The precipitous drop in COVID-19 testing across the world since January has made it harder to track the evolution of variants, and is also undermining the potential of new antiviral drugs that have to be taken early to be effective.

Testing was a major focus of Tuesday’s meeting of the Access to COVID Tools Accelerator (ACT-A) facilitation council and the World Health Organization (WHO) media briefing that followed, which celebrated the publication of the Accelerator’s two-year impact report.

The ACT-A was created to develop and equitably deliver vaccines, therapeutics and diagnostics to those that need them the most, and the global vaccine delivery platform, COVAX, is its most renowned component.

“As many countries reduce testing, WHO is receiving less and less information about transmission and sequencing. This makes us increasingly blind to patterns of transmission and evolution. But this virus won’t go away just because countries stop looking for it,” chided WHO Director-General Dr Tedros Adhanom Ghebreyesus at the media briefing.

Earlier, he had told the council meeting that “low-income countries are testing at an average of two tests per day per 100,000 population. This is over 100 times lower than the testing rate in high-income countries.”

“In the last four months in the midst of Omicron, as cities in East Asia go on lockdown and vaccination rates stall, testing rates have plummeted by 70 to 90% worldwide,” added Bill Rodriguez, CEO of the Foundation for Innovative New Diagnostics (FIND). 

Limited access to new antivirals

Last Friday, the WHO approved Pfizer’s Paxlovid antiviral – a combination of nirmatrelvir and ritonavir – for patients with mild or moderate COVID-19 at high risk of hospitalization. But Paxlovid needs to be taken within three to five days of infection to be effective – which means access to testing.

While COVID-19 therapeutics hold a lot of promise, “there are some caveats and considerations around these treatments, particularly given the need to align with testing strategies and given those very testing strategies and rates are so low”, Loyce Pace, US Health and Human Affairs Assistant Secretary for Global Affairs, told the council.

MPP licensees for COVID treatments, April 2022

The Medicine Patent Pool’s (MPP) Charles Gore told the council meeting that generic versions of Paxlovid were only likely by the end of the year.

He added that the MPP, which has an agreement with Pfizer to license generic producers to make Paxlovid for 95 low and middle-income countries, “cannot give a licence unless somebody applies for one” and when a company did apply “they’ve got to be able to meet our quality standards”. 

The MPP had offered two licences to companies in Africa, “but they for various reasons declined to sign the licences”, he added

“There is a clear gap here in terms of promoting and supporting companies to be able to get to a standard where they can apply for licences, so that we have the most geographically dispersed manufacturing base that we can have in order to ensure this sort of supply security that we’ve been talking about so much in vaccines,” added Gore.

ACT-A achievements

Seth Berkley

Despite the ongoing issues, various speakers lauded the ACT-A’s achievements.

COVAX has delivered over 1.4 billion to date across 145 countries worldwide, with Seth Berkley, CEO of Gavi, The Vaccine Alliance, calling it the “largest and most complex global vaccine rollout in history.” 

It has also enabled 40 countries to begin their COVID-19 vaccination campaigns, helped build the sequencing capacity in Southern Africa that first detected the Omicron variant, and negotiated unprecedented deals with the world’s largest oxygen suppliers to increase access in more than 120 low- and middle-income countries. 

But in spite of these accomplishments, Berkley noted: “We still have plenty to do.” 

While 44% of people in lower-income countries have now been vaccinated with at least two doses of a COVID-19 vaccine and global coverage is 59%, the global vaccine equity gap is still too wide, said Berkley. 

There are some 18 countries that have only protected 10% or less of their populations.

A  key criticism of the ACT-A in the first year of its operation was that it took COVAX too long to buy the mRNA vaccines  because it lacked the cash to compete with rich countries’ pre-market commitments to Pfizer, Moderna and Johnson & Johnson. 

“The good news is that today we have access to as much supply as countries need to meet their national targets,” said Berkley. “That means that countries in turn can plan large scale rollouts with confidence that the doses they have requested. will arrive on time, including usually with our product of choice. 

“But we cannot ignore the fact that many country’s health systems lack the capacity to simply switch on massive vaccination programmes alongside the other vital routine immunization services,” he added.

To address this Gavi has already made $600 million available for COVID delivery support to lower-income countries.

First steps towards a pandemic contingency fund 

Loyce Pace

Berkeley also said that Gavi is creating a “pandemic vaccine pool” that could respond more quickly in the future. 

A Gavi/ ACT-A pledging event on 8 April that raised $4.8 billion earlier this month, was the first step towards that ambition, said Berkley. 

“Our donors stepped up and helped us launch a contingent financing facility that will help us ensure that when the need arises, and COVAX can step up and order new doses immediately,” he added.

While COVAX may not be fully funded, “this is still in stark contrast to 2020, when we first had to raise cash before we could place any orders, and it’s a sign of how far we have come as a multilateral solution, not just in helping address the challenges of this pandemic, but leaving us better prepared for the next one.” Berkeley said.     

To rally the global community to support the flagging vaccination drive, a global COVID-19 summit co-hosted by the governments of Belize, Germany, Indonesia, Senegal and the US will be held on 12 May.

“We are inviting ambitious policy or financial commitments for that particular engagement. It’s going to be very important for all of us to come up with a new set of commitments that will help continue to drive this change and ensure that we are closing the gap and reaching those most in need or and most often left behind,” said Pace.

We’re particularly focused on locally-led solutions and opportunities.”

Image Credits: UCT.

A premature baby in the neonatal unit in Nelson Mandela Children Hospital in Johannesburg, South Africa.

More newborn babies with sepsis are dying because their infections are not responding to the usual antibiotics, according to the biggest global study on the subject yet.

The study’s sponsor, the Global Antibiotic Research and Development Partnership (GARDP), is now designing an interventional trial to identify better treatment regimens. to combat rising resistance.

GARDP’s study, which involved over 3200 newborns diagnosed with sepsis in 11 countries, was released at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) on Tuesday.

It found that many physicians were forced to use last-line antibiotics such as carbapenems due to the high degree of antibiotic resistance in their treatment units. 

Last-line antibiotics were prescribed to 15% of babies enrolled in the study. Overall, 11% of the newborns died over the course of the study – but there was huge variation between countries and hospitals.

In 2019, nearly 1.3 million deaths – including nearly 140,000 deaths of newborns – were caused by bacterial antimicrobial resistance (AMR).   

Major threat to newborns

“Our study has shown that antibiotic resistance is now one of the major threats to newborn health globally,” said Mike Sharland from St George’s, University of London and the principal investigator. 

“There are virtually no studies underway on developing novel antibiotic treatments for babies with sepsis caused by multidrug-resistant infections. This is a major problem for babies in all countries, both rich and poor. 

The World Health Organization (WHO) recommends the standard antibiotics – ampicillin plus gentamicin – for the treatment of neonatal sepsis, but the study showed that many hospitals are using other combinations due to high levels of resistance to the WHO-recommended treatment.   

But the use of antibiotics varied noticeably across sites in Bangladesh, Brazil, China, Greece, India, Italy, Kenya, South Africa, Thailand, Vietnam and Uganda, “with many different antibiotic combinations being used, often without any underlying data”, according to GARDP.  

Okwenathi Sibango, born prematurely at six and a half months, was one of the babies enrolled in the study. After fighting off an intestinal infection, the tiny boy, who weighed less than a kilogramme, picked up a life-threatening antibiotic-resistant infection in the hospital. He also developed meningitis and his doctors had to treat him with antibiotics of last resort.

“Over the past decade we have a seen a year-by-year increase in antibiotic resistance,” says Dr Angela Dramowski, Clinical Head of General Paediatrics at the Cape Town hospital that treated Sibango.

“We urgently need new antibiotic options. We are also hopeful that the study by GARDP and partners will go far in working out the best treatment options for babies, with the right dose and the least possible toxicity. This will help us in treating babies like Okwenathi.” 

Testing new antibiotic combinations

The GARDP trial will test the safety and effectiveness of three potential new antibiotic combination treatments, ranking them against existing commonly used antibiotic regimens for neonatal sepsis. It will also look into the comparative efficacy of other approved but less common antibiotics and describe local patterns of antibiotic resistance.

It starts in Kenya and South Africa later this year and will expand to up to eight other countries next year.   

“There is an urgent need to develop and ensure access to novel antibiotic treatments to keep pace with rising rates of drug-resistant infections among babies with neonatal sepsis,” said GARDP Executive Director Manica Balasegaram.

 “We are incredibly grateful to our numerous partners and funders who have given us essential support to make this observational study possible. Guided by these new insights, we have the opportunity to place children at the centre of the international response to antibiotic resistance.”  

Image Credits: 20 May 2021South AfricaKL Schermbrucker/GARDP.

On the occasion of World Immunization Week, influential global health figures share lessons learned in the global fight against two age-old diseases, malaria and polio – and more recently, COVID-19 – and how we should tackle existing and future pandemics.  

A child in Malawi gets drops to prevent polio.

While COVID-19 surprised and shocked the world, it should not have. For decades, infectious disease experts have asserted that it was a matter of when and not if the next pandemic was going to strike.

Global health security has unprecedented urgency. While pandemic preparedness remains atop our list of public health priorities, we cannot afford to lose sight of existing diseases that remain active threats and continue to put millions at risk.

Polio and malaria are two such diseases that are strikingly similar; efforts to eradicate and contain these diseases span decades. While we have seen remarkable progress – with global malaria deaths substantially reduced and elimination achieved in 40 countries and territories, and endemic wild polio eradicated in all but two countries – significant gaps remain.

The global response to COVID-19 has highlighted the tremendous power of both innovation and political will. We have witnessed first-hand the ability to pool resources across geographies and sectors to tackle challenges when a disease is truly a global priority; the result has been diagnostics, drugs, and vaccines at lightning speed.

Yet simultaneously, as a recent review of lessons from polio and malaria highlighted, health delivery programs continue to be challenged in many countries – especially those where malaria and polio continue to be endemic – by the same health system weaknesses that make tackling diseases effectively challenging.

Three key lessons are clear:

1. Building equitable health systems to reach even most at-risk

Both polio and malaria are diseases of the most marginalized populations. Unfortunately, they endure in these pockets; the last cases are the most challenging and the hardest to reach. But real health equity means embracing these challenges head-on.

Whether it is through surveillance, outbreak management, supply chain, or the use of data to plan, implement, and evaluate, both polio and malaria present opportunities to strengthen systems in key health pillars that can also be leveraged against other communicable diseases threats, be they current or future ones.

For example, malaria case management begins with the recognition of acute febrile illness (AFI) in patients presenting at health facilities or to community health workers. Appropriate triaging of AFI can help identify new emerging pathogens, and thus simultaneously improve patient outcomes and strengthen surveillance systems.

Likewise, the global service organization Rotary International, the catalyst behind the global polio eradication effort, is at the forefront of utilising polio-established infrastructures to help address broader public health efforts.

Reaching the end game is not viable without targeting the places that are hardest to reach and building equitable health systems in those places. From tribal communities in India and Pakistan, to last-mile communities in Papua New Guinea, there is nothing more equitable than the elimination and eradication of a disease.

In the case of polio, it not only protects those who are vaccinated but crucially also those who are not – the most marginalised who are persistently missed with health interventions. We will see continued transmission and/or face subsequent challenges such as the resurgence of both diseases if we leave the marginalised behind.

Confirmation in February of a child paralysed by wild poliovirus in Malawi linked to a virus originating in Pakistan, for instance, underscores this risk. The current refugee movements associated with the Ukraine tragedy in addition to the ongoing humanitarian crises in Myanmar and Afghanistan further raise this spectre.

2. Innovating by listening to communities

Whether it is delivering polio vaccines, insecticide-treated bed nets or antimalarials, tailored approaches are critical along with the readiness to adapt. While new tools are welcome additions to our defence strategies, at the end of the day we need to ensure that service delivery aligns with what works for communities.

We need socio-behavioural informed public health interventions adapted to local systems.  Health interventions must be delivered in a culturally appropriate manner, addressing the core needs of individual communities. This can only be achieved through innovation in delivery approaches and forging the right partnerships to create new delivery models and measure their impact. At the same time, research efforts continue to develop more effective, safer, easier-to-use and more affordable health solutions, to address communities’ needs in the most cost-and-humanitarian effective manner.

From training youth volunteers to become health champions in their own remote and tribal communities, to mobile clinics (“Haat Bazaar Clinic”) offering routine health check-up services including tests for malaria in tribal areas in Chhattisgarh, India, to community health workers delivering house-to-house malaria services in Cambodia and Lao PDR – approaches like these have not only accelerated service delivery but have played a critical role in mobilising communities, particularly women and children. In fact, social mobilisation and India’s Social Mobilisation Network (SMNet) are often cited as instrumental to immunisation efforts for polio in hard-to-reach communities with poor immunization services, conflict, and dense populations.

3. Fostering greater political will

Malaria and polio are two diseases that have already been eliminated from many parts of the world –Asia Pacific, in particular, has made significant progress, having achieved the global goal of reducing malaria cases and deaths by 40% by 2020. They are both preventable diseases.

As much as we need innovation to accelerate our fight, especially among last-mile communities, we have the tools and the technology and, in many cases, the adequate resources to achieve success. What is needed is political will and leadership – the same forces we saw at work as the COVID-19 pandemic emerged – by both countries still affected by the diseases and donor governments, to fully implement and resource these proven strategies.

Urgency, priority and accountability are key, as evidenced over the last two years by governments and local authorities taking ownership of evolving epidemiology, and rapidly adapting operations to the new reality to ensure a maximum number of communities can be reached with life-saving health interventions.

The Global Fund to Fight AIDS, Tuberculosis and Malaria’s Seventh Replenishment later this year is a forthcoming opportunity to demonstrate this collective will. Commitment will back an ambitious $18 billion plan, of which a third will be dedicated to reinforcing systems for health and pandemic preparedness, in addition to financing over half of all malaria programs that also help to accelerate the pathway to ending the disease. Similarly, on Tuesday the GPEI is publishing a comprehensive ‘investment case’, which will outline the humanitarian and economic benefits of investing in the achievement of a polio-free world.

The need for equitable health systems, innovative community-tailored approaches and greater political will to tackle both existing threats and future pandemics could not be clearer. As we rightly double down on efforts to prepare for the next pandemic, we need to also ensure all necessary resources are mobilized to overcome age-old diseases that are still with us today. Let us commit both in word and in deed to tackling malaria and polio once and for all.

Dr Sarthak Das is Chief Executive Officer of the Asia Pacific Leaders Malaria Alliance (APLMA).

Aidan O’Leary is Director of the Global Polio Eradication Initiative (GPEI) at the  World Health Organization.

Shekhar Mehta is President of Rotary International

 

Image Credits: UNICEF Malawi.

UNICEF’s Global Supply and Logistics Hub in Copenhagen

CAPE TOWN – As the health sector celebrates World Immunisation Week, one of the most pressing related problems is Africa’s almost total dependence on imported vaccines –  something that predates, but was highlighted by, the COVID-19 pandemic.  

But addressing this dependence will mean dismantling the ‘charity’ model that has underpinned many of Africa’s immunisation programmes over the past two decades at least – since the creation of Gavi, the Vaccine Alliance.

The terrible price of Africa’s vaccine dependence was brutally highlighted a year ago at the height of the Delta period of the COVID-19 pandemic. India banned the export of vaccines produced by its generic companies. Western countries bought up the limited international global supply of vaccines. And there were no vaccines left for Africa, which had been relying on COVAX for supplies.

It was a bitter replay of the HIV pandemic when antiretroviral drugs were not affordable or available on this continent. 

Key African leaders resolved that there was only one feasible way forward to break this dependence: to build continental vaccine production capacity.

John Nkengasong, director of the Africa Centre for Disease Control, then-Africa Union chairperson and South African President Cyril Ramaphosa, and Strive Masiyiwa, appointed as the African Union Special Envoy on COVID-19, have led the quest to change the balance of manufacturing power and prowess.

Under pressure to address this inequity, wealthy nations, the global health sector, and the pharmaceutical industry have responded with an array of African-based endeavours.

The most committed initiative to addressing structural inequity is the mRNA vaccine production hub in South Africa initiated by the World Health Organization, which produced a copy of the Moderna-based COVID-19 mRNA vaccine in a few months flat, and is now preparing the product for trials.

Another promising initiative includes generic producer Aspen, which was recently licensed to package, distribute and sell the Johnson & Johnson COVID-19 vaccine under its own name in Africa. 

There also are fill-and-finish operations in South Africa, Egypt, Senegal, Morocco, and Algeria for a range of vaccines from Pfizer’s mRNA COVID vaccine to the Russian Sputnik.

About 40 of Africa’s 54 countries depend on partially or wholly subsidised childhood vaccines from Gavi through UNICEF. 

The donor as ‘competitor’

But the elephant in the room is how these newer – and initially more expensive – innovations will be able to ‘compete’ with donated or subsidised vaccines from Gavi-UNICEF and more recently the COVAX platform, in the case of  COVID-19 vaccines, without derailing entire countries’ immunisation programmes

UNICEF’s Supply Division based in Copenhagen is the world’s biggest buyer and supplier of vaccines for developing countries and it procures the majority of Gavi-funded vaccines.

Patrick Tippoo, Biovac

Back in February, Patrick Tippoo took this elephant by the trunk in a webinar organised by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA).

Tippoo has over 30 years’ experience in the vaccine manufacturing arena, and is a founding member of the African Vaccine Manufacturing Initiative (AVMI).  He also is an executive at Biovac, the South African company playing a key role in the mRNA vaccine hub alongside Afrigen.

“Critically important is the whole issue of sustainability of that which is being built and is being invested in going forward,” said Tippoo. “Without a significant change in the market dynamics on the African continent there’s very little likelihood of successful sustainability of all our efforts behind this initiative.”

Tippoo explained that about 40 of Africa’s 54 countries are “wholly or partly dependent on partially or wholly subsidised vaccines from Gavi through UNICEF. Much of the vaccine supply into Africa comes in a subsidised form, partially or completely by GAVI through UNICEF.” 

And that market is not just COVID-19 vaccines but billions of dollars of vaccines for childhood diseases ranging from measles and mumps to polio.

Traditionally, Gavi and UNICEF have focused on buying the cheapest medicines rather than addressing supply chain diversity or equity, insiders have told Health Policy Watch.

More recently, however, Gavi has given the Developing Countries Vaccine Manufacturing Network (DCVMN), an alliance of 44 companies from 16 developing countries, a seat on its board. It also says that “by 2017, nearly two-thirds of our vaccine suppliers were based in Africa, Asia or Latin America”, although this statement obscures the fact that precious few African companies are part of the mix.

The procurement patterns of the big donor-driven agencies have also tended to foster market dominance by a few, larger firms – whether based in India, China or western nations – at the expense of smaller, start-up (and often African) manufacturers whose products also are inevitably going to be more expensive, at least in the early years.    

“We know that Gavi drives prices down to make vaccines more affordable so more vaccines can be purchased and therefore distributed,” Tippoo added. 

“So some say that the vaccine market in Africa is actually in Copenhagen [the headquarters of UNICEF’s Global supply and Logistics Hub]. This is a structural thing that will have to be addressed because, in order to stimulate and incentivize technology transfers, investment in skills, development, regulatory capacity building and all these things that we repeat ad nauseum, there needs to be an assurance that there’s going to be a market [for African vaccines] when all of this is built.”

Gloomy forecast for African vaccine manufacturing 

Hardly two months later, Tippoo’s gloomy forecast of the market dynamics has already proven accurate: Aspen has not received a single order for its J&J COVID-19 vaccine from African countries that are getting free or heavily subsidised vaccines either directly from rich countries or indirectly through COVAX-backed procurement orders.

This was disclosed two weeks ago by Africa CDC’s John Nkengasong recently, who appealed to Gavi and COVAX to “rally around” Aspen to protect vaccine production on the continent.

It was “shortsighted” of African countries to rely on vaccine donations at the expense of the continent’s vaccine manufacturing capacity, Nkengasong told an Africa CDC media briefing:

“There is a global consensus that, in order to ensure global health security, there must be regional vaccine manufacturing capacity,” he said.

“Here we are with a company that is producing an amazing vaccine that the continent is using, that is running a risk of shutting down that production. We cannot and must not allow that to happen.

“If we only rely on donor vaccines and do not invest in and promote our own facilities on the continent that is a recipe for going backwards the next time we are hit with another pandemic.”

South African President Cyril Ramaphosa visits Aspen Pharmacare manufacturing facility in Gqeberha.

Gavi ‘in discussion’ about Aspen

A GAVI spokesperson told Health Policy Watch on Monday that “COVAX is committed to diversifying global supply, including through the development of regional manufacturing sites, especially in Africa. 

“In the case of Aspen, the current overall demand situation means we are currently not in a position to buy large quantities of vaccines. However, we are in discussion to see if a collaboration would be feasible as part of expanding regional supply.” 

Nkengasong confirmed that there were discussions with Gavi, which manages COVAX, about supporting Aspen’s COVID-19 vaccine production line, which the company has warned it will have to close soon if it doesn’t get orders.

But the immediate outlook is not rosy now that there is a glut of COVID-19 vaccines.  And competition between the big global pharmaceutical players for the African vaccine market is becoming more intense as the continent is the last major source of unvaccinated people on the planet. 

More equity also equals more global health security 

In all the many discussions about a pandemic instrument to address future pandemics, all WHO member states have committed themselves to the principle of equity. But the diversification of vaccine procurement is not just about equity. It will also ensure more robust and flexible supply chains during a pandemic, which will strengthen global health security. 

“We need diversification in terms of geographic locations, where these capacities might be located across the continent, diversification in terms of product mix, what different entities are going to focus on in terms of vaccine development and vaccine manufacturing pipeline, but also diversification in terms of technologies,” Tippoo said. 

“This is not only about Africa for Africa. This is about Africa gearing up to take a significant position and place around the global table. Africa can contribute to a diversified global supply chain when it comes to vaccines.”

Image Credits: UNICEF South Africa/2013/Hearfield.

H3D scientists take their J&J counterparts on a tour of their Cape Town laboratory.

CAPE TOWN – A new partnership between African scientists and pharmaceutical company Johnson & Johnson (J&J), aimed at finding solutions to antimicrobial resistance (AMR), was launched in South Africa on Monday.

The J&J Satellite Center for Global Health Discovery, housed at the University of Cape Town (UCT)’s Holistic Drug Discovery and Development (H3D) Center, will ensure that African scientists get mentorship from J&J scientists while they tackle one of the world’s greatest public health challenges.

The centre will focus on developing “precision antibiotics to treat multidrug-resistant Gram-negative bacteria (MDR-GNB)”, according to a media release by the two bodies.

It will be led by H3D founder and renowned scientist Professor Kelly Chibale, who has been working with J&J since 2016.

“We have a strong history of building drug development capacity together on the African continent,” said Chibale. “This new development will help us to engage with that capability and support the innovation ecosystem to thrive and grow.”

WATCH BELOW FOR MORE DETAILS:

 

J&J’s Dr Ruxandra Draghia-Akli said that “investing to increase the capacity of the innovation ecosystem in Africa is critical to strengthening the research and development (R&D) pipeline for entrenched and emerging global health challenges”.

“By leveraging the unique strengths of H3D and the J&J Centers, we can cultivate the talent and capacity needed to drive innovation in the global fight against AMR,” added Draghia-Akli, who is head of Global Public Health R&D at J&J’s Janssen Research & Development. 

The partnership will ensure that any preclinical drug candidates will align with South African public health needs and “boost the H3D’s AMR drug discovery portfolio, which will in turn attract additional projects and investments to the region”, according to H3D. 

It will also support the efforts of the South African Medical Research Council to set up a national antimicrobial screening platform at H3D, which is coordinating and accelerating the discovery of novel starting points for AMR drug discovery research in South Africa.

Second in the world

The Cape Town centre is only the second such initiative to be set up globally, following the launch of a similar satellite centre at the London School of Hygiene & Tropical Medicine (LSHTM) in July 2021. That centre is focusing on developing next-generation drug regimens that are capable of treating all forms of tuberculosis (TB). These medicines are also needed to counter the rising threat of AMR, with a proliferation of drug-resistant forms of TB emerging worldwide.

Announcing the LSHTM centre, J&J said that “the response to the COVID-19 pandemic has powerfully demonstrated both the importance of science, and that scientific advances do not reach all those who need them quickly”. 

The global centres are the company’s attempt to both encourage R&D and address inequity, it added: “Unless these inequities are addressed and new, equitably accessible solutions are developed, millions of people living in vulnerable and underserved communities around the world will be prevented from living healthy lives.”

Welcoming the launch, the university’s Vice-Chancellor, Professor Mamokgethi Phakeng, said: “While South Africa’s innovations have positioned the country as a key player in global collaborations around COVID-19 vaccines, the focus on other diseases remains narrow. South Africa needs to serve the continent by proactively developing the skills to address global health issues such as AMR.  UCT is proud to be leading the way through H3D.”

AMR was responsible for an estimated 1.5 million deaths in 2020 and is one of the World Health Organization’s top 10 global health threats. Scientists warn that, unless AMR is addressed, its effect could be worse than the COVID-19 pandemic as it can transform easily treated diseases into deadly killers by rendering medicines ineffective.

Pfizer’s Paxlovid has shown 85% efficacy in preventing severe disease in who take it in the first few days of COVID-19 infection.

The World Health Organization (WHO) has recommended Paxlovid, the antiviral medicine produced by Pfizer, for patients with COVID-19 at high risk of developing severe disease – but it is concerned about limited access to the life-saving medicine.

Friday’s WHO recommendation is aimed at “patients with non-severe COVID-19 who are at highest risk of developing severe disease and hospitalization, such as unvaccinated, older, or immunosuppressed patients”. 

It comes after a recent clinical trial of over 3000 patients found that Paxlovid reduced the need for COVID-related hospitalisation by 85% in high-risk patients who were given the medication early on in their infection.

Lack of availability

WHO Access to Medicines Technical Officer Jane Hedman

But the WHO added that “availability, lack of price transparency in bilateral deals made by the producer, and the need for prompt and accurate testing before administering it, are turning this life-saving medicine into a major challenge for low- and middle-income countries”.

Lisa Hedman, WHO technical officer for access to medicines, noted that the Paxlovid deals reported in the public domain “show a total that appears to be within Pfizer’s production capacity, which they’ve estimated to be approximately 80 to 100 billion treatments per year”. 

However, Hedman told a media briefing on Thurday, “not all deals are reported in the public domain”, and the WHO was aware of “several large procurers, including to multilateral deals and a couple of countries” that “could actually strain supply in the short term”.

Pharma flags regulatory and health system barriers

Pharmaceutical manufacturers including Pfizer also flagged the problem of access to Paxlovid at a media briefing last week – but cited the main barriers as lack of swift regulatory approval, allocation strategies, health systems capacity, and a lack of COVID-19 testing (the antiviral is only effective if it’s given to people early on in their infection), 

Last month Pfizer announced it would supply UNICEF with up to four million treatment courses for 95 low- and middle-income countries, pending authorization or approval.

“Supplying to UNICEF is an important part of our comprehensive strategy to accelerate access to Paxlovid to treat COVID-19 infection as quickly as possible and at an affordable price in order to decrease the strain on healthcare systems and help save lives in low- and middle-income countries,” said Pfizer CEO Albert Bourla.

Last November, Pfizer signed a voluntary licensing agreement with the Medicines Patent Pool (MPP) enabling it to granting sub-licenses to qualified generic medicine manufacturers to produce and supply 95 countries with Paxlovid.

This covers “approximately 53% of the world’s population”, including “all low- and lower-middle-income countries and some upper-middle-income countries in sub-Saharan Africa as well as countries that have transitioned from lower-middle to upper-middle-income status in the past five years”, according to a media release.

Pfizer CEO Dr Albert Bourla

Last week, Bourla told a media briefing hosted by International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) that almost 250 companies had indicated their interest in producing Paxlovid to the MCC, which in turn had suggested around 35 companies.

“I don’t think that they will be able to manufacture pretty soon though, although it is very, very easy to do it, and they will do it in already existing facilities,” said Bourla.

“But right now, my concern is what do we do in the meantime for these countries. And this is why we signed an agreement with UNICEF to provide them at-cost, millions of doses that can go to countries, [and] after that the generic companies can take over and provide those doses.”

Call for transparency

The WHO noted on Friday that, since the MCC agreement had been signed, “several generic companies are in discussion with WHO Prequalification but that it may take some time to comply with international standards before they can supply the medicine internationally”.

“WHO therefore strongly recommends that Pfizer make its pricing and deals more transparent and that it enlarge the geographical scope of its licence with the Medicines Patent Pool so that more generic manufacturers may start to produce the medicine and make it available faster at affordable prices,” the organisation added.

“Ninety-five countries is a good number, but WHO would really like to see that number expanded to include more countries to recognise the need for equitable access across really the broadest group of countries possible,” said WHO’s Hedman.

Lack of testing

A significant access barrier to Paxlovid is the global drop in COVID-19 testing amid the perception that the pandemic is over. In addition, only 21.5% of tests administered worldwide have been used in low- and lower-middle-income countries, despite these countries comprising 50.8% of the global population, according to the global test tracker, FIND.

These countries also tend to have lower vaccination rates, which means their populations are more vulnerable to severe disease. Yet only people caught with early infection can benefit from Paxlovid.

On Thursday, the Africa Centre for Disease Control reported a 23% drop in tests over the past week despite five African countries experiencing a fifth COVID-19 wave.

Danger of drug-on-drug interactions

WHO’s Janet Diaz

WHO official Dr Janet Diaz, explained at a media briefing on Thursday that “Paxlovid is made up of two medicines, nirmatrelvir and ritonavir. The nirmatrelvir inhibits the SARS-CoV2 protease and thus stops viral replication”

Diaz, who is the WHO’s COVID Clinical Care lead, added that nirmatrelvir is “co-administered with ritonavir,  an HIV protease inhibitor that boosts the effect of the nirmatrelvir but it itself does not exert any antiviral effect against SARS-CoV2 so this is considered a monotherapy antiviral.”

However, Diaz warned that Paxlovid was not to be given to pregnant or breastfeeding women or children, as it had not been tested on these groups.

“This drug does also have many possible drug-to-drug interactions. And this is because of the effect of ritonavir on an enzyme that’s important in the metabolism of other drugs,” warned Diaz. 

“So it is important if you are a patient that you tell your doctor what other medications you may be taking so they can do a quick check to see if there are any serious possibilities of a serious drug-to-drug interaction.”

Image Credits: Pfizer .

An infant is vaccinated at a primary health care clinic in India.

Discussions about the creation of a new global convention on pandemic preparedness and response have already become a bit like a Christmas tree. 

Last week’s WHO-convened public hearings, saw a wide array of interest groups trying to attach a number of features to the proposed international pandemic instrument, ranging from stronger accountability and transparency measures in reporting outbreaks to ensuring equitable access to vaccines and treatments – and rapid and transparent pathogen-sharing so that new treatments can be quickly created.   

These issues will be further explored in a high-level discussion at the upcoming Geneva Health Forum (GHF) (3-5 May), on the pandemic treaty on the morning of Day 2.

Professor Stéphanie Dagron, Faculty of Law and Medicine at the University of Geneva

However, one important issue that has not yet figured prominently in the discussions is how the new legal instrument could also be used as a tool to concretely advance national social health protection systems that are fundamental to reaching the objective of Universal Health Coverage (UHC), notes Stéphanie Dagron, a professor in international health and social security law at the University of Geneva.

Linking UHC with a pandemic instrument 

Having robust social health protection systems, whether they are entirely tax-financed or based on contributions (through social insurance), or more likely a hybrid of both financing models, is key to getting more people to turn to health care providers when they become ill, she points out to Health Policy Watch ahead of the start of the GHF.

And that, in turn, is critical to identifying emerging disease threats very early on, as well as to rolling out treatments.

 “I’m really convinced that if we want to prevent a novel outbreak, it is absolutely necessary that the population has regular contact with a health system,” says Dagron.  “And without Universal Health Coverage, if people do not have basic access to health care services, they will wait and wait before turning to medical help if an outbreak occurs – and at some point, it will explode. 

In addition, COVID-19 has shown how people with pre-existing conditions, including obesity and diabetes, are particularly vulnerable to severe illness. So getting non-communicable diseases (NCDs) under control – through the extension of UHC –  is equally critical to pandemic preparedness and response, she points out. 

“In a pandemic, we are not only dealing with communicable diseases. NCDs are a big factor, as well as being the cause of most deaths overall, and that burden is getting bigger and bigger,” says Dagron.

Countries with 50% or less of the population covered by essential UHC services: most are in WHO’s African or Eastern Mediterranean regions. The WHO UHC Service Coverage Index tracks progress on the SDG indicator 3.8.1

Lack of UHC legal and financing frameworks 

But many challenges need to be overcome to make UHC a reality, including legal preparedness. The elements of the system authorizing access to health care services for all should be defined in the national legislation (the benefit package and the collective mechanisms used to cover the cost of care).

Despite constant lip service paid to UHC, current SDG indicators for achieving UHC by 2030 lack any clear reference to the kinds of legal and financing frameworks that countries, and the global community, really need to develop to achieve the goal, she points out. 

Rather, the two existing indicators to track progress on UHC (SDG Target 8.3) look purely at “endpoints” such as UHC essential health service coverage. And even such basic coverage is woefully low – 50% or less in about 65 countries,  mostly in Africa, the Middle East and Asia, according to the latest WHO reporting on the UHC indicator SDG 3.8.1. 

“There are only two indicators, and they are primarily medical or economic indicators [of healthcare spending] at household level,” Dagron says. “They say nothing about the kind of health coverage schemes that need to be put in place to achieve UHC.” 

Endpoints are important to track, of course. But likewise, tracking also needs to follow progress on what countries are doing to actually create universal health coverage systems – for which a legal framework for the different healthcare schemes, and transparency and sustainability of the main sources of funding for healthcare coverage, are critical.    

“Many countries need help to create the necessary legal and financing structures for social health protection systems – this is one expertise that is missing at WHO, the legal expertise to support countries in creating a basic legislative architecture for UHC,” she points out.  

Pandemic treaty offers an opportunity to advance UHC 

Dagron sees, therefore, an opportunity for the pandemic treaty talks to empower WHO, together with the International Labour Organization (ILO), to help advance UHC by building country capacity to create, fund and implement their own national social health protection systems. 

That could be a win-win for the negotiations, she says, paving the way for some early achievements in the treaty negotiations between WHO member states – which may be more enthusiastic about setting goals for UHC, than for other, highly controversial issues that the treaty’s proponents will eventually need to tackle.  

Currently, international legal frameworks referencing the creation of social health protection systems exist only in piecemeal forms, with norms to be found in human rights and social security standards, she said. 

However, one significant precedent is the  2012 ILO Recommendation (202) on “Social Protection Floors. This Recommendation, approved by the ILO’s General Conference of member states, sets out a framework for countries to establish social security systems – in which access to essential healthcare services based on diverse arrangements for the financing is framed as an essential component. 

A ‘Global Fund’ for UHC?  

Economic initiatives to support countries in extending social health protection systems that foster universal health coverage are similarly lacking, she notes.  By all available indicators, national government spending on health is woefully behind global and regional targets. 

But UHC and NCD advocates have often pointed out that even governments in low-income countries could potentially raise more tax revenues from unhealthy products such as sugary drinks, tobacco, dirty vehicles or fossil fuels – and channel those into health systems – for a win-win approach.   

In the 2001 Abuja Declaration, most African governments committed to increasing public health spending to at least 15% of the government’s budget. 

However, between 2002 and 2014, the share of government spending allocated to health actually decreased in about half of African countries. Only four countries were above the Abuja target in 2014, notes a 2021 World Bank report that reviews the dismal progress on advancing UHC in the African context. As of 2016, only two of 55 AU member states met the target – Madagascar and Eswatini although South Africa, Namibia and Zimbabwe were close to the goal – and some 35 AU states overall had increased spending in the past year. However since then, the AU’s UHC scorecard hasn’t even been updated. 

Only four African countries had met or exceeded the Abuja target of spending 15% or more of the national budget on health as of 2014 (World Bank, 2016).  And that declined to just 2 countries by 2016.

To assist with the rollout of UHC, the global community could create another, new “Global Fund” for UHC modeled along the lines of the successful Global Fund to Fight AIDS Tuberculosis and Malaria – which currently spends about $4 billion a year supporting low- and middle-income countries’ spending on related health programmes – but also creates criteria for such support and a pathway for countries to become financially self-sufficient. 

Solidarity as a principle

Among the big-picture principles that a pandemic instrument should address, Dagron would like to insist on solidarity. 

“There are so many things that people want to pack into a pandemic treaty,” she observes. “You need to define the central principles that are going to be applicable, and for a lawyer, having principles defined at first, is extremely useful because you use the principles to interpret the rest of the convention. 

“Countries with social health protection systems all rely upon the principle of solidarity in their legal frameworks,” says Dagron. “This has implications for the way you define the objectives of your system, finance the services and essential goods needed and the way you organise access to these services and distribute needed goods.  

“The principle of solidarity should guide and structure the activities of the global community.

Barriers to UHC

In order for countries to expand social health protection to achieve UHC, they will have to enshrine the different health care schemes into their national legal framework. To facilitate this, the global community should define a system that offers more support (technical and financial) to member states and an adequate monitoring system.

A monitoring system for the implementation of UHC in the pandemic treaty should assess the actual implementation.

Effective health coverage is different in most countries and certain groups are often excluded from national health schemes or certain benefits. 

At the same time, the fact that exceptions may occur is not a good argument for avoiding the implementation of UHC altogether, she points out. 

“Admittedly, these are complex issues.  You have to define what is an essential health service in a country, and this is something that cannot be decided at the international level. 

“But that is why the ILO recommendation of 2012, to which WHO contributed,  was interesting because it said that states have to do four things, including making sure there is access to a nationally defined set of goods and services, constituting essential health care; adapted to the needs of the population and creating systems of income security for security for children, for older persons and people active in the workplace.”  

 

See the complete GHF 2022 programme. Register here: Until 2 May fees are CHF 400 for the entire event and CHF 150 for participants from low- and middle-income countries (OECD classification).  Daily rates are also available. 

Check out Health Policy Watch’s ongoing coverage of other themes featured at this year’s Forum on our GHF 2022 microsite

Image Credits: WHO/Christopher Black, S. Dagron , WHO Global Health Observatory , UHC in Action: A Framework for Africa .

Children are routinely vaccinated against hepatitis.

More than 100 mysterious cases of hepatitis in children under the age of 10 around the world are raising a red flag among the medical community, with some doctors and scientists starting to hypothesise that the cases could be triggered by a new strain of adenovirus or even COVID-19.

“Severe hepatitis in children is very rare and we don’t yet know what’s causing this highly unusual rise in cases,” according to Conor Meehan, a senior lecturer in Microbiology at Nottingham Trent University. “The leading theory is that it’s some kind of viral infection, perhaps even SARS-CoV-2, the coronavirus that causes COVID-19.”

Hepatitis is inflammation of the liver. Adenovirus is a common virus that generally causes cold-like symptoms, such as fever, sore throat and diarrhoea. It is super-common in children, and nearly every child has at least one adenovirus infection before the age of 10.

Are adenoviruses to blame?

“Adenovirus can cause hepatitis,” Meehan said.

He told Health Policy Watch that several of the children diagnosed in his area have had adenovirus, though the number of hepatitis cases is unusually high. “There could be a new variant that is increasing the chance of developing hepatitis or it could be that these children have something else in common that makes them more susceptible to developing hepatitis from adenovirus. It is still early to peg the cause directly on this.”

In total, 91 children in the United States and Europe have now been reported to be confirmed or suspected ill with hepatitis of unknown aetiology since January, according to the World Health Organization (WHO) and American health reports. This includes nine children in Alabama, three in Spain and at least 74 in England, Scotland and Northern Ireland. There were also 12 cases reported in Israel, the country’s Health Ministry said, and a handful of others in the Republic of Ireland, according to WHO’s latest report.

At least six children in the UK have undergone transplants of liver lobes donated by their parents so far and another two children in Israel. No one has died.

WHO said Friday that Hepatitis viruses (A, B, C, E, and D where applicable) have been excluded after laboratory testing, bewildering medical personnel who are now investigating an alternate cause. The organisation said that given the increasing number of cases reported over the past month, and that it has now called on paediatricians and other doctors to keep an eye out for children experiencing hepatitis from an unknown cause, it expects that the number of cases will rise in the coming days.

In Israel, seven cases were managed at Schneider Children’s Medical Center in Petah Tikva and five at Shaare Zedek Medical Center in Jerusalem.

Prof Eyal Shteyer, director of the Paediatric Liver Unit at Shaare Zedek, told Health Policy Watch that the sick children came from across Israel and were not of the same ethnicity or religious affiliation. But what most of them did have in common is that they had been infected with SARS-CoV-2.

Almost all the kids had COVID-19

“Ninety-nine percent of the children had COVID,” said Shteyer, who treated the children who came to his hospital with steroids and the children recovered quickly, in most cases within days.

“I think COVID did trigger the immune system to injure the liver in some cases, but other viruses can do this as well,” he said. “Since we see so much COVID, I think that is what is happening here.”

Meehan confirmed that there have been suggestions that COVID could be behind these cases of hepatitis, as SARS-CoV-2 has been detected in some of the children.

“Isolated cases of hepatitis have been reported in COVID patients, but this is even rarer than autoimmune hepatitis, and has mostly been observed in adults with severe COVID,” Meehan cautioned in an article he wrote for The Conversation. “If this was the case, we would have expected to see hepatitis in immunocompromised adults as well, not just these children, and that is why it seems less likely.

“I would not rule it out, but I would not put most of my money there,” he said.

Instead, he said, another possibility is that this is a new symptom resulting from the interaction between the two viruses – adenovirus and COVID – which could both infect children at the same time. Or that the hepatitis is being caused by a totally different virus that hasn’t been detected yet.

Unusual scenarios

“As the COVID pandemic continues, we must routinely consider coronavirus as a possible cause for unusual healthcare scenarios. At the same time, we shouldn’t assume there’s always necessarily a link. Such thinking carries the risk of blinding us to what’s really going on,” Meehan wrote.

WHO said that both COVID-19 and/or adenovirus had been detected in several cases and added that the UK has recently observed an increase in adenovirus activity, which is co-circulating with COVID.

“The role of these viruses in the pathogenesis (mechanism by which disease develops) is not yet clear,” WHO said.

The Alabama Department of Public Health said its analyses have revealed a possible association of this hepatitis with Adenovirus 41.

“To date, nine children less than 10 years old have been identified as positive for adenovirus and two have required liver transplants,” it said in a statement.

“The affected children were from throughout the state of Alabama, and an epidemiological linkage among them has not been determined. None of these children has had any underlying health conditions of note.”

None of the children was known to have been vaccinated against COVID-19, ruling out any tie to the vaccine.

Liver inflammation under a microscope

Data-sharing is key to solving the mystery

Shteyer explained that hepatitis is a generic name for inflammation of the liver and does not indicate anything about the cause, which can range from viral, autoimmune to genetic. What has raised the flag here is not hepatitis but that there “has been a dramatic increase in the last four to six months in those children coming to the hospital with acute elevation of liver enzymes and we did not find a proper diagnosis”.

He said in 70% of cases before now doctors were able to find a cause.

Moreover, he added, that usually children who develop viral hepatitis see their liver enzymes elevated to around 300 U/L or 400 U/L, but in these cases, the levels were in the 1,000s.

“That signals to us that there is severe injury to the liver,” he said.

One of the challenges of this is tied to the fact that adenoviruses or coronaviruses only stay in children’s systems for a finite period of time, and in some cases, parents do not even know that their children have had the viruses.

“Think about a PCR test, after a few weeks this is going to be negative,” Meehan said. “If the infection was months ago and this is a delayed system, it is difficult to identify.”

He said that more sophisticated testing is usually conducted at hospitals could be required to develop the case definition. In Israel, hospitals have been asked to send blood samples from the infected cases to the Central Virology Lab at Sheba Medical Center for a more in-depth analysis.

Meehan said the next step will be to do novel virus testing, meaning to do more of a broad search for a cause using genome sequencing and looking for anything that looks like a virus or bacteria in these children’s blood samples.

“This could hint at a new variant of a virus that we normally would not think causes hepatitis and may have been inadvertently ruled out or even a new virus,” Meehan said.

And, of course, he said data sharing is key.

“As we see cases in Spain and the US it is about determining if and how they may be connected,” he told Health Policy Watch.

What should parents watch for?

The general symptoms of hepatitis are dark urine, grey-coloured faeces and yellowing of the skin and eyes, as well as fever.

“I think if your child looks even a little yellow, I would go fast to the hospital and do a blood test,” Meehan said.

Adenovirus and COVID-19 are not necessarily preventable, but the risks can be minimised by good hygiene, most importantly hand washing.

“As kids go back into the world, we should try to reduce their chances of infection in general and this will help reduce adenovirus infections too,” Meehan said.

Image Credits: F1000research.com, UNICEF South Africa/2013/Hearfield, PIXNIO.

Africa CDC director John Nkengasong

Only 10 of Africa’s 54 countries have vaccinated more than a third of their citizens, although the continent has administered over two-thirds of the vaccine doses it has procured.

The top 10 vaccinators are Seychelles (81%), Mauritius (76%), Rwanda (64%), Morocco (63%),  Cape Verde (55%), Botswana (54%), Tunisia (53%), Mozambique (43%), São Tomé and Príncipe (40%) and Lesotho 36%. Five of these are countries with very small populations.

In total, only 16.3% of Africa’s population has now been fully vaccinated, according to Africa Centres for Disease Control director Dr John Nkengasong.

However, he told a Thursday media briefing that, of 770 million vaccine doses procured, 517 million had been administered, representing 67% of the total available stock.

Vaccine consumption in the 14 most populous AU member states ranged from 21% in Madagascar to 94% in South Africa and 93% in Ethiopia. Egypt and Morocco have used up 90% of their vaccines but Nigeria and Ghana had only administered about half their doses. 

Fifth wave

While nine African countries are experiencing a fifth COVID-19 wave, Africa reported a 21% decrease in new cases  – although at the same time, it also performed 23% fewer tests.

Nkengasong urged all countries to continue testing, adding that the test positivity rate was “a high 11%”.

Algeria, Benin, Congo Republic, Egypt, Guinea-Bissau, Kenya, Mauritius, Somalia and Tunisia are in the midst of their fifth wave.

The five countries reporting the highest increases in cases are (in order of increases): South Africa, Egypt, Tunisia, Seychelles and Zambia.

On Wednesday, South Africa reported its highest cases in three months – 2,846 new cases with a 13,4% positivity rate, according to the National Institute for Communicable Diseases (NICD).

 

COVID-19 vaccine is being administered to a woman in Iran.

Some 42% of the World Health Organization’s (WHO) Eastern Mediterranean is fully vaccinated, but only five of the 22 member states have met the global goal of vaccinating 70% of their populations despite enough vaccine stocks being available, according to a media briefing on Wednesday.

WHO Region Director for Eastern Mediterranean, Dr Ahmed Al-Mandhari, ascribed the low vaccine rate in some countries to the reach of the vaccine campaigns, and vaccine hesitancy among populations.

The region includes a number of countries wracked by war and conflict, including Afghanistan, Sudan, Somalia, the Occupied Palestine Territory and Yemen.

The vaccination rates vary hugely from 99% in the United Arab Emirates all the way down to 2.1% in Yemen.

Meeting the global COVID-19 vaccination targets remains a priority in the Eastern Mediterranean region even as they registered some of the lowest reported cases and deaths in the region since the pandemic began, according to Al-Mandhari.

The region had 21.7 million confirmed cases of COVID-19 and 324,000 deaths up to 16 April, but the transmission rate remains a matter of concern, the WHO said. 

The region also saw a 21% decrease in new cases and a 24% decrease in deaths, but Al-Mandhari warned member states not to let their guard down, especially with pilgrims and tourists expected to arrive in the region in the coming months. 

“While the trends may seem encouraging, it is important to note that we have seen an increase in the number of new cases in two countries and an increase in deaths in six countries,” he said.

“Transmission remains high, vaccination coverage remains low in several countries, and the relaxation of public health and social measures is still being widely observed, allowing continued transmission and the risk of new variants emerging.” 

Dr Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean.

“Extensive use of multiple booster doses in a small number of countries will not end the pandemic. The global and regional priority is to achieve full protection of the highest priority groups in all countries with full vaccination and a booster dose first, and then advance to lower priority groups based on vaccine supply and health system capacity,” said Al-Mandhari, adding that 9% of the region had been boosted.

Preparing for hajj pilgrims, FIFA World cup 2022

The Region is set to welcome and host a number of mass gathering events, including umra and hajj pilgrims in Saudi Arabia in July, and the FIFA World Cup in Qatar in November. These events are set to welcome over a million pilgrims and tourists from around the world and concerns remain on the COVID-19 situation and spread with such events.

When asked about COVID-19 precautionary measures in the region in the run-up to the World Cup, the WHO tols Health Policy Watch that they were working closely with the Government of Qatar and FIFA on this very issue. 

Dr Richard Brennan, Regional Emergency Director, said that the WHO was working with the regional authorities to do its best to adhere to the protocols but there was no guarantee that there would be no cases of COVID-19 infections.

“We’ve learned enough from this virus to indicate that we cannot guarantee that[spreading] but I can assure you that as many of the most appropriate measures that can be taken are being taken out in the lead up to the World Cup, and we hope to keep it as virus-free as possible,” said Brennan.

Image Credits: Johnson & Johnson, Wikimedia Commons, WHO Eastern Mediterranean Region .