Older highly drug-resistant TB treatment (above) compared with new BPaL regimen (below).

In the face of the COVID-19 pandemic, tuberculosis mortality has started to increase for the first time in a decade. In 2020 alone, more than 1.5 million people died from TB. Every year, about half a million people develop a drug-resistant form of TB (DR-TB).

The vast majority of people with TB live in low- and middle-income countries, where access to tests and treatments for all diseases is often challenging. This lack of access means more than a third of all TB infections go unreported.

The problem is even more acute among those with drug-resistant forms of the disease. Since 2020, due in part to the impact of the COVID-19 pandemic on global TB control programs, the situation has been getting worse, not better. Less than 60% of DR-TB patients treated were cured in 2020.

Doctors reviewing a patient’s medication in a rural TB clinic in South Sudan.

Antimicrobial awareness

World Antimicrobial Awareness Week 2021 is drawing increased attention to the global health, financial, and security impacts of growing resistance to drugs the world has long relied on to treat many infectious diseases.

This is therefore a timely moment to examine the threats, progress, and needs relating to drug-resistant tuberculosis (TB) – the single largest cause of death from resistant infections.

The inadequacy of tools to effectively diagnose and treat DR-TB has led to this diagnosis and treatment gap, but recent advances could turn the tide. However, we need to protect these advances long enough for them to have a meaningful impact on the fight against TB.

New drugs need to be used appropriately, matched against the bacterial strains that are susceptible to them. New diagnostics can confirm this match. But using the new drugs to treat the wrong strains will inevitably lead to more infections becoming resistant to the new drugs, and the overall threat of drug resistance will continue to increase.

In the fight against DR-TB, time is of the essence. Slower diagnosis and treatment times increase the risk, giving the bacteria more time to become resistant. Increasing access to rapid testing and shorter drug regimens for DR-TB allows for patients to be tested and treated faster, increasing the prospects that patients would complete treatment.

Gold-standard molecular diagnosis can now be made when patients meet with their doctors. A new testing platform from an Indian manufacturer—endorsed by the World Health Organization in 2020 and available today in more than 50 countries—can provide both the initial diagnosis of TB and the detection of rifampicin resistance.

Next-generation tests for multi-drug resistant and extensively drug-resistant forms of the disease approved earlier this year mean clinicians can now generate rapid and accurate drug-resistance profiles, allowing doctors to start patients on better, targeted treatments. A pipeline of new, affordable point-of-care tools for both TB infection as well as drug resistance testing could be made possible with only a small fraction of the investments currently devoted to COVID-19.

Advances in treatment

Site initiation and training for MolBio TrueNAT HCV assay multi-center performance evaluation at St. Paul Hospital, Addis Ababa, Ethiopia.

On the treatment front, therapy for DR-TB had long been characterized by extremely lengthy drug regimens rife with debilitating side effects, such as hearing loss and kidney failure.

Those suffering from highly drug-resistant disease were routinely subject to therapy lasting 18-months or longer, with poor cure rates despite up to 14,000 pills. The financial and human resource cost of administering such therapies has restricted patient access to these treatments in low-income settings.

Recent advances in therapy for highly drug-resistant TB include a six-month, three-drug regimen with a cure rate of approximately 90% and a significantly lower price tag. It is now being procured by more than 30 countries – a promising start to widespread adoption.

Testing and treating are inextricably linked as pillars of fighting AMR. The right diagnosis does not matter if the treatment is intolerable and ineffective. And the best possible treatment only works if it is administered to a patient who actually has the disease for which it is intended.

Crisis of neglect

TB and COVID-19 are both respiratory diseases, with patients often presenting with a cough. But one is bacterial, requiring several specific antibiotics, and the other viral, requiring a different set of therapeutics, the first of which is only now being presented to regulatory authorities.

The important point is that we must be able to distinguish between different causes of the same symptoms and do it quickly. “Just in case” – or uninformed – antimicrobial use for a range of diseases in the absence of a definitive diagnosis drives resistance and puts our hard-won antibiotics at risk.

The ongoing battle against DR-TB is being waged by researchers and clinicians whose labs are starved for resources, and health systems striving to overcome a crisis enabled by decades of neglecting TB. In 2020, the death toll from TB globally was second only to COVID-19 among infectious diseases. And for TB, this death toll has happened for decades if not centuries and, without action, will continue unabated.

AMR has long been considered in global health circles as a silent threat, lacking urgency, resources, and focus. Yet DR-TB is a potent reminder that AMR is quickly getting louder and will become catastrophic if inaction continues.

As we shine a light this week on AMR, it’s important to remember a fact clearly illustrated by the COVID-19 pandemic: tackling a global health threat is a choice. It’s not science, but financial commitments and political will that are the greatest barriers to overcoming deadly infectious diseases.

Mel Spigelman
Bill Rodriguez
Mel Spigelman, MD, is the president and CEO of TB Alliance, a product development partnership dedicated to discovering and delivering better and faster TB cures. 
Bill Rodriguez, MD, is Chief Executive Officer of FIND, the global alliance for diagnostics. He has extensive experience serving as advisor to the World Health Organization and national governments on global HIV, Tuberculosis, Ebola, and COVID-19.

 

 

 

Image Credits: Dato Koridze , WHO/John Rae Photography, Ryan Ruiz/ FIND.

Austrian police tackle anti-lockdown protesters in Vienna over the weekend.

Other European countries may follow the example of Austria, which entered a nationwide lockdown on Monday, as COVID-19 cases continue to surge across the region.

New COVID-19 cases increased by over 3,5 million in a single week, and deaths by over 50,000, according to the latest report from the European Centre for Disease Prevention and Control (ECDC). 

German health minister Jens Spahn grimly warned on Monday that, by the end of winter, Germans could either be “vaccinated, recovered or dead”. ICU beds in the country are under pressure as Germany recorded 45,326 new daily cases on Tuesday and 309 new deaths, according to the Robert Koch Institute. 

As civil protests mounted and debate raged across Europe over COVID certificates and vaccine mandates, WHO’s headquarters remained largely silent about exactly what policies countries should follow, saying primarily that countries should pursue a “risk-based approach.”   

However, WHO’s European Regional Director Hans Kluge has been more assertive on both, saying that along with more mask wearing, requiring a COVID pass for entry to entertainment or workplaces “is not a restriction of liberty, rather it is a tool to keep our individual freedom.” 

“In order to live with this virus and continue our daily lives, we need to take a ‘vaccine plus’ approach,” said Kluge in a statement on Tuesday.

“This means getting the standard doses of vaccine, taking a booster if offered, as well as incorporating preventive measures into our normal routines,” said Kluge. Only 48% of Europeans report wearing a mask indoors

Kluge also appealed to citizens to “do everything we can by getting vaccinated and taking personal protective measures, to avoid the last resort of lockdowns and school closures”.

“We know through bitter experience that these have extensive economic consequences and a pervasive negative impact on mental health, facilitate interpersonal violence and are detrimental to children’s well-being and learning,” he added.

After that, outright vaccine mandates should be a “last resort” but that a “legal and societal debate would be “very timely,” Kluge said in a weekend interview with the BBC.   

The WHO expects “high or extreme stress” on hospital beds in 25 countries, and “high or extreme stress” in intensive care units (ICU) in 49 out of 53 countries between now and 1 March 2022.

In the absence of urgent action, WHO’s sprawling European region, which extends from the United Kingdom to Russia and the Central Asian republics of the former Soviet Union, could see another 500,000 deaths by March, Kluge warned. 

Austria sets out the toughest vaccine mandates seen so far in Europe 


Austria’s 20-day lockdown – which has closed all but essential businesses and largely confined people to their homes – is necessary to safeguard the country’s public health system, according to Chancellor Alexander Schallenberg.

Describing the measure as “drastic”, Schallenberg said that the lockdown was the only way out of the current crisis.

Austria also intends to introduce mandatory vaccinations on 1 February, which Schallenberg told the CNN was necessary as around 33% of Austrians – almost two million people – were still unvaccinated despite a year of intensive vaccination campaigns. He said there were a number of reasons, including mistrust of science, and political campaigning against vaccinations, including by the Freedom Party, one of the three biggest parties in the country’s parliament. 

Schallenberg said those who refused to get vaccinated would face an “administrative fine”, although the amount has not yet been set, and that there is a precedent for this in other countries such as France and Italy in regard to certain groups of people, as well as compulsory smallpox vaccine mandates in the 1940s.

Cases in Austria, Netherlands and Belgium are currently among the highest in Europe – reaching or exceeding 1,400 new infections a day. However, Slovakia has the highest case rate per 100,000 people, while Slovenia and Czechia are also struggling.

Statistic: Incidence of coronavirus (COVID-19) cases in the past seven days in Europe as of November 22, 2021, by country (per 100,000 population) | Statista
Find more statistics at Statista

Vaccine rates below EU average in Switzerland, Poland and elsewhere 

Switzerland and Poland, in contrast, are seeing only about half as many new cases a day. But with vaccination rates in countries like Switzerland and Poland even lower than those in Austria, health authorities there are also bracing for increases in the months ahead.   


Even so, large protests against COVID-19 vaccine passes, lockdowns and vaccine mandates were held over the past weekend in at least seven European countries including Austria, Germany, Italy and France. 

They are also potentially super-spreader events as few protestors wore masks.  

Protests in the Netherlands and Brussels turned violent with protestors overturning and setting police vehicles afire, while police barricaded protestors and fired water cannons in response. 

ECDC  warns of ‘high and rapidly increasing’ case rate

The European Centers for Disease Control (ECDC) has described the current phase of pandemic as being characterised by “a high and rapidly increasing overall case notification rate and a slowly increasing death rate”, with countries with the lowest vaccination rates worst affected.

Twenty of the 29 EU countries reporting data on hospital and ICU admissions or occupancy reported increases by mid-November, according to the ECDC.

Latvia has been under lockdown since late October. In the first two weeks of November, Latvia’s COVID-19 mortality rate increased to 268.6 deaths per one million population, the third-highest in the European Union (EU) and the European Economic Area (EEA) after Romania and Bulgaria. Romania and Bulgaria also have the lowest vaccination rates in the region, at 38% and 25% respectively.

Path out of restrictions lies in high vaccination rate 

Meanwhile, a new discussion paper published by the Centre for Economic Policy Research suggests that, once a country has reached a high threshold of vaccinations, their effect on mortality is sufficient that governments do not have to adopt hard lockdown measures.

The economists tested whether the UK experience, which has a vaccination rate of 83,5% to 89,8% (two doses) across its four counties, and where deaths have remained low despite a surge in new infections and few social controls, could apply in other countries. 


By examining data from 208 other countries from early 2020 to this month, the economists – from the universities of Southern California and Tel Aviv, the Asian Development Bank and the Internals Monetary Fund – concluded that “in the presence of a sufficiently high share of inoculated individuals, governments can shade down containment measures, even as infections are still rampant, without significant adverse effects on mortality”.

The impact of vaccinations on mortality was so significant that the economists were confident that lockdown measures could be dialled down despite finding that vaccines’ impact on new infections was “insignificant”. 

Israel’s experience – booster campaign & learning from mistakes 

The paper also described how Israel’s attempts to remove its “COVID-19 pass” restrictions for entry to restaurants and other venues too early on led to surging caseloads over the summer – which peaked at world-record rates of new infections per capita in early September – or nearly 10,000 cases a day in a country of nine million people”.  

The country later reversed course, reimposing COVID-19 pass restrictions, mask mandates in closed spaces, and limits on venues, while launching a massive booster campaign.  

While “daily mortality was initially zero,” hospitalizations and also deaths increased by mid-September, as well,  “before receding to around seven daily deaths at the end of October”, according to the paper.

“The decrease in new infections since the mid-September peak is probably due to a vigorous booster campaign that raised total vaccinations to 180 per hundred individuals”, the paper argues.

That, along with the preferential treatment of vaccinated individuals in public events as well as continued restrictions on  international travel, probably played a lesser role in dimming the infection’s fires, they argue:

“Be that as it may, this opens the door for the hope that, following a sufficiently potent accumulation of vaccinations, infections are likely to recede as well.” 

Image Credits: CNN.

Spanish Minister of Science and Innovation Diana Morant at the announcement of the license.

The first non-exclusive license for a COVID-19 health tool – a serological antibody test that checks for the presence of anti-SARS-CoV-2 antibodies – has been finalised by the World Health Organization’s (WHO) COVID-19 Technology Access Pool (C-TAP) and the Medicines Patent Pool (MPP).  

The license, announced on Tuesday in partnership with the Spanish National Research Council (CSIC), will facilitate the rapid manufacture and commercialization of CSIC’s COVID-19 serological test worldwide. 

WHO Director-General Dr Tedros Adhanom Ghebreyesus commended the CSIC, a public research institute, for “offering worldwide access to their technology and know-how.” 

“This is the kind of open and transparent licence we need to move the needle on access during and after the pandemic. I urge developers of COVID-19 vaccines, treatments and diagnostics to follow this example and turn the tide on the pandemic and on the devastating global inequity this pandemic has spotlighted.”

MPP Executive Director Charles Gore hailed CSIC for sharing its test, noting that there has been “too much selfish behaviour” during the pandemic.

Gore added that, as MPP had recently concluded a deal to licence and distribute two anti-viral treatments for COVID-19 with Merck and Pfizer, “the importance of diagnostic testing has increased ten-fold”.

Launched in 2020 by the WHO Director-General and the President of Costa Rica, C-TAP aims to pool technologies to boost manufacturing capacity and expand access to COVID-19 health products.   

Test is easy to use and royalty-free for LMICs 

The test is relatively simple and suitable for basic laboratory infrastructure, and if being offered royalty-free to low- and middle-income countries to promote equitable access to COVID-19 tools.

“This licence is a testament to what we can achieve when putting people at the centre of our global and multilateral efforts,” said Carlos Alvarado Quesada, President of Costa Rica, the founding country of C-TAP.  

“It shows that solidarity and equitable access can be achieved and that it is worthwhile continuing to support the principles of transparency, inclusiveness and non-exclusivity that the C-TAP defends.”

In July, WHO called on pharma companies developing therapeutic options for those with severe COVID-19 to waive exclusivity rights or issue transparent, non-exclusive licensing agreements, such as the one finalized with CSIC, in an effort to address ongoing global vaccine inequity. 

In order to sell the tests in low- and middle-income countries, companies producing the technology will need to supplement this manufacturing with performance data in the European population. 

CSIC president Rosa Menendez noted how this type of technology, and all COVID-19 technologies in particular, need solutions that reach all countries, especially those most vulnerable. 

“In this sense, we would like this action by CSIC, of taking part in the international initiatives of MPP and WHO, to become an example and a reference for other research organizations in the world,” she said.

The technology currently has four different serological tests, of which one has the potential to distinguish the immune response of COVID-19 infected individuals from vaccinated individuals. 

Health Action International (HAI) Senior Policy Adviser, Jaume Vidal, described the agreement as “a milestone for global health and a major step toward achieving more equitable access to health technologies”.

“The first product ever to be licensed to C-TAP is an example of public return on public investment in action. It is also evidence of the political will necessary to address protracted issues currently affecting the global response to the pandemic, such as limited manufacturing capabilities or obstacles to technology transfer,” said Vidal.

“The Spanish government is leading by example,” added Vidal. “Not only are they pushing for non-exclusive licensing through the Medicines Patent Pool (MPP) of a critical health technology and committing funding to C-TAP, but have also come out in support of the TRIPS waiver proposal currently under discussion at World Trade Organisation (WTO).”

Former Liberian President Ellen Johnson Sirleaf (left) and Former New Zealand Prime Minister Helen Clark (right), co-chairs of The Independent Panel

Six months after publication of their landmark report, Make it the Last Pandemic, the co-chairs of Independent Panel have re-entered the political fray over the slow pace of urgently needed reforms to vaccine equity, pandemic finance and countries’ legal obligations – that they say are required to end the COVID-19 pandemic and head off the next disaster.  

In a progress report dubbed “Losing Time: End this Pandemic and Secure the Future” former New Zealand Prime Minister Helen Clark and Liberia’s President Ellen Johnson Sirleaf issued a sharp call for the UN General Assembly to convene a summit of heads of state, following next week’s World Health Assembly special session on a pandemic treaty.  

The UNGA summit is needed to come up with “an ambitious and forthright declaration of the United Nations General Assembly..[to] tackle issues of equity, leadership and accountability, governance and financing,” according to their new report, launched Monday. 

“Two years after the first appearance of the novel coronavirus, the world still isn’t getting a lot of things right or moving fast enough,” declared former Clark, co-chair of the now disbanded “Independent Panel”, in a Chatham House briefing Monday. 

And unless countries can muster the will to “seize the moment”, the world risks being just as poorly prepared for the next pandemic, she warned. 

Clark called for the world to “put it’s feet on the accelerator to negotiate new legal instruments at the World Health Assembly next week” and to “get cracking” on a special United Nations GA summit to set out a broader “roadmap” for pandemic finance and greater vaccine equity. 

Ellen Johnson Sirleaf, at Chatham House event

“In the past six months 90 million more people have contracted COVID-19 and more than 1.6 million people have died. Those are only the reported cases,” added Johnson Sirleaf, the report’s co-author. “Waves of disease and death continue. Resolve [on] protective measures  is waning. Vaccine coverage is uneven – people in the poorest countries still have almost no access to vaccines at all. The world is losing vital time against a virus that continues .. when we don’t work urgently together.  

‘Absurd situation’ – rich countries protest vaccine mandates and poor countries can’t get jabs 

Top left clockwise: Chatham House moderator Robert Yates, Helen Clark, UK MP David Miliband and South African special advisor Zane Dangor at report launch event.

Rising street protests in Europe over new pandemic restrictions, illustrates the “comprehensive global failure” of the world to conquer the virus so far, observed United Kingdom MP David Miliband, CEO of the International Rescue Committee.

“We’re in the absurd situation of countries in Europe returning to lock down because of an anti-vaccination movement, at a time where the countries where we work have vaccination rates of under 5%,” said Miliband, who also appeared at the report launch, hosted by the United Kingdom’s Chatham House think tank.  

Key actions needed….  now  

Helen Clark, co-chair, The Independent Panel

In the briefing, Clark and co-chair Johnson-Sirleaf, recapped the headlines for jump-starting the sweeping reforms still needed, including:  

  • A new “legal instrument” governing states’ obligations in disease outbreak alerts and authorizing WHO to visit countries to investigate and report on outbreaks of concern – with “visa ready authorizations”;   
  • Creation of a Global Health Threats Council, operating under the joint auspices of the UNGA and G-20;
  • Creation of a sustainable finance mechanism for a $10 billion global pandemic preparedness facility and a $100 billion emergency fund  – linked to either the new Global Health Threats Council, global financial institutions like the World Bank, or both;
  • Immediate action on vaccine equity, including faster redistribution of rich countries’ vaccine surpluses and approval of a waiver on World Trade Organization intellectual property and trade secrets rules – particularly in the absence of sufficient voluntary action to voluntarily expand vaccine manufacture. 

Hopes UNGA Summit and World Health Assembly special session will accelerate pace

Clark expressed cautious optimism that a UN GA special session on a political “road map” might occur before the end of the year.  That, along with the special World Health Assembly session on the pandemic treaty, could help accelerate the pace of action, she said. 

“The President of the General Assembly has made it clear that leadership to confront the COVID-19 pandemic must be at the top of the Assembly’s priorities in this year’s session,” concludes the report. “He has signalled his intention to call a high-level thematic debate on vaccine equity with leading experts and world leaders for early in 2022, with the commitment of all states at the highest level”. 

I’m quite optimistic that there will be a special session of the UN General Assembly,” said Clark at the Chatham House briefing.

Next week’s WHA Special Session, meanwhile, will be a moment of decision on whether WHO member states move ahead on a new Pandemic Treaty – or focus on reforms to the existing International Health Regulations (IHR) that now govern WHO member states’ emergency response. 

Clark said she was optimistic that the WHA would indeed agree to move toward a new “legal instrument” such as a convention or a treaty – adding “just don’t take too long about it.”

She said that the IHR lacks the teeth required for WHO and its member states to rapidly and clearly respond to an outbreak – let alone address longer-term issues, such as vaccine finance, supply and equity.

“One of the key gaps [in the existing IHRs] is being very clear about responsibilities and member states, and powers of WHO,” she said, adding that she was seeing “traction” around the concept of a “notification protocol,” outlining “what are the responsibilities of states and how is an international organization to respond?”. 

“It [WHO] needs, in our Panel’s view, enough power to access the site of an outbreak immediately, no questions asked – with standing visas,” she said, pointing to the findings of the original Independent Panel report, released in May 2021. 

“It needs to be able to publish the information that it gets without seeking country permission.  It clearly needs to be empowered to act and the precautionary fashion where you have a respiratory pathogen on the move.” 

While, in theory, the IHR could be revised to accommodate those concerns, “The whole IHR process doesn’t give WHO the power or the authority to act in a concerted and very decisive way. 

“We felt that a Framework Convention  could spell out more the responsibilities of Member States and international organizations. It could fill gaps in the existing legal framework.” 

Building a broader legal framework for vaccine equity & finance over time 

Expected Vaccine Supply at End-2021 (% of Total Population): Most of sub-saharan Africa, and parts of Asia, would only reach 10-20% vaccine coverage – at most – as compared to the 40% WHO goal.

Clark said that she would, however, recommend keep any new treaty or convention within a “narrower” scope at the beginning, leaving space to broaden the mandate over time. 

“Rather than trying to negotiate very broad, initially, I think I would focus on some of the key gaps,” she said. However, as a “Framework Convention”, the new legal instrument could be built out with “more protocols” over time to refer to issues that could never be covered by the IHR, such as vaccine distribution and equity: : 

“It’s possible, for example, that you could, in such a convention, refer to financing mechanisms, oversight councils, the design of the global public goods platform for supply of goods and therapeutics,” said Clark.

Rejects idea that treaty could take years to approve   

Clark rejected the claims of some critics who have said that such a treaty could take years for a large number of states to approve and ratify. 

She pointed to the Convention on Early Notification of a Nuclear Accident, adopted by UN member states at a September 1986 meeting of the International Atomic Energy Agency  just five months after the April 1986 Chernobyl nuclear disaster, as evidence that countries can move rapidly on treaties when they wish. 

The treaty was also ratified by the then-Soviet Union – the country responsible for the accident. 

“The old saying where there’s a will there’s a way. Post Chernobyl, still in the Cold War period, member states of the UN agreed to two new global conventions within five months of nuclear safety.  And when we look at that, we think what is wrong with the international community now?  Here we are with a pandemic which is a threat to the health of every human being, and they don’t act with the same alacrity.”

But a splintering of the pandemic debate also has impeded progress on the wide range of issues that need to be addressed – from finance, to vaccine equity and distribution to early warning systems, she and other panel members added.  Too many groups are haggling over the grammar and syntax of texts, rather than their essence. 

Voluntary IP Transfer – or IP Waiver ? 

Airfinity’s COVID Vaccines Revenue Forecasting predicts 545 million Covaxin doses to be sold to low-middle-income countries in 2022.

The new report also comes out in favor of an IP waiver on vaccine IP and know-how, not only for this pandemic:

 “Global health cannot be left hostage to a pharmaceutical industry which buys up patents and develops them in the interest of making profits. They say that the development of a true end-to-end global public goods model remains the answer,” state the co-authors.

At the briefing sessions, those recommendations were couched in reflections over the failure of voluntary actions so far.

For instance, voluntary vaccine license deals that have so far been reached have been primarily bilateral arrangements, rather than through multilateral groups like the MedicinesPatentsPool – which also limits their effectiveness, said Zane Dangor, special advisor to South Africa’s Minister of International Relations and Cooperation, also appearing at the Chatham House event. 

“If voluntary tech transfer is not possible, then we should move with speed with discussions on the WTO IP waiver,” said Dangor said.  

Clark added that there should be a permanent IP waiver mechanism that automatically kicks in during a pandemic. 

“We have the tools to fight this pandemic & they are systematically being denied to a significant proportion of the world’s people.  We need some kind of trigger, when there’s a disease outbreak at scale.”

More immediately, she appealed to wealthy countries to speed up the redistribution of surplus vaccines saying: 

“We get pledges, but they are always ‘not this month, not next month, but next year,’ ” she pointed out, noting that meanwhile: 

“We  have wealthy countries like the UK, which is throwing vaccines down the drain now.  If they had better planning at home, they could have released the surplus doses into countries that can’t get their hands on any at all.

“We have to scale up manufacturing, with manufacturing countries exerting the levers that they can on the pharma industry,” Clark added.

IFPMA says real problem is not IP but ‘political will’ for dose-sharing

Vaccine dose-sharing promises by rich countries against actual deliveries, as of November 2021.

In a response, James Anderson, executive director of global health for the International Pharmaceutical Manufactureres and Associations, said that “political will” in high-income countries to redistribute doses faster and more equitably is the real problem.

“We’ve seen a historic manufacturing scale-up. By end of this year, vaccine manufacturing output will reach 12 billion doses. By the middle of 2022, it is estimated to reach 24 billion doses,” he said.

“Vaccine manufacturers are sharing their know-how: to date, 329 manufacturing and production agreements are helping scale up COVID-19 vaccines production in volumes never seen before. There are enough supplies, what’s needed is the political will to redistribute them fast and redouble the focus on dose sharing and country readiness.

“We also acknowledge that much more needs to be done to ensure equitable and fair distribution and access of pandemic products around the world and are committed to playing our part…

“But in so doing, we should not throw the baby out with the bathwater… We need to build on what has worked: first, immediate, unhindered pathogen sharing; second, an IP-backed innovation eco-system that enable R&D and technology transfer and voluntary licensing; third, the contributions of the leading global regulatory authorities who have streamlined their processes and allowing fast access to safe and effective COVID products.”

Image Credits: @TheIndPanel, https://covid19globaltracker.org/, Airfinity, @Airfinity/BBC .

Zoleka Mandela lost her 13-year-old daughter in a car crash

Two parents who lost their children in car crashes urged governments to adopt better road safety policies on the World Day of Remembrance for Road Traffic Victims on Monday.

South African Zoleka Mandela’s daughter died in a Johannesburg crash on her 13th birthday, while Australian Peter Frazer’s 23-year-old daughter was killed by a truck on Hume Highway on her way to university.

“As a mother who lost her daughter to road traffic injury, I can tell you that the pain never goes away,” said Mandela, now the Global Ambassador for the Child Health Initiative.

Describing the rates of death and injury on our roads as “monstrously high”, Mandela – the granddaughter of iconic leader Nelson Mandela – said that solutions were completely within their grasp of governments. 

“Low-speed streets, particularly with a vulnerable and traffic mix; safe crossings and sidewalks; action on drink driving; safe vehicles and helmets,” said Mandela. “Road traffic injuries are predictable and preventable.”

She also called for “a shift from car dependence to zero-carbon active travel; a shift to public transportation cleaner air and lower CO2 emissions.

‘Drive so others survive’

Peter Frazer, Australian road safety advocate, lost his daughter in a car crash.

Frazer said that his daughter, Sarah, had broken down at the side of one of Australia’s major highways on her way to start studies as a photojournalist. A truck ploughed into her and a tow-truck driver, killing them both on a road that was too narrow to enable her to pull off safely.

“We must all drive as if our loved ones are on the road ahead. We must drive so others survive. We already have the technology and know-how to massively reduce trauma,” said Frazer, who started and leads the Safer Australian Roads and Highways (Sarah), in memory of his daughter.

Dr Etienne Krug, the World Health Organization (WHO) Director of the Department of the Social Determinants of Health, said that 1.3 million lives were lost every year in vehicle crashes.

The WHO launched its Global Plan for the Decade of Action for Road Safety (2021 – 2030) late last month, which has the ambitious target of preventing at least 50% of road traffic deaths and injuries by 2030.

Abdulla Shahid, President of the United Nations, told the remembrance that, aside from deaths, around 50 million people were also injured in road crashes annually.

“Today, we pause to pay tribute to the fathers, mothers, sons and daughters, friends and colleagues whose lives were cut short,” said Shaid. “We remember those suffering from life-impacting injuries as a result of reckless driving and unsafe road systems. Each is an individual tragedy and a source of profound grief and pain.”

The UN will host a High-Level Meeting on global road safety from 30 June to 1 July 2022, preceded on 3 December by a planning meeting to be hosted by Shahid.

 

 

Michigan’s Lieutenant Governor, Garlin Gilchrist II gets his COVID booster shot on Friday. Moving ahead of today’s US FDA recommendation, a few US states have already begun rolling out boosters to all adults six months after their second jab.

The United States Food and Drug Administration (US FDA) on Friday gave its greenlight to the mass rollout of both Pfizer and Moderna COVID booster shots to all adults over the age of 18, from six months after a person’s second vaccine dose.  J&J vaccine boosters would be authorized after just two months of the single jab vaccine.

The US Centers for Disease Control was due to meet later Friday on a policy recommendation to expand booster shot eligibility to all American adults accordingly – CDC Director Rochelle Walensky was expected to sign off on the recommendation immediately.

“This is a very encouraging step to further protect Americans, especially as we enter the winter months,” said White House press secretary Jan Psaki in a press briefing Friday afternoon.

Boosters of Moderna and Pfizer’s mRNA vaccines have been repeatedly decried by the World Health Organization as pumping global vaccine inequities while lacking an adequate evidence base.

“No more boosters should be administered except to immunocompromised people,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus earlier this month. “Most countries with high vaccine coverage continue to ignore our call for a global moratorium on boosters at the expense of health workers and vulnerable groups in low-income countries who are still waiting for the first dose.”

The decision was not without its naysayers – some critics pointed out that the critical FDA decision was made largely on the basis of industry data of its clinical trials, but without reference to the FDA’s expert Vaccines and Related Biological Products Advisory Committee, VRBPAC, which usually weighs in first.

The FDA decision was being cheered, however, by many US experts as a correct response to mounting medical evidence about waning immunity after the first two jabs, as well as a nimble way of warding off another winter COVID wave.

“I’ve said since January that Pfizer/Moderna are three dose vaccines,” said Peter Hotez, a vaccine expert at Texas Children’s Hospital and popular media commentator.

Signal to Europe

The US moves will also surely be seen as a signal to European policymakers – facing sharply rising case rates accompanied in some countries, such as The Netherlands, by partial lockdowns.

In Europe, boosters have not been widely administered yet beyond immuno-comprised individuals and people over the age of 65.  The United Kingdom has been the boldest so far – gradually scaling down eligibility ages.  On Monday, UK officials announced that the age limit for booster eligibility would be lowered once again to people aged 40-49 who received their second shot more than six months ago.

Boosters sharply opposed by WHO – but appeals likely to be ignored

In most African countries, less than 15% of people have received even one vaccine dose, and in many countries, less than 5%.

The booster shot trend has been sharply opposed by the World Health Organization as siphoning off vaccines that are badly needed in low- and middle-income countries to merely administer a first dose.

WHO has repeatedly called for a  moratorium on booster shots until the end of the year for everyone except immunocompromised people – so as to reach a 40% vaccine coverage goal in under-vaccinated countries – including most of Africa.

WHO scientists have contended that even if infection rates are rising right now in the northern hemisphere, as Europe and North America head into winter, people with two jabs remain good immunity against serious disease and hospitalization – which is a more central aim of vaccination that preventing simple infections.

However, WHO’s appeal may be increasingly ignored by countries anxious to head off another winter surge in case rates – in countries that were the epicenter of the COVID storm at its outset in 2020, riding another major wave last winter.

The dilemmas become particularly acute when those surges are also leading to more hospitalization – straining health care services.

Israel’s booster drive cited by US expert Anthony Fauci as example

 Israel’s experience has been widely cited in the United states, which has seen a steady rise in new infections over the past month. In Israel, COVID infection rates soared to the highest in the world in August – pushing hospitals to their limits.

At that point a massive booster campaign was implemented, which officials there now admit was a “calculated gamble”.  Along with stricter social distancing measures in bars and restaurants, the campaign drove case rates down to one of the lowest in the developed world.

But more significantly, the Israeli campaign drove down the incidence of serious infections and hospitalizations among older people, most at risk, said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, in an interview with CNN.

Recent data from Israel shows that people age 60 and older who received a booster were less likely to become severely ill than vaccinated people who had not received a booster. Rates of severe disease, however, remained highest among those who weren’t vaccinated at all.  In the biggest Israeli study to date, covering some 728,000 people and published 29 October in The Lancet, the booster was estimated to be 93% effective in preventing hospital admissions, and 81% effective in preventing deaths – in comparison to people who received only two doses.

Tackling vaccine inequities – and uncovering the root causes of serious COVID disease

In terms of the continuing vaccine inequalities between the global north and south, some commentators have argued that vaccine hoarding of excess doses by rich countries may be an even bigger equity bottleneck than booster doses.

Others continue to ponder what are the drivers between the strikingly low case rates in most of SubSaharan Africa – South Africa excepting – and chronically high case rates elsewhere in Latin America, India and the Europe.

While partially due to under-reporting, some researchers have speculated that Africa’s generally lower rates may also be partially explained by immunity acquired from other, prior diseases, including possibly malaria.

That, at least, was the conclusion of researchers with the Uganda-based Malaria Consortium, which recently published a study in The Lancet Microbe, suggesting that people with high prior exposure to malaria also may have less severe forms of COVID-19.

The study, which analysed the results of 597 COVID patients at treatment centers in Uganda, found that 30% of the proportion of people with low previous exposure to malaria had suffered severe or critical COVID, as compared to only 5.4% of poeple with high previous malaria exposure.

“The results suggest that if you’ve had a high previous exposure to malaria, you’re likely to control or manage COVID-19 better,” said Jane Achan, senior research manager at the Malaria Consortium in a blog post.

Insufficient progress on delivering pledged doses to COVAX – across most high-income countries

Regardless of mitigating factors, the fact that vaccine rates in some 80 countries have not yet reached the 40% mark, and remain under 5% in much of Africa, continues to frustrate global health officials that see the inequalities as both an ethical stain as well as a health security risk for the rest of the world – creating more fertile territory for COVID variants to flourish long-term.

The US administration’s response to global vaccine constraints has been firstly donations,  followed by negotiated deals with Pfizer and other manufacturers for vaccine supplies at cost to LMICs, and a call for the rapid expansion of its own domestic vaccine manufacturing capacity – to respond to needs in both the domesitc and global markets. But the donations have so far failed to be delivered; similarly Pfizer’s promised supplies as well as more domestic production will only rev up in 2022.

At home, meanwhile, some states have already moved ahead of the US FDA and CDC, issuing their own recommendations that approved booster shots for adults six months after their first jab.

“Vaccines are the best way to protect ourselves, our loved ones, and everyone around us,” tweeted Michigan’s Lieutenant Governor, Garlin Gilchrist II on Friday.  “Today I got my booster, I encourage Michiganders to get their primary doses- for themeslves and their kids 5 and up – or their boosters when eligible.”

https://twitter.com/LtGovGilchrist/status/1461751602554015762

Image Credits: @LtGoVGilchrist, https://covid19globaltracker.org/.

Opening ceremony for the second meeting of the Protocol to Eliminate Illicit Trade in Tobacco Products (MOP2) at WHO headquarters in Geneva.

While the world was focused last week on the Glasgow Climate Conference (COP26), officials from 160 countries and the European Union gathered virtually to address another urgent global crisis – the crisis in tobacco consumption that is one of the largest causes of death worldwide, year after year.

Otherwise known as COP9, the ninth Conference of Parties to the WHO Framework Convention on Tobacco Control (FCTC), made significant strides with comparatively little attention – apart from partisan campaigns that denigrated the WHO and the global health treaty.

The fact that such negative messages align with the interests of cigarette companies should come as no surprise. There is clear urgency for this work: tobacco use kills more than 8 million people every year. The FCTC is central to ending the global tobacco epidemic.

At the same time, progress is a threat to the rich and powerful vested interests of tobacco companies.  As with efforts to address climate change, advancing proven policies to save lives from tobacco is a hard-won battle.

Worryingly, in the week before COP9, new research published by industry watchdog STOP, suggested that big tobacco – cited by governments as the main barrier to treaty implementation – had taken advantage of the COVID-19 crisis to advance its interests. Industry efforts during the pandemic delayed and weakened health policies to reduce tobacco use in several countries.

Influence of vested interests is key theme at both COP meetings

Global tobacco industry interference ratings (STOP). Countries in yellow and light green experience the least interference – those in red and burgundy, the most.

The influence of vested interests was a key theme at both COP meetings – the one addresing the climate crisis and the one addressing the public health crisis of tobacco use. Industry rhetoric aimed to portray health policies as part of a ‘nanny state’ or even ‘authoritarian.’ Even more insidious were disingenuous claims that regulating industry harms the poorest in our society, when this group often bears the brunt of unhealthy and unsustainable policies – whether they are related to climate change or tobacco use.

The virtual format for COP9 meant there was a shorter, pared-down agenda, with several issues deferred to COP10 in 2023 when they can be discussed and agreed upon in person. These include topical issues like more systematic regulation and disclosure of the contents of tobacco products, including products like waterpipes, smokeless tobacco and heated tobacco products.

Some delegations were understandably concerned that the industry could use this deferral to further influence policy between now and the next meeting in 2023, although expert reports on the key issues, which were published at COP9 could be used to help guide national policy development in the interim.

In a first-ever COP that was fully open to accredited media, news reports also noted how some countries’ interventions appeared to be designed to delay discussions at COP9, reflecting the interests of powerful tobacco companies.

For example, delegations from the Dominican Republic and the Philippines, which included officials from departments such as trade & industry, finance, agriculture and foreign affairs, argued that tobacco is a positive force in their country, while not fully addressing the costs or harms of tobacco use. Such industry-aligned activity was so pronounced within the Philippines delegation that the Philippines’ Department of Health was compelled to issue a statement disassociating itself from statements made by its other delegates.

Virtual pro-vaping event on COP9 sidelines tried to divert attention

The tobacco industry is using deceptive advertising to promote its products, according to WHO.

Industry-friendly rhetoric was abundant on the virtual sidelines of COP9 too. One group created a virtual pro-vaping event it tried to cast as an alternative to COP9; it was amplified by a flurry of social media activity and press releases.

Despite all this chatter, however, the more than 1,200 delegates present made progress, and the results represent a global consensus.

Included in these positive decisions was an agreement to establish a new sustainable funding mechanism to support countries’ and global FCTC implementation, with a hoped-for $2-3 million annually in additional resources. There was also explicit support for the FCTC Secretariat’s efforts to increase transparency: as per the agreement by delegates to open the meeting to accredited media in addition to accredited non-state observers (as well as countries and territories that are not formal FCTC parties). Opening and closing sessions also were broadcast live.

At a regional level, nearly all the delegates from the Americas region issued a joint statement to confirm that they had voluntarily signed and submitted Declaration of Interest forms, in line with a decision at COP8 to help reduce industry interference. Delegates from across Africa called out tobacco industry tactics and called for the tobacco industry to be held liable for the harm it has caused. Both regions are strategic targets for tobacco companies working to expand their markets and grow their profits in emerging economies.

COP9 Declaration – protecting policy from industry influence

Global tobacco industry interference ratings (STOP). Countries in yellow and light green experience the least interference – those in red and burgundy, the most.

The culmination of the week was the approval of the COP9 Declaration, in which Parties agreed to accelerate implementation of the Framework Convention, and make efforts to protect policy from industry influence to support COVID-19 recovery. Governments were also encouraged to implement parts of the treaty that protect policy from industry interference.

This will not, of course, stop tobacco companies from trying to recast themselves as a solution to the problem they created. This is an issue that echoed through this week, at the subsequent Meeting of Parties to the Protocol to Eliminate Illicit Trade in Tobacco Products (MOP2). Evidence shows that, even while the tobacco industry promotes flawed, proprietary solutions to address tobacco smuggling, it may be complicit in the illicit trade of its own products.

We are reminded, meanwhile, by WHO’s latest report on tobacco trends, also published this week, that there are still more than a billion tobacco users around the world, not including e-cigarettes and heated tobacco products. Tobacco companies are producing and selling trillions of deadly cigarettes every year, while their rhetoric steers public conversation away from that inconvenient fact.

As Health Policy Watch said in its report on COP9, it’s a David and Goliath struggle. Taking action in line with the COP9 declaration would be a true win-win for health. With political will and support from the FCTC Secretariat and other organizations, governments can make real progress to reduce tobacco use before COP10 in 2023. The time to act is now.

Gan Quan is the Director of Tobacco Control at The Union, and a partner in STOP, a tobacco industry watchdog, funded by Bloomberg Philanthropies. He has over 17 years of experience in tobacco control advocacy and research in Asia, North America and globally. Gan Quan has a PhD in Public Health from the University of California – Berkeley.

Gan Quan, director of tobacco control at The Union, a Partner in STOP

Image Credits: City of Bengaluru, WHO/Pierre Albouy, Global Tobacco Industry Interference Index 2021 (STOP), STOP: Global Tobacco Industry Interference Index 2021.

First long-acting injectables to treat HIV approved by NICE.

People living with HIV in England and Wales may be eligible for injectable antiretroviral treatment every two months, rather than daily pills.

Two injectable drugs, cabotegravir and rilpivirine, were recommended for use by the UK National Institute for Health and Care (NICE) on Thursday after trials proved they work as effectively as daily tablets, according to their draft guidance. 

To be eligible for cabotegravir with rilpivirine, people must already have a low and stable viral load. 

The Scottish Medicines Consortium has also approved the injections for adults living with HIV in Scotland.

Cabotegravir (also called vocabria), which is made by Viiv Healthcare, and with rilpivirine (also called Rekambys), made by Janssen, are the first long-acting antiretroviral injections available for HIV. 

“Clinical trial results show that cabotegravir with rilpivirine is as effective as oral antiretrovirals at keeping the viral load low,” according to NICE.

“Both cabotegravir and rilpivirine are administered as 2 separate injections every 2 months, after an initial oral (tablet) lead-in period.”

Meindert Boysen, deputy chief executive and director of the Centre for Health Technology Assessment at NICE, said that while  HIV is still incurable, the virus “can be controlled by modern treatment”.

“For some people, having to take daily multi-tablet regimens can be difficult because of drug-related side effects, toxicity, and other psychosocial issues such as stigma or changes in lifestyle,” added Boysen.

“The committee heard that stigma remains an issue for people living with HIV and can have a negative impact on people’s health and relationships,” he added.

“We are pleased therefore to be able to recommend cabotegravir with rilpivirine as a valuable treatment option for people who already have good levels of adherence to daily tablets, but who might prefer an injectable regimen with less frequent dosing,” added Boysen.

Pill fatigue 

antiretroviral
People living with HIV typically have to take daily pills to lower viral load.

“HIV unfortunately remains a stigmatised condition. Although we’re working hard to tackle the stigma surrounding HIV, this new injectable treatment option could help people in house-shares for example who do not wish to share their HIV status and will no longer have to worry about hiding their medication,” said Debbie Laycock, head of policy at HIV charity, Terrence Higgins Trust.

“Pill fatigue is also an issue for some people living with HIV who struggle with the idea of taking antiretroviral drugs every day,” added Laycock.

“Long-acting injectable treatment is also a better option for those who have difficulty swallowing medication. Therefore, the institute’s approval provides a welcome additional treatment option for people living with HIV across England and Wales.”

The United Kingdom has a relevantly small, concentrated HIV epidemic, with an estimated 101,600 people living with HIV in 2017. An estimated 13,000 people will be eligible for the injectable treatment in England

Added Laycock: “This is a great step forward as we work towards ending new cases of HIV by 2030. The institute’s decision brings great potential for HIV prevention including long-lasting pre-exposure prophylaxis (PrEP) in the future.”

Image Credits: PharmacyMagUK/Twitter, Flickr.

Dr Ali Ahmed Yahaya, WHO Africa lead on antimicrobial resistance.

Over four million Africans a year could die as a result of antimicrobial resistance (AMR) by 2050, according to WHO’s Africa Region at the start of World Antimicrobial Awareness Week on Thursday.  And if global action isn’t taken to head off risks, nearly nine million of the estimated 10 million people dying around the world from AMR by 2050, will be either Africans or Asians. 

Drug-resistant tuberculosis is a growing phenomenon, while malaria parasites also are becoming resistant to once-effective first-line anti-malarial treatments.

“Antimicrobials – including antibiotics, antivirals, antifungals, and anti parasites – are the backbone of modern medicine,” explained World Health Organization (WHO) Director-General Dr Tedros Adhanom Ghebreyesus.

“They allow us to treat deadly infections successfully, and make essential health services safer for everyone. However, the overuse and misuse of antimicrobials are the main drivers of drug-resistant pathogens,” he warned in a recorded message as events were held all over the world to draw attention to the threat posed by the growing trend of “superbugs” resistant to existing drugs and treatment.

In light of the growing threats, six global and regional organisations on Wednesday issued an appeal for stronger policies to fight AMR. They included the World Health Organization (WHO), the Food and Agriculture Organization of the United Nations (FAO), the World Organisation for Animal Health (OIE), the UN Environment Programme (UNEP),  the Africa Centres for Disease Control and Prevention (Africa CDC), and the African Union Inter-African Bureau for Animal Resources (AU-IBAR).

The FAO’s Regional Representative for the Near East and North Africa, Dr Abdulhakim Elwaer, said that his organisation, together with the WHO and OIE were establishing AMR multi-stakeholder partnership platforms across all sectors to implement an AMR global action plan.

FAO’s Dr Abdulhakim Elwaer

COVID-19 illustrates ease of infection spread

Projection of deaths annually from AMR by region as of 2050 in business-as-usual scenario, show Africa and Asia bearing the brunt of the burden. Source: Review on Antimicrobial Resistance: Wellcome Trust & HM Government, 2014

“The COVID 19 pandemic has shown the ease with which infections can spread, threaten global health security, and destabilise economies, lives and livelihoods,” Elwaer told an African regional AMR meeting on Thursday.

“Trans-boundary animal diseases and zoonotic diseases have a devastating impact on animal production, food security, trade, public health, and economy,” he warned, calling for the responsible use of antimicrobials in animal and plant health.

The estimate of 4.1 million deaths annuall in Africa by 2050 is part of a broader assessment of global health risks that concluded some 10 million people a year could die from AMR by 2050 – mostly in Asia and Africa.  The estimates from the review, conducted in 2014 by an independent commission, co-sponsored by the UK government and the Wellcome Trust, were also highlighted in a major UN assessment of AMR trends and risks, No Time to Wait, published in 2019 just before the COVID pandemic took off.

Worldwide, agriculture is one of the biggest users of antibiotics alongside human health – and in some developed countries like the United States animals may even be the largest consumers of these life-saving drugs.

Dr Yahaya Ali Ahmed, the WHO’s Africa Team Lead for AMR, said that routine administration of antibiotics to animals as a prophylaxis against disease, and to promote growth, is now also a growing practice on the continent – and that is driving resistance too.

In addition, inadequate treatment of sewage, particularly emissions from health care facilities that use and inevitably discharge medicine residues in their waste, provides a media where resistant microbes may breed and multiply.

“Animals might also acquire resistance from water contaminated with human sewage. We have several issues in our region, specifically inadequate hospital sewage systems,” added Ahmed.

“These examples highlight that there is really an interface between humans, animals, plants and the environment,” said Ahmed. “If a single sector tries to work alone, it will fail and this is why we really need to adopt an integrated and holistic multi-sectoral, ‘One-Health’ approach in combating AMR.”

Wildlife and aqua-culture

OIE Africa representative Dr Karim Tounkara Africa said that his organisation was working to integrate environmental, aquatic and wildlife issues into the region’s One Health approach.

“OIE developed a wildlife health framework in 2020 aiming at reducing the risk of disease emergence and protecting wildlife health,” said Tounkara.

The wildlife framework aimed to “improve member states’ capacity to manage the risk of pathogen emergence in wildlife and at the human animal ecosystem interface, whilst taking into account the protection of wildlife”, said Tounkara.

“The second objective is about enabling OIE members to improve surveillance systems, early detection and the reporting and management of wildlife of diseases,” he added.

Antibiotic shortages may also drive inappropriate use – leading to AMR

While drug resistance develops from overuse and incorrect use in both people and in animals, it can also be an outcome of antibiotic shortages – when an antibiotic that is already vulnerable to resistance is routinely prescribed because a better one is unavailable.

“In Uganda, doctors write prescriptions based on availability rather than suitability,” according to a report from the Center for Disease Dynamics, Economics & Policy (CDDEP) published in 2019. 

In addition, poor medicines regulation in Africa also drives a black market trade – including fake medicinal treatments.  Widespread use of fakes, which may contain weakened formulations of antibiotics or other inappropriate treatments, also enable drug resistant microbes to flourish, leading to more AMR.

Despite the pandemic, Europe sees reductions in antibiotic use between 2019-2020

There has been widespread concern that the COVID-19 pandemic may be stimulating AMR trends – in light of the widespread administration of antibiotics to COVID patients to prevent secondary infections – even in cases when the risks were very low.

Nonetheless, Europe saw a net decline in antibiotic use in 2019-2020, according to a recent report by the European  Centre for Disease Prevention and Control (ECDC). The report, showcased at ann event sponsored by the ECDC and the European Union, found that virtually all of the member states of the European Economic Community (EEC) had reduced their antibiotic consumption by 18% in 2019-2020. Bulgaria was the only country that reported increased antibiotic use.

This decrease could be explained by a reduction in respiratory tract infections, thanks to the use of masks, phyical distancing and other measures introduced to curb COVID-19, reported the ECDC.

Even so, the risks of AMR in most regions of the world are mounting – and with them the risk that AMR will lead to the routine loss of more and more lives – if not the next pandemic.

“The World Bank has estimated that, if nothing is done to address the factors driving AMR, it will have the same impact and cost as much as COVID-19, not once, but annually, year after year,” warned Hans Kluger, the WHO’s European Regional representative, at the EU event.

Image Credits: WHO / M. Edwards, Source: Review on Antimicrobial Resistance: Wellcome & UK Govt. .

Cervical cancer screening campaign in rural India – most women who die from cervical cancer live in low-income countries lacking access to screening or vaccinations.

Some two-thirds of deaths of women from cervical cancer are happening in low- and middle-income countries that have not yet included human papillomavirus (HPV) vaccines for girls and young women into their immunization regimes, said WHO’s Director General Dr Tedros Adhanom Gheybresus on Wednesday. 

He was speaking at a high level event that saw First Ladies from four African countries call for stepped up action on the disease, which is one of the largest but also most preventable causes of cancer deaths.   

“Cervical cancer is the fourth most common cancer among women globally, but it is almost completely preventable and, if diagnosed early enough, is one of the most successfully treatable cancers,” said Tedros, at the Cervical Cancer ELimination Day event, on the first anniversary of WHO’s launch of a new global strategy to eliminate cervical cancer. 

“This disease claims the lives of 300 thousand women each year – 1 every 2 minutes” he added. “Like COVID-19, we have the tools to prevent, detect and treat this disease. But like COVID-19, cervical cancer is driven by inequitable access to those tools.” 

Setbacks in strategy to expand access to vaccinations to 90% within a decade 

The WHO global strategy aims to: 

  • Vaccinate 90% of all girls against human papillomavirus by the age of 15; 
  • Expand access to screening services for 70% of women;
  • Expand access to treatment for 90% of women with pre-cancerous lesions, and palliative care for 90% of women with invasive cancer.

But the WHO Director admitted that there already have been setbacks in advancing those goals. Due to the pandemic, the proportion of girls globally with access to HPV vaccines has declined – from 15% pre-pandemic to %13 percent today. 

“At the same time, there are encouraging signs of progress,” he added, noting that over the past year, seven more countries have introduced the HPV vaccine into their national immunization schedules, including: Cameroon, Cabo Verde, El Salvador, Mauritania, Qatar, Sao Tome and Principe, and Tuvalu.

WHO has also prequalified a fourth HPV vaccine called Cecolin, produced by Innovax, which it expects will increase supply and decrease prices.

And WHO is promoting new innovations such as “self-sampling” for cervical cancer,   which can make it easier for women to be screened – even if they are reluctant to undergo a full pelvic exam. 

Botswana – three key approaches to elimination 

Neo Jane Masisi, First Lady, Botswana

Increasing coverage for HPV vaccines along with the successful treatment of women with pre-cancerous lesions – and effective access to treatment of women with full-blown cervical cancer – are three key strategies that Botswana has pursued in order to reduce cervical cancer deaths, said Neo Jane Masisi. Masisi was one of four “First Ladies” to appear at the WHO event – along with the wives of the heads of state of Rwanda, Burkina Faso and South Africa.    

“HPV vaccination coverage was about 90% until 2019, when the country started experiencing supply challenges,” Masisi noted, referring to a constraint faced by many developing countries that lack domestic vaccine manufacturing facilities – not only for COVID vaccines, but for other types of jabs.

Dearth of accurate screening techniques

Deaths from cervical cancer by age in 2018

Another key barrier has been the dearth of accurate screening techniques suitable for low- resourced settings. 

In high-income countries, traditional cervical cancer screening rely upon the laboratory analysis of a cervical smear and possible cell abnormalities by trained technicians – the so-called Pap smear named after its inventor. But in lower-income settings, that option is often unavailable. 

One alternative has involved the visual inspection of a cervical cell sample with acetic acid, which is cheaper and comparatively easier to carry out.  

However, such visual inspections are not as accurate – missing some 30% of potentially cancerous abnormalities, which, if caught at the earlier stages, could be more easily treated. 

New FIND initiative to improve cervical cancer diagnostic tools

The Smart Scope, an Indian invention, uses AI technologies to detect abnormal cells.

Other, new generation screening approaches focus on identifying the presence of high risk types of HPV infection –  most likely to cause pre-cancers and cancers of the cervix. 

DNA-based testing for high-risk strains of the HPV virus, was recently recommended by WHO as a preferred screening method – above either Pap smears or visual inspections. Such testing can be carried out affordably and with comparative ease in developing countries – providing test kits and tools are available, WHO says. 

Other emerging technologies, such as the Indian “Smart-Scope”, rely upon AI to provide better detection of cell abnormalities – and ready analysis via a link to a laptop computer.  The device was the focus of interest and review at the Geneva Health Forum in November 2020.

Just recently, the Geneva-based Foundation for Innovative New Diagnostics (FIND), announced a new initiative to further investigate and assess emerging digital and AI technologies with potential for mass application in cervical cancer diagnosis and screening in low and middle income countries. 

“Our work will encompass point of care, HPV tests, use of digital and mobile technology for screening, and self sampling approaches to screening to overcome barriers and improve access to testing,” said Ilona Kickbusch, a FIND senior advisor. “Together, we can make sure that everyone who needs a test can get one, that every woman can get a test.”

Stigma also impedes access 

Princess Nothema Simelela, WHO Assistant Director General and Special Advisor

But even when services are available, stigma about the disease and about conducting intimate physical exams, keeps many women away from clinics and checkups. 

“There are both supply side and demand side challenges,” said WHO’s Princess Nothemba Simelela, a Special Advisor to WHO’s Director-General.

“There is very limited access to the technologies that we need.  Many low income and lower middle income countries are still using very old fashioned methods of screening women, with acetic acid…. 

“And you have demand side issues, a stigmatized disease, a disease that really makes it difficult for women to come into the centre and ask for help.

“It’s a very very private part of a woman’s body.  And it’s something that we see makes it very, very difficult.”

Added Kickbusch, women may also often need money or permission from husbands and fathers to even attend a health service.  She referred to, “a complex cocktail of technical, social, cultural and economic barriers.”

“As we see with so many diseases, lack of access to testing is robbing women of that chance of an early diagnosis.  In low and middle income countries where health systems are weakest and access barriers are highest, three times as many women die of cervical cancer then in high income countries.”  

Image Credits: Shutterstock , Periwinkle Technologies, The Lancet.