nuclear
A Nuclear powerplant in Belgium.

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

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

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

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

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

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

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

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

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

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

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

Only a handful of recommended medicines 

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

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

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

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

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

Bone marrow syndrome – emerging treatments

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

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

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

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

WHO: Stockpile based on population size

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

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

Image Credits: Photo by Frédéric Paulussen on Unsplash.

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

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

Pandemic treaty: tough political negotiations ahead 

By Daniela Morich

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

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

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

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

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

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

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

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

An existential moment for the International Health Regulations

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

By Gian Luca Burci

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

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

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

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

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

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

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

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

Wildly diverse amendments but a few trends emerge

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

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

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

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

Two negotiating processes unfolding at the same time

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

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

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

About the authors

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

Image Credits: Geneva Graduate Institute.

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

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

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

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

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

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

Dr FIfa Rahman

WHO diagnostics resolution

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

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

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

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

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

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

Three steps to fast-track tests

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

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

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

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

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

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

Diagnostics to prevent antimicrobial resistance

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

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

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

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

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

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

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

Image Credits: Maxpixel, DNDi.

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

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

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

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

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

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

Diphtheria and a mystery flu hit Nigeria

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

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

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

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

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

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

The 2022 cholera outbreak continues

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

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

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

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

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

Omicron remains the dominant variant in Africa

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

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

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

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

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

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

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

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

Dr Samukeliso Dube, FP2030 executive director.

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

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

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

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

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

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

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

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

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

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

Funding flatlining

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

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

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

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

A resident of Ifakara tucked into a mosquito net.

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

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

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

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

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

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

Clever insects

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

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

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

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

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

Constant innovation

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

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

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

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

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

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

A doctor at Ifakara district hospital treating a malaria patient

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

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

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

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

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

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

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

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

Genetically modified mosquitos

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

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

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

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

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

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

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

Image Credits: Peter Mgongo.

Dr Tedros Adhanom Ghebreyesus

While the World Health Organization’s (WHO) emergency committee on COVID-19 will decide this week whether the virus still constitutes a global health emergency, the body’s Director-General, Dr Tedros Adhanom Ghebreyesus, is “very concerned” about the pandemic.

“While I will not pre-empt the advice of the emergency committee, I remain very concerned by the situation in many countries and the rising number of deaths,” Tedros told a media briefing on Tuesday.

He described the global COVID-19 response as being “under strain” with too few vulnerable people adequately vaccinated, too many people behind on their boosters, antivirals remaining too expensive, fragile health systems struggling with COVID-19 and other diseases, alongside a “torrent of pseudoscience and misinformation”.

“My message is clear. Do not underestimate this virus. It has and will continue to surprise us,” Tedros warned.

Dr Joachim Hombach, executive secretary of the WHO Strategic Advisory Group of Experts on Immunization (SAGE) agreed: “For the time being, COVID hasn’t really come down to the usual seasonal seasonality that we see for other viruses. The virus is still fairly unstable so it is a bit of anticipation if we end up in a seasonal pattern as we have it for instance for influenza.”

“It is conceivable that annual vaccination would be suitable. You basically have to find  the sweet spot between waning immunity and the benefit and the effort of providing an additional vaccination,” said Hombach.

Dr Joachim Hombach, executive secretary of the WHO Strategic Advisory Group of Experts on Immunization (SAGE).

Meanwhile, Dr Maria van Kerkhove, WHO’s lead on COVID-19, said that there were “a lot of uncertainties in terms of what is circulating in our ability to assess them”, given that surveillance of the virus had dropped substantially.

Funding appeal for emergencies

Tedros also appeal for an additional $2.5 billion to assist the WHO to address 54 health crises around the world, 11 of which are classified as Grade 3, WHO’s highest level of emergency.

“The number of people in need of humanitarian relief has increased by almost 25% compared with last year, to 339 million people, and 85% of humanitarian needs globally are driven by conflict.,” said Tedros.

“The world cannot look away and hope these crises resolve themselves.”

WHO Executive Board focus on resources

The key issues to be discussed at next week’s WHO’s executive board meeting, involve money and resources, according to Dr Tim Armstrong, WHO’s director of the department of governing bodies.

Armstrong’s top three issues from over 40 agenda items are the new programme budget for 2024/25, sustainable financing and an enhanced central role for the WHO in the global health architecture, particularly to support member states during health emergencies.

The board meeting starts next Monday, 30 January.

Better surveillance of contaminated medicines

Dr Hanan Balkhy

Tedros called on governments to ensure better surveillance of medicines following “incidents of contaminated cough syrups for children”. 

While the WHO had issued medical alerts focused on the Gambia (last October), Indonesia (last November) and Uzbekistan this month,  “at least seven countries have been affected”, said Tedros. 

“Most of the [over 300] deceased have been children under the age of five. These contaminants are toxic chemicals used as industrial solvents, and antifreeze agents that can be fatal even in small amounts,” he said.

This week, the WHO issued an “urgent call for countries manufacturers and suppliers to do more to prevent detect, and respond quickly to contaminated medicines,” said Tedros. 

“Governments must increase surveillance so they can detect and remove from circulation any substandard medicines identified in the WHO medical alerts. They must also enforce illegal measures to help stop the manufacture, distribution and use of substandard and falsified medicines. 

“Manufacturers must purchase pharmaceutical grade ingredients from qualified suppliers and conduct comprehensive testing before using them.”

Meanwhile, Assistant Director-General Dr Hanan Balkhy, said the WHO was appealing to governments and specifically the regulatory authorities to ensure that they “have proactive surveillance mechanisms to be able to detect the presence of these medications”.

Balkhy, who oversees Antimicrobial Resistance and is Acting interim Assistant Director-General for Medicines and Health Products, said that while contamination would always be an issue in the production of medicine, the WHO’s “ask” was that member states strengthen the capacity of their regulatory authorities’ oversight capacity.

The new Brazilian government under President Lula da Silva intends to propose that the World Health Organization (WHO) addresses the health of indigenous people systematically, including by training indigenous health workers.

Santiago Alcazar, the former head of WHO in Brazil, told a discussion convened by the Geneva Global Health Hub (G2H2) on Monday that Brazil would propose that the WHO establish a project on indigenous people’s health at the body’s executive board meeting, which starts this weekend.

Alcazar was addressing a G2H2 discussion on authoritarianism in a pandemic, which focused on the judgement of the Permanent People’s Tribunal (PPT) that former Brazilian president Jair Bolsonaro was “liable for crimes against humanity” during the COVID-19 pandemic.

Indigenous peoples, Black people, and quilombola (descendants of escaped slaves)  were worst affected by the Bolsanaro administration’s “rejection of isolation, social distancing, [COVID] prevention, and vaccination”, according to the PPT, which was set in 1979 up to expose human rights violations of ordinary people worldwide.

“Contrary to the unanimous position of scientists around the world and WHO recommendations, Bolsonaro not only ensured that the Brazilian population did not adopt the planned measures to limit the infection but repeatedly created various obstacles to them, frustrating his own government’s attempts to protect the population from the virus,” according to the PPT judgement.

Bolsonaro is infamous for declaring during the pandemic: “Everyone has to die one day. We have to stop being a country of sissies.”

During the height of the pandemic, there were reports of people being buried in mass graves in the Mannaus in the Amazon as graveyards struggled to cope with the death toll. In June 2020, as the death toll soared, Bolsonaro’s government simply stopped publishing statistics on COVID-19 infections and deaths.

Infographic: Brazil Stops Publishing COVID-19 Figures As Deaths Soar | Statista You will find more infographics at Statista

‘Genocidal weaponisation of COVID’

G2H2 co-chair Nicoletta Dentico, who was part of the PPT jury that heard evidence against Bolsonaro, said that the tribunal had drawn global attention to Bolsonaro’s “genocidal weaponization of COVID”.

Dentico indicated that having public hearings was one of the few tools that civil society could use against authoritarian governments during a pandemic.

PPT secretary Gianni Tognoni told the meeting that the Commission for the Defense of Human Rights Dom Paulo Evaristo Arns, the Articulation of Indigenous Peoples of Brazil (Apib), the Black Coalition for Rights, and Public Services International (PSI) has requested the hearing.

They argued that Bolsonaro and his government “intentionally spread COVID-19”, causing an estimated 480,000 unnecessary deaths that “mainly affected the indigenous population, people of colour, and health workers”.

Brazilian human rights lawyer Eloisa Machado said that the Bolsonaro government had a “deliberate project to disseminate COVID-19”, yet the country’s general prosecutor, aligned with the former president, had not been interested in investigating any criminal activity.

“There was an explicit recommendation to follow recommendations that were not medically endorsed, there was a resistance to adopting measures to reduce the circulation of people and there was also an explicit ruling against using masks,” said Machado.

Outrageous claims

“States and municipalities also did not have the financial resources to fight against COVID-19,  there was negligence in the purchase of vaccines and there was a lack of vaccination campaign,” said Machado.

While a  parliamentary commission found that Bolsonaro was propagating the pandemic by failing to implement preventive measures, the conditions in the country were not conducive to openly challenging the “democratically elected dictator”, added Machado.

There was court action against some of Bolsonaro’s more outrageous claims – such as that a person could get AIDS from the COVID-19 vaccine – but nothing to expose the systemic way in which he pursued a deliberate policy of mass COVID-19 infection instead of trying to protect people.

As a result, civil society organisations opted to approach the PPT for a hearing to show that there had been a systemic policy that had particularly affected the country’s most vulnerable people.

“We’re confident that the judicial interpretation of the PPT ruling will be able to be used to bring justice, aside from this occurring in a symbolic realm,” said Machado, stressing that civil society is adamant that there should be no amnesty for the crimes against indigenous populations committed during the pandemic. 

State of emergency in Yanomami

Alcazar, who now works for the Fiocruz Foundation, said that indigenous communities had been abandoned during COVID-19. Last week, the government declared a state of emergency in Yanomami territory, Brazil’s largest indigenous territory, in reaction to severe malnutrition.

During Bolsanaro’s reign, illegal gold miners have been operating freely in the area, often clashing violently with local people, and the health system has been neglected.

“Brazil has 2.7% of the world’s population but it has 11% of deaths due to COVID,” said Alcazar, adding that this was not just a result of incompetence but “evil intent”.

Image Credits: Aljazeera.

Trans Fats
Policies to eliminate industrially produced trans fats are relatively simple to implement, and can save lives and economies.

Five billion people around the world have no protection against industrially produced trans fats (ITFAs), putting them at risk of heart disease and death, the World Health Organization said.

ITFAs are responsible for over 500,000 premature deaths from coronary heart disease every year. Commonly found in baked goods, cooking oils, and packaged foods, ITFAs are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid.

“Take any liquid oil and bubble hydrogen through it, and that makes it more solid,” Dr Tom Frieden, CEO of Resolve to Save Lives said at a WHO press conference announcing the launch of the report. “That’s pretty good for baking. Unfortunately, it’s also solid in your coronary arteries.”

The WHO first called for the worldwide elimination of ITFAs in 2018. Best-practice policies have gained significant traction since, protecting 2.8 billion people globally – a six-fold increase – but the WHO target for the total elimination of trans fats by 2023 is “unattainable,” the report said.

Momentum for banning ITFAs has grown, but the world still has “a long way to go,” WHO Director-General Dr Tedros Adhanom Ghebreyesus said.

Most legislation policing ITFAs has been implemented by high-income nations, with the Americas and Europe taking the lead. The European Union successfully banned all ITFAs from its food supply in 2021, and nearly 80% of people living in high-income countries are protected by what the WHO considers best-practice policies.

Four countries – Bangladesh, India, the Philippines and Ukraine – account for all 51% of people covered by best-practice policies in lower-middle income countries, with India representing 41% of that total. While 62 countries have implemented laws to ban ITFAs, covering 46% of the global population, no one living in low-income countries enjoys any legislative protections.

“Trans fat has no known benefit, and huge health risks that incur huge costs for health systems,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Put simply, trans fat is a toxic chemical that kills, and should have no place in food. It’s time to get rid of it once and for all.”

The tobacco of the food industry

No one living in low-income countries is protected from trans fats, putting them at risk of its devastating health effects.

Unlike sugar, sodium, or saturated fats, ITFAs are not naturally occurring in any food group. While sugar and sodium can pose serious health risks, their omnipresence in foods people around the world rely on every day makes a ban both impossible and impractical. A ban on nutrients like sugar and sodium is also unnecessary, as their adverse health effects can be managed through light-touch regulation paired with dietary guidelines and recommendations.

But ITFAs are produced industrially and injected into the food supply, and can be easily replaced by healthier alternatives like vegetable oils. Experts say this makes their total elimination an easy decision for governments.

“It’s very rare for us in the nutrition space to be able to say it’s just so bad,” said Dr Rain Yamamoto, a scientist at the WHO’s department of nutrition and food safety. “There are no health benefits whatsoever.”

While significant progress has been made in the fight against ITFAs in recent years, nine of the 16 countries facing the highest estimated burden of trans fat-induced coronary heart disease deaths do not have best-practice policies in place. These include Australia, Egypt, Pakistan, Iran, and South Korea.

WHO also emphasized the cost of falling behind the regulatory wave for countries not currently facing a high burden from ITFAs. As more economies become off-limits to industrial producers of trans fats, countries unprotected by legislation policing ITFAs face the prospect of companies dumping products into their food supplies. This is particularly concerning given the lack of any legislation in low-income nations regulating ITFAs.

“If it’s not present, then there’s no harm in banning it and preventing other countries from dumping products into your country,” Frieden said. “Think of artificial trans fats as the tobacco of nutrition. It has no valid use.”

Today, 62 countries have implemented bans on ITFAs.

Denmark leads the way

Studies suggesting that trans fats could be a cause of the large increase in coronary artery disease were penned as early as 1956, but it would take until the early 1990s for renewed scientific scrutiny to confirm their negative health impacts.

The findings spurred Denmark to begin enacting policies to cut ITFAs out of the country’s food supply in 1991. What began as mandatory labelling and nutritional education policies evolved into a political and social pressure on companies to phase out ITFAs from their products in the decades that followed.

By the time Denmark became the first country in the world to pass a total ban on ITFAs in 2007, consumption had already been cut by some 90% since 1991.

A 2022 study found the policies substantially reduced coronary heart disease mortality, preventing an estimated 1,200 deaths by 2007. The 11% reduction in mortality observed over that period is similar to the contribution from decreases in smoking rates.

National legislative bans on ITFAs following Denmark’s lead by Iceland, Austria, and Switzerland, have also proven to be extremely effective.

“There’s really no alternative to governmental action,” Frieden said, adding that proper enforcement mechanisms are critical to ensuring industry takes action to eliminate trans fats.

Globally, legislation to remove ITFAs from foods is seen as one of the most potent public health measures for reducing non-communicable disease burdens emphasized by WHO in the Sustainable Development Goals to reduce premature deaths from NCDs by 30% by 2030.

In the absence of legislation, WHO Director-General Dr Tedros Adhanom Ghebreyesus called on companies to pull their weight.

“I call on the food industry to help us make up for lost time by replacing industrially produced trans-fatty acids with healthier oils,” Tedros said. “If they so choose, these companies could have an almost unparalleled impact on global health.”

Although some experts predict that the past weekend’s celebrations of China’s lunar new year will hasten the spread of COVID-19 to rural parts of the country, one of the country’s top scientists has disputed this.

Wu Zunyou, China Centre for Disease Control and Prevention’s chief epidemiologist, downplayed the risk on the Chinese social media platform, Weibo, claiming that 80% of Chinese people had already been infected before the week-long celebrations.

 

On this past Sunday, international travel restrictions in and out of China were lifted, while lockdowns and other measures to curb domestic travel have also been lifted in past weeks, enabling many people to travel to see their families in rural areas for the first time in three years.

 

Global health analytics company Airfinity said last week that it had “updated its cases and deaths forecast for China’s COVID-19 outbreak as the lunar new year holiday hastens the spread of the virus”. 

It had initially predicted two COVID waves, but Airfinity’s analytics director Dr Matt Linley said that it “now expects to see one larger and more prolonged wave with infections reaching a higher peak”.

Airfinity’s new model predicts that, between 1 December 2022 when restrictions were lifted, and 17 January 2023, 99.5 million people were infected (up from its December prediction of 72.9 million). This squares with Wu Zunyou’s assertion about mass infections happening before the new year celebrations.

Airfinity COVID-19 predictions for China, 1 December 2022 – 1 April 2023

Linley warned that provinces such as Hubei and Henan “could see patient demand for intensive care beds being six times hospital capacity”, and that there would be .”a significant burden on China’s healthcare system for the next fortnight”.

However, unlike China’s very low official mortality data, Airfinity’s new model estimates daily deaths to have been 32,200 by 17 January with cumulative deaths from 1 December 2022 to 17 January to be 608,000.

“Deaths are forecast to peak at 36,000 a day on 26 January during the lunar new year festival. This is up from our previous estimate of deaths peaking at 25,000 a day,” said Aifinity. 

It warned that one larger wave as opposed to two smaller ones meant “increased pressure on hospitals and crematoriums and therefore also potentially a higher case fatality ratio”.

Meanwhile, the full extent of COVID-19’s impact is unlikely to surface after Chinese authorities announced an internet crackdown on people spreading “false information” and “gloomy sentiments” about COVID-19 for a month around the new year festivities, according to The Guardian.

Previously, social media has been filled with stories about families reporting on relatives’ infections and their struggles to get Pfizer’s anti-viral medicine, Paxlovid, the black marker price of which has soared.

Paxlovid is not covered by Chinese medical insurance because of its high price.