO/Sebastian Oliel, WHO Africa Region, Mass Communication Specialist 3rd Class Everett Allen/Flickr, Paul Hudson/Flickr, UN Women, World Health Summit , Kersti Kaljulaid/Twitter .

Intergovernmental Negotiating Body (INB) co-chair Precious Matsoso applauds delegates at the end of the meeting.

World Health Organization (WHO) member states have agreed that the future pandemic “treaty” currently being negotiated will be legally binding at the Intergovernmental Negotiating Body (INB) meeting that ended on Thursday – a day earlier than expected thanks to smooth negotiations.

The INB agreed that the treaty will be set up in terms of Article 19 of the WHO constitution, which enables the WHO’s highest decision-making forum, the World Health Assembly (WHA), to adopt “legally binding conventions or agreements” if agreed on by two-thirds of members to cover “any matter within the competence of the organization”. 

However, the INB did not close the door to including some “non-binding” clauses in the treaty as well as using Article 21 of the constitution “if appropriate”, which allows the WHO to adopt legally binding regulations.

WHO Director-General Dr Tedros Adhanom Ghebreyesus expressed satisfaction with the outcome of the INB meeting, the second since the body was agreed on last December.

“The legally binding instrument is very, very important, and that’s what you have decided and I am very glad to see that,” said Tedros.

“The legally binding principle is really key because this is the generation that has suffered and still suffering due to the pandemic. No generation can write this treaty or instrument or accord other than this generation, so that our children and the children of our children can  benefit and what happened over the last two to three years is not repeated in the future.”

‘Bitter pills’ to follow ‘honeymoon’

INB vice-chair, Thailand’s Viroj Tangcharoensathien, warns that negotiations ahead will be tough.

However, INB Bureau vice-chair Viroj Tangcharoensathien (Thailand) warned that the smooth running of the meeting marked the “honeymoon period”, and the tough challenge of negotiating the content of the treaty still lay ahead.

“We have achieved consensus on using Article 19 of the constitution as there was majority support to go that way, although we do not discard Article 21, and I feel that this is the honeymoon period and the honeymoon period will finish very quickly,” said Tangcharoensathien, warning of “bitter pills” at the next INB meeting scheduled for December.

“Based on the spirit and trust of INB in the Bureau and secretariat, I believe that we will be there by May 2024 and we will have achieved something substantial for the world because the world is waiting. Monkeypox is attacking us all the time and H5N1 [avian flu] is in the air,” he added.

The INB has until May 2024 to present a draft pandemic treaty to the WHA. Once it is passed, it will come into force for each Member State “in accordance with its constitutional processes”. This clause has only ever been used once – to adopt the Framework Convention on Tobacco Control, which contains both binding and non-binding clauses.

“The Health Assembly could adopt a legally binding instrument (under either Article 19 or 21 of the Constitution), and that instrument could contain both legally binding and non-legally binding provisions, with the non-binding provisions being, for example, recitals, principles, recommendations or aspirations,” according to a

According to a WHO explainer issued before the INB meeting, a legally binding instrument can contain “both legally binding and non-legally binding provisions, with the non-binding provisions being, for example, recitals, principles, recommendations or aspirations”, and this practice is “standard both in WHO and with other international instruments”.

Process ahead

In December 2021, WHO’s Member States decided at a WHA special session to establish the INB to draft an international instrument on pandemic prevention, preparedness and response.

The INB is expected to deliver a progress report to the 76th World Health Assembly in 2023 and submit its draft agreement to the WHA’s 77th meeting in May 2024.

The INB Bureau is comprised of co-chairs Roland Driece (Netherlands) and Precious Matsoso (South Africa), with vice-chairs Tovar da Silva Nunes(Brazil), Ahmed Soliman(Egypt), Kazuho Taguchi (Japan), and Thailand’s Viroj Tangcharoensathien, representing all WHO regions.

Between now and the end of October, the INB will conduct regional briefings and public hearings, which will result in a “zero draft” agreement to be presented to the next INB meeting on 5 December.