Earlier in the pandemic, some travellers donned protective plastic jackets at Hong Kong airport.

Travellers entering the US from other countries no longer need negative COVID-19 tests, Rochelle Walensky, director of the Centers for Disease Control and Prevention (CDC) announced on Sunday.

The CDC continues to recommend that all people stay up to date with COVID-19 vaccinations and wear masks on public transport.

From Saturday, 11 June 2022, all COVID-19-related restrictions for entry into Germany were also preliminarily lifted, meaning that no proof of vaccination, recovery or testing is required.

Meanwhile, Canada has suspended mandatory random testing of  COVID-19 for international travellers at its airports during the month of June, saying that it is preparing to take this testing “off site”.

“There is no change for air travellers who do not qualify as fully vaccinated. Between June 11 and June 30, these travellers will continue to be tested on arrival at the airport and on Day 8 while they quarantine for 14 days,” Health Canada and the Public Health Agency of Canada announced.

Random testing has caused substantial delays at Canadian airports, particularly as more people resume travel.

 

Canadian President Justin Trudeau announced on social media on Monday that he had tested positive for COVID-19, adding that “I feel okay, but that’s because I got my shots. So, if you haven’t, get vaccinated – and if you can, get boosted.”

South Korea lifted its seven-day quarantine mandate for unvaccinated arrivals from overseas on 8 June. All travellers, regardless of vaccination status, still need a pre-departure Covid test and a PCR test within three days of arrival.

China still requires all international travellers to be screened for COVID-19 on arrival and subjected to at least 14 days of quarantine, some of it in designated government quarantine sites.

Similarly, travellers to Hong Kong need to provide a negative test and hold a reservation in a designated quarantine hotel.

All vaccinated travellers must undergo COVID-19 tests on arrival in Hong Kong and wait for a negative result before continuing to their quarantine hotel, where they can leave after a week if they have had two successive negative tests on days five and seven. Unvaccinated travellers face a 14-day quarantine but can also have this cut to seven days following two successive negative tests.

 

Image Credits: WHO Africa.

international labour conference
Renate Hornung-Draus, delegate of Germany at 110th session of the International Labour Conference

The principle of a safe and healthy working environment has been adopted to be included in the International Labour Organization’s (ILO) Fundamental Principles and Rights at Work in a landmark decision during the annual International Labour Conference (ILC).

The International Labour Conference, held 27 May – 11 June, brings together delegates from ILO member states that represent governments, workers and employers to establish and adopt international labour standards.

Delegates adopted the measure at the Conference’s plenary sitting on Friday 10 June. 

Until now, there have been four categories of Fundamental Principles and Rights at Work:

  • Freedom of association and the effective recognition of the right to collective bargaining;
  • Elimination of all forms of forced or compulsory labour;
  • Effective abolition of child labour;
  • Elimination of discrimination in respect of employment and occupation.

The decision by the Conference means that Occupational Safety and Health will become the fifth category, with delegates celebrating the landmark addition. 

“The solid confirmation of a safe and healthy working environment by including it as a fifth pillar into the 1998 declaration reconfirms that all ILO members need to step up their work on the realisation of a safe and healthy working environment,” said Renate Hornung-Draus, delegate of Germany, speaking at the plenary on Friday.

“Ever since the adoption of the ILO Constitution in 1990, the pursuit of the protection of the life and health of workers has featured prominently in the work of ILO,” said Amos Kuje, delegate of Nigeria. 

“The ILO and its members will be in a better place to pursue it with greater legal effectiveness in the future. The life, health, and well-being of millions upon millions of workers depends on this [resolution]. We have to rise to the challenge.”

The ILO had published a joint report with the World Health Organization last September 2021 on work-related burden of disease, finding that diseases associated with long working hours and workplace injuries accounted for the top two causes of worker deaths. This report, the first global comparative risk assessment on work-related burden of disease, led to calls from both organizations to use the findings of the report to shape policies and practices that created healthier and safer work environments.

Creating inclusivity at work for vulnerable populations a focus of the International Labour Conference 

Women on their way to work in Raipur, India.

Earlier that day, the ILC held its high-level World of Work Summit tackling multiple global crises and promoting human-centered recovery and resilience, with specific focus on an urgent need to address the labour and social consequences of current crises, and creating an inclusive environment, particularly for vulnerable populations. 

“While the picture is bleak and the outlook uncertain, we must not lose sight of our vision for a better future of work. The hopes and dreams of millions depend on us. We cannot let them down. Together, we must deliver on our promise of a better, fairer, more inclusive, future for all,” said ILO Director-General Guy Ryder at the opening of the Summit. 

“We must renew our efforts to create decent work opportunities, especially for the most vulnerable groups,” he added.

President Wavel Ramkalawan of Seychelles and President Xiomara Castro of Honduras called for better work protections for women and children. “Our message should be one of hope,” said Ramkalawan. “Our actions and policies should present hope for our people, while we fight the scourges of corruption, exploitation and injustice,” 

Image Credits: ILO, Prem Kumar Marni/Flickr.

WTO Ngozi Okonjo-Iweala speaking just ahead of the opening of the 12th Ministerial Conference of WTO on Sunday.

The World Trade Organization’s Director General Dr Ngozi Okonjo Iweala said she was “cautiously optimistic” about the potential for WTO members to reach long-delayed agreements on issues such as a limited IP waiver for COVID vaccines as well as a decision to curb harmful fisheries subsidies that allow big industrial rigs to plunder the oceans  – depleting global fish stocks and harming food security for billions of people. 

Iweala spoke at a press briefing Sunday just ahead of the opening of WTO’s long-delayed 12th Ministerial Conference (MC12) that afternoon. The conference in Geneva, the first ministerial meeting in five years, will consider a newly-published draft text that would end subsidies to long-range fishing fleets operating on the “high seas”. The draft text also would require countries to  invest in oceans maintenance to preserve fish stocks in coastal waters, offset any subsidies they may continue to offer.  

MC12 also will attempt to finalize a long-disputed agreement on a limited waiver on intellectual property for COVID vaccines. And in response to the global food security crisis triggered by Russia’s war in Ukraine, members will will consider a draft ministerial decision exempting the World Food Programme from export restrictions on agricultural products – levied by many countries in the wake of the halt to exports of Ukranian and Russian food and agricultural inputs. 

Civil society groups, however, protested being locked out of the physical conference corridors on opening day, saying that the last-minute move by WTO, ostensibly on security grounds, had “sidelined” voices of dissent at the meeting, being attended by over 100 trade ministers.  

Iweala – ‘You have to get us over the finish line’

Director General Ngozi Okonjo Iweala next to co-sponsor Kazakhstan’s MC12 Chairman Timur Suleimenov

In her formal statement at the conference’s ceremonial opening, Iweala urged WTO members to move ahead assertively on the wide range of issues before them – and thus ensure the continued relevance of the global trade body to multilateral policy-making. 

“Strengthening the multilateral trading system is a global public good that we have collectively and carefully built up over 75 years,” Iweala said. Her speech set out key points of focus for the debates of the next three days – around agriculture and food security, as well as draft agreements on fisheries subsidies and a waiver on some WTO TRIPS provisions on the use of intellectual property – for the purpose of COVID-19 vaccine production. 

“I hope as ministers you can work even better together to complete nearly completed deliverables. So this organization can be put back on a result focus trajectory,” she urged, noting that the fisheries decision has been over 20 years in the makaing.   

On the much discussed IP waiver – as well as a companion  “trade and health” draft declaration reducing barriers to trade in essential medicines and inputs, Iweala urged ministers to “please let’s do it.

“You have to  get us over the finish line. Get us an agreement on the response to the pandemic…  for millions of people to access affordable vaccines and  medical countermeasures – in this and future pandemics.”   

Critics say IP waiver language verging on irrelevance

Critics on both sides of that debate, however, slammed the draft version of the IP waiver text -although the final text of that has not yet been formally released by WTO.  But it is said to be based on a so-called “outcome document” published in May after weeks of final negotiations by co-sponsors India and South Africa along with the European Union and the United States.

See related story here:

After Months of Deadlock, WTO’s TRIPS Council Will Finally Discuss Intellectual Property Waiver Compromise

Some medicines access advocates have even suggested that countries should walk away from the text, which has been limited in scope to only to vaccines and not treatments. Critics also say they fear that the language of the new “waiver” could subtly undermine existing WTO flexibilities enshrined in the original 1994 Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS), and the 2001 Doha Declaration, which together allow countries to issue “compulsory licenses” for vaccine production in times of public health emergency.

Said Jamie Love, director of Knowledge Ecology International the new TRIPS waiver proposal in fact “includes the most restrictions [to date] on which countries can import or export vaccines.  No other agreement placed restrictions on which countries can export vaccines under a compulsory license, but this one does, excluding most countries that currently have vaccine manufacturing capacity.” He was speaking at a civil society press briefing earlier Sunday.    

Pharma opponents, meanwhile, say the IP waiver would inhibit innovation at a time when low- and middle income countries are facing a surfeit of vaccines that they cannot absorb  – rather than the dearth experienced in the first phase of the 2021 rollout. 

“Today, it is widely accepted that the issue is not vaccines but vaccinations,” said Thomas Cueni, Director General, International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), in a comment to Health Policy Watch. He added that for the past year, the “real challenges” have been more around trade and supply side barriers. “So it is really puzzling why so much energy is going into a waiver that we don’t need and has and will do little to tackle its stated aim, e.g. vaccine equity.  

“A TRIPS Waiver on vaccines would never have contributed to a single more vaccine – for that you need voluntary know-how sharing and tech transfer – but it would do harm to future pandemic preparedness because of the signal it sends.”

Fisheries  – can a deal finally be reached ? 

The draft fisheries text has, on the other hand, is being promoted by WTO as a deal that is indeed inching closer to the finish line – with broad buy-in.

And it has been welcomed by a broad array of environmental NGOs, such as the World Wildlife Foundation, as well as by former US trade ambassadors from both Democratic and Republican parties for its long-overdue moves to protect ocean fish stocks, 90% of which are fully exploited, over exploited or already depleted, according to the UN Food and Agriculture Organization. 

The draft text represents the fruits of more than 20 years of negotiations over an estimated $35 billion annually doled out by governments in fisheries subsides.  About $22 million, or two-thirds of those subsidies directly contribute to the depletion of global fish stocks, harming food security and nutrition, recent studies say. The risks are particularly grave for people in low– and  middle-income coastal communities across Africa and Latin America, highly dependent on local fish protein for healthy diets. 

Coastal fishermen and women in those same communities have also seen a depletion in their catches, and thus livelihoods, with no means to compete with big industrial rigs scraping the ocean floor just outside of their territorial waters – and then selling the fish to wealthy nations on global markets. More than 820 million people depend on fisheries and aquaculture for food, nutrition, and income, according to FAO.

“The agreement is not everything we might have wanted. It’s not everything anyone wanted, and that’s the nature of negotiations. But it is a remarkable achievement. It goes beyond anything that has been agreed previously on this topic,” said Alice Tipping, of the International Institute of Sustainable Development, speaking at a Sunday morning press briefing on the fisheries issue, co-sponsored by IISD and WWF, among others. 

Key to the draft agreement are prohibitions on subsidies that enable fishing outside a country’s national waters, incuding “a standalone prohibition on subsidies for fishing in the unregulated high seas, and those apply to all members equally.” The text also requires that future subsidies within a country’s territorial waters be accompanied by fish and ocean management measures to preserve stocks – with a proposed 7-year transition period for low- and middle-income countries to develop and invest in such management systems. 

Agreement still faces rough waters 

Shailendra Yashwent, senior advisor with Climate Action Network

Even so, the agreement still has rough waters to navigate to final approval, with some developing countries like India, as well as some civil society groups protesting its provisions as being tilted towards rich countries that have ample money to spend on oceans management to offset their continued high subsidies.

Dveloping countries need longer than the seven years proposed in the text to transition to new ocean management formulas, the critics say, even if those aim at ensuring the long-term maintenance of fish stocks and oceans health. Removing subsidies too rapidly could harm “artisanal fisheries” in poor countries, that rely on very small handouts for subsistence livelihoods, they add.

Developing countries subsidies, per capita, also are miniscule in comparison to those in developed countries, pointed out  Shailendra Yashwent, a journalist and senior advisor with the Climate Action Network, who also spoke at the fisheries press briefing. 

“India gives only $141 million USD as total subsidies to the sector, which means the subsidy for (an Indian) fishermen is approximately $14 per year per annum, which is nothing compared to $4,956 in the USA, $8,358 in Japan and a hopping $31,800 in Canada,” he pointed out, “and many of those [Indian fishermen] involved in the trade are permanently impoverished.  

“So like the carbon space argument in climate negotiations, the India government says that it wants the countries that have provided huge subsidies for unsustainable fishing in the past to first take the responsibility for significantly cutting down.  

At the same time Yashwent cautioned against attempts by India or other developing countries to throw out the agreement so long overdue: “It is really my hope that middle path has found that India does not block negotiations while protecting the interests of small scale fishermen. 

“India’s position, I truly believe, should not be at the cost of an agreement that is already 22 years in making. And any delay now will allow the industrial fishing fleets of rich nations to wipe out the remaining marine life and cause an irreversible collapse of marine systems and the humanity that depends on it.”

Unsustainable agriculture subsidies, plastics pollution – advancing dialogue 

Timur Suleimenov, chief of staff of the president of Kazakhstan, which is co-hosting MC12

This week’s conference also aims to set out frameworks for future dialogue on, and potentially negotiations over, other looming, environmental health issues that touch the WTO such as: how global trade rules are enabling the burgeoning plastics and environmental pollution of land and water resources; billions of dollars in agricultural subsidies that harm climate and biodiversity; as well as the even more challenging task of reforming trade rules around fossil fuel subsidies, currently estimated to be about $5.9 trillion annually. 

But the focus at this MC12 on those themes, at least for now, will be more around building long term collaborations and understandings – rather than negotating potentially binding decisions, one observer told Health Policy Watch: 

“They represent important opportunities to identify ways forward on a range of trade, environmental and sustainable development issues.”  

Cross-cutting to all of the talks will be the challenges of ensuring the future viability of a rules-based system for global trade – to which leading countries adhere despite the war in Ukraine that has sharpened the already yawning geopolitical chasm between big and emerging powers, including the United States, China, Russia, and India.

Said Timur Suleimenov, chairman of the conference originally to have taken place last year in Kazakhstan, and which the country is now co-hosting in Geneva. “Over the next three days, the world’s eyes are on the WTO.”

Chinese wet market

The first report by the new WHO-convened expert group, Scientific Advisory Group for the Origins of Novel Pathogens (SAGO) has fanned the flames of controversy over evidence about whether a lab leak or a natural “spillover” of the virus from animals to humans was the most likely source from which the COVID pandemic emerged – although in fact it contains little new information on either. 

The preliminary SAGO report, published Thursday, is significant in that it redresses some of the perceived pro-China “biases” of WHO’s first report by an international group of experts on the virus origins issued in March 2021.  

The report marks the first formal acknowledgement by a WHO-sponsored expert group that a possible biosafety failure in the Wuhan Virology Institute should be further investigated as the pandemic trigger – stating: “it remains important to consider all reasonable scientific data that is available through published or other official sources to evaluate the possibility of the introduction of SARS-CoV-2 into the human population through a laboratory incident.” 

The lab escape theory was something the previous WHO international expert group that also visited Wuhan China in January 2021, had discounted as “extremely unlikely” – provoking a political and scientific uproar by critics who said that group lacked adequate biosafety expertise or evidence to draw that conclusion, and had been politicized by its Chinese participants.  

The new WHO report also calls attention to the continuing political barriers to studies that get at the roots of the SARS-CoV2 narrative – including the lack of access to individual patient data and blood samples from tens of thousands of confirmed and suspected SARS-CoV2 cases from late 2019 and early 2020 that China has refused to share, as well as a lack of comparable data from animal studies.  

No intermediate host or spillover event clearly identified

Blyth’s Horseshoe Bat (Rhinolophus lepidus)
Location: Bandhavgarh National Park, Umaria, Madhya Pradesh, India

The committee confirms long-stated claims that the virus originated in bats, “with the closest genetically related viruses being beta coronaviruses, identified in Rhinolophus bats in China in 2013 (96.1%) and Laos in 2020 (96.8%). However, so far neither the virus progenitors nor the natural/intermediate hosts or spill-over event to humans have been identified. 

“Early investigations suggested that the Huanan seafood market in Wuhan played an important role early in the amplification of the pandemic with several of the patients first detected in December 2019 having had a link to the market and environmental samples from the market testing positive…. 

However, the report also concludes that  “the source of SARS-CoV-2 and its introduction into the market is unclear and it is yet to be determined where the initial spillover event(s) occurred….  Furthermore, follow-up studies to identify possible animal sources from which the environmental contamination could have originated have not been completed.” 

In fact, there is so far little new evidence that has really been brought to the table on either the spillover or lab leak theories, WHO sources told Health Policy Watch. These sources stressed that the report remains preliminary in nature and that a final version may hopefully include more definitive information. 

China, Russia and Brazil object to further studies on lab escape studies 

While the report recommends further research into whether a lab biosafety failure could have triggered the SARS-CoV2 outbreak – it also admits, in roundabout diplomatic language, that the prospects for obtaining key information from China on biosafety conditions at the Wuhan Institute of Virology that studied bat coronaviruses in Wuhan, that remain  dim. 

“To support biosafety and biosecurity investigations into the introduction of SARS-CoV-2 into the human population through a laboratory incident; the SAGO notes that there would need to be access to and review of the evidence of all laboratory activities (both in vitro and in vivo studies) with coronaviruses including SARS-CoV-2-related viruses or close ancestors, and the laboratory’s approach to implementation and improvement of laboratory biosafety and biosecurity,” the report states. 

“As it is not common practice to publish the institutional implementation of biosafety and biosecurity practices of individual laboratories in peer-reviewed scientific journals, additional information will need to be obtained and reviewed to make conclusive recommendations.”

Notably, the SAGO team’s three scientists from China, Russia and Brazil, objected to further pursuit of the lab escape theory, as reported in a footnote that states: 

“Dr Vladimir Dedkov, Dr Carlos Morel, Professor Yungui Yang do not agree with the inclusion of further studies evaluating the possibility of introduction of SARS-CoV-2 to the human population through a laboratory incident in this preliminary report due to the fact that from their viewpoint, there is no new scientific evidence to question the conclusion of the WHO-convened global study of origins of SARS-CoV-2: China Part mission report published in March 2021.”

Battle between spillover versus lab escape adherents in scientific circles 

lab leak
Seafood and fresh food market in Wuhan, Hubei, China. Most confirmed cases of SARS-CoV2 were traced back to Huanan Wholesale Seafood Market.

Outside of the SAGO group – a fierce battle also continues to rage over the merits of the “lab escape” versus “natural spillover” theories. 

And if anything the new report only seemed to fan the flames of arguments on both sides – with adherents to one theory or the other facing off in the media over the merits of the report.

Experts urging more attention to the natural spillover theory lamented that the WHO report did not seem to give enough credit to recent studies of SARS-CoV2 samples found in the Huanan Seafood Wholesale Market, which have been published, but not yet peer-reviewed. 

“I think if you read our pre-prints and understand the evidence, actually there’s very strong evidence that the pandemic emerged through wildlife at the Huanan market,” the lead author of two such studies, Michael Worobey of the University of Arizona, was quoted as saying. 

Worobey and his colleagues pieced together the genetic evidence about the virus’ presence and evolution in studies of Wuhan residents in early 2020 as well as analysis of environmental samples taken from Wuhan’s live animal markets between December 2019 and February 2020. Some of those environmental samples showed high levels of SARS-CoV2 in areas in and around the cages of racoon dogs, being sold for slaughter – although no “Animal X” was identified. And critics also have said the sample size is too small to be conclusive. 

Lab biosafety advocates express satisfaction with report’s findings

On the other side of the fence, Richard H Ebright, a scientist at Rutgers University an advocate of further research on the potential biosafety failures, welcomed the new WHO report’s balance, telling Health Policy Watch: 

“The SAGO report concludes that, based on available data, it is not possible to determine whether SARS-CoV-2 entered humans through natural spillover or through research-related spillover.

“This conclusion will be anathema to those who have falsely claimed over the last two years that science shows SARS-CoV-2 entered humans through natural spillover.”

Ebright also welcomed the report’s call for “strengthening of regulation of biosafety, biosecurity, and biorisk management for pathogens research, with special attention to regulation of gain-of-function research” as part of a broader Global Framework to prevent future pathogen risks from emerging.  

“The recommendations on strengthening of regulation in the SAGO report  closely track those of a second WHO report that was released just over a week ago, that has gotten no news coverage,” he added. 

Missing gene sequence data and phylogenetic studies also under debate 

Partisans of further research into a possible biosafety failure also have pointed to SARS-CoV2 gene sequence data “deleted” by Chinese researchers early on in the pandemic from a US National Institutes of Health database as evidence of a possible cover-up.  

And recent phylogenetic studies of the virus’ family tree don’t necessarily correlate with a narrative of an initial natural spillover from animals to humans in Wuhan’s markets either, the critics say – although that claim is hotly disputed by Worobey.   

Said Jesse Bloom, a virologist with the Seattle-based Fred Hutch Research Institute: 

“I still think, (1) early COVID-19 case & sequence data that have been released by the Chinese government are likely incomplete; 

(2) for this reason, the origin of human #SARSCoV2 in Wuhan remains unclear.” 

Framework for Way Forward 

In light of the barriers faced in obtaining more original data from Chinese government sources relevant to either the lab leak or natural spillover narratives, the most constructive role that the SAGO group may have to play going forward could be in  the synthesis of  work by virus hunting scientists around the world.

The report also strikes a forward-looking note, etching out a broad “Global Framework” for how scientists should take forward research into practices and policies along the whole chain of l risks, from food safety to lab security – all critical in preventing future pandemics. 

That new framework should include:   

  • Studies of zoonotic  risks in animal groups and marketplaces;
  • Reviews of existing legislation and governance mechanisms related to lab biosafety;
  • Studies of epidemiological samples of human patients, including blood and viral samples. 

Concluded Bloom: “Continuing to openly study the possible origins of the virus is crucial both for the sake of science itself, and to design strategies to mitigate the future risks of both zoonotic and lab-based outbreaks.”   

Image Credits: dietertimmerman, abhijeet jagtap/Flickr, Arend Kuester/Flickr.

african lab
Pros Quarraisha Abdool Karim explains how to use an applicator

Africa has the scientific and intellectual capital to develop new interventions to tackle global health challenges. Particularly when local problems emerge, surely local research is the best path towards a solution. But pursuing this path requires funding that will support and promote the growth and expertise of Africa’s scientists. 

Africa is plagued by many epidemics — from tuberculosis and HIV/AIDS to malaria and wild polio — but the continent has also worked for decades to fight these threats. The key to beating these deadly diseases is turning inward to existing expertise and finding locally driven solutions.

The recent COVID-19 pandemic has placed public health back in the global spotlight and has also served as a reminder that science is not undertaken in an ivory tower. Science shapes humanity because it takes place among us. COVID-19 has also showcased that no epidemic takes place in isolation. Through collaboration, we can build on the foundations of our knowledge to bring forward innovative ways to address health challenges that benefit all of humanity.

This is not a new idea. In fact, it is something that we became all too familiar with during the AIDS pandemic.

From despair, pain and loss to transformational research

Despair, pain, and loss were rampant during the 1980s and early 1990s, at the beginning of South Africa’s HIV epidemic. Every weekend, white funeral tents in rural KwaZulu-Natal seemed to mushroom up and multiply, signifying the growing toll the virus was taking on the country.

Witnessing this helped catalyse me to undertake one of the earliest population-based studies that looked closely at this emerging health issue in South Africa. HIV prevalence was low at the time, with less than 1% of the population having been infected.

But lurking within the data was a shocking revelation: young women (15-24 years old) were six times more likely to be infected compared to their male counterparts.

We knew something had to be done. That meant understanding what had led to this striking disparity in risk. So, we began speaking to women from all parts of society to try and get a better sense of what they were experiencing. 

Power dynamics of relationships disrupting disease prevention

Here’s what we learned: power dynamics of relationships and sex were disrupting disease prevention. Women didn’t have the ability to protect themselves because of the limited options available to them — options like condoms, that placed the responsibility of reducing risk in the hands of men.

 Meanwhile, cases continued to surge in South Africa at an alarming rate, doubling annually in the general population.

Existing methods to prevent HIV infection weren’t going to cut it. Approaches designed in the global North were never going to be able to fully account for the needs of women in Africa. That’s why new solutions had to be brought forward instead.

Tenofovir: pathfinding protection from infection 

One way that we sought to empower women was through a gel that contained Tenofovir, an antiretroviral (ARV) medication. This innovative approach, shown in the CAPRISA 004 trial, enabled HIV-negative women to protect themselves from the virus. CAPRISA’s research on PrEP was recently recognised by the  VinFuture Prize as a lifesaving innovation from the global South. 

Today, Tenofovir is taken daily as a pill for HIV prevention, a solution also known as pre-exposure prophylaxis (PrEP). It has been adopted by the World Health Organization (WHO) as a key prevention option for both women and men.

And it hasn’t stopped there — a range of new anti-retroviral drugs and long-acting formulations, delivered as injections and implants, are currently being evaluated to expand prevention choices.

AIDS is no longer a fatal condition, instead it is chronic yet manageable. But we still see too many deaths and new HIV infections, particularly in marginalized populations. Two-thirds of all people living with HIV/AIDS are in sub–Saharan Africa and the region accounts for 60% of all new infections.

Saving the gains made in HIV 

As we turn our focus towards other pandemics, such as COVID-19, we cannot afford to lose the gains made in HIV. It is a trap we fell into before — when early HIV work overshadowed TB efforts — and it is not one we can afford to be caught in again.

Even now, COVID-19 continues to draw on lessons from the decades of work that have been poured into our HIV/AIDS response. This includes leveraging existing testing tools to detect COVID, utilising clinical trial infrastructure to expedite vaccine development, calling on community engagement processes to educate the public, and relying on scientific expertise to guide governments in their response.

The AIDS pandemic has taught us that scientists, policy-makers, and civil societies cannot work in a vacuum. There must be a unity of purpose that galvanises the steadfast support of global leaders in governments and funding agencies across the world.

Africa has the scientific leadership and intellectual capital to develop new technologies and interventions. This is something we have shown time and time again. If there is a problem, then local research is surely the best path toward finding a solution.

Pursuing this path of innovation requires funding that will support and promote the growth and expertise of Africa’s scientists. Our inter-dependency and shared vulnerability underscores the importance of collaboration and resource-sharing both globally and regionally that must be used for the benefit of humanity. There is no time for complacency. We must ensure that solutions are tailored by local research to best benefit those in need.

Quarraisha Abdool Karim

Professor Quarraisha Abdool Karim is an infectious diseases epidemiologist and Associate Scientific Director of the Centre for the AIDS Programme of Research in South Africa (CAPRISA). A researcher of HIV/AIDS, she  played a key role in the development of pre-exposure prophylaxis (PrEP), a daily pill to prevent HIV. Professor Abdool Karim was a 2021 Laureate of the VinFuture Prize, in the ‘Innovators from developing countries’ category.

Image Credits: CAPRISA.

Dr Ahmed Ogwell Ouma, Acting Director of the Africa Centres for Disease Control.

Eritrea has yet to start vaccinating its citizens against COVID-19, whereas two African countries – South Africa and Tunisia – are now offering citizens over 50 a second COVID-19 booster vaccine.

However, but the vaccination rate on the continent is far behind the global vaccination target of 70%.

Dr Ahmed Ogwell Ouma, Acting Director of the Africa Centres for Disease Control, told a media briefing on Thursday that only 17.3% of Africans had been vaccinated against the virus, describing it as “very far from our target of 70% that we set last year”. 

Ten of the 54 member states have vaccinated over 35% of their citizens, with the small island states of the Seychelles (80.6%) and Mauritius (76.5%) leading.

They are followed by Rwanda (62.6%), Morocco (61.7%), Botswana (61.3%), Cabo Verde (54.6%), Tunisia (52.7%), Mozambique (43.1%) Sao Tome and Principe (40%) and Lesotho (37.6%). 

Some 37 of the 54 countries in Africa are offering boosters.

Boosters encouraged

“We are encouraging our member states to offer booster doses to citizens who have already received their full vaccination coverage, so as to ensure that their immunity remains high and to avoid situations of serious illness amongst those who have been vaccinated,” said Ouma.

Some 818 million COVID-19 vaccine doses had been procured by the 54 member states and about 70% of this (579 million) had been administered.

In the past month, there has been a 90% surge of cases in east Africa, 36% increase in the Northern region, 35% increase in the Western region and a 12% increase in the Central region. However, there has been a 19% decrease in the Southern region 

 Ethiopia reported a 109% average increase in the number of cases, while Kenya saw a 70% average increase. In the Democratic Republic of Congo (DRC), cases increased by 51% and Nigeria saw a 41% increase. However, cases Egypt 60% average decrease South Africa 23% average decrease 

“This month marks a historic milestone in Africa, the sequencing and sharing of the 100,000th SARS-CoV-2 genome,” Ouma noted, describing this as an example of an advance in science on the continent.

Shortage of monkeypox vaccine

Monkeypox is endemic in 10 African countries and seven of these and one non-endemic country have reported a total of 1,495 monkeypox cases since the beginning of this year. There have been 66 people deaths, a case fatality rate of 4.4%

The vast majority of cases have been recorded in the DRC, with 1284 cases and 58 deaths. Nigeria follows with 66 cases with one death.

 

Cameroon has reported 25 cases and two deaths, the Central African Republic has 17 cases and two deaths, Congo Brazzaville has five cases and three deaths. Liberia (seven cases), Sierra Leone (two cases) and Ghana (one case) have not had any deaths.

“Only one non-endemic country in Africa is reporting a case and that is Morocco, which has reported one case, which seems to have a travel history to France during the preceding days,” said Ouma.

“Africa CDC has already activated a team within our Emergency Operations Centre, that is following very closely and monitoring the situation on the continent and also globally,” said Ouma. “We have also initiated a One Health approach to this particular intervention by bringing on board all our assets beyond human health in animal health and the environment to be able to get an accurate picture across the continent.”

Ouma said that while the smallpox vaccine was effective against monkeypox, Africa had not yet started vaccinations because of a shortage of vaccines.

“We are not yet actively vaccinating on the continent due to a lack of vaccine but we recommend the ring vaccination, where we treat those who have been diagnosed and vaccinate the people who are around them,” said Ouma. “In this way, we can be able to interrupt transmission of this virus as quickly as possible and reduce the risks for serious illnesses.”

He added that there are “very small stocks of vaccine stockpiles across the world”, and the World Health Organization (WHO) only had a small amount of about 2.4 million doses.

“In Africa, we do not yet have any stockpile and we are working with countries to see if there will be need to go beyond isolation and interruption of transmission using non-pharmaceutical methods,” he added.

 

mariupol
Woman boiling water in Mariupol

Fears of cholera have emerged in the ruined and Russian-occupied Ukrainian port city of Mariupol. 

Exiled local officials have voiced concern over the drinking supply in the city, which has been contaminated as a result of decomposing bodies and garbage. 

“The city has really turned into one with corpses everywhere,” said mayoral aide Petro Andryushchenko on national television. “They are piled. The occupiers cannot cope with burying them even in mass graves. There is not enough capacity even for this.”

Andryushchenko said that Russian occupiers of Mariupol are considering quarantining the city in response to the potential outbreaks. 

“You can enter the city with a residence permit in Mariupol. But this is a one-way ticket, because you cannot leave,” he said. 

“Of all the possible scenarios to fight the epidemic, in our opinion, Russia has chosen, as always, the most cynical one — just to close the people in the city and leave everything as it is: Whoever survives, survives.”

In order to access clean water, Mariupol residents must queue for hours, Andryushchenko said on Telegram, with water available every two days at most. Mariupol mayor Vadym Boychenko has also said last month that due to problems with the water supply, the city may face an infectious catastrophe, and more than 10,000 people may die at the end of the year. 

Citizens lining up for water in Russian-occupied Mariupol.

National authorities monitoring potential outbreaks 

Ukrainian national authorities have begun monitoring potential cholera outbreaks across the country 1 June, with Ihor Kuzin, Ukraine’s chief sanitary doctor, calling Mariupol’s situation especially dire. 

“We can’t be 100% sure that there will be disease outbreaks,” he said. “But all prerequisites for them are already there.”

In response to growing concern of cholera, WHO Ukraine has “positioned cholera treatment and vaccination supplies in the area,” said WHO spokeswoman Margaret Harris in a WHO Ukraine press release Wednesday. 

No official reports of cholera to WHO – yet

Ibrahima Socé Fall, WHO Assistant Director-General for Emergencies Response

While the World Health Organization (WHO) has not been able to verify any report of cholera in the southeastern Ukrainian city, following public health risk analysis and needs assessment, officials have said that given the conditions of the city, it is to be expected. 

“Since the beginning of the attack in Ukraine, we have been highlighting the risk of infectious disease, including cholera, measles, typhoid fever, and other waterborne diseases because of the living conditions,” said Ibrahima Socé Fall, WHO Assistant Director-General for Emergencies Response, a press briefing Wednesday. 

“We haven’t received any report of cholera so far, but that is something we expect.” 

Last month, WHO said that it was sending cholera medicine to the central Ukrainian city of Dnipro, to prepare for possible outbreaks. WHO officials highlighted the dangerous conditions of Mariupol. 

“There are swamps, actually, in the streets and the sewage water and drinking water are getting mixed,” said Dorit Nitzan, a regional emergency director at WHO. “This is a huge hazard. It’s a hazard for many infections, including cholera.”

Deteriorating water, sanitation, and hygiene infrastructure have heightened risk of cholera, said a report conducted by the WHO’s Health Cluster Ukraine agency in April. The warmer weather of spring and summer can also increase the risk of transmission. 

“The weather is hot. There are still dead bodies on the streets of the city — especially under the debris of residential buildings. In some blocks, it is impossible to walk by — due to the stench of rotten human flesh. There was no rain for a while, and it is getting hotter,” a resident of Mariupol, who did not want to be named for security concerns, told ABC News.

Image Credits: OCHA Ukraine/Twitter, Lesia Vasylenko/Twitter.

WHO Briefing, 8 June

Confirmed cases of monkeypox reported to WHO outside of Africa’s endemic zone have doubled once again since last week, 1 June – with more than 1000 cases now having been reported in some 29 countries that don’t usually see the disease. 

So far, no deaths have been reported in those countries. But some 66 deaths have been recorded among the 1400 cases reported in central and western Africa since the beginning of the year, said WHO Director-General Tedros Adhanom Ghebreyesus, speaking at a press briefing on Wednesday. 

WHO Director-General Tedros Adhanom Ghebreyesus

While WHO is “clearly concerned” about the spread of the disease outside of Africa, Tedros also contrasted the sudden interest in the cases seen abroad with the neglect of the disease in the dozen or so central and western African countries where monkeypox is endemic. 

“This virus has been circulating and killing in Africa for decades. It’s an unfortunate reflection of the world we live in, that the international community is only now paying attention to monkeypox because it has appeared in high-income countries,” said Tedros. 

“The communities that live with the threat of this virus everyday deserve the same concern, the same care and the same access to tools to protect themselves.” 

Still unclear if asymptomatic people can transmit the infection 

monkeypox lead
Rosamund Lewis, WHO lead on monkeypox

There remains, however, a “window of opportunity to prevent the spread of monkeypox in those who are at highest risk right now,” said WHO’s monkeypox technical lead Rosamund Lewis at the briefing. 

She noted that most of the cases occurring outside of Africa so far have been among men who have sex with men.

“It is possible to control the further onward spread of this outbreak at this time with standard public health control measures, and this includes contact tracing, surveillance, clinical care, and that folks should remain isolated for as long as they are infectious,” she said.  

However, she also admitted that cases among women are appearing. And there are still many unknowns regarding transmissibility, including potential for asymptomatic transmission of the infection as well as the extent of aerosol (airborne) viral transmission. 

Gathering data on available vaccines and efficacy

The smallpox vaccine protects against monkeypox.

WHO is currently assessing the types and quantities of vaccines available globally, as well as the extent to which vaccine manufacturers have capacity to step up their production and deployment  – with the aim of developing an equitable distribution plan for available vaccines.  

Available vaccines include strategic stockpiles of smallpox vaccines, new vaccines targeted against monkeypox, and even vaccines against chickenpox, the experts said. 

But WHO is not recommending that countries launch campaigns for mass vaccination, Lewis and other experts stressed. Rather, targeted vaccination of the close contacts of infected people, health workers and other caregivers should be the priority for the limited quantities of vaccines that exist today. 

Sylvie Briand, WHO Director of Epidemic and Pandemic Preparedness and Prevention

“We have a limited number of cases but they are spread across different geographies. It’s not sending millions of vaccines to one place, but rather a few hundreds of vaccines to many different places in the world,” said Sylvie Briand, WHO Director of Epidemic and Pandemic Preparedness and Prevention.  

Primary driver remains skin to skin contact, other modes of transmission unclear 

A man shows the rashes on his hands caused by monkeypox.

Meanwhile, the primary driver of monkeypox transmission in non-endemic countries appears to be skin-to-skin physical contact, although other modes of transmission are possible too, Lewis said. 

“Anyone who has the virus in the mouth can also spread that through close face to face contact,” she observed.

But she added, “There’s a lot we still don’t know and more research needs to be done in this area.  Being mindful, being aware, and being knowledgeable is really important for preventing onward transmission.”  

Debates over monkeypox travel precautions erupt in the United States 

While the United States Centers for Disease Control issued and then rescinded recommendations for travelers to employ “enhanced precautions” as a result of the outbreak, WHO has not recommended any measures for the general public. 

WHO is, however, recommending that family members and health workers looking after or receiving patients with monkeypox or an undiagnosed rash, should wear a mask because of the risks of  transmission through virus-laden droplets released in close proximity. 

“The same applies for persons if they have had lesions in the mouth or on the face that they are able to transmit,” Lewis said, adding that they, too, should wear a mask.  

There have also been reports of the virus being transmitted to health workers or caregivers via fomites on surfaces such as contaminated bedding or laundry, she said. 

Regarding the knowns and unknowns of transmission, Lewis concluded: “It’s sometimes useful to think about what precautions can be taken in order to avert any risk of onward spread, and this must be nuanced with what we already know.” 

WHO will soon be releasing guidance to address how to prevent spread in these groups and settings, including sexual health clinics, emergency rooms, and dermatology clinics, she said. 

More vaccines may be needed if virus spreads 

Vaccines for smallpox can be used for monkeypox with a high level of efficacy, as both diseases are in the same family of viruses. 

Though there are enough vaccines to cover ‘current needs’, WHO anticipates needing more vaccines in the event monkeypox were to spread.

“What is really important for us is making sure we prevent further amplification of cases, reducing close contacts so that there is no further spread to communities,” said Briand.

Additionally, given the different types of vaccines available, there is currently not a ‘one size fits all’ approach to vaccination.

“There’s a lot that is not known about how to best use vaccines,” said Kate O’Brien, WHO Director of Immunization.

Post-exposure prophylaxis (PEP) vaccination  is recommended for contacts of cases with an appropriate second- or third-generation smallpox or monkeypox vaccine, ideally within four days (and up to 14 days) of first exposure to prevent onset of disease.

“Countries are deciding how they will use vaccines, and that data is collected in a way that can inform future vaccine use,” said O’Brien.  

Ecological factors driving virus spread in Africa 

Regarding the spread of monkeypox in Africa WHO also pointed to ecological factors, such as climate change, deforestation and reduced biodiversity.

“Clearly climate change is an important factor,” said Ibrahima Socé Fall, WHO Assistant Director-General for Emergencies Response. 

Deforestation increases the likelihood that zoonoses  – diseases present in animals – will make the leap to human populations. 

As forests are destroyed by loggers, poachers and miners, so are the predators of rodents, squirrels and other animals that may act as a natural reservoir for monkeypox infection.  Meanwhile, infected animals also relocate from the wild into human communities – where they are even more likely to transmit the infection to people.  

The loss of forests and related biodiversity has also played a factor in the emergence of other  recent diseases in Africa, including Ebola and Lassa fever, said Socé Fall. 

“[We need] to make sure that we can continue maintaining biodiversity, but also make sure that communities at the frontline have the knowledge and understanding to protect themselves and prevent the disease from expanding to other countries,” he said. 

See our related Health Policy Watch story here:  

https://healthpolicy-watch.news/monkeypox/

Image Credits: WHO.

Vacccination can effectively prevent mother-to-child transmission of hepatitis B – but few children in Africa receive the jab despite high prevalence

As the World Hepatitis Summit 2022 takes place this week, some 354 million people are still living with viral hepatitis, despite the fact that vaccines, treatments and even cures are now available, says Finn Jarle Rode is Executive Director at the Hepatitis Fund. 

Until now, viral hepatitis elimination has been the neglected child of global health. At a glance that may appear an odd statement to make given that both a vaccine and treatment for hepatitis B (HBV) exist.

And the 25 years that elapsed between the discovery of the HCV virus in 1989 and that of a cure for hepatitis C in 2014 represents one of the shortest periods of time for such a major R&D effort in infectious disease history. 

But these scientific breakthroughs are not enough. Today some 354 million people are still living with viral hepatitis, mainly in low and middle-income countries such as India, Bangladesh, China, and Pakistan. 

People wait to receive free hepatitis testing and treatment in Lahore, Pakistan, at a dedicated Hepatitis Prevention and Treatment Clinic.

Only 9% of people living with HBV and 20% of those living with HCV have been tested and diagnosed. Of those diagnosed with HBV infection, 8% are on treatment, while 7% of those diagnosed with HCV infection have started treatment. 

Globally 1.4 million people are dying from viral hepatitis each year. Before COVID-19, tuberculosis was the world´s biggest infectious disease killer, claiming 1.6 million lives each year. That means that hepatitis has been the world’s third deadliest infectious disease even during the pandemic.

Clearly, the World Health Organization’s (WHO) goal to eliminate viral hepatitis by 2030 is not going to be reached if the inertia being seen today remains.  

This, despite the potential benefits of doing so: Every dollar invested in HBV elimination returns up to $2.23. Every dollar invested in HCV returns up to $3.42. A $1.00 vaccine course can prevent one child from getting HBV, and $80.00 can cure someone from HCV.

Lack of political will & funding

Event at Davos on the margins of the World Economic Forum discussed the still formidable financial and political barriers to viral hepatitis elimination

The root cause of the problem is money followed by a lack of political commitment, issues covered in a 25 May panel at Davos held on the sidelines of the World Economic Forum on “Financing Viral Hepatitis Elimination”, including former New Zealand Prime Minister Helen Clark, among other speakers. Today no government clearly leads on the Sustainable Development Goal Target 3.3 of ending communicable diseases including hepatitis.

Advocacy and funding are not reaching the critical mass required to realistically end hepatitis. Polio eradication for instance, has been largely driven through the long-standing commitment of the Bill and Melinda Gates Foundation, working in unison with the WHO. We need a similar show of leadership from the philanthropic community to replicate that success with hepatitis.

The WHO estimates that only US$500 million is invested in hepatitis elimination per year. Malaria, with a comparable disease burden and lower mortality rates, receives $US3.3 billion per year.  The hepatitis response is an unfortunate example of the disconnect between science and policy-making – where tools to effectively end the epidemic are available but decision-makers lack the financial impetus to do so. 

African region sees highest HBV burden – but newborns aren’t vaccinated 

Vaccination can effectively prevent mother-to-child transmission of hepatitis B

In 2019, about 66% of the 1.5 million new HBV infections were concentrated in WHO’s Africa region. The majority of HBV transmission is driven by vertical transmission (from mother to baby). 

This is the most common and deadliest form of HBV transmission, as approximately 90% of children infected this way develop chronic HBV infection and up to a quarter of these infants also die prematurely from HBV-related causes. The younger a person is when they acquire HBV, the greater chance of chronic infection and premature death. 

Fortunately, an almost 100% effective vaccine exists to prevent HBV, delivered in a three or four-dose schedule. The first critical dose is known as a “birth dose” and must be delivered within 24 hours of birth (as recommended by WHO) to prevent 70-95% of transmission that occurs during or just after birth. Given the availability of this simple and effective intervention, no child should be born with this life-threatening, chronic disease.

But despite the high burden of HBV in the region, only 11 of 47 countries in Africa include hepatitis B birth dose (HepB BD) as part of the routine infant immunization schedule. Only six per cent of African newborns are receiving the birth dose vaccine today.

Linking up HIV and HBV services 

People waiting to receive free hepatitis C tests and vaccines on World Hepatitis Day, Rwanda. But campaigns are no replacement for integration into primary health care services

Hepatitis needs big donors to drive bilateral aid and national government buy-in. But this doesn’t have to lead to exorbitant costs. 

First of all, we need to ensure better integration of viral hepatitis treatment into existing global health programmes, and take a people-centred approach to prevention, diagnosis and treatment.  

It makes no epidemiological or economic sense, for instance, that an HIV positive pregnant woman in Kenya attending a health care centre be provided with Nevirapine to prevent her infant from contracting HIV, but not also be given access to Tenofovir prophylaxis preventing mother-to-child transmission of HBV in late pregnancy, along with an  opportunity to vaccinate her newborn against HBV.

Secondly, we need more of the public-private partnerships that have to date proven effective. Much more. And that includes external catalytic funding. We need the World Bank, the Asian Development Bank, The Islamic Bank, philanthropists, foundations.

Inroads are possible

This is not the stuff of fantasy. Inroads are possible, even in the most unlikely scenarios.  Take Egypt: it has long held the highest rate of HCV infection in the world. One person out of every 10  used to live with viral hepatitis. But in 2014 the country began implementing a strategy that has made  huge progress against the disease.

A first step was to get the buy-in of various government ministries, not just the health portfolio. The second was to make the decision to integrate hepatitis C screening with screening for non-communicable diseases (NCDs) in primary healthcare facilities. 

This approach reached some 60 million people, including nine million school children. At the same time, partnerships between civil society, the private sector and philanthropic organisations mobilised communities and drove high rates of screening, diagnosis and treatment.

Since the country’s programme began, the number of Egyptians living with hepatitis C has dropped from 4.346 million in 2014 to 516,000 in 2021.  Egypt´s remarkable response has shown that the goal of eliminating viral hepatitis is possible. With the right backing, it can be done everywhere.

Finn Jarle Rode is Executive Director at the Hepatitis Fund, a global non-profit organization that funds catalytic actions by partners, including support for the development of strategic plans at the national and sub-national level; country-specific data; and health system capacity-strengthening.

Image Credits: WHO, PKLI , WHO, WHO.

Protestors in New York City.

World Trade Organization (WTO) leaders are hopeful that an agreement could be reached on a waiver on intellectual property rights for COVID-19 vaccines at the Ministerial Council starting on Sunday – but the People’s Vaccine Alliance has organised global protests to demand “a real TRIPS waiver” ahead of the meeting.

WTO Director-General Ngozi Okonjo-Iweala has expressed “cautious optimism” that agreement on the IP waiver is possible at the council, according to WTO spokesperson Daniel Pruzin.

Speaking at a media briefing on Tuesday following a special meeting of the WTO General Council earlier in the day, Pruzin said that Ambassador Lansana Gberie, chair of the TRIPS Council, which is leading discussions on the waiver and the WTO’s response to the pandemic, was also optimistic.

According to Gberie, delegations “entered into real negotiation mode [on Monday] in an effort to try to iron out their differences, particularly with regards to the waiver discussions,” said Pruzin.

A small group meeting of the TRIPS Council on the waiver resumed negotiations on Tuesday evening.

Too little, too late?

On 3 May, Okonjo-Iweala put forward an “outcome document” on the waiver that had emerged from discussions with “the Quad” – the European Union, India, South Africa and the US.

According to the WTO, the Quad adopted a “problem-solving approach aimed at identifying practical ways of clarifying, streamlining and simplifying how governments can override patent rights, under certain conditions, to enable diversification of production of COVID-19 vaccines”.

However, there are still some sticking points on the proposal, even within the Quad, and the proposal has been widely condemned by health activists for being too little, too late. 

An IP waiver proposal for all COVID-related technology was first put on the table over 18 months ago by India and South Africa during the height of the pandemic when vaccines were in short supply. 

The current agreement is confined to COVID-19 vaccines, and it is being negotiated when there is a global glut of vaccines.

The People’s Vaccine Alliance is planning global protests during the week aimed at pressuring US and European countries to “end COVID monopolies” and “deliver a real TRIPS waiver”, the global network announced on Tuesday.

“The WTO is having its biggest meeting since the start of the pandemic. Feeling the pressure to do something on COVID, WTO leaders have introduced a bogus new proposal that not only fails to remove WTO barriers to COVID medicine accessibility, but actually introduces new obstacles,” according to the alliance.

Other big WTO agenda items

Other big items on the agenda of the WTO Ministerial Council are a reduction in fishing subsidies, agricultural trade reform and reform of the WTO itself, including more regular ministerial meetings.

Pruzin said the “significant progress” had been made on the fishing subsidies proposal, which has been negotiated for a number of years, and on  possible ministerial declaration on WTO’s response to the pandemic,

“There are still some very important differences which remain in the texts, and I think all the chairs recognise this, be it fisheries, be it agriculture, be in other areas as well,” said Pruzin.

“But I think it’s fair to say that the atmosphere is much better than it has been in some time. I think there’s some good momentum going into the final preparations.”

Image Credits: People's Vaccine Alliance.