shanghai
Shanghai eased its lockdown restrictions 1 June 2022, following continuous low cases reported.

Sixty five days after one of the toughest lockdowns in the world, China has eased COVID-19 restrictions on its financial hub, Shanghai, on Wednesday – finally allowing the majority of its 25 million residents to move freely again.

However, at least 890,000 residents are confined at home, in “quarantine” or “control zones”. 

The announcement to lift restrictions came as official figures showed on Sunday that daily new coronavirus cases fell from 170 to 122 in a 24-hour period. The city reported just 13 cases for Wednesday, and an additional 7 cases on Thursday.

This is a marked turnaround from the beginning of April, when tens of thousands of cases were reported daily. 

“This is a day that we dreamed of for a very long time,” Shanghai government spokeswoman Yin Xin told the BBC

China to maintain ‘zero tolerance’ policy 

Shanghai residents will be required to hold a negative nucleic acid test result taken within 72 hours of entering public spaces or using public transportation from June

But while China seems to have moved into the clear with COVID, the country is keen to maintain its “zero tolerance” policy, and is already preparing for future waves

Beijing municipal officials said Thursday that 12 of its planned 14 ‘transition hubs’ will be used to test and disinfect all imported frozen food before goods are distributed across the city. 

This follows China’s contention that frozen food could transmit COVID-19 in while the World Health Organization’s independent panel on the virus’s origins favour an unknown animal vector as the most likely cause, while others have pointed to laboratory accident for the spread of the coronavirus first found in bats in China.

Tens of thousands of testing booths will also be set up across China’s largest cities, including Beijing, Shanghai, and technological hub Shenzhen, to require testing as often as every 48 hours.  

New rules in Shanghai will now require residents to show a green health code on their smartphone, with proof of a negative PCR test in the last 72 hours, to leave their residential compounds and enter most places, including banks, malls, and public transportation.  

However, cinemas, museums, and gyms remain closed, as well as in-person schooling. 

Restrictions on leaving the city still remain, with anyone traveling to another city facing a quarantine of seven to 14 days upon return. 

Beijing also lifted its restrictions earlier this week, following similar protocol with some of its public transportation system, malls, and other venues opening up. 

Shanghai testing centers tested by overcapacity and staff shortages

Shanghai testing center

Shanghai’s 72-hour rule has tested the capacity of its testing centers, as crowds flocked to the 15,000 stations. While some said their test took only a matter of minutes, others complained that they had to wait over an hour to test. 

Many testing booths are only open for about three hours each in the morning and afternoon, although some hospitals offer a 24-hour service. 

Shanghai resident Zhang Zehong told Sixth Tone that she was unable to test Wednesday as the station in her neighborhood closed two hours earlier than shown on the city’s health code app, which features all the testing centers. Instead, she went to a hospital with a 24-hour service Thursday morning, only to find no staff and a line that stretched on for over 100 meters. 

So many issues need to be fixed,” Zhang said.

Chinese microblogging platform Weibo also featured complaints with the stations.

“It’s been very hot recently, several people passed out when standing (in line),” one Weibo user wrote.

“I visited five sites but each had long queues. This is not really humane enough. Don’t these mobile kiosks cause more people to gather?” another Weibo user wrote.

Fifty-point plan to revive Shanghai economy 

A fifty-point plan has also been drawn up to support Shanghai’s economy, crippled in the wake of closures, quarantines, and lockdowns. 

New measures include reducing taxes for car buyers, speeding up the issuance of local government bonds, and fast-tracked approval of building projects. Drivers who also switch to an electric vehicle will also be able to claim a $1500 subsidy.

Businesses may also be able to delay insurance and rent payments, with subsidies available for utility charges.

Image Credits: Appriseug/Twitter , DA Trade Market Securities/Twitter , Don Weinland/Twitter.

AMA headquarters host country is expected to be named at the end of an ongoing meeting in Addis Ababa

A meeting to decide which African country will be the host country for the African Medicines Agency (AMA) is underway and at the last count, expressions of interest in hosting the agency have been received from Uganda, Algeria, Egypt, Morocco, Rwanda, Tanzania, Tunisia and Zimbabwe.

The decision is expected to be one of the outcomes at the ongoing first Ordinary session of the Conference of State Parties (CoSP) of the AMA, in  Addis Ababa, Ethiopia from 1 to 3 June 2022. 

The CoSP is reviewing the AMA assessment report and at the end of their meeting, it will make recommendations on the host country of the AMA Headquarters. A final decision on this recommendation will be made at the next assembly of the African Union.

Uganda is one of the countries vying to host the AMA Headquarters and the country’s delegation to the CoSP meeting is led by the country’s Minister of Health, Dr Jane Aceng, and Dr Diana Atwine, a Permanent Secretary in the Ministry of Health. 

Zimbabwe’s team is a four-member delegation led by the country’s Health and Child Care deputy Minister, Dr John Mangwiro.

Sierra Leone is also attending the session led by Minister of Health and Sanitation Dr Austin Demby.

In his remark at the official launch of the Africa CDC’s Ministerial Executive Leadership Program (MELP), Dr John Nkengasong, Africa CDC’s outgoing Director General confirmed the CoSP’s outcome would play a critical role in deciding the future of the agency.

“The launch of the AMA is really another landmark initiative of the African Union as part of the Agenda 63. I can’t wait to hear the outcome of the deliberations. It’s going to be transformational when the AMA and we are truly excited with that,” Nkengasong said.

The three-day ministerial meeting will deliberate on the priorities and next steps to establish the AMA.

From Geneva to Addis Ababa

At last week’s World Health Assembly, Amref Health Africa’s Desta Lakew,  on behalf of the African Medicines Agency Treaty Alliance (AMATA) described AMA as an initiative of the African Union aimed at strengthening the regulatory environment to guarantee access to quality, safe and efficacious medicines, medical products, and technologies on the continent.

Countries that have signed the treaty, according to AMATA, are Algeria, Benin, Chad, Ghana, Madagascar, Mali, Morocco, Rwanda, Saharawi Arab Democratic Republic, Senegal, and Tunisia. But about four years after the AU Assembly adopted the AMA Treaty, Lakew noted that some Member States still haven’t given it the authority to fulfill its mandate. 

“The increased risk of disease outbreaks in the region and globally has made access to medical products a priority. Trade in locally produced medical products, including Personal Protective Equipment, across African countries will be hampered if we do not have a harmonized regulatory environment,” Lakew told WHA 75. 

At the CoSP meeting, the AU called on all member states to sign the Treaty to see improved regulation and easy flow of medical products and technologies, are expected to be reechoed. Lakew described the call as an urgent matter “for the sake of ensuring that there is equitable access to quality, safe, efficacious medicines and technologies for a healthy Africa”.

Last month, Health Policy Watch reported Kenya was preparing to join the AMA alongside thirty-one other African Union member states following the Kenyan cabinet’s decision to approve the ratification of the African Union Treaty.

See more about the African Medicines Agency on our special AMA Countdown page:

African Medicines Agency Countdown

75th World Health Assembly

Health and peace, sex and war, money and management. Whether in chorus or cacophony – last week’s World Health Assembly of WHO member states played most of the notes in the symphony of global debate over strategies to tackle disease, epidemics and pandemics and bolster health systems. But the root causes of emerging disease threats – in modern environmental health threats and nature gone awry remained under-represented themes.   

From the opening notes of the WHA, on a health for peace theme, to Saturday’s late night closing and end-run charges over language on sexual orientation – this year’s WHA was a seesaw of successes and setbacks.

Highs included the consensus vote Tuesday to increase member states contributions to WHO, followed by a resolution Friday to move ahead on the first real reforms to the International Health Regulations in almost 20 years.  

And at the same time, unprecedented polarization was evident during Thursday’s debate over a resolution condemning Russia’s invasion of Ukraine, which won approval by a vote of 88 to 12. 

That was followed by the dispute that emerged Friday and continued until nearly midnight  Saturday over references to terms such as “sexual rights” and “men who have sex with men” (MSM) in a WHO strategy on HIV, hepatitis-B and sexually transmitted infections (STIs). That, too, was resolved only by a painful series of rollcall votes, leading to the strategy’s passage by just 60 member states, with twice as many delegates absent or abstaining. 

Like a bullet train ride 

sexual rights strategy wha
Dr Hiroki Nakatani joins in the applause for the resolution’s passage on HIV, Hepatitis B and STIs

Dr Hiroki Nakatani, who presided over the committee that faced the thorny final hours of WHA dealing with the clash among nations over sexual health terms that HIV professionals regard as the standard usage, compared this year’s WHA session to a ride on a bullet train. 

“The train ride was sometimes bumpy but we arrived at our destination,” he said of the first Assembly to be held in person in several years because of the pandemic.

Perhaps so, even more so than the war in Ukraine, the exceptionally large number of abstentions in the vote on a new HIV, Hepatitis and STI strategy was a bitter pill to swallow for delegates on both sides of the debate. 

It highlighted the fact that the battles still being waged in Europe, the Middle East, Asia and Africa over the control of territory are not the only big issues dividing member states. Fissures over social norms shape and guide public health policies run just as deep.

Sex & War – Global social divide as deep  as territorial conflicts 

And among those norms, there remains a deep divide around health policies that interface with human sexuality – that other primordial urge that co-exists alongside the urge for power and territory. 

For WHA delegates, in fact, the series of votes Saturday over sexual terminology may have been even more unsettling than the votes over Russia’s invasion of Ukraine – precisely because they sit in Ministries of Health, not Defence, with day-to-day responsibility for designing and implementing policies on HIV and other STIs.  

As with the Ukraine conflict, the divide that emerged, however, was not strictly drawn along the lines of global North and South.

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

Rather, it was the oil-rich Saudi Arabia that led the charge in the quest to purge references to men who have sex with men from the strategy on HIV treatment, followed by emerging economies of Asia and Africa where conservative views about sexual expression are often protected by law as well as custom.   

Against that, was Europe, North America, much of Latin America  and high-income Asia- where more new attitudes about gender identity and LGBTI terminology have taken root over the past few decades. 

There were also exceptions, such as South Africa, which voted in favour of the HIV strategy.  And European Serbia abstained from the vote as did the Russian Federation. 

Respect for culture, versus respect for evidence  

In the aftermath, the abstaining countries pleaded for more understanding of norms guided by tradition and culture. Western delegates, meanwhile, referred to the compass of science – whereby recent research has revealed how oft-marginalized MSM groups often fall through the cracks of programmes for HIV/AIDS prevention, diagnosis and treatment.

“We appreciate those member states acted in good faith as part of these deliberations. Unfortunately this has served as a painful reminder of the need to reinforce our focus on evidence, human dignity and decency,” said US Assistant Secretary of State for Global Health Loyce Pace just after the strategy was approved.  

Loyce Pace, Assistant Secretary of State for Global Health, USA

“[But] we should not need to hold a vote on the existence of entire communities of people,” she added.  “We have a strategy on critically important global health issues, yes. But at what cost to those we risk leaving behind?

“So to gay, lesbian, bisexual, queer, intersex, transgender and gender non-conforming people around the world, the United States government sees you, and will continue to support you.  Stay strong.”

(Right) Denmark’s EB representative, Søren Brostrøm, Director-General, Danish Health Authority, at the WHO Executive Board meeting 30 May, (left) Loyce Pace Assistant Secretary of State for Global Health, USA

Reviewing the issue at Monday’s Executive Board meeting, member states on both sides of the divide expressed concerns over the failure of the WHA to find consensus over such a flagship health strategy – and the “dangerous precedent” that the voting set. 

“It is important that this does not set a precedent for consideration and adoption of technical documents by the Health Assembly,” said Dr Edwin Dikoloti, Botswana’s Minister of Health and Wellness, speaking on behalf of the African group, saying that greater efforts need to be made to find consensus in future WHAs over such controversial issues.  

Money – landmark decision on WHO finance – but not a ‘done deal’ 

Members of the WHO Working Group on Sustainable Finance hammer out the final agreement on increasing member state contributions, Germany’s Björn Kümmel on far left.

The holy grail of consensus was restored in other key moments – including around the WHA resolution to increase regular member state contributions to WHO – in a bid to stabilize the agency’s finances 

The agreement, the fruit of months of grinding backroom diplomacy led by Germany, saw member states commit to  increase annual assessments to cover  50% of WHO’s core budget by the end of the decade. 

However, each stepwise increase up until 2030 will still need endorsement at future WHAs to go forward.  And so the vote should not be seen as a blank check either, a senior official in the Department of Health and Human Services, told Health Policy Watch

“I would say that the US, as a big contributor to the WHO, is definitely committed to that [resolution], and we were very happy to join the consensus,” the official said.  

“But I hope it’s also been clear that that is not a done deal and neither for us as the administration or for Congress.”

According to the resolution, final approval of each year’s increase is contingent on progress in WHO internal reforms that are supposed to make the organization more transparent,  efficient and well-managed. 

Those demands include overhaul of WHO’s budget management system, said the senior US official: “The budgets that are adopted by the Health Assembly are not real budgets. They’re just budget space. And creating budgets that are aspirational is very different from programming and reporting on and demonstrating the impact of real budgets.”

Management – following election Tedros faces new demands  

Applause just after WHA re-elects Dr Tedros Adhanom Ghebreyesus to serve a second five-year term as Director-General of the World Health Organization on 24 May. He ran un-opposed.

But the expectations go beyond budget reform, pressing newly re-elected Dr Tedros Adhanom Ghebreyesus for changes in WHO’s management culture, including more merit-based appointments of senior WHO staff, such as those serving as heads of WHO country offices, and structural reforms in WHO’s internal justice system.

“I think, from our perspective….  there’s a very significant culture change… that needs to happen within the organization,” the official told Health Policy Watch.   

Further related to that, are demands for a “full resolution” of the ongoing investigation of the cases of sexual harassment and abuse of women in the Democratic Republic of Congo by WHO staff and consultants, whose progress also was reviewed at last week’s WHA and Monday’s EB.     

Justice – WHO internal justice system lacks independence  

While the revelations of the DRC sex abuse scandal, which first came to light in 2020, and whose perpetrators have yet to be fully prosecuted, highlight failures of WHO internal justice to date, they also are evidence of a broader and more systematic problem, some WHO insiders maintain. 

One key problem, highlighted in multiple interviews with both past and present WHO staff, is the fact that WHO’s Internal Oversight Office (IOS) – the legal mechanism that manages staff and management complaints – is housed in the  Director-General’s Office and effectively controlled by the Director General himself – rather than at arms length. Politically influential managers or staff with the ear of the DG, may receive different treatment than staff who do not, critics say.   

The flaws in the current process featured in a WHO Staff Association letter to Monday’s Executive Board. The Staff Association demanded that the WHO Global Board of Appeals, the three-member body that hears cases, and recommends disciplinary action to the Director General, be expanded and also include staff-appointed representatives.  

“The panel of the Global Board of Appeal (GBA) should have five-members,” stated the Staff Association. “A three-member panel – the current practice – is simply not reassuring staff that GBA deliberations are sufficiently robust,” the Staff Association letter stated.“Furthermore, the staff representatives on each of the GBA panels should be selected by the respective staff association rather than selected by the GBA Chair or Deputy-Chair.”  

The net result of the current system is that – short of a costly and lengthy appeal to the International Labour Organization – disciplinary cases are heard by a GBA board appointed by senior managers who report directly to Tedros, who also decides on the final outcome of the cases. 

Dr Boubacar Diallo with WHO Director-General, Dr Tedros Adhanom Ghebreyesus and then-WHO Emergency Response Team leader, Dr Michel Yao in DRC in June 2019; Diallo was among those accused of harassment and Yao was alleged to have ignored those and other reports.

With regards to the DRC cases, allegations that high-ranking WHO managers or consultants with ties to Tedros may have turned a blind eye to the reports of abuses going on in the field, have never been publicly resolved.  But the concerns extend beyond sexual harrassement, to the need to foster an institutional culture of professionalism free of political interference, critics also say, pointing to other episodes like the suppression of a 2020 WHO report on Italty’s pandemic response, which criticized another senior WHO advisor to Tedros

From a sustainable budget a sustainable planet?        

While WHO’s financial sustainability received considerable attention at this year’s WHA, there was comparatively little debate on the planet’s sustainability crisis – and how that may be fueling a cascading array of health impacts – from more noncommunicable diseases to emerging outbreaks, such as SARS-CoV2 and more recently a worldwide surge in monkeypox.   

A new roadmap to accelerate work on noncommunicable diseases fails to give more than a nod to air pollution as one of the leading causes of NCDs – responsible for some 7 million deaths a year from cancers, cardiovascular and lung diseases every year. And that doesn’t even include risks from chemicals exposures that make the total estimate of deaths from pollution closer to 9 million annually, according to a new Lancet Planetary Health Report released on 18 May.

Deaths attributable to key “modern” and “traditional” pollution sources for which data is available

In a debate over an NCD roadmap that aims to slash NCD risks by one third by 2030, France, speaking on behalf of some European Union member states,called for a more “integrated” approach that includes environmental health and climate change. 

So far, such approaches have been slow in coming. Despite the rhetoric about air pollution being a leading risk factor for NCDs, there are, as yet, no WHO “Best Buys” for environmental strategies that reduce deadly pollution risks – even if measures like clean public transport and compact cities, built around cycling and walking networks, are regarded by urban planners and transport managers as evidence-based solutions that have a record of demonstrated results.  

‘One Health’ and food safety – some new approaches

Caged animals held for sale and slaughter in unsanitary conditions at Wuhan’s Huanan Seafood Market, prior to the outbreak of COVID-19, including: (a) King rat snake (Elaphe carinata), (b) Chinese bamboo rat (Rhizomys sinensis), (c) Amur hedgehog (Erinaceus amurensis) (the finger points to a tick), (d) Raccoon dog (Nyctereutes procyonoides), (e) Marmot (Marmota himalayana) (beneath the marmots is a cage containing hedgehogs), and (f) Hog badger (Arctonyx albogularis).

On the brigher side, a new WHO Global Strategy for Food Safety was approved by member states. For the first time ever, the strategy makes reference, at least in passing, to the need for a “One Health approach when addressing health risks emerging at the human-animal-ecosystems interface.”  

A companion decision asks WHO to also update its guidance on  Reducing public health risks associated with the sale of live wild animals of mammalian species in traditional food markets

Such guidance emerges out of the SARS-CoV2 pandemic, where peoples’ exposure to SARS-CoV2 infected animals in the Wuhan, China live animal market is considered to be one of the most plausible routes by which SARS-CoV2 initially leaped from animal to human populations in Wuhan, China during 2019.

But the caging and slaughter of live, wild animals in areas heavily trafficked by customers are practices common in thousands of traditional markets in Asia and Southeast Asia, as well as  parts of Africa, leading to further risks of human exposure to pathogens the animals may harbour.  

Not nearly enough action to stop pandemics at source

The unsafe handling of live animals that are sold for slaughter at traditional markets can risk the spread of foodborne and infectious diseases.

Such “One Health” issues need far more deliberate and systematic WHO and member state attention than the nod that they have so far, a growing chorus of “Ecohealth” experts say.

In a little-noticed press release issued during WHA, Dr Nigel Sizer, executive director of the consortium Preventing Pandemics at the Source called upon the WHA to do more to address ecosystem risks upstream that increase “spillover risks” of pathogen leap from animal to human populations: 

“Such actions include shutting down or strictly regulating wildlife trade and markets, stopping deforestation and forest degradation, and providing better health to communities in emerging infectious disease hotspots, as well as strengthened veterinary care and biosecurity in animal husbandry,” said Sizer, an internationally known conservationist,  in his statement. 

“Overall throughout the WHA process and in the preparations for negotiation of a possible global instrument on pandemic prevention and preparedness there has been remarkably little attention given to true pandemic prevention,” Sizer later told Health Policy Watch.  

“We know where most pandemics come from and we know how to reduce the risk of zoonotic spillover of the vruses that cause them,” he added. 

“Governments in general and health agencies in particular should embrace these approaches, including One Health efforts.  They should also work much more closely with environmental agencies to address spillover risk from tropical deforestation, wildlife exploitation and trade, and intensive animal agriculture. The public health return on investment in such activities would be enormous.”

Health and Environment: WHO structures preserve a deep divide  

Researcher explores evidence around the wildlife-trade- pandemic nexus (Wildlife Conservation Society)

There are parallel calls to better incorporate such concerns into any future “pandemic instrument” intended to have a broader scope than the International Health Regulations, and to be the focus of intense negotiations by a WHA Intergovernmental Board (INB) in coming months.  

However, the yawning chasm environmental groups encounter in trying to to interact with WHO and WHO member states over environmental health and One Health concerns, can sometimes appear as wide as the divide between member states on the terms around sexual health.   

“It has been exceedingly difficult to engage with the WHA or with the intergovernmental negotiating body’s (INB) process to draft and negotiate a new pandemic instrument,” Christine Franklin, of the Wildlife Conservation Society, another member of the Preventing Pandemics coalition, told Health Policy Watch. 

The club of non-state actors in ‘official relations’

“Only non-State actors in official relations with the WHO are invited to engage with the WHA,” she remarked.

That status of ‘official relations’ not only allows civil society groups the privilege of expounding on their positions at the annual World Health Assembly, it gives them access to lengthy and detailed informal member state consultations and intergovernmental negotiating sessions that are closed to the general public and the media. 

Some 220 civil society actors hold that coveted status, mostly mainstream medical and health societies as well as pharma groups, but also agro-business foundations, such as CropLife International, as well as the outliers like the World Plumbing Council. A review by Health Policy Watch found nary an environmental or eco-health group on the list, as of February 2022.  

“So even though Wildlife Conservation Society has been working across the globe for more than 125 years; is the only international conservation organization with an embedded health program, works on the ground in more than 60 countries; and our health program is recognized as a One Health founder and a leader at the nexus of health and the environment, the INB’s public hearing has been the only opportunity we have had to provide input,” Franklin lamented. 

“Oral testimonies were limited to two minutes and written statements restricted to 250 words. In fact, there are no organizations from the conservation or environment communities in official relations with the WHO and the process to gain status is complex and lengthy.” 

Image Credits: Germany's UN Mission in Geneva , WHO, Lancet Planetary Health, Nature , Pierce Mill Media, Wildlife Conservation Society .

Monkeypox lesions

In just a matter of three days, the number of monkeypox cases reported to WHO outside of central and west Africa has doubled – with reports Wednesday of some 550 cases in more than 30 countries outside of the countries where the disease is endemic, WHO Director General, Dr Tedros Adhanom Ghebreyesus told a press briefing on Wednesday. 

That, as compared to reports of 257 cases outside of Africa, as of Sunday, 30 May. 

The ‘sudden appearance’ of monkeypox in so many non-endemic countries is prompting new concerns that it could spread to more “vulnerable populations” in countries where it has suddenly emerged, including pregnant women and children, added WHO’s Maria Van Kerkhove, Health Emergencies technical lead. 

WHO Briefing, 1 June 2022

“Investigations are ongoing, but the sudden appearance of monkeypox in many countries at the same time suggests there may have been undetected transmission for some time,” said WHO Director-General Tedros Adhanom Ghebreyesus during a press briefing Wednesday.  

“WHO’s priority now is to first provide accurate information to those groups most at risk, and second to prevent further spread among at-risk groups, to advance our understanding of monkeypox.” 

WHO is organizing two R&D meetings of experts on Thursday and Friday of this week, to further discuss monkeypox and understand the current surge in cases. 

Ecological pressures prompting rapid disease emergence 

monkeypox
Gambian pouched rat – rodents are a common animal reservoir for monkeypox

Monkeypox has long circulated in 12 countries of central and western Africa, with a rising incidence over time. Disease prevalence is highest in the Democratic Republic of Congo, which has reported several thousand cases a year, and where the monkeypox clade, or variant, in circulation is more deadly. 

The disease has been reported to have mortality rates of up to 10% in the DRC. Noone has yet reported to have died from the outbreak that has occurred abroad recently  – which has been traced to the milder West African clade.  

Cases of monkeypox in endemic countries between 15 December 2021 to 1 May 2022

Increased circulation of the disease in Africa in recent years has been linked to deforestation – which put wild animals in closer contact with humans, as well as increased agro-food storage, and consequent infestation of food containers by infected rats. 

Additionally, human travelers as well as the trade in exotic animals has been linked to the appearance of some cases overseas in the past.  But the appearance of so many cases abroad is a new phenomenon, where community transmission is now occurring, including among networks of men who have sex with men, WHO said. 

The changes in ecosystems, trade and travel have been exacerbated by a decline in human immunity to the disease, due to the discontinuation of smallpox vaccination in the 1970s, which was protective against monkeypox as well.   

Ecological pressures need to be addressed 

Michael Ryan, WHO Executive Director, Health Emergencies

Beyond the immediate health system measures needed to track and trace the spiral of increasing human cases occurring daily,  more attention needs to be given to the underlying drivers, and ‘ecological pressure’ that has caused disease outbreaks to expand in size and scope,WHO’s Executive Director of Health Emergencies Mike Ryan told the briefing. 

“Animals are changing their behavior, humans are changing their behavior. What we’re dealing with is a lot of ecological fragility,” said Ryan. 

“We’re dealing with the animal-human interface being quite unstable, and the number of times that these diseases cross into humans is increasing, [as well as] that ability to amplify the disease and move it within our communities.” 

But he did not elaborate on how WHO might address such drivers – beyond saying that they could be a topic of discussion at this week’s R&D meeting convened by the global health agency. 

Inequity of investment in monkeypox in Europe versus Africa already apparent

The current outbreak also highlights once more, the boomerang effect of inequitable investments in health systems and disease control in Africa, where monkeypox has been circulating for decades in countries that lack the tools to track and tackle such infections, Ryan said.  

“There are thousands and thousands of cases of monkeypox every year in Africa, and there are deaths every year….. And now, we have a concern about this disease spreading in Europe, but I certainly haven’t heard that same level of concern over the last five or ten years.” 

“Are we in a position to collectively respond? Are we in a position to share resources in order to stop transmission of these diseases within human communities?,” Ryan asked. 

Already, countries such as the United Kingdom have vaccinated more than 1,000 people at risk of contracting the virus, and the European Union is in discussions to buy smallpox vaccines from Bavarian Nordic, the only maker of the vaccine licensed in Europe, according to media reports. 

Smallpox vaccines are estimated to be about 85% effective against monkeypox, which is in the same orthopox family of viruses – but there have been no such vaccination campaigns in monkeypox hotspots such as DRC for decades. 

“It’s a bit uncomfortable that we have a different attitude to the kinds of resources we deploy depending on where cases are,” said Dr Jimmy Whittworth, of the London School of Hygiene and Tropical Medicine, speaking to the Associated Press

“It exposes a moral failing when those interventions aren’t available for the millions of people in Africa who need them.”

Stigma against disease may prevent care, increase transmission 

Tedros Adhanom Ghebreyesus, WHO Director-General

Meanwhile, WHO’s Tedros urged people to fight against stigma associated with the transmission of monkeypox in networks of men who have sex with men (MSM) – and underlined that the disease can be transmitted in a range of ways.

Those include through contact with: infected saliva and mouth lesions, bedding as well as transmission of pregnant women to their unborn children through the placenta, according to a WHO seminar on the issue Tuesday.   

Tedros said that MSM advocacy groups “are working hard to inform [members of their community] about the risks of monkeypox and prevent transmission. But all of us must work hard to fight stigma, which is not just wrong. It could also prevent infected individuals from seeking care, making it harder to stop transmission.”   

“Anyone can be infected with monkeypox if they have close physical contact with someone else who was infected,” he said. 

The virus was first identified in 1958 in a colony of captive African research monkeys. The first human case was identified in the DRC in 1970, during the period of smallpox elimination campaigns.  

Even before the current outbreak, there have been limited waves of cases reported in non-endemic countries through channels such as the export of exotic animals, such as infected mice, squirrels, and rats, from Ghana to the United States in 2003, as well as by infected travelers. 

Misinformation campaign to target monkeypox 

Maria van Kerkhove, WHO Technical Lead on COVID-19

WHO is also mounting a campaign on disinformation about the disease, said Gabby Stern, WHO Communications Director. 

WHO is currently working with both social media companies and tech companies, urging them to filter out the misinformation and push out accurate information through their channels and platforms, said 

She said that misinformation and disinformation was a ‘major priority’ for both WHO and the United Nations. 

“Misinformation kills, just as these viruses kill, misinformation kills as well,” added Dr Maria van Kerkhove, WHO technical Lead on COVID-19.  

“This remains a constant challenge, not only COVID-19 across the entire spectrum of interventions and the response that we have. It’s the attacks on science that undermine the effectiveness of our countermeasures.” 

Image Credits: Tessa Davis/Twitter , Laëtitia Dudous, WHO, Disease Outbreak News, 21 May 2022 .

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

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

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

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

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

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

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

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

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

Majority of cases discovered in European region

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Expert advises parents to keep threat in perspective

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

WHO Staff Association Calls for Reshaping Internal Justice Board 

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

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

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

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

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

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

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

More ‘fairness’ needed in administrative leave processes  

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

‘We are going backwards’

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

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

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

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

Clean air is a human right

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

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

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

Winning indoors but worsening outdoor air quality

Transitioning to cleaner cookstoves and fuels in Uganda.

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

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

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

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

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

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

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

Clean air gap in health action and funding

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

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

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

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

From deadly air to clear skies ahead

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Transmission rates generally have not been that high in the past

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

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

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

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

Congo Basin clade more severe

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

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

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

 

Image Credits: US Centers for Disease Control.

 

Pakistan is one of two countries where polio remains endemic.

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

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

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

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

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

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

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

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

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

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

Vaccine-derived outbreaks increased 

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

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

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

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

Civil insecurity, and vaccine hesitancy 

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

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

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

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

Build capacity for countries to produce their own vaccines 

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

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

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

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

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

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

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

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

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

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

Wildvirus re-emergence due to fragile anti-polio drives

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

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

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

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

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

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

Ten recommendations – including global polio integration into health systems 

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

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

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

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

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

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

Image Credits: Sanofi Pastuer/Flickr.

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

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

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

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

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

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

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

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

Glossary of terms removed in last-minute compromise 

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

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

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

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

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

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

Dismay among many member states over the lack of consensus

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

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

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

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

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

US makes spirited defense

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

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

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

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

Clock ran down as debate dragged on

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

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

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

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

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

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

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

Untenable we don’t reach agreement

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

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

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

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

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

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

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