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UK Prime Minister Boris Johnson at the Covid-19 Vaccine Centre, Guy’s Hospital in central London earlier this year.

Amid soaring COVID-19 cases in the UK, the government is prioritising giving third booster shots to people as it banks on the country’s high COVID-19 vaccination rate being able to prevent severe illness and death.

Over the past week, COVID-19 cases in the UK increased by almost 18% – with 52,000 new cases confirmed on Thursday alone. 

COVID-19 deaths have also increased by almost 11% in the past week, and some medical experts believe that the country should consider returning to additional safety measures such as masks and social distancing.

However, Prime Minister Boris Johnson said this week that the pandemic’s current trajectory is not unexpected and has so far ruled out any additional measures to curb cases.

The UK has been counting on its high vaccination rate to enable its residents to live relatively normally alongside the virus, but its sheer volume of cases is starting to put pressure on the health system.

Almost 80% of Britons over the age of 12 are fully vaccinated, while around one in nine people – 5.3 million – have had booster shots.

During the current surge, around 2% of people infected have been hospitalised in comparison to 9% in January when vaccinations were less available. Around 14% of unvaccinated people with COVID-19 have ended up in hospital.

In last year’s peak (October – January) there were 2,7 million cases and 185,000 of these were hospitalised whereas in the current phase (July – October) around 3 million people have been infected yet only 79,000 people have ended up in hospital.

“The important thing is that is the fact that our vaccination programme has been successful in breaking the link between cases and hospitalisations and deaths,” said a UK government spokesperson this week. “Our focus remains on ensuring we get boosters out to those who are eligible.”

 

However, the UK Scientific Advisory Group for Emergencies (SAGE) said that a higher death toll was unlikely, but SAGE warned that a variant of Delta becoming dominant is a very real possibility.

The UK Health Security Agency has designated the Delta mutation, known as AY.4.2, as a variant under investigation. By Wednesday, there there were 15,120 confirmed cases in England since it was first detected in July.

Fourth wave in Europe

Europe is the only World Health Organization (WHO) region to report an increase in cases for the third week in a row. Cases increased by 7% in the past week, exacerbated by colder weather driving more people indoors.

Cases in Belgium, Czechia, Hungary and Poland have increased by 50% over the past week, according to the WHO.

Belgian Health Minister Frank Vandenbroucke said on Wednesday night that the country’s fourth wave had started, with the country experiencing over 3,200 new daily cases. Some 86% of Belgian adults have now been fully vaccinated.

Belgian Prime Minister Alexander De Croo told VTM Nieuws this week that people might need to go back to wearing masks.

“The first priority must be to vaccinate those who have not been vaccinated as soon as possible. We are really monitoring the situation in detail to see if we need to intervene at a certain point,” De Croo added.

Poland is experiencing over 5000 new cases per day, the highest rate since May, and it has vaccinated 61% of its population.

 

‘It’s this easy’ rabies awareness drive.

In the US, cases of dogs infected with the rabies virus being brought into the country are significant enough to warrant national headlines and a year-long dog importation ban on dogs from hundreds of countries worldwide.

Yet, in India, rabies does not get much media attention but it accounts for a shocking total of 20,000 human deaths each year – that’s more than 50 a day.

While the US has eliminated the dog rabies virus variant and is able to keep it controlled through active border controls, surveillance and comprehensive dog vaccination programmes, rabies in India, and at least 100 other countries throughout the world remains a significant challenge.

In these countries, people are forced to live alongside one of the deadliest diseases known to humankind. Rabies is 99% fatal to humans once symptoms appear. By the time a person shows symptoms of the virus, it is usually too late for effective treatment.

This is despite the fact that the first vaccinations for rabies date back to the 19th century.

This imbalance can, and needs to be, addressed. Although there is far less global competition for rabies vaccines than for COVID-19 vaccines, many countries are still not benefitting from the full suite of inexpensive and effective rabies control tools that exist throughout the world.

Applying what works

By combining what we already know works in controlling rabies and the extensive lessons of the COVID-19 pandemic, we can ensure the countries that need vital vaccines and resources can get them.

Firstly, knowing where the disease is most prevalent is crucial to directing vaccines, mass vaccination efforts, and other tools and resources, to effectively control rabies. 

Measures such as the Global Alliance for Rabies Control’s Rabies Epidemiological Bulletin (REB), which provides comprehensive rabies data, particularly for countries who do not have the resources or capacity to build their own systems, are leading the way in surveillance.

Likewise, technical innovation in health information systems and in-field diagnostics can also allow resource-poor countries the opportunity to build their own rabies surveillance systems in a timely and efficient manner, tracking and containing the spread of the virus.

The Community-Based Rabies Surveillance (CBRS) system, which has been used by GARC in the Philippines, links information about the biting animal from the field to laboratory and pairs this with human treatment data from clinics.

This ensures that the best treatment decisions are made, and that dog vaccinations are carried out where the rabies exposure occurred to prevent further cases in the future.

Animal health is a cornerstone of public health

Secondly, much as the COVID-19 pandemic has been managed at a country level, efforts to combat and control rabies need to be led by countries and fine-tuned to address the specific challenges that are faced in different regional contexts.

Rabies-affected countries need to be encouraged to build their own national strategies that address their unique challenges, whether they are related to funding for surveillance and rabies control, the availability of expertise or access to community animal health workers.

Finally, governments and health authorities must adopt a “One Health” outlook and prioritise animal health as a cornerstone of public health, ensuring that the vaccination of dogs can continue amid lockdowns and other restrictions that have arisen during the pandemic.

Improving the coordination between sectors and departments will be key to a holistic vision of public health which treats the disease at source, in the dogs, alongside access to human vaccines.

If dog vaccination coverage is low, particularly because of a slowdown in vaccinations during the pandemic, it is essential that dog bite victims, who may be exposed to rabies, can receive quick and life-saving treatment.

Effective surveillance

Ultimately, the persistence of rabies clearly illustrates how difficult it is to control a zoonotic disease, especially one which requires the close cooperation of countries across animal and human health departments.

Despite these difficulties, this approach is essential to create a more robust and resilient health infrastructure, for rabies and beyond.

The countries that have ended human deaths from dog rabies have done so in large part thanks to dog vaccination, access to crucial human post-exposure treatment and surveillance to monitor the disease and ensure that it is not being introduced into rabies-free zones.

That is why we must continue to strive to provide countries with support for vaccine-led strategies alongside more effective surveillance for the disease, which have also formed the centrepiece to the response of the current Covid-19 pandemic.

Rabies, despite its long history, is no less a deadly threat. Yet, while most governments have accepted that “Zero Covid” is not possible, the elimination of rabies is entirely possible through proven methods such as dog vaccination, as long as every country is adequately prepared with the tools and resources we know can work.

Professor Louis Nel is the Executive Director of the Global Alliance for Rabies Control.

Image Credits: WHO/ Daniel Stewart.

climate change
Globally, extreme temperature events are increasing in frequency, duration, and magnitude – leading to more heat-related illness, reduced water resource access and also reduced labour outputs by agricultural and other outdoor workers.

Surging fossil fuel use to feed a COVID economic recovery and record numbers of heat-wave days for older groups and agricultural workers; these are just a few of the sobering messages contained in the new Lancet Countdown on Health and Climate Change,  just 10 days before the start of the Glasgow Climate Conference. 

The report, published on Thursday, offers a view of humankind’s future on a warming planet from the health endpoint – with the pace and intensity of heat waves, storms, floods, and droughts increasing, depleting food production and degrading air, water, and other natural ecosystems.  

While most of the world’s attention in 2020 was focused on the COVID pandemic, some 51.6 million people were directly impacted by climate change-related extreme weather, the report notes.  

Already, people aged 65+ suffered from 3.1 billion more “person-days” of heatwave exposures in 2020, as compared to the 20 years between 1986 and 2005, the Lancet Countown also finds. 

Infectious disease zones are expanding with warmer seasons and temperatures as “climate change and its drivers are creating ideal conditions for infectious disease transmission, potentially undoing decades of progress to control diseases such as dengue fever, chikungunya, Zika, malaria, and cholera,” the report stated.

Fossil fuel subsidies continue apace 

Traffic jam in Dhaka (Bangladesh) – Fossil fuel burning, including for unsustainable urban transport systems, leads to deadly air pollution emissions that kill millions every year – as well as exacerbating physical inactivity and traffic injury.

With the world already 1.2℃ higher than the pre-industrial period, warming trends are hitting ever harder in poor regions, which are experiencing the worst effects of heat waves, sea level rise and other intertwined environment and health emergencies. 

Some 79% of losses in labour capacity due to heat waves, for instance, is occurring in the agricultural sector of low-income countries – the ones that can least afford to lose food production capacity.  

And yet the world continues to subsidize fossil fuels apace –  tens of billions of dollars annually in some countries, according to a 2018 survey of 84 countries responsible for around 92% of global CO2 emissions. Post-pandemic indicators suggest little change in those trends with increased fossil fuel consumption fueling economic rebounds from COVID.  

And even as the Countdown was issued, policymakers from countries such as Japan, Australia and Saudi Arabia were reported to be looking for ways to tamp down the key findings from a forthcoming UN scientific report about the dangers of continued fossil fuel use. The comments on the latest draft assessment report by the Intergovernmental Panel on Climate Change (IPCC) were released by a Greenpeace team of UK journalists, Unearthed.

UN advises concrete action for future generations

UN Secretery-General Antonio Guterres

The UN warns countries primarily responsible for global CO2 emissions to take ‘concrete action now’, ahead of the COP 26 UN Climate Change Conference in Glasgow, starting 31 October. 

“The carbon pollution of a handful of countries has brought humanity to its knees, and they bear the greatest responsibility,” said UN Secretary-General Antonio Guterres, during a Thursday afternoon press conference.

“Now before Glasgow, G20 leaders will meet in Rome, and they know their economies are responsible for four-fifths of planet-heating carbon pollution.”

The Group of 20 Summit, or G20, will take place in Rome 30 – 31 October, with the need to curb greenhouses gases high on the agenda for the gathering of the twenty richest’s countries.

Guterres advised these countries: “My message to them is clear: Do not fiddle with half measures and shallow promises while our planet burns. Do not pass up this opportunity to do the right thing for current and future generations.”

‘Grim Warnings’ 

Potential labor lost due to heat-related factors in each sector

“These are grim warnings that for every day that we delay our response to climate change, the situation gets more critical,” Marina Romanello, lead author of the Lancet Countdown report said. 

The report used 44 indicators to track the rise in health impacts of climate change and the current health consequences of a “delayed and inconsistent” response of countries globally. 

“This year’s indicators give a bleak outlook: global inequities are increasing, and the direction of travel is worsening all health outcomes. Health services in low-income and middle-income countries are in particularly urgent need of strengthening… Succumbing to the climate emergency is not inevitable,” stated a Lancet editorial, published at the same time as the Countdown report.  

As countries, diplomats and activists prepare to meet at the COP 26 UN Climate Change Conference, the report aims to make health a more central focus of  the intense debates expected at the conference – a setting where the issue has often remained confined to the sidelines. 

“Climate change is here and we’re already seeing it damaging human health across the world,” Prof Anthony Costello, Executive Director of the Lancet Countdown said.

Current global commitments insufficient to halt temperature rise

Global land area affected by drought events per month

The overriding goal of Glasgow is to keep the average global temperature from rising over 1.5°C in the course of this next century – as set forth at the 2015 Paris Climate Conference.

A rise over this threshold would mean even more flash floods, droughts, heatwaves and disease spread. 

But the world is now 1·2°C warmer than in the preindustrial period (1850–1900), with the last seven years being the hottest on record yet. So there is growing panic about holding to a 1.5°C limit among policymakers, scientists and activists aware of the dangers.  

And in fact, global average temperatures right now are on a trajectory to rise by around 2·4°C average global temperature, in line with woefully insufficient global decarbonisation commitments seen so far. 

And at current rates, the world will take 150 years to fully decarbonise the energy systems, the report warns.

Coming up next: more epidemics, increasing inequalities

Change in climate suitability for infectious disease

As the world’s temperature rises, the devastating impacts of heatwaves, drought and forest fires have been well reported in countries like the U.S and Canada. 

But in low and middle income countries, rising average temperatures and altered rainfall patterns threaten to reverse decades of progress made in addressing food and water insecurity that are fundamental to peoples’ good health.

Just as alarming are the risks of new epidemics of vector-borne, air-borne and water-borne diseases – as they spread their infectious arc to more regions of the world and more days in the year. 

The number of months suitable for malaria transmission, for instance, has increased by 39 percent in the highland areas of low-income countries where the disease is endemic. 

Today, dengue and Zika virus, and chikungunya majorly affect populations in central America, South America, the Caribbean, Africa, and south Asia. However, while low-income countries remain the most vulnerable, the epidemic risks for these diseases is increasing globally, the report warns. 

Northern European and US coastal areas are also becoming more conducive to bacteria which produce gastroenteritis, severe wound infections, and sepsis.

Air pollution continues to choke & kill 

Deaths attributable to exposure to PM 2.5

The health impacts of air pollution continue to lead to millions of lives lost every year – with 7 million deaths from both household and outdoor air pollution sources, according to WHO. 

A third of those air-pollution related deaths are attributable to fossil-fuel combustion, with medium-and-high HDI countries seeing the highest mortality rates. 

And while air pollution is just one of multiple health risks associated with a carbon-addicted lifestyles, diets and economies. 

For instance, promoting healthier, low-carbon diets that are heavier in plant-based foods, as well as urban environments conducive to more active  lifestyles would “prevent millions of deaths annually from reduced exposure to air pollution, healthier diets, and more active lifestyles, and contribute to reducing health inequities globally,” the report finds. 

Low-Income countries face the biggest economic losses – including reduced farmworker capacity   

Potential labor lost due to heat-related factors in each sector

Low income countries ultimately will bear the biggest economic brunt of the climate crisis – particularly as rising temperatures affect people’s ability to work outside, leading to more heat-related illness and reduced earnings.

In countries at the lowest end of the human development index (HDI), estimated income losses in 2020 were equivalent to 3.9–7.6 percent of GDP, depending on the degree of shade or sun exposure during agricultural and construction work.

And that is without regards to the effects on unpaid and informal domestic and agricultural labour.   

Although countries in the highest income countries have collectively made the most progress in the decarbonisation of the energy system, they are still the main contributors to carbon-dioxide emissions.  Collectively, high-income countries represent 45% of the world’s total contribution to climate emissions – although China remains the largest single contributor.    

Only 18 percent of all funds earmarked for economic recovery from the COVID-19 pandemic by the end of 2020 involved a reduction of greenhouse gas emissions. 

This meant that despite the dip seen during the pandemic, the year 2020 saw a rise in greenhouse gas emission by 5 percent – returning global anthropogenic CO2 emissions back to their peak, pre-pandemic levels. 

States the report: 

“The overshoot in emissions resulting from a carbon-intensive COVID-19 recovery would irreversibly prevent the world from meeting climate commitments and the Sustainable Development Goals and lock humanity into an increasingly extreme and unpredictable environment. Data in this report expose the health impacts and health inequities of the current world at 1·2°C of warming above pre-industrial levels and supports that, on the current trajectory, climate change will become the defining narrative of human health.

“By directing the trillions of dollars that will be committed to COVID-19 recovery towards the WHO’s prescriptions for a healthy, green recovery, the world could meet the Paris Agreement goals, protect the natural systems that support wellbeing, and minimise inequities through reduced health effects and maximised co-benefits of a universal low-carbon transition.

“This pivotal moment of economic stimulus represents a historical opportunity to secure the health of present and future generations.”

Image Credits: Flickr – joiseyshowaa, Oxfam East Africa, UN, The Lancet.

Gordon Brown, WHO Ambassador for Global Health Financing,

Western stockpiles of surplus COVID-19 vaccines are predicted to reach 600 million doses by the end of the year and millions might expire – yet the global vaccine facility COVAX is still short of 500 million doses to vaccinate 40% of the population by December.

This is according to former UK Prime Minister Gordon Brown, recently appointed as the World Health Organisation’s (WHO) Ambassador for Global Health Financing, who addressed the WHO’s media briefing on Thursday.

He described the next 10 days leading up to the G20 meeting in Italy at month-end as “decisive”.

“If at the G20 summit in Italy, the world’s richest countries cannot mobilise an extraordinary, expedited airlift of doses to the unvaccinated and unprotected of the world, and do so starting immediately, an epidemiological economic and ethical dereliction of duty will shame us all,” said Brown.

He called for a “globally coordinated, month by month operational plan and timetable” to transfer unused vaccines being held by the richest countries of the world to the world’s poorest countries.

Medecins san Frontiers (MSF) has estimated the figure of Western surplus doses for the 10 richest countries to be in the region of 870-million doses by year-end, while Brown said that this figure could balloon to one billion by February.

COVID kills thousands of health workers

At least 115,000 health workers have died of COVID-19 between January 2020 and May 2021 yet millions are still unvaccinated, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus.

“In Africa, less than one in 10 health workers have been fully vaccinated. Meanwhile, in most high-income countries, more than 80% of health workers are fully vaccinated,” Tedros told the briefing.

This is not a vaccine manufacturing problem, he added, but “an indictment on the countries and companies that control the global supply of vaccines”. 

“High and upper-middle-income countries have now administered almost half as many booster shots as the total number of vaccines administered in low-income countries,” said Tedros – but COVAX was in the dark about how many doses it would be getting and when.

It needed 500 million vaccine doses to vaccinate 40% of the world’s population by the end of the year, but 82 countries were in danger of missing this target, mostly because of a lack of supply.

“The G20 countries have pledged to donate more than $1.2 million to COVAX. So far only 150 million doses have been delivered,” said Tedros.

“For most donations, we have no timeline. We don’t know what’s coming and when manufacturers have not told us how much COVAX will receive, or when we receive it. We cannot have equity, without transparency.”

Tedros also called on wealthy countries and vaccine manufacturers to “share know-how, technology, licences and waive intellectual property rights”, adding  “we’re not asking for charity; we’re calling for a common-sense investment in the global recovery”.

Ahead of next week’s G20 summit next week, the ACT Accelerator is going to release a new 12-month strategic plan and budget to set out the actions and resources needed to achieve the WHO’s global vaccination targets. 

“It’s clear what needs to happen. The countries that have already reached the 40% target, which includes all the G20 countries, must give their spot in the vaccine delivery queue to COVAX and AVAT [the African Vaccine Acquisition Trust],” said Tedros.

Huge nurses’ shortage looms

Annette Kennedy, President of the International Council of Nurses

The WHO and partners have called on all countries to improve monitoring and reporting of infections and deaths among health and care workers, ensure they are prioritised for COVID-19 vaccines and enjoy “safe and healthy working conditions” including regular salaries, pay equity, appropriate education, career opportunities, and social protection. 

Describing the deaths as an underestimate, Annette Kennedy, President of the International Council of Nurses (ICN), said that deceased nurses’ families did not get compensation because COVID-19 was not recognised as an occupational health injury.

Lamenting the deaths, Kennedy asked: “Is it that health care workers lives mean so little? Is that governments do not realise that they have a duty of care to their health workers, the most valuable resource?” 

She added that nurses were “burnt out, devastated and physically and mentally exhausted” from working long hours in dangerous conditions, often without personal protective equipment (PPE), during the pandemic.

She also predicted a dire shortage of nurses in the next decade, with as many as 13 million – half the global workforce – could leave the profession in the next decade, mostly retiring or looking for better working conditions.

Image Credits: Adnan Abidi/Flickr.

German Chancellor Angela Merkel arriving at the EUCO. Germany is one of the key opponents of the TRIPS waiver.

Health activists have appealed to the European Council (EUCO) to discuss a waiver on Trade-Related aspects of Intellectual Property (TRIPS) on all health goods necessary to address the COVID-19 pandemic, but there is no indication that this is on the agenda of the meeting which started in Brussels on Thursday afternoon.

While COVID-19 is on the agenda, the invitation letter from EUCO President Charles Michel to Member States simply states that “we will touch upon international solidarity, to ensure the speedy delivery of vaccines to countries most in need”. 

The main focus of the COVID-19 discussion will be on vaccination within Europe itself in the face of rising COVID-19 cases in some countries despite vaccinations.

“The pandemic is not over yet and figures are on the rise in several member states,” Michel notes in his letter. “Vaccination has brought significant progress in the fight against COVID-19 but more still needs to be done, especially regarding vaccine hesitancy and disinformation.”

Health Action International, Human Rights Watch, One Campaign, Oxfam, The People’s Vaccine Alliance have written to Michel requesting that the TRIPS waiver be discussed at the meeting, which ends on Friday.

Pointing out that “massive Covid-19 vaccination campaigns have allowed European Union (EU) Member States to scale back restrictions and those living within the EU are gradually going back to offices, classrooms and dining venues”, the letter adds that “for many outside the EU there is no semblance of a return to normal as access to vaccines and other life-saving technologies are still not guaranteed, and their human right to health not fulfilled.”

Noting that “the need for scaling up vaccine production and therapeutics was never more acute”, the letter points out that South Africa and India submitted a proposal to waive certain rights and obligations of the World Trade Organization (WTO) TRIPS treaty over a year ago.

“Despite growing support from governments, civil society and academics, and the calls from European Parliament and elected officials, a handful of governments, led by the European Commission, oppose the proposal and refuse to engage in meaningful negotiations,” the letter notes.

However, it adds, governments have human rights obligations concerning international cooperation. 

EUCO only considered, briefly, the issue of the waiver in November 2020, but hasn’t addressed it since, according to the activists.

“This is unacceptable. The institutional separation of powers must not impede the accountability of actions taken on behalf of the EU, especially when there is no unanimity among members and when such actions have consequences for global health and the EU’s reputation as a human rights and moral leader,” it adds.

They call on Michel to allow countries to discuss the TRIPS waiver at EUCO, and raise it at the next G20 meeting t on 30-31 October, and at the WTO Ministerial Conference from 30 November to 3 December.

 

Teenage TB patients in a hospital in Vietnam.

The days of people with rifampicin-resistant tuberculosis (TB) taking up to 20 pills daily, interspersed with injections,  for up to 20 months might be over.

This follows the release on Wednesday of the preliminary results of a trial of a six-month oral treatment that researchers found to be substantially more effective than the current standard of care.

The TB-Practecal trial tested a six-month regimen of bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM), against the locally accepted standard of care. 

The trial involved 552 patients at seven trial sites across Belarus, South Africa and Uzbekistan.

“Some  89% of patients in the BPaLM group were cured, compared to 52% in the standard of care group. Tragically four patients died from TB or treatment side effects in the control group,” according to trial leaders Medecins Sans Frontieres (MSF), who revealed the findings at the 52nd Union World Conference on Lung Health.

“Patients were telling us how hard it was to adhere to treatment, but little progress was being made to find kinder treatments because diseases most prevalent in low- and middle-income countries don’t attract investment. So we were compelled to pursue new treatment options ourselves. These results will give patients, their families and healthcare workers worldwide, hope for the future of DR-TB treatment,” Dr Bern-Thomas Nyang’wa, MSF Medical Director and Chief Investigator of the trial, told the Union press conference on Wednesday.

Around 500,000 people develop rifampicin resistant tuberculosis (RR-TB) annually, and this intervention could save lives and substantially improve the quality of life of people with rifampicin-resistant TB.

Genome sequencing

Meanwhile, the conference also heard from researchers who used genome sequencing to effectively predict strains of tuberculosis susceptible to antibiotics that were likely to develop drug resistance.

The researchers looked at drug-susceptible bacteria and aimed to identify mutations that would increase the probability of a bacteria becoming resistant in the future. The mutations confer “pre-resistance”. Monitoring these mutations could prevent the amplification of drug resistance in the population by targeting those bacteria more likely to become resistant. 

We found that isoniazid mono-resistance backgrounds have a much higher risk of acquiring further rifampicin resistance than susceptible backgrounds,” said lead author Arturo Torres Ortiz, a PHD Student at  Imperial College in the UK.

“Rapid molecular tests usually focus on rifampicin resistance, which means that isoniazid mono-resistance is missed. This results in amplification into multi-drug resistance. We thus recommend that rapid molecular tests also identify regions associated to isoniazid resistance-conferring mutations.”

Image Credits: globalgiving.org.

COVAX
COVAX vaccine deliveries in Africa.

The global vaccine facility, COVAX, is on the cusp of delivering large amounts of vaccines to countries that need them the most – but will poorer countries have the ability to properly absorb these?

And how can COVAX ensure that it has the trust of low and middle-income countries (LMICs) who need the vaccines most, given complaints about its lack of transparency by the African Union’s vaccine envoy?

These are some of the issues flagged in a recent review of the Access to COVID Tools Accelerator,(ACT-A) of which COVAX is the most prominent project, with diagnostics and therapeutics forming the other pillars

The global vaccine alliance, Gavi, which manages COVAX, told Health Policy Watch that the coming months “will represent the busiest period of the largest and most complex roll-out of vaccines in history”. 

COVAX’s latest public supply forecast projects that it will have around 1.4 billion vaccine doses ready for delivery by end of year – 1.2 billion for the world’s poorest 92 countries to enable them to vaccinate 20% of their populations.

More support for countries to absorb vaccines

The review recommends “greater downstream support” to help LMIC to absorb more vaccines, something that Gavi says has been addressing over the past few months.

For instance, there has been a massive roll-out of ultra-cold storage facilities as the mRNA vaccines Pfizer and Moderna vaccines need to be stored at very cold temperatures.

“Over the last few months we’ve seen the largest roll-out of ultra-cold chain in history: hundreds of units to 47 countries in under five months,” a Gavi spokesperson said.

However, Gavi added that “ultimately, however, delivery is the responsibility of participating countries and so it is important that countries are able to access all sources of support for delivery”. 

Gavi and its alliance members, including WHO and UNICEF, have been working with many of these countries for two decades, and work closely with national governments and partners to monitor, identify and help to resolve delivery challenges. 

While Gavi acknowledges that new challenges will emerge once doses start arriving in larger volumes, it is “confident at least that systems are in place to ensure that when there is a risk of wastage, to ensure doses are redeployed rapidly to other countries”.

The cold storage facility at Pfizer’s warehouse in Kalamazoo, Michigan.

COVAX undermined by bilateral deals

When COVAX was set up, it declared its aims to be “speeding up the search for effective vaccines for all countries” and “supporting the building of manufacturing capabilities and buying supply, ahead of time, so that two billion doses can be distributed fairly in the places of greatest need, worldwide, by the end of 2021”. 

COVAX aimed to pool investment in candidate vaccines and, if any were successful, become the procurement facility for the entire world, wealthy and poor countries alike. Wealthy countries would pay for their own doses while the Advance Market Commitment (AMC) would use donor funds to help buy vaccines to cover 20% of people living in the world’s 92 poorest countries.

But COVAX was so underfunded that it couldn’t buy enough vaccines, and its paralysis fuelled bilateral deals between pharmaceutical companies and the high-income countries (HIC) that were also COVAX members.

“The critical lesson to be learned from this experience, and the current inequity in access to vaccines between HICs and LMICs, is the need for dedicated resourcing to be in place – before a pandemic occurs,” the Gavi spokesperson told Health Policy Watch. 

“It is notable that, building on the initial $4 billion raised via upfront payments and donor pledges in 2020, the COVAX AMC was only fully funded in June 2021 – by which time bilateral deals between governments and manufacturers had locked up most of the doses available in 2021,” said Gavi.

If funding had been available to COVAX earlier, says Gavi, the facility “would have been able to secure earlier supplies of vaccine from the manufacturers who are currently prioritising those bilateral customers”. 

“This, combined with transparency and accountability from manufacturers on which deals are being prioritised and when, could have avoided many of the supply challenges COVAX has faced to date.”

Gavi believes that it was important to include all countries “given the unknowns” about vaccine development at the start, but it is currently finalising new rules of engagement for the wealthy self-financing countries for next year.

Lack of LMIC representation

A COVAX vaccine delivery of vaccines is offloaded in Abuja in March

The ACT-A review notes “a lack of inclusion and meaningful engagement of LMICs, regional bodies, civil society organisations (CSO), and community representatives” in the ACT-A.

Some LMICs have felt left in the lurch as COVAX has failed to deliver vaccines while those countries that broke ranks and did private deals with pharmaceutical companies 

In July, Strive Masiyiwa, African Union Envoy on Vaccines and head of the African Vaccines Acquisition Task Team, accused COVAX of not being upfront about its vaccine supply problem early enough, resulting in false complacency amongst members who thought their vaccine supply was secure.

Other civil society members have said that COVAX was based on a Western charity model.

Dr Bruce Aylward, the World Health Organization’s (WHO) lead on COVAX, said the concern that the ACT-A Council was not balanced across low, middle and high-income countries “is going to have to be addressed and rebalanced”.

“We need to go back and look at every single one of the engagement mechanisms that already exists…  if it’s not working, we need to fix it,” Aylward told a WHO media briefing last week.

The Global Fund to Fight AIDS, TB and Malaria, which manages the diagnostics pillar of the ACT-A, said that the limitations identified by the review would be addressed by a “revised strategy and budget which is being prepared by the ACT-A partners for publication by the end of October”, a Global Fund spokesperson told Health Policy Watch.

However, Gavi says that lower-income countries are on the Gavi Board and committee structures as well as in the COVAX AMC Engagement Group and the WHO also gives member states regular briefings on COVAX. 

“All of these groups are actively involved in the governance and decision making for COVAX design, strategy and policy,” says Gavi, adding that “each country involved in COVAX has a dedicated team focused on providing tailored information and support, both at the Gavi Secretariat or COVAX Office level as well as via UNICEF and WHO country offices”. 

“These teams liaise directly with country-appointed focal points, usually at ministries of health, and communicate on a daily basis to receive participants’ feedback on various COVAX processes,” said Gavi.

Diagnostics and therapeutics

The review complemented ACT-A’s COVID-19 Response Mechanism (C19RM), which is based on the Global Fund’s well-established health procurement and distribution system, which was already operating in 100 countries. 

To address its three priority diseases – HIV, TB and malaria – the Global Fund had developed wambo.org, an online marketplace for medicines and health commodities that enables  countries to get cheaper prices through pooled procurement.

“When the COVID-19 crisis hit, we opened wambo.org to all countries and organisations so they can access pooled procurement volumes of quality-assured health products, including COVID-19 products,” said the Global Fund spokesperson.

Over 38 million diagnostic tests have already been procured for 90 countries through the Global Fund’s Pooled Procurement Mechanism and wambo.org. Countries could also buy oxygen and PPE on wambo.org. 

While many countries are not doing nearly enough COVID-19 testing, the Global Fund identifies those with the lowest number of tests (less than seven tests per 1000 population per week for 24 months) and offers support to procure rapid tests or laboratory strengthening support.

The review noted that the ACT-A therapeutics pillar “does not yet have a clearly articulated procurement structure to supply countries or to negotiate contracts”.

Tanzanian and US officials celebrate the arrival of the first COVID-19 vaccine donations in the country.

Funding the gap

The review notes that there is a funding gap of $16.6 billion and warns that some of the country pledges to COVAX have not yet been turned into contributions agreements. 

It also recommends that ACT-A should ensure “regular access to up-to-date consolidated financial data to enhance trust and accountability between donors and agencies”. 

WHO’s Aylward puts the shortfall over the next year to be closer to $20 billion “to get equitable rollout” of vaccines, diagnostics and therapeutics to defeat COVID-19. 

“If we go forward next year with the same gaps we had last year, the pandemic will be prolonged,” said Aylward, adding that WHO Director-General Dr Tedros Adhanom Ghebreysus was lobbying G20 finance and health ministers to close the financing gap.

 

Image Credits: UNICEF, Pfizer, NPHCDA.

Researchers describe new findings about TB transmission and diagnosis tools, on the first day of the 52nd Union World Conference on Lung Health

New research published at the opening of the 52nd Union World Conference on Lung Health has demonstrated that routine breathing can transmit tuberculosis even more effectively than coughing – in a finding that also echoes one of the signature lessons from the COVID-19 pandemic about SARS-CoV2 transmission. 

While large droplets jammed with bacteria produced by coughing has long been assumed to be the main course of TB transmission – the new study published on the pre-print server bioRxiv, demonstrates how even more TB bacterium, like COVID, may be transmitted by tinier aerosol droplets released during the course of natural breathing. 

The study by a team of University of Cape Town researchers was just one of a number of new findings released at the opening day of the iconic Union conference – which is meeting virtually for the second year in a row. 

Other new findings released in the first day of the three day, global event (19-22 October)  include a new gene-based blood-prick test for initial TB screening – particularly useful for children who do not produce sputum-filled coughs; and the use of face masks to capture, and screen for, TB and multi-drug resistant tuberculosis (MDR-TB)  as yet another novel diagnostic tool.   

But it is the new study on aerosol TB transmission that is one of the most revolutionary – challenging the fundamental dogmas around TB transmission. Using sensitive measurement devices, the study documents how so-called ‘tidal breathing’ – routine inhalation and exhalation by a TB-infected person – will typically release over 90% TB bacteria (Mycobacterium tuberculosis –Mtb), over the course of a routine day – as compared to only 7% by coughing. 

That’s partly because an infected person will simply breathe many more times  – some 22,000 times in fact, as compared to about 500 coughs.  In contrast to the large droplets released by a cough, most of the bacteria released by breathing are in the form of tinier aerosols, which can remain suspended in the air and travel much further as well. 

Findings on Aerosols Echo lessons from SARS-CoV2 – But Research Preceded the Pandemic 

The signature findings echo lessons learned from the COVID pandemic – where the big aerosol transmission risks of SARS CoV2 have now been well acknowledged – despite fierce resistance among some experts – including at the World Health Organization – in the pandemic’s early days.   

They also illustrate why traditional public health measures such as better housing, less crowding, and improved ventilation may deserve more attention in modern TB control – strategies that have perhaps been too often sidelined to the shadows by modern drug therapies.

Despite the comparisons, the research team at the University of Cape Town has been studying the aerosol transmission of TB long before COVID appeared on the horizon, asserted the study’s lead author, Ryan Dinkele, in a press briefing on Tuesday morning.  

They did so with the help of a device developed by Robin Wood, another University of Cape Town researcher and study co-author, which can more sensitively detect the bacteria in aerosols emitted by a TB-infected person’s breath or cough.

“We have been working on this technique for a long period of time,” Dinkele said. “We did chat about whether we should implement our system for COVID. COVID came across our lines during this process.”

Conference sheds light on a neglected disease 

Tereza Kaseva, director of the WHO Global TB Programme

The three-day conference on lung health, attended by several thousand specialists and policymakers from around the world also casts its net on a wider array of respiratory diseases  – including pneumonia, asthma, chronic obstructive pulmonary disease (COPD) – and COVID-19.  Sessions also will address the two biggest environmental risk factors for lung health – tobacco smoke and air pollution.

However, most of the conference’s attention is focused on TB, which paradoxically remains one of the deadliest diseases on the planet, despite the fact that it is also one of the oldest.  And the COVID pandemic has only made that worse – dramatically reducing the number of TB-infected people who are being diagnosed and treated in 2020 – according to the latest Global TB Report, released by WHO just last week. 

“TB remains critically underfunded,” said Tereza Kaseva, director of the WHO Global TB Programme. “Global spending on TB is $5.3 billion, less than half of the $13 billion annually that we need,” she stressed, saying that the world urgently needs to invest in new TB diagnostics, treatments, and ultimately, vaccines.     

Additionally, TB is a “social disease” whose transmission is facilitated by poverty and marginalization, making it a disease endemic to many migrant groups and informal communities, she and others emphasized.  

Co-morbidities of TB & COVID are unexplored

Uvistra Naidoo, South African pediatric doctor and TB/COVID survivor

“TB is grossly underfunded, and that is why we are behind in the race,” said Uvistra Naidoo, a pediatric doctor and himself both a TB and COVID survivor. Not only governments are to blame, however, he added: 

“When I compare with HIV or cancer,” he added, “there is a lot more activism that happens on behalf of the patient in the latter.”

The COVID pandemic has only added fuel to the fire in another way – not only shifting resources but also saddling many former TB patients, like himself, with additional COVID disease risks.

Those co-morbidities are still poorly understood, said Naidoo who knows this from bitter first hand experience.

After beating drug resistant TB in a difficult three-year battle –  he came down with COVID in 2020, and continues to battle the effects of long COVID today.

“I picked up severe COVID-19 twice,” he said, speaking at The Union session with the aid of a nasal oxygen cannula.

“I’ve got complications to my heart, my lungs, and my adrenal glands recently. We’ve just found out and as you can see, I’m still intermittently oxygen dependent,” said Naidoo. He described how COVID, when it struck South Africa, infected almost everyone in his family  – as well as many in his professional community.

“I’ve lost a father, I’ve lost 25 medical colleagues, doctors and nurses. I’m beyond humbled. I think the courageous thing that we can show the general public out there is that to actually just describe with the TB front and the COVID-19 front, that we don’t know what we’re doing just yet.” 

Image Credits: Roche , The Union .

taliban afghanistan polio
Visiting one neighbourhood after the other to vaccinate Afghan children against polio is the hope to eradicate the disease.

The World Health Organization and UNICEF welcome the decision made by Taliban to support the resumption of house-to-house polio vaccination across Afghanistan.

The vaccination campaign, which begins 8 November, will be the first in over three years to reach all children in Afghanistan, including more than 3.3 million children in some parts of the country who have previously remained inaccessible to vaccination campaigns.

A second nationwide campaign has also been approved and will be synchronized with Pakistan’s own polio campaign in December.

WHO officials have said that this is an “extremely important step in the right direction.” 

“We know that multiple doses of oral polio vaccine offer the best protection, so we are pleased to see that there is another campaign planned before the end of this year.  Sustained access to all children is essential to end polio for good.  This must remain a top priority,” said WHO Representative in Afghanistan Dapeng Luo.  

Both WHO and UNICEF have made joint calls in August for the establishment of a “humanitarian airbridge” for the sustained and unimpeded delivery of much-needed medicines and supplies to millions of people in aid, following the rise to power of the Taliban. 

Taliban seeks international recognition with polio campaign 

Though WHO has called the resumed campaign a much-needed step forward, others have pointed out the Taliban’s desperate grab for international recognition.

“The Taliban are desperately seeking international recognition, that is for sure.  And, for that, they do seem to be trying to behave in a much civilized manner,” said Thomson Reuters journalist Shadi Khan, who has also contributed to Health Policy Watch.

Khan pointed out the efforts of the international humanitarian community in weakening the Taliban’s stance on polio vaccines, though these efforts are at odds with other extremist groups in the region.

“Over the past few years, the Taliban’s stance on polio vaccines has softened drastically thanks to the untiring efforts of the humanitarian community in engaging people at grassroots for awareness and immunization in Afghanistan as well as in the neighbouring Pakistan. However, hardliners among the Taliban and other extremist groups such as the so-called Islamic State Khorasan and others are seriously opposed to the vaccines as they see it part of the West’s alleged conspiracy against Muslims. Such individuals and groups continue to have significant clout in Afghanistan and can orchestrate deadly attacks even against mainstream Taliban like in a Kabul mosque”.

With opportunity to eradicate wild poliovirus, vaccination remains crucial 

Inactivated polio vaccine

With only one case of wild poliovirus reported so far in 2021, Afghanistan now has an opportunity to eradicate polio.

Pakistan and Afghanistan, both members of the WHO Eastern Mediterranean Region, are the only two polio-endemic countries in the world. 

While cases have declined dramatically, when compared to the 56 reported cases in 2020, surveillance continues to remain an issue in Afghanistan. 

This means that restarting the polio vaccination campaign remains crucial to preventing any significant resurgence of polio within the country and mitigating any potential risk of cross-border and international transmission. 

“This decision will allow us to make a giant stride in the efforts to eradicate polio,” said Hervé Ludovic De Lys, UNICEF Representative in Afghanistan.  

“To eliminate polio completely, every child in every household across Afghanistan must be vaccinated, and with our partners, this is what we are setting out to do,” he said.

In addition to the polio vaccine, children aged 6 to 59 months will also receive a supplementary dose of vitamin A in the months during the upcoming campaign. 

UN, WHO engaging with Taliban in supporting immunizations

The violence in Afghanistan has taken a toll on an already fragile health system.

The polio programme has already begun making preparations to rapidly implement the nationwide vaccination campaign, in the midst of ongoing high-level dialogue between the UN, WHO, and the Taliban. 

WHO officials have called it a win not only for Afghanistan, but for the region as a whole as it works to achieve wild poliovirus eradication.

“The urgency with which the Taliban leadership wants the polio campaign to proceed demonstrates a joint commitment to maintain the health system and restart essential immunizations to avert further outbreaks of preventable diseases,” said Dr Ahmed Al Mandhari, WHO Regional Director for the Eastern Mediterranean. 

WHO Director General Dr Tedros Adhanom Gheybreyesus noted last month that engaging with the new government is necessary to support the people of Afghanistan during this time, when the overall health system of the country remains vulnerable.

All parties have agreed on the need to immediately start measles and COVID-19 vaccination campaigns, which will be complemented with the support of the polio eradication programme and other outreach activities that will urgently begin to deliver other life-saving vaccinations. 

For their part, Taliban leaders have promised to remove “impediments” to aid, to protect humanitarian workers, and to safeguard aid offices, according to a 15-point proposal addressed to the UN’s humanitarian aid coordination arm, OCHA, and signed by the Taliban’s acting minister of foreign affairs, Amir Khan Muttaqi.

Image Credits: Canada in Afghanistan/UNICEF/Flickr, Flickr – Sanofi Pasteur, British Red Cross/Twitter.

WHO, other UN and humanitarian agencies recruited hundreds of staff to respond to DRC’s 2018-2020 Ebola response who received little or no real training in how to prevent and respond to sexual exploitation and abuse.

The World Health Organization would allocate some US$ 15 million annually to ramp up training programmes for WHO staff and consultants in the Prevention of Sexual Exploitation and Abuse (PSEA), beginning with ten countries that have the “highest risk” profile, according to a draft plan under discussion with member states. 

The proposed “Management Response Plan”, presented to WHO member states in a closed door meeting last week, will focus on “putting the victim and survivor at the heart of prevention and response to SEA,” said a WHO spokesperson, who shared new details of the plan with Health Policy Watch on Monday.

The WHO plan  was developed in response to the recent findings of an Independent Commission that found widespread WHO staff and consultants supporting the agency’s response to the 2018-2020 Ebola outbreak in the eastern Democratic Republic of Congo had raped, harassed, and traded sex for jobs and other favours with Congolese women.  

“The findings reported by Independent Commission are horrifying,” the spokesperson added, echoeing statements made by senior WHO officials when the Independent Commission’s findings were first published. “WHO apologises unreservedly to the victims and survivors of these appalling events, as well as to their families and communities. 

“WHO is committed to ensuring the survivors get the support and assistance they need.  WHO will take every measure in its power to bring perpetrators to account, including referring to and collaborating with relevant national authorities on any criminal proceedings.”  

Accountability in reform of WHO culture  

Gaya Gamhewage, WHO director of Prevention and Response to Sexual Exploitation and Abuse, at the 28 September press briefing on the findings of the Independent Commission.

The new plan outlines a series of “immediate” actions to be taken between mid-October and end March 2022, including: “completing investigations, taking urgent managerial action and launching a series of internal reviews and audits,” the spokesperson said.

Medium term, from mid-November 2021 to end December 2022, the plan will prioritize: 

  • Embedding a “victim- and survivor-centred approach, framework and services”;
  • Establishing and enforcing “accountability and capacity of WHO personnel, managers and leaders for prevention and response to sexual exploitation, abuse and harassment (PRSEAH)”; 
  • Reform of WHO structures and cultures. 

A new PSEA focal point has already been dispatched to the eastern DRC, which reported its second Ebola case last week following the end of the 2018-2020 epidemic that struck Ituri and North Kivu provinces.

Other countries to be immediately prioritized for the training include: Afghanistan, the Central African Republic, the Democratic Republic of the Congo, Ethiopia, Nigeria, Somalia, South Sudan, Sudan, Venezuela, and Yemen, WHO said. 

Prevention was just a Box to be “Ticked” – Former UN worker tells Health Policy Watch 

The Commission’s findings, published last month, found that some 83 emergency responders to DR-Congo’s 2018-2020 Ebola outbreak, including at least 21 WHO employees and consultants, had likely abused dozens of Congolese women, obtaining sex in exchange for promises of jobs, as well as raping nine women – some of whom later became pregnant and gave birth. 

https://healthpolicy-watch.org/humbled-and-horrified-who-reacts-to-findings-on-dr-congo-sexual-abuse-but-will-high-level-who-officials-accused-be-investigated-too/

The Commission was formed in the wake of an investigation by The New Humanitarian and Thomson Reuters Foundation in September of 2020, which found evidence of widespread sexual abuse among the WHO and other UN responders – who used their positions of power to leverage sex from DRC women. 

The epidemic was a perfect storm for such abuse since the same UN agencies and humanitarian groups that had hired hundreds of local and international workers to respond to the deadly emergency also  failed to provide any real training in the sensitive balances of power that their new jobs entailed, one former UN PSEA counselor told Health Policy Watch in an interview.   

“It was a tick, it was a tick box exercise of like, Oh, we’ve got someone doing it, someone’s attending the meetings,” said the former UN worker, who asked not to be identified.

She said the lack of sensitivity to the risks of sexual exploitation by men freshly hired and empowered by their jobs was widespread among UN and humanitarian response groups – although WHO as the largest agency on the ground, also became the lightning rod for spreading rumors about abuse. 

Ebola response activities in DRC involved the massive recruitment of new WHO and UN staff – who received little or no training in how to use their positions of power in workplace relationships.

Senior UN Agency heads displayed little interest in the quality or extent of preventative training offered to the new response teams – leaving it to a handful of PSEA focal points to design and execute their own programmes. 

“I’d go out in person, and explain what is the difference between sexual harassment and sexual exploitation and abuse, and why that’s not the same; what is ok and what is not ok, and what the reporting mechanisms are; and what we mean by zero tolerance,” the former PSEA worker said.  

“But they [my supervisors] never even asked me about anything that I did until the New Humanitarian article came out.  By that time, I’d already left. I’d finished my contract – but suddenly they were interested in what the f-k, I was doing this whole time?” 

Plan to be developed as a three-year strategy  

Following feedback from member states, WHO’s new abuse and exploitation prevention plan is due to be published within the next few days.   

But it will remain a “living document” “drawing on the learnings during its implementation as well as on the experience of other UN Agencies, partners and Member states,” the WHO spokesperson said.

Ultimately, WHO will develop a full-fledged three year strategy, for the years 2023-2025, the spokesperson said. 

“WHO has allocated an initial US$7.6 million to immediately strengthen its capacity to prevent, detect and respond to SEA, in ten countries with the highest risk profile: Afghanistan, the Central African Republic, the Democratic Republic of the Congo, Ethiopia, Nigeria, Somalia, South Sudan, Sudan, Venezuela, and Yemen,” the spokesperson said.   

“WHO is also committing additional funds to address the longer-term surge in capacity that we need to implement the MRP. An initial estimate is that we’ll need about US$15 million a year, but we are still working on the details,” the spokesperson added. 

 

Image Credits: WHO AFRO, WHO AFRO/Twitter, WHO.