The Wellcome trust is pledging up to US $100 million (£70m/€80m) to accelerate Covid-19 research and development to ensure science keeps pace with the virus.

The funding will help advance treatments and vaccines and SARS-CoV-2 tracking research in low and middle income countries.

Announcing the funding on Wednesday, the trust said the rise and spread of COVID-19 meant new vaccines and treatments were needed along with better global systems to identify and track changes in the virus.

Jeremy Farrar, Director of Wellcome, announced massive funding on Wednesday to accelerate Covid-19 research and development.

Jeremy Farrar, Director of Wellcome, said: “More funding is vital to develop the range of treatments and vaccines the world needs – and to make sure these, and those we already have, are fairly and equally available in all countries. The job for science is a long way from done – either to exit this crisis or ensure the world can keep Covid-19 in check long-term”.

The trust said international funding was not keeping pace with global research needs. The ACT-Accelerator faces a $22.1billion global funding gap. 

Divya Shah, Wellcome’s Epidemics Research Lead, said: “Virus mutations threaten the effectiveness of the Covid-19 tools we have worked so hard to develop. We need to build capacity for genomic sequencing globally to identify new variants and map their spread to inform public health measures and further research”.

The US $100 milion package follows $80m (£60m/€70m) Wellcome pledged in 2020 for treatments, research and capacity building in low- and middle-income countries. The US $80 million included up to $50m in seed funding for the Covid-19 Therapeutics Accelerator.

 

Image Credits: Wellcome Trust.

Manual screening of patients will be accelerated with the use of new AI which makes the screening process more efficient – significantly reducing the time taken to make a diagnosis.

NEW DELHI – Reversing decades of negative messages, the World Health Organisation is once again endorsing the use of X-rays as a TB screening tool  in lower-income countries – this time in conjunction with the use of new artificial intelligence programmes that can read digital x-rays and identify suspected TB cases more accurately. 

For community-level screening of TB, the WHO has ranked the tools that could be used. The guideline says that if resources are available, the state should first use chest X-rays at the community level since an abnormal chest X-ray is very likely to be a TB-positive case. However, patients with abnormal chest X-rays have to undergo rapid molecular diagnostics to confirm TB. The other tools that can be used are deploying rapid molecular tests at community level, or screening of symptoms.  

The WHO guidelines also give a huge boost to computer-aided AI detection software and said that it can better interpret the digital X-rays, and triage suspected cases, more accurately than human X-ray readers. 

The new AI makes the screening process more efficient, and significantly reduces the time taken to make a diagnosis. The WHO has said that they would release a more detailed guideline this month, coinciding with World TB day, on Wednesday (March 24).

The move has been welcomed by TB experts as a tried-and-true means of screening – which was effectively used by countries for over a century, but falling by the wayside in recent decades. 

“This is huge,” said Salmaan Keshavjee Director, Harvard Medical School Center for Global Health Delivery. “It can find more people with potential disease. It was the approach that was used in Western countries since the early 20th century, so it’s more than 100 years old.”

In December last year, the WHO released the Rapid Communication on Systematic Screening for Tuberculosis recommended for community-wide screening, and particularly for HIV-positive people, pediatric contacts of TB patients, among others. The WHO released a consolidated guideline on systematic screening of TB recently which includes the use of chest X-ray and artificial intelligence. 

“This Rapid Communication is being issued to help national TB programmes and other stakeholders prepare for the changes that will be introduced with the new guidelines on TB screening.” the WHO said in its statement.

10 Million People Annually Diagnosed with TB – Mostly In Asia & Africa 

Globally, an estimated 10 million people fell ill with TB in 2019. Eight countries accounted for two-thirds of the global total including India, Indonesia, China, Philippines, Pakistan, Nigeria, Bangladesh and South Africa. India has the highest TB burden among these nations and accounts for 26% of the global total number of TB cases.

Many lower-income countries, including India still use smear microscopy as the first line of testing for most of the population. Smear microscopy involves simply looking for the bacteria through the microscope, a method which misses about half of TB-positive patients. The more sensitive diagnostic test- that is the Cartridge-based Nucleic Acid Amplification test or CB-NAAT — is mostly used for those who are sputum-positive to detect resistance to one TB drug- rifampicin. 

“We miss too many people with TB, and a relatively simple test like X-ray might help us find more people with TB. And AI-based software like Computer-aided detection software could help us do that, even when trained radiologists are not there for example in the rural or remote areas,” said Madhukar Pai from McGill University in Montreal, Canada.

Messaging On X-Ray Went Off The Tracks  

When TB programmes evolved, X-rays were a mainstay of diagnosis. Historically, miniature radiography for mass TB screening activities was widely used in high-income countries throughout the 20th century. 

In the early 90s, the WHO declared TB a global emergency. It advocated TB programmes to follow Directly Observed Treatment Short-course or DOTS. DOTS categorically recommended a limited use of X-ray, mostly as a supplemental diagnosis if sputum microscopy failed. 

This meant that patients who were not sputum-positive had to wait for chest X-rays to be ordered but continued to have TB symptoms, depending on who was treating them. 

“But the messaging was off the track. The idea was to say X-ray could be a diagnostic tool, but not a confirmatory tool. But somewhere along the line, doing X-ray was a sin, and only bad doctors use X-ray,” said Shibu Vijayan, Global TB Technical Director at PATH. The organisation engages the private sector in diagnosing and treating tuberculosis. 

The guidelines reflected a differential treatment for those in the lower and middle income countries and higher income countries, say some global health experts like Keshavjee. 

“DOTS did not recommend it  (use of X-ray) because they saw it as being too expensive.  It’s always been known that it is more effective. So they are correct to come back to it finally,” he said.

It was during the TB prevalence studies in countries such as Vietnam, Kenya and Zambia that found chest X-rays were detecting more patients, as compared to sputum microscopy.

 “It was found that around 40% of those surveyed with X-ray shadows and were positive for TB did not have any symptoms at all. That’s how experts asked for X-ray to be brought back,” said Vijayan. 

The focus is now, however, on using X-ray as a screening tool, and not a diagnostic tool, per se.

“We now know that X-rays are good for triage or screening, to find out who needs further confirmatory testing. So, someone with TB symptoms could get an X-ray, and if that is abnormal, then CBNAAT could be done. So, the current focus is really on screening, not diagnosis. For diagnosis, WHO still endorses rapid molecular tests,” said Pai.

Lower Cost Digital X-Rays & AI Been Game Changers

WHO has once again endorsed the use of X-rays as a TB screening tool  in lower-income countries.

The game changer has been the relatively low cost of digital X-rays and artificial intelligence programmes that enhance the efficiency of the screening process.

Friends for International TB Relief (FIT) in Vietnam has been conducting chest X-rays screenings across the country, even in remote parts. It works with multiple global agencies focusing on implementing TB and HIV programmes in Vietnam. 

“I think my organisation in Vietnam has shown that chest X-ray screenings can be done anywhere,” said Andrew Codlin from FIT. 

“The new portable X-ray machines are the size of digital cameras, something that you can put in the backpack and walk up the hill.  We have done screening campaigns in a remote island, in mountainous areas. We also had a screening camp during a cyclone with water running through the streets,” he said.

“If there is commitment, and the right buy-in from the political establishment, it is not difficult to scale up screening campaigns,” Codlin said.

Qure.ai  is a computer-aided technology that can detect abnormalities in the chest X-ray and is used in 20 countries. It is particularly useful in mass screening camps.

“Our product -qXR processes the X-rays that are recorded in a cloud. The health worker can see the report within a minute of taking the X-ray in an app,” said Prashant Warrier, founder of Qure.ai. In case of an abnormal X-ray, the patient’s sputum sample can then be sent for rapid molecular diagnostics.

In Nagpur, a city in West India, PATH helped run a pilot programme with a local nonprofit, Disha Foundation using chest X-ray with a computer-aided detection software called Qurei in the private sector. 

In India, more than half of the TB patients are treated in the private sector. Presumptive TB patients were provided a free X-ray under this pilot. If the patient had an abnormal X-ray, the sputum samples would be sent for rapid molecular testing in a medical college there. 

“When patients do not feel better, they switch doctors. The quick turnaround of the AI technology helps retain patients in the programme and ensure they take treatment,” said Lucky Richardson Masih, operations manager, Disha Foundation in Nagpur. 

The organisation works with local private doctors in Nagpur’s slums in providing the patients with approved diagnostic facilities and treatment. They tied up with PATH for this project in 2019.

The use of radiological screening and AI resulted in a 13% additional TB cases being detected, said Vaishnavi Jondhale, Operations Manager, Path Mumbai.

Warrier claimed that the product can find more cases, and is far more sensitive than a radiologist reading X-ray reports. The cost works out cheaper as well.

Codlin explained how AI is more sensitive. 

 “If a human reader reports 100 abnormal chest X-rays, perhaps 10 would be positive for TB.  If we use qXR it will report 50 abnormal chest X-rays for 10 TB positive cases will be found. We are effectively using fewer CBNAAT tests and resources that way,” he said.

 

 

 

 

Image Credits: Andrew Codlin.

Dag-Inge Ulstein, Norway’s Minister of International Development.

In a decisive act of global solidarity, Norway has offered almost a third of its allocation of COVAX vaccines to poorer countries, according to Dag-Inge Ulstein, Norway’s Minister of International Development.

Norway has only fully vaccinated about 5% of its population – 260,000 people – and unlike many other European countries, it has not stockpiled vaccines and is mainly depending on COVAX for vaccines.

However, it decided to allow COVAX to redistribute 700,000 out of its 1.9 million vaccine doses to lower-income countries despite domestic pressure not to, Ulstein told the Access to COVID-19 Tools (ACT) Accelerator facilitation council meeting on Tuesday.

“People are asking: ‘Why give vaccines away when we need them here?’ And this is a good question, representing an obvious dilemma. But the answer is equally simple: the virus crosses borders. This is not a local outbreak. And this combination of solidarity and self-interest gives me no choice but to stand firmly in the face of domestic criticism,” said Ulstein. 

‘Colossal Task Force’ on Vaccine Manufacturing

He also expressed Norway’s support for a “colossal task force on expanding vaccine production” co-led by the World Health Organization (WHO) and the Coalition on Epidemic Preparedness Innovation (CEPI) to “do better” and expand beyond COVAX’s initial target of vaccinating 20% of the global population by the end of the year.

Earlier, CEPI CEO Richard Hatchett had announced that his organisation was setting up a task force to address vaccine manufacturing and invited all interesting parties to join.

Highlighting global achievements, Hatchett reported that, in little over a year, “we have nine manufacturers that are scaling up rapidly across three technology platforms: inactivated vaccines. viral vector vaccines and mRNA vaccines.”

Between them, the manufacturers had administered 400 million vaccine doses – but only 30-million of these doses had gone to COVAX.

“The nine manufacturers envision manufacturing between 10 and 14 billion doses of vaccine in the coming year,” he added. “Those are very aspirational numbers, and they may be very difficult to achieve. But that is based on the capacity they already have. So I would argue that the immediate problem is supply chains: making sure that the critical inputs of material are provided.”

Soumya Swaminathan, WHO’s Chief Scientist

But Soumya Swaminathan, WHO’s Chief Scientist, said that many countries were still waiting for the first dose of vaccines to arrive “and it’s clear that there has been a mismatch between what manufacturers thought they would be able to produce and what they’ve actually been able to produce”. 

While there was an urgent need to address immediate bottlenecks, Swaminathan urged the global community to take a medium- to long-term approach to solving these problems.

“We need to think about the future and the possibility that we may need booster vaccines,” she said. “We may need vaccines regularly in order to deal with the emerging issue of the variants. We’re not sure about that as yet. But we need to prepare for repeated technologies and it is critical to increase the ability of all regions in the world to respond without being dependent on restricted global supply chains.” 

‘Global Hypocrisy’

Fifa Rahman, the NGO representative on the ACT Accelerator, said that low and middle income countries (LMICs) may only vaccinate 80% of their populations by 2024. 

However, the leaked text of a WHO draft resolution to strengthen local production of health technologies showed that some wealthy countries had deleted text that would enable technology transfer, said Rahman.

Fifa Rahman, NGO representative at the ACT Accelerator

“To sit here and talk about global solidarity and then to ask for the deletion of text and important provisions that would help LMICs get access to more vaccines is hypocrisy,” said Rahman. “We thus call upon the United States, Norway, the UK and Switzerland to withdraw their objections to the text.”

Rahman also criticised an over-reliance on industry to address the pandemic. Although the pharmaceutical industry claimed that it had the capacity to produce 14 billion doses by end of 2021, “according to an Airfinity document, industry developed delivered 96% fewer doses in 2020 than it had promised”, she said.

“Why are we blindly trusting that 2021 will be any different? We can’t take industries’ claims at face value. There’s too much at stake to rely on these aspirational projections as our route out of the biggest public health crisis of our generation,” said Rahman.

Instead, she proposed a mapping exercise on manufacturing capacity and expertise available in the global south to ensure viable vaccine manufacturing for entire continents.

Prioritise the Dose-Sharing

John Nkengasong, Director of Africa’s Centers for Disease Control (CDC), made two simple pleas: for any countries with excess doses of vaccines to “release them” to countries that do not have, and to “strengthen regional capabilities to manufacture vaccines across the world as part of our collective security”. 

Wellcome Trust Director Jeremy Farrar urged the ACT Accelerator not to “pretend that everything is going in the right direction”, but to develop a coordinated response to health system, regulatory and human resource challenges.

“We have to also push on with support for the diagnostics – critically, increasingly importantly – of the genomic surveillance globally, for the new variants of concern as they will continue to arise,” said Farrar.

Summarising various country and partner inputs, Ayoade Olatunbosun-Alakija, a member of the Africa Union Africa Vaccine Delivery Alliance, said that “we cannot have equitable outcomes without an equitable process”.

Olatunbosun-Alakija said countries had spoken about “prioritising the dose-sharing of existing vaccines” which meant that a “three-way conversation is required between countries, industry and COVAX to explore the potential sharing modalities”.

“There’s strong support for a task force to explore these options on the table and enforce the options where necessary,” she added.

 

Image Credits: ABC7 News.

Anthony Fauci, director of the US National Institute for Allergies and Infectious Diseases.

British-Swedish pharma company AstraZeneca may have included outdated information from their COVID-19 vaccine trial, the US National Institute of Allergy and Infectious Diseases (NIAID) said in a statement released Tuesday. 

The NIAID, part of the National Institutes of Health, urged AstraZeneca to work with the US  Data Safety and Monitoring Board (DSMB) to review the efficacy data to ensure up-to-date efficacy data can be made public as quickly as possible. 

The AstraZeneca US Phase III trial results published on Monday showed a 79% vaccine efficacy of preventing symptomatic COVID-19, and 100% efficacy at preventing severe disease and hospitalization. 

However, US health officials felt that the information was “outdated” and may have provided an incomplete view of the efficacy data. 

NIAID Director Anthony Fauci also discussed the issue during an appearance Tuesday morning on Good Morning America. 

“Because the fact is, this is likely a very good vaccine,” said Fauci. “It [just] wasn’t completely accurate.” 

Unforced Error

Fauci calls AstraZeneca’s “unforced error” something that will cause some people to doubt the vaccines and contribute to the ongoing vaccine hesitancy. 

“We essentially have to keep trying as hard as we can to get people to understand that there are safeguards in place,” he added, calling the DSMB’s ability to pick up on the discrepancy one example of a safeguard. 

While Fauci oversees the DSMB that assessed the trial results for AstraZeneca and other vaccine makers, he is not directly involved in its assessments. The final decision will be made by the US Food and Drug Administration (FDA), which will conduct their own review following the independent advisory committees. AstraZeneca plans to file with the FDA by mid-April, though their timeline relies on the DSMB clearing its trial results.  

AstraZeneca responded to the NIAID’s claims, saying in a statement that the numbers published on Monday were consistent and said it will “immediately engage with the DSMB to share our primary analysis with the most up to date efficacy data.” The company intends to issue results of the analysis within the next 48 hours.  

‘Stunned’ Health Experts Question AstraZeneca’s Credibility 

The national institute’s statement stunned experts, leaving them to question the pharma company’s credibility.  Dr Eric Topol, a clinical trials expert at Scripps Research in San Diego, called AstraZeneca’s response to the DSMB’s statement “unacceptable”. 

“They know exactly what is going on with respect to the time cutoff for primary analysis, which appears to be at odds with the independent Data and Safety Monitoring Board. It should not take 48 hours to sort out,” Topol tweeted on Tuesday.  

“Let’s see all the data, AstraZeneca,” Topol added, calling out the company. “Let’s be clear. This is not about the vaccine. It is about AstraZeneca, their own worst enemy, with an apparent breach on data dissemination. And where is the University of Oxford on this, their partner?” 

Topol had called the DSMB’s statement, which is supported by the National Institutes of Health, to be “unprecedented” in the history of large scale clinical trials. 

“I am rarely speechless. This turn of events has rendered me speechless. What a debacle,” said Helen Branswell, senior writer at Stat News.  

Branswell quoted the Washington Post, which said that the “AstraZeneca results were the equivalent of “telling your mother you got an A in a course, when you got an A in the first quiz but a C in the overall course.” 

Branswell added that, after this “extraordinary public rebuke of AstraZeneca by the DSMB”, the company team will “face tough, tough questioning.” 

Laurie Garrett, a former senior fellow at the Council on Foreign Relations, tweeted that the Board should “fire the entire AstraZeneca management team. “[The team] has made so many major blunders in launching the company’s COVID-19 vaccine that it will be a textbook study for decades in business schools and Communication departments.” 

The renewed skepticism for the pharma company in the US may counter the European Medicines Agency’s statement last week, which declared that the vaccine was safe, in spite of rare blood clotting events seen in Europe. 

 

Image Credits: Flickr, National Institutes of Health.

Escalating violence in Aleppo, northwest Syria, has claimed innocent lives and further devastated homes and one critical health facility.

Syria needs $US 78-million to vaccinate 20% of its population against COVID-19 by the end of this year, and its pandemic response is being challenged by a worsening humanitarian crises in the country, including continued attacks on health care facilities.

This is according to Akjemal Magtymova, the World Health Organisation (WHO) Representative in Syria, who told a media briefing on Tuesday that the country had only received half of the funding it had requested for this year and that additional assistance was needed to combat the virus and save lives.  

The briefing comes two days after the Al-Atareb Hospital in the Aleppo area was hit by artillery shelling from Syrian government forces, killing six people and injuring 17, including patients and medical personnel. 

The underground hospital, in an area controlled by forces opposed to the Syrian regime, sustained structural damages, resulting in the evacuation of all patients and staff, and the suspension of health services.  Hospitals and clinics in opposition-held areas have been repeatedly targeted, and destroyed in attacks by government forces – backed by Russia and Iran, according to a recent report by the International Rescue Committee. The attacks have continued despite a Russian-Turkish ceasefire covering rebel-held areas of northwest Syria, in effect since March 2020. Only 58 percent of hospitals remain fully functional, according to UN data.

“Thousands of people who depend on this hospital for basic and lifesaving health care are now deprived of this basic human right. Our thoughts and prayers are with the families of the victims,” said Ahmed Al-Mandhari, WHO Regional Director for the Eastern Mediterranean Region. 

Magtymova said funding is needed for creating mobile clinics, services, training, administration of vaccines, surveillance and dealing with side effects in the country whose health system and financial resources have been severely strained by war.

The country is expected to get its first delivery of AstraZeneca vaccines from COVAX within the next two to three weeks, allowing it to kick off a national COVID-19 vaccination programme starting with healthcare and frontline workers. Its immediate need is $7-million to vaccinate 2% of the population before the end of June.

Magtymova said WHO was working with dozens of different international and regional partners to address some of the country’s challenges, including funding, security issues and the fight against COVID-19. 

“We have worked hand in hand with our partners for coordinated efforts for COVID-19 preparedness and response against enhancing laboratory surveillance capacity, infection prevention and control points of the case management,” said Magtymova. “Most importantly is to maintain essential health services…and health care professionals are severely depleted.”  According to the IRC report, following a mass exodus of medical personnel, there remains just one Syrian doctor for every 10 000 civilians. 

COVID Adds To Multiple Healthcare Challenges in a Complex Environment

Describing the situation as “one of the most complex environments”, Magtymova said some of the challenges included “expanding public trust measures and achieving behaviour change, protecting health workers, security and access in ensuring continued use of essential health services, as well as establishing reliable supply chains”.

Some of the challenges at health care facilities include patients being treated in overcrowded rooms with no masks or social distancing and patients with abdominal wounds due to artillery strikes being treated in the same rooms as mothers with children. Some patients had to take detours of about six hours to get medical help due to hostilities and violence in their areas.

Magtymova added that while the pandemic was WHO’s priority, non-communicable diseases remain one of the major causes of mortality and morbidity with COVID-19 making people even more vulnerable. 

“Access to essential medicines have been severely compromised due to economic constraints. WHO sustains provision of life saving medicines to patients with diabetes, kidney diseases and failure, cancer, alongside with COVID-19 patients,” she said.

Giving an update on the situation in the northwest part of Syria, held by opposition forces, Mahmoud Daher, head of the WHO’s Gaza sub-office, said increased attacks on healthcare facilities were impeding the provision of critical health services.

“In Syria in general, and in northwest Syria, we have witnessed the attack on a hospital that was providing 5700 outpatient consultations, 375 hospital admissions and 160 major surgeries per month,” said Daher.

“This situation continues, and shows the fragility of that system that is prevailing in the northwest Syria. We are working with the international community and with the UN system in order to continue to provide health care services to the entire population. We are working under the United Nations Security Council Resolution to ensure that humanitarian assistance can continue despite the current volatile situation,” said Daher.

Syria’s COVID-19 real COVID-19 Numbers Are Much Higher than Official Data

On 26 March 2020, children in the town of Binnish, Syria, watch a member of the Syrian Civil Defence disinfect a former school building, now inhabited by displaced families, as part of measures to prevent the spread of COVID-19.

Syria has nine dedicated COVID-19 hospitals, 70 community care treatment centres for moderate to mild cases of the virus. Three laboratories have been established to detect and confirm COVID-19 cases. The country has registered 21, 260 COVID-19 cases, with 411 deaths.

Daher believes that investment from the international community, led by WHO, has contributed to the low numbers. He however warned that: “The situation is in need of all our efforts in order to contribute to humanitarian assistance, including radical services”.

As of 19 March, Syria had 21,000 COVID-19 cases reported in northwest Syria, more than 9,000 in the northeast and more than 17,000 in government-controlled Syria – the highest case fatality ratio is under government control territory. 

However, Magtymova believes that the numbers are not a true reflection of the COVID-19 situation, partly due to the country’s testing and record-keeping capabilities.

I do believe that the real numbers are much, much higher. The virus is not behaving differently in Syria. In fact, we are not aware of what kind of variants of the virus we are dealing with, because of the level of the capacities, but as WHO we have sent samples for sequencing to understand,” said Magtymova, adding that they were seeing a 100% bed occupancy level.

“Our epidemiological curve shows an increase in the new cases…which means that we are working in a very steep curve. And I have no reason to believe that, you know the situation of recorded cases is real. I’ve seen much more people with COVID-19, said Magtymova.

Magtymova concluded that the current infection patterns emerging in Syria and the looming third wave of the pandemic necessitates a more vigorous and urgent response.

 

Image Credits: Unicef.

WHO Director General Dr Tedros Adhanom Ghebreyesus

For the fifth week in a row, global COVID-19 cases have increased, with substantial increases in South-East Asia (49%) and the Western Pacific (29%), according to the World Health Organization (WHO).

India is driving up numbers in South-East Asia, while the Philippines and Papua New Guinea are responsible for the Western Pacific increases, according to Maria Van Kerkhove, WHO’s technical lead on COVID-19 speaking at the global body’s bi-weekly pandemic briefing.

Europe’s 12% increase was largely being driven by the spread of the B.117 variant “that was first identified in the UK, that is now starting to circulate in many countries in the eastern part of Europe,” said Van Kerkhove.

“The Americas and Africa have seen a slight decline in the last seven days, but overall, we’re seeing increasing cases and these are worrying trends in Europe and across a number of countries,” she added.

Brazilian Deaths Have Doubled in a Month

Despite a decline in the Americas, COVID-19 cases in Brazil have exploded with around 70,000 new cases a day and 2,000 deaths.

Describing Brazil’s cases as “accelerating really, really fast”, WHO Director General Dr Tedros Adhanom Ghebreyesus said that the global body was “especially worried about the death rate, which doubled in just one month from 7,000 to 15,000 a week”. 

However, Tedros was non-committal about giving Brazil’s new health minister – the fourth since the pandemic started – much advice other than that only “concerted effort of all actors that will reverse this upward trend”.

Van Kerhove reported that the ICU capacity has been running at over 80% in 25 of Brazil’s 27 federal units in the past week, and said that the P.1 variant prevalent in the country had increased the transmissibility of the virus.

“The country is under a heavy burden, but as you have heard us say many times before, Brazil has a lot of experience of dealing with not only COVID-19 but many infectious diseases,” she said.

WHO’s country staff are “working with the different federal levels in the state levels to support the country and to make sure that those who are needing care received the oxygen that they need”, and “vaccination is well underway”, added Van Kerkhove. 

Driving the increases

Van Kerkhove attributed the global increase to four main factors: pressure for countries to open up, difficulties in people and communities complying with “proven control measures”, uneven distribution of vaccines and the spread of variants, particularly B.117, B.1351 and P.1.

“If you have a combination of factors: of virus variants that transmit more easily, individuals who are fatigued and frustrated because we want this to be over, and are perhaps not being supported in carrying out the individual behavioral measures … to reduce our contact with others, and vaccination that is not yet reaching those who are most at risk – that is a very dangerous combination,” said Van Kerkhove.

Suppliers Can’t Keep Up With COVAX Orders

WHO special adviser and COVAX representative, Dr Bruce Aylward, said that “the facility can deliver that over 300 million doses” and “we’ve seen in the last couple of weeks some incredible work by t

“The procurement coordinators that are part of COVAX and UNICEF have been able to very rapidly put in place the purchase orders and very rapidly put the shipping pieces in place as well. 

“The problem that we have, quite frankly, is we simply cannot get enough vaccine to be able to keep up and the manufacturers are unable to keep up with our orders. We have two main suppliers to COVAX in this period, the Serum Institute of India, which got off to a great start but has had trouble now with its deliveries in March and April. And then AstraZeneca itself, the facility in Korea has also gotten off to a good start, but is having challenges keeping up with the rate of orders.,” said Aylward.

“We are hoping that both companies will be able to scale up and keep up with the rate of deliveries that we’re aiming for. But we’re still having some teething problems on the part of the suppliers that are trying to keep up with the demands that we’re making.”

Globally, 785 million people lack a basic drinking-water service and over half of the world’s population could be water-stressed by 2025.

COVID has highlighted deep-seated weaknesses in urban water and sanitation systems that are vital to health – but the pandemic has also underlined how improvements can hit back at the SARS-CoV2 virus – as well as reducing other traditional waterborne diseases. 

That was a key message at a seminar Monday on “Water and Sanitation in the City” – sponsored by the Geneva Cities Hub, UN Habitat, and Geneva Water Hub, on the occasion of World Water Day. It was the first in a series of ‘Geneva Urban Debates.’ 

“COVID in some ways has given us a huge opportunity in the water sector, because it has acted as an x-ray,” said Graham Alabaster, Chief of the Geneva Office of UN Habitat. 

He pointed to evidence that showed in cities where hygiene standards were improved so as to combat the spread of the SARS-CoV2 virus, the incidence of waterborne diseases has dropped significantly. “So we know that the ideas around hygiene and providing people with water and sanitation work,” Alabaster added.

On the right, Graham Alabaster, Chief of the Geneva Office of UN Habitat, and on the left, Kamelia Kemileva, Executive Manager of Geneva Cities Hub.

Water also is a a critical “engine for economic growth” and a precondition for development, said Sami Kanaan, Mayor of Geneva and the President of the Geneva Cities Hub. It is an issue that converges with health, poverty, climate change, education, and livelihoods. 

“Increasing access to safe drinking water and basic sanitation is a crucial step in eradicating growing poverty and reducing inequality in cities,” said Kanaan. 

The importance of accessing water and sanitation has been highlighted by the COVID pandemic, whereby one of the key infection prevention measures promoted from the beginning by WHO was effective handwashing and other good hygiene measures.

And yet, in many low- and middle-income cities, low-income households and neighbourhoods are often left without reliable access to clean water and must buy it from private vendors, paying up to five times as much as that paid by middle class residents. That makes uptake of hygiene messages for disease prevention all the more challenging.  

Over Half of World’s Population May Be Water-Stressed by 2025

By 2025, over half of the world’s population will be living in water-stressed areas. And some 68% of the global population is projected to be living in cities by 2050, making urban challenges around the universal provision of safe water and sanitation all the more daunting. 

At the same time, some cities have found innovative ways to meet growing demands, and sharing urban experiences across continents can help improve cities’ performance, the panelists underlined.  

The panelists highlighted the need to move beyond an approach to water and sanitation focused merely on service provision; instead attention also needs to be paid to broader assessments of water resources, the effective distribution of water, and sustainable financing for infrastructure. 

“We need an effective multi stakeholder framework, it must be an institutional will and institutional intention at the city level, with the support of the upper institutional levels,” said Kanaan. “Water management needs cooperation of all levels.”

Sami Kanaan, Mayor of Geneva and President of the Geneva Cities Hub, at the ‘Water & Sanitation in Cities’ event on Monday.

“Sustainable management of fresh water is a vital issue of this century at the center of health security, food security, energy security, and in short human security,” said François Münger, General Director of the Geneva Water Hub. 

Conference Featured Stories from Kenya, Tanzania, Nepal & Mauritania 

The conference featured good practices from cities in in Mauritania, Tanzania, Nepal and Kenya highlighting how public and public-private partnerships involved in managing urban water and sanitation had brought about change, in some of the following ways: 

Informal settlements in Dar-es-Salam, Tanzania.

Dar-es-Salaam in Tanzania – Only 10% of the city’s 7 million people have sewer connections or safe onsite septic tanks.  New approaches have revolved around “simplified sewerage” hookups, that involve laying small diameter pipes at a fairly flat gradient/slope to sewer ponds. The municipal water and sewerage utility provide technical support and finance, while households in the community provide space and labour to lay the pipes. A more recent pilot has connected households to a community-based waste water treatment plant (DEWAT) that produces biogas from the methane extracted from the sewage. The biogas then provides a clean and climate friendly fuel source for household cooking.

Nairobi, Kenya – Chronic water shortages affecting some 60% of the population have been traced to the conversion of wetlands and forests that form the watershed for the Tana River – into agriculture land. The unsustainable agricultural development has increased volumes of sedimentation that enter the river with rainfall, reducing the flow of the river and its watershed which supply 95% of the water for Nairobi’s population and causing blockages in water treatment facilities.

Several public and private partners joined to provide training and tools to over 25,000 farmers upstream on river and soil conservation and to restore forest land. These efforts have benefited farmers, by increasing agricultural yields by over US$3 million per year, and city residents, with 27 million more litres of water available every day for the city’s water needs.

The steps involved in the Upper Tana Nairobi Water Fund project in Kenya.

Dhulikhe, Nepal –  A national sanitation and hygiene campaign was launched in 2010, leading to the prioritisation of investment in sanitation facilities and increasing access to sanitation for the majority of households. In the country’s Dhulikhel municipality, the local government passed a ‘’one house, one tap’’ policy with the goal of providing safe drinking water to every household in the city. The plan arranged for every resident to get 65 liters of water per day. 

Dhulikhel also joined Banepa and Panauti, all in the Kavre district, to collaborate and manage drinking water in an integrated manner. The project identified and mapped existing drinking water sources and established Water Supply User Committees to represent and engage local communities in governmental water supply schemes and improve investment in the needs of communities.

Health Impacts of Poor Access to Clean Water and Sanitation 

Long before COVID, diarrhoea was estimated to kill some 829,000 people a year, as a result of unsafe drinking water and poor sanitation, according to the World Health Organization. Contaminated drinking water – which may be due to the encroachment of sewage or industrial pollutants into drinking water resources – is estimated to cause 485, 000 diarrhoeal deaths each year.

Many neglected tropical diseases (NTDs), which infect millions of people worldwide, are water or hygiene-related and are most often found in places with unsafe drinking water, poor sanitation, and insufficient hygiene practices.

Some of the biggest challenges occur in fast-growing cities, where sprawling informal settlements often develop on the periphery, without adequate water and sanitation infrastructure planning – leaving only ad hoc approaches. 

Poor sanitation in informal settlements disproportionately impacts women and girls, with an estimated 335 million girls attending schools without access to safe latrines, not to mention water and soap for hygiene. Deprived of adequate sanitation and hygiene facilities, adolescent girls may just avoid school on days when they are menstruating.  

Improved water, sanitation and hygiene has the potential to prevent at least 9.1% of the global disease burden and 6.3% of all deaths, according to the US Centers for Disease Control and Prevention.

Image Credits: UNHCR, Geneva Cities Hub, Geneva Cities Hub.

The Oxford/AstraZeneca COVID-19 vaccine during the vaccine development process.

In news that should be reassuring for skeptics, the Oxford/AstraZeneca COVID-19 vaccine was found to be 79% effective in preventing symptomatic COVID-19 and 100% effective against severe disease and hospitalization in results of a late-stage clinical trial, published today by the pharma company.

What’s more, analysis of safety results by an independent board found no increased risk of blood-clotting (thrombosis) among the trial participants, the company said in it’s statement – reinforcing findings of the European Medicines Agency (EMA) last week that the vaccine is safe – despite some rare blood clotting events seen in Europe, particularly among young women, that warrant further investigation.

Among trial participants over the age of 65, the vaccine efficacy rate reached 80%. This news is also reassuring, given the limited data on the vaccine efficacy in older individuals that had been seen to date, and which had led many EU countries to set age restrictions on the AstraZeneca vaccine in the first phases of rollout. 

The results of the large-scale trial, with many participants in the United States, also are expected to pave the way for approval of the vaccine by the United States Food and Drug Administration (FDA).

EMA Executive Director Emer Cooke reports the results of the body’s safety committee report  on the AstraZeneca vaccine last week.
New AZ Trial Results – United States, Peru & Chile

The new trial was conducted in the US, Peru and Chile, with 32,449 participants. Efficacy was consistent across age and ethnicity, although 79% of the participants were white, 22% were hispanic, and only 8% were black, 4% asian, and 4% native American. 

In the initial set of Phase 3 trials, which had taken place largely in the United Kingdom and Brazil, only 12% of participants were older than 55. In contrast, the newly reported US trial arm had one fifth of the participants over 65 and approximately 60% had co-morbidities – which would normally increase their risk of developing severe illness, including diabetes, severe obesity, and cardiac disease.

“These findings reconfirm previous results observed in AZD1222 trials across all adult populations, but it’s exciting to see similar efficacy results in people over 65 for the first time,” said Ann Falsey, co-lead Principal Investigator for the US trial, in a press release issued by the pharma company. 

“This analysis validates the AstraZeneca COVID-19 vaccine as a much-needed additional vaccination option, offering confidence that adults of all ages can benefit from protection against the virus,” she added. 

AstraZeneca said that it now plans to submit these findings to the FDA in the coming weeks to receive emergency use authorization. The primary analysis of the data, once it is completed, will also be submitted for peer-reviewed publication.

Planned Delivery of Doses

Meanwhile, AstraZeneca announced on Monday in a press conference that it would deliver 30 million doses of the vaccine to the United States in the first half of April after receiving approval and another 20 million later on in the same month. Subsequently, 15 to 20 million doses will be delivered. 

US health officials have predicted that the country will have enough doses to vaccinate every adult by May using the three vaccines currently approved – Pfizer/BioNTech, Moderna, and Johnson & Johnson.

It is unclear how big of a role the AstraZeneca vaccine will play in the US’ vaccination campaign and whether the government will donate excess doses to countries lacking in vaccines.

At a press conference on Monday, Ruud Dobber, President of AstraZeneca’s Biopharmaceuticals Business Unit, said he would be “very surprised” if the doses were not used to vaccinate Americans. 

Blood Clots and Vaccine Hesitancy
From Europe, concerns have spread worldwide. (on right) Paul Kelly, Australia’s Chief Medical Officer addresses blood clot concerns over AstraZeneca vaccine.

In addition to the trial results, an independent data safety monitoring board (DSMB) conducted a specific review of thrombotic events, including cerebral venous sinus thrombosis (CVST) – a rare disorder of clots in vessels draining from the brain – seen in association with the vaccine’s administration in a number of cases in Europe.

The board found no increased risk of thrombosis among the trial participants, echoing the message from the EMA last week, which stated that the vaccine is safe and effective. 

“We hope this will lead to even more widespread use of the vaccine in the global attempts to bring the pandemic to an end,” said Sarah Gilbert, Professor of vaccinology at Oxford University and co-designer of the vaccine.

According to the latest EMA data, of an estimated 20 million people in the United Kingdom and Europe that had received the vaccine as of March 16, the EMA had identified 18 cases of CVST (cerebral events), occurring shortly after vaccine administration, as well as seven other cases of disseminated intravascular coagulation, DIC.

Although no causal connection has been found between the vaccine and the blood clotting, and several countries have now resumed the rollout of the vaccine, trust in AstraZeneca’s vaccine has taken a hit, particularly in Spain, Germany, France and Italy. 

In a poll conducted by YouGov in March, which included 8,000 participants in seven European countries, respondents were more likely to view the AstraZeneca vaccine as unsafe than safe. 

Some 61% of French, 55% of Germans, 52% of Spaniards, and 43% of Italians said it was unsafe. Confidence in the vaccine has fallen since a poll conducted in February.

“After concerns about its protection and potency were raised by leaders across Europe, the Oxford/AstraZeneca vaccine has undoubtedly suffered damage to its reputation for safety on the Continent,” said Matt Smith, lead data journalist at YouGov, in a statement.

“Not only have we seen considerable rises in those who consider it unsafe in the last two weeks in Europe, the AstraZeneca vaccine continues to be seen as substantially less safe than its Pfizer and Moderna counterparts,” Smith added.

The same decline in public confidence was not seen in the UK, where 77% of participants considered the jab safe. 

According to William Schaffner, Professor of Medicine in Infectious Diseases at the Vanderbilt University School of Medicine, “there will be spillover to the United States, where…there is a substantial group of vaccine hesitant and skeptical people whom we have yet to win over. And all of this discussion, I’m sure, gives them further pause,” he said in an interview with CNBC.

The vaccine has been granted authorization in over 70 countries and received Emergency Use Listing from WHO, leading the way for its use in the COVAX facility to supply low- and middle-income countries with vaccines. 

Serum Institute of India Announces Delays in Supply of AZ Vaccine to several countries.

In other AstraZeneca vaccine news, the Serum Institute of India, a pharma company producing the Oxford/AstraZeneca vaccine for many low-  and middle-income countries, informed Brazil, Morocco and Saudi Arabia that there will be a delay in delivering vaccines they ordered due to a fire in one of the production buildings.

This has “caused obstacles to the expansion of our monthly manufacturing output,” said the Serum Institute in a statement delivered to the Fiocruz Institute in Brazil. 

The statement contradicted one that was provided immediately after the fire took place in which SII said that it would have no effect on vaccine production.

On a brighter side, the company said a production factory in the Netherlands could soon be approved by the EMA. This would expand the doses available to the EU, which has been plagued by vaccine shortages and a slow rollout across the 27-member bloc. 

The announcement came after several months of dispute between AstraZeneca and the European Union over manufacturing hiccups and vaccine supply constraints.   

At the same time, AstraZeneca is the major vaccine supplier of the WHO co-supported COVAX initiative  – and even as production in Europe and the United States moves into higher gear, it may be expected that countries in those regions will come under increased scrutiny for holding onto precious vaccine doses – while LMICs continue to wait.    

“AstraZeneca continues to engage with governments, multilateral organizations and collaborators around the world to ensure broad and equitable access to the vaccine at no profit for the duration of the pandemic,” said AstraZeneca’s statement. 

Image Credits: gencat cat/Flickr, University of Oxford, Sophie Scott/ABC.

Dr Tereza Kasaeva, Director of WHO’s Global TB Programme.

An estimated 1.4 million fewer people received care for tuberculosis (TB) in 2020 than in 2019 – a drop of 21% – according to preliminary data compiled by the World Health Organization (WHO) from over 80 countries.

Countries worst affected are Indonesia (42%), South Africa (41%), Philippines (37%) and India (25%), and the WHO fears that over half a million more people may have died from TB ilast year simply because they were unable to obtain a diagnosis.

“The effects of COVID-19 go far beyond the death and disease caused by the virus itself. The disruption to essential services for people with TB is just one tragic example of the ways the pandemic is disproportionately affecting some of the world’s poorest people, who were already at higher risk for TB,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“These sobering data point to the need for countries to make universal health coverage a key priority as they respond to and recover from the pandemic, to ensure access to essential services for TB and all diseases.”

The WHO report follows a report released last week by the Stop TB Partnership which showed that the drop in people diagnosed and treated for TB in nine high-burden countries had dropped to 2008 levels – a setback of 12 years.

New TB Screening Guidelines

“Twelve years of impressive gains in the fight against TB, including in reducing the number of people who were missing from TB care, have been tragically reversed by another virulent respiratory infection,” said Dr. Lucica Ditiu, Executive Director of the Stop TB Partnership.

“In the process, we put the lives and livelihoods of millions of people in jeopardy. I hope that in 2021 we buckle up and we smartly address, at the same time, TB and COVID-19 as two airborne diseases with similar symptoms.”

To mitigate the impact of COVID-19 on service delivery, the WHO has developed new screening guidance, including the use of rapid diagnostic tests, computer-aided detection to interpret chest radiography and the use of a wider range of approaches for screening people living with HIV for TB. 

The WHO recommends that the contacts of TB patients, people living with HIV, people exposed to silica, prisoners and other key populations should be prioritized for TB screening. 

People With TB Most Marginalised

“For centuries, people with TB have been among the most marginalized and vulnerable. COVID-19 has intensified the disparities in living conditions and ability to access services both within and between countries,” says Dr Tereza Kasaeva, Director of WHO’s Global TB Programme.

“We must now make a renewed effort to work together to ensure that TB programmes are strong enough to deliver during any future emergency – and look for innovative ways to do this.”

The new guidance also recommends different tools for screening, namely symptom screening, chest radiography, computer-aided detection software, molecular WHO-approved rapid diagnostic tests, and C-reactive protein. 

As the popularity of tobacco products wanes, tobacco companies are developing new products to expand their markets.

NAIROBI – The Kenyan government issued a directive in mid-February this year requiring the tobacco industry to register all nicotine products as tobacco products – but the industry has yet to comply. 

This follows the decision by the Cabinet Secretary in the Ministry of Health, Mutahi Kagwe, to declare “nicotine pouches” illegal, thus overturning a decision last year by the Pharmacy and Poisons Board (PPB) to license the manufacture and sale of nicotine products in the country.

 The criteria used to issue the license was not clearly defined, according to the Ministry of Health, hence the unprecedented move by the Cabinet Secretary.

The government’s directive comes in the wake of a nicotine production plant by the British American Tobacco (BAT) company being planned in Kenya. The plant will not only serve the east African region with nicotine products but will cater for the entire African market, making Kenya the gateway for nicotine products into the continent.

 Marketing Hub for Harmful Product

“Kenya is a manufacturing hub of this harmful tobacco product. It is unfortunate that they [BAT Kenya] are putting up another plant specifically to produce Lyft,” said Samuel Ochieng, CEO of the Consumer Information Network at a press briefing called by the Kenya Tobacco Control Alliance towards the end of February.

Lyft is the brand name for the “nicotine pouches” being manufactured by BAT. These pouches are small bags of powder containing either tobacco-derived nicotine or synthetic nicotine, but no tobacco leaf, dust, or stem. People place them under the lip to get nicotine. 

All this comes a year after the Cabinet Secretary in the Ministry of Health, Mutahi Kagwe overturned an earlier decision by the Pharmacy and Poisons Board (PPB) to license the manufacture and sale of nicotine products in the country.

The criteria used to issue the license was not clearly defined, according to the Ministry of Health, hence the unprecedented move by the Cabinet Secretary.

When asked about the government’s position on why Kenya was singled out by the tobacco multinational company, Kepha Ombacho, the Chief Public Health Officer in the Ministry of Health, told Health Policy Watch: “We cannot say for sure that they are targeting Kenya.”

Trying to Diversity Product Line

The tobacco industry is trying to diversify its product line after years of well-documented health risks associated with smoking has had an impact on consumers and industry profits. 

In the past week, the WHO published a new report calling for the strengthening of the tobacco control measures to protect the health of children.

The study, Tobacco Control To Improve Child Health and Development  found that of the 1.2 million deaths every year caused by second-hand tobacco smoke exhaled by smokers, 65,000 occur among children under 15 years.

However, the third edition of the WHO global report on the trends in prevalence of tobacco use 2000-2025 published in 2019 shows a decline in tobacco use among people of both sexes in the world.

According to the report, about a third of the global population aged 15 years and above used of some form of tobacco in 2000. This rate declined by nearly 10% to about a quarter by 2015.

If current tobacco control efforts are maintained, the rate is projected to decline to around a fifth of the (20.9%) by the year 2025, says the report.

Use of Social Media Influencers

The furore generated by the Lyft nicotine pouches in Kenya was well captured by The Guardian in February, which detailed how the brand was using social media influencers to promote Lyft. 

The influencer in the article is a young beauty blogger with an Instagram following of more than 250,000 and a Youtube channel following of well over 55,000 subscribers. She appears to have deactivated her account and removed the Lyft tweets since the expose.

Meanwhile, a PR agent working for BAT even offered a Kenyan journalist a bribe to leak details about an investigation by Bureau for Investigative Journalism into how tobacco companies were targeting young people. BAT has since suspended the agency.

It is clear from these reports that tobacco companies have been using influencers that are popular among the youth to push their nicotine products.

This is made more serious because Kenya is a signatory to the WHO’s Framework Convention of Tobacco Control (FCTC). Article 13 of the Convention clearly talks about banning all forms of tobacco advertising, promotion and sponsorship.

 The Ministry of Head’s Ombacho says that Lyft and any products that contain nicotine are not alternative products to tobacco and should be accompanied by clear labeling stating as much.

 Significant Health Risks

According to the Tobacco Act of 2007, tobacco companies are required to set aside 2% of their revenue to go into the Tobacco Fund to assist people suffering from the health effects associated with smoking.

Only BAT has started to make contributions to the fund although there are at least three active tobacco companies in Kenya, and Ombacho said that “they will just have to comply”.

Nicotine pouches appear to have been developed in Scandinavia. They have significant health risks. Issuing a health warning about them last November, Health Canada warned that they had not been authorised in the country and should not be used “by anyone”

“Nicotine is a highly toxic and addictive substance. Excessive amounts of nicotine can cause acute poisoning, resulting in respiratory failure and death,” according to Health Canada.

Image Credits: By Bystroushaak/ CC BY-SA 4.0, Chris Vaughan.