Health workers in full protective gear do a COVID-19 throat swab in a Addis Ababa isolation centre.

Cape Town – As South Africa records over 930,000 COVID-19 cases and its scientists race to understand whether a new variant is driving the country’s second wave of infections, countries across the African continent are reporting an increase in cases.

But there is widespread anecdotal evidence that many African countries are massively  under-reporting their COVID-19 caseloads, primarily because not enough tests are being performed. The threat is that this is giving citizens a false sense of complacency.

According to the latest report from Africa Centers for Disease Control and Prevention (CDC), the countries with the highest caseloads on the continent are South Africa, Morocco, Egypt, Tunisia and Ethiopia, with Libya and Kenya not far behind. Nigeria, Zambia and the Democratic Republic of Congo are also reporting rising infections.

Since late October, the Africa CDC has been warning the continent to prepare for this scenario. And In the light of the new, potentially more infectious variant identified in South Africa, the CDC urged African countries “not to relent in their efforts to step up testing, contact tracing and early treatment of cases”.

Denial Across the Continent

But few countries have ramped up testing. In fact, many have even seen non-clinical prevention measures flaunted.

Large election rallies in Ghana, Tanzania and Uganda have seen large crowds of people in very close proximity without masks.

People fail to wear masks at election rallies in Uganda.

Tanzania is perhaps the most extreme example of COVID-denialism. President John Magafuli replaced 3 of the country’s top health officials in April and simply stopped reporting cases to the World Health Organisation (WHO) from 29 April.

In May, he said that imported coronavirus tests were faulty after claiming several non-human samples – including from goats and papayas – tested positive.

“We should not accept that every aid is meant to be good for this nation,” he said at the time.

The following month, he declared the country COVID-free thanks to the prayers of citizens, praising them for not wearing masks.

Tanzania stopped reporting its COVID-19 cases to the WHO in April.

 

Since this declaration Tanzanian truck drivers, who are required to provide negative tests before entering neighbouring countries, have tested positive.

Health sources inside the country claim that it is impossible for anyone to receive a positive coronavirus test result as the government has taken control of testing at all private laboratories: only negative test results are being released to patients.

“Even travellers who need a test only get it back if it is negative, otherwise their test never comes back,” a source told Health Policy Watch.

In July, Kwanza TV was taken off air for 11 months for an “unpatriotic” post on Instagram: a message from the US embassy in Tanzania warning of “elevated risk” of community transmission in the country.

East Africa – Limited Capacities and Public Complacency

Meanwhile, in Kampala, Uganda, a doctor working in a busy hospital told Health Policy Watch that “all the hospitals are full and there are many respiratory-related cases” but that COVID-19 surveillance was low, in large part due to difficulties with the tests.

“The results come back late, and the patient might have already passed away, or the lab doesn’t send the results at all,” he said, adding that people were only able to get COVID-19 tests in Kampala or at major regional hospitals. “We are also under pressure not to put COVID-19 on the death certificate.”

Ghanaian President Nana Akufo-Addo has closed the country’s land and sea borders, and confirmed that beaches and pubs will remain closed during the festive period.

Last week, Zambia’s President Edgar Lunga raised concern about “a generalised spread of COVID-19” in North-Western, Muchinga, Copperbelt, Central, Lusaka and Southern provinces.

Zambian Ministry of Health Permanent Secretary Kennedy Malama has cautioned that the country is still at risk of a second wave. Cases in Zambia continue rising, especially in patients with HIV and other non-communicable diseases such as diabetes.  

But Zambia’s National Director for Infectious Diseases, Dr Lloyd Mulenga, said that his country has managed the pandemic  “pretty well” with the help of cooperating partners like the Africa CDC, which had helped to address shortages of health workers and in Personal Protection Equipment (PPE) for health workers.

Zambia closed four of its isolation centers in various parts of the country in October because not enough patients required the services.

However, a medical doctor at Levy Mwanawasa Teaching Hospital, one of the 12 isolation centers, warns of a likelihood of a spike in infections as people relax their adherence to safety measures.

Zambia’s official COVID-19 cases.

He is also wary of the health ministry’s weekly COVID-19 statistics, claiming that these  under-represent the number of people infected with the virus and deaths due to COVID-19, which is making people complacent.

He believes that the recorded number of infections is small – 18,716 cases by 21 December – because the testing sample size is small. Usually, there are around 5,000 to 6,000 tests performed daily in Zambia.

“And yet in July, we were told the country could test up to 12,000 people a day. Why are we not doing it? We do not have sufficient test kits,” he said.

He worries that untested and unconfirmed infections could raise the rate of disease and fatalities in a susceptible population. That wards and health facilities have not been oversubscribed is not an indication that there are few COVID-19 infections, he says.

“Going by [government] statistics, there are 366 deaths recorded. Of those, 283 were brought in dead. This figure tells you that there are uncaptured infections in the community.” 

While there are several reasons people do not seek medical attention in health facilities, there is insufficient testing conducted in communities, he says. The government cannot reasonably say it is managing the crisis.

Another medical officer who worked in an isolation center and was part of the public testing campaign in the initial phase of the pandemic, told Health Policy Watch that  said the Ministry of Health was advised to stop random testing in communities because of a shortage of test kits. 

“Now we only test people coming to health posts presenting with one or more of COVID -19 symptoms, and those who are travelling abroad. This leaves out the huge segment of the population who do not, as a matter of course, seek medical attention when they are sick and are not going out of the country,” he said.

West Africa – Test Shortages and High Positivity Rates Among Youth

While Nigeria is the most populous country on the continent, it has the ninth highest number of cases of COVID-19 on the continent and has only conducted the sixth-highest number of COVID tests in Africa.

Nigeria’s daily new confirmed COVID-19 cases per million people have been rising steadily since 2 December but there are indications that there are more cases than are being reported. 

By 19 September, Oyo state had the third-highest number of confirmed cases of COVID-19 in Nigeria, but health officials attribute this to a community testing exercise. 

Kemi Ayoola, a medical scientist with the Oyo state ministry of health, said that during this time, she and her team were involved in community testing exercises in densely concentrated areas of the state.

“We would go to a community, announce that there was free testing and people would show up. During the period, we were seeing lots of cases. But when we stopped, the number of cases drastically dropped,” Ayoola told Health Policy Watch.

COVID-19 cases also emerged when young men were tested before being admitted to camps for the mandatory National Youth Service Corps (NYSC) service.

The Director of the Nigeria Center for Disease Control (NCDC), Dr Chikwe Ihekweazu, said that 138 out of a total of 34,785 corps members tested positive, representing a prevalence of 0.4%.

“It means one out of 200 people,” Ihekweazu said. For a population of 200 million, that could mean about 800,000 cases.

Officials at the NCDC told Health Policy Watch that testing with the recently approved antigen-based rapid diagnostic testing kit for SARS-CoV-2 would improve access to testing and is likely to further increase the number of confirmed cases.

The NCDC reported a “sharp increase” in cases between 30 November and 6 December, with almost three-quarters of those new infections found in Lagos, Kaduna and the Federal Capital Territory. Lagos has closed schools and banned large gatherings including concerts and carnivals over the festive season.

Boss Mustapha, chairperson of the Nigerian Presidential Task Force (PTF) on COVID-19, warned last Thursday that these indications seemed to spell a second wave.

“We are in a potentially difficult phase of the COVID-19 resurgence. Accessing the hope offered by the arrival of the vaccine is still some time ahead,” Mustapha said.​​​​​​​ 

Nigerian Health Minister Osagie Ehanire had earlier announced that the government would receive 20 million doses of a COVID-19 vaccine by January 2021.

PPE Shortages

After an 8-month stand-off with the government, the 7,000-strong Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) began striking from Monday in protest against pay problems and a shortage of PPE for health workers.

After months of negotiating, Kenyan health workers went on strike this week.

Health workers in Uganda have also reported chronic shortages of PPE in hospitals receiving COVID-19 patients – with doctors and nurses having to purchase their own masks and gloves. 

While teams undertaking the testing may be specially equipped with PPE, other doctors and health workers treating suspected COVID-19 patients often only have masks and gloves, and suspected COVID-19 patients remain in regular wards until their tests are confirmed.   

In Nigeria,  frontline health workers also embarked on a strike action to protest shortages in PPE, but this has been addressed by the local production of PPE.

In North Africa – Egypt To Be First Country Rolling Out Vaccines

Meanwhile, cases in Tunisia and Morocco peaked in November and are starting to reduce but Egypt’s caseload is rising again. However, Egypt has received a batch of doses of a Chinese COVID-19 vaccine, clinical trials for which were conducted in Egypt, and the country is now due to roll out vaccinations in early January, starting with health workers and people with chronic conditions.

Many other African countries are likely to have to wait a lot longer to get access to a vaccine and face increasing sickness and economic hardship as they do.

Image Credits: WHO, © WHO/Otto B..

Development workers hand over relief aid to a woman amid the COVID-19 pandemic at Madartek area in Bashabo of Dhaka.

Nearly all countries’ development rankings have been shaken up, following the addition of new climate and environmental metrics in a UN global index designed to measure human progress, with the greatest decline in ranking position occurring among high income and developed countries.

The 2020 Human Development Report, published by the United Nations Development Programme (UNDP), details the myriad of challenges posed by climate change and poverty, which have been exacerbated by the ongoing pandemic.

But it also includes a new generation of human development metrics to reflect countries’ progress in lowering climate emissions and making more efficient use of natural resources, in what UNDP describes as an attempt to better visualise and measure the effectiveness of countries’ climate and environmental policies.

The two new metrics – measuring national carbon dioxide emissions and material footprint, per capita – have been added to UNDP’s Human Development Index (HDI), as part of its ‘planetary pressures’ adjustments.

The HDI is a system used to assess the multiple dimensions of the development of a country, including health, education, and standard of living. The Index ranks countries by how they expand people’s freedoms and opportunities.

With the HDI’s adjustments in place, more than 50 developed countries fall from a very high human development ranking to much lower ones due to their high dependence on fossil fuels and their raw material consumption.

The adjustment to standard Human Development Index values by the Planetary pressures–adjusted Human Development Index widens as human development levels increase.

The top ten countries that fared poorly under the adjusted index are: Luxembourg (falling the furthest, dropping 131 places), Singapore, the United Arab Emirates, Qatar, Kuwait, Australia, Brunei Darussalam, Kazakhstan, the United States, and Canada. 

Luxembourg, the country with the highest energy consumption per capita and lowest share of renewable energy consumption in Europe, has an enormous ecological footprint, causing it to fall from position 23 to 154. The economies of the Gulf states rely heavily on hydrocarbon revenues and environmentally unsustainable industries, prompting many of them to drop over 70 places. The United States dropped 45 places on the ranking, from position 17 to 62, which reflects its outsized environmental impact. Additionally, Norway, which has led the HDI rankings for 3 decades, fell 15 places to position 16 due to its oil-fueled economy. 

In contrast, several countries – including Costa Rica, Moldova, and Panama – rose on the ranking by at least 30 places. Countries that crossed the threshold from the high to very high development category, included Sri Lanka, Cuba, Albania, Armenia, and Colombia.

Among countries with very high development levels, Argentina rose 20 places, France’s ranking inceased by 16, the UK rose 10 places, and New Zealand moved upwards by 6 places.

The rise in temperatures, sea levels, epidemics, extreme weather events, and forest fires are expected to result from anthropogenic climate change.

“This is the reality of the Anthropocene, the age of humans, as we refer to it. And in it, humanity is, in a way, waging a war against itself,” said Achim Steiner, UNDP Administrator, at a WHO press briefing on Monday.

The report also found that global emissions and material footprint per capita have been increasing consistently for the last 30 years: the amount of time since the first Human Development Report was published. No country has achieved very high human development without placing a heavy toll on the planet’s health.

Environmental damage is highly correlated with wealth and power, as the world’s 10 largest emitters account for 45% of total global emissions, while the bottom 50% account for only 13%. The wealthiest 1% of individuals worldwide emit 100 times as much carbon dioxide annually as the poorest 50%.

“Inequality is both a cause and a consequence of planetary imbalances and it stands in the way of solutions,” said Steiner.

Redefining the Anthropocene

“As the Human Development Report makes clear, COVID-19 is the latest in a string of consequences resulting from the ever growing pressures we put on the planet in the name of progress,” Steiner warned on Monday.

The COVID-19 pandemic has triggered a social and economic development crisis, destroying livelihoods, disrupting health systems, and barring millions of children from classrooms, indicating that – for the first time in 30 years – global human development progress is going backwards.

The COVID-19 pandemic’s unprecedented shock to human development.

By UNDP’s estimate, 1 billion people could be living in extreme poverty by the end of the decade, with potentially a quarter of them pushed into poverty as a consequence of the pandemic.

The COVID-19 pandemic is linked to anthropogenic environmental changes and rising temperatures, which contribute to increasing zoonotic diseases, caused by pathogens that jump from animals to humans.

Additionally, changes in the number of extreme temperature days, which result from climate change, will worsen inequalities in human development and social vulnerability, the report says.

Projections estimate that by the turn of the century, the poorest countries in the world could experience up to 100 more days of extreme weather each year.

Achim Steiner, Administrator of UNDP, at the WHO press briefing on Monday.

“Humans wield more power over the planet than ever before. In the wake of COVID-19, record-breaking temperatures and spiralling inequality, it is time to use that power to redefine what we mean by progress, where our carbon and consumption footprints are no longer hidden,” said Steiner in a press release.

Redesigning the path to human progress begins with ensuring the equitable, efficient, and trusted delivery of COVID-19 vaccines to all countries regardless of income or development levels, the report stated.

Change Requires Incentive

The Human Development Report called for transformations in the way individuals, governments, and organizations live, work, and cooperate by influencing social norms, improving incentives for change.

For example, cumulative global investment in low-carbon power is estimated to total about US$16 trillion between 2020 and 2040. To reach net-zero emissions by 2050 would require at least an additional US$11 trillion, however.

“Such shifts call for a wide range of changes in incentives, with governments playing a key role,” the report noted. “But [these shifts] can also emerge as a result of pressure from the investors who entrust their savings to financial firms.”

Steiner said: “This is the ultimate stress for planetary health: delivering the largest public health intervention of a lifetime and driving in a concurrent way the recovery in an inclusive and green direction.”

“The next frontier for human development is not about choosing between people or trees; it’s about recognizing, today, that human progress driven by unequal, carbon-intensive growth has run its course,” said Pedro Conceição, Director of UNDP’s Human Development Report Office.

“By tackling inequality, capitalizing on innovation and working with nature, human development could take a transformational step forward to support societies and the planet together,” he added.

Image Credits: Flickr – UN Women Asia and the Pacific, UNDP, UNDP, WHO.

The Pfizer-BioNTech COVID-19 vaccine during the manufacturing process.

The European Medicines Agency (EMA) announced on Monday that it would recommend conditional marketing authorization for the Pfizer/BioNTech COVID-19 vaccine – positioning Europe to finally begin rolling out vaccines across the continent – albeit after the United States, Canada, the United Kingdom and Israel have already moved into high gear vaccine campaigns.  

Mass vaccinations were set to begin next week in a number of countries across Europe – following the expected European Commission approval of the EMA recommendation later this week. Germany, France, Austria and Italy all said that they planned to start vaccination programmes for their most vulnerable groups beginning on Sunday 27 December.

The EMA move was preceded by Swiss approval of the Pfizer vaccine on Saturday; like the EMA, the Swiss approval came earlier than previously expected. Mass vaccine campaigns of vulnerable, priority groups, will begin in Swizerland on 4 January, 2021, Swiss health authorities said. However, a spokesperson declined to provide details on the planned pace of vaccinations – saying only that Swiss authorities hope to immunize most of those who want the vaccine “by summer.” 

Emer Cooke, Executive Director of the European Medicines Agency.

Originally set to meet on vaccine approvals in January, the high rates of infection coupled by the fast pace of rollouts occurring elsewhere – apparently inspired both the EMA and the independent Swissmedic regulatory agency to act earlier – although not with undue haste, an EMA official was careful to point out.  

“Our thorough evaluation means that we can confidently assure EU citizens of the safety and efficacy of this vaccine and that it meets necessary quality standards,” said Emer Cooke, the newly appointed Executive Director of EMA – who only recently left the World Health Organization to assume the post. 

The Swiss approval also marked the first time that a COVID-19 vaccine had received a standard regulatory authorization.  Since Switzerland has no emergency use or conditional approval process the normal process was the only one that could be followed – observers explained. 

Vaccine Rollouts – Race Against Mounting Infections  

The authorizations and vaccine rollouts coincide with mounting levels of infections and death rates in many parts of Europe, despite successful infection control campaigns over the spring and summer.  Concerns have now risen further with the discovery of a new, and more contagious variant of SARS-CoV2 in Britain, South Africa, leading to travel bans and flight cancellations  (See related story).  

It is still too soon to know if the vaccines being rolled out now will be as effective against the new coronavirus variant as they have proven to be against those prevalent until now.  But experts are hopeful that the recently-approved vaccines will meet the test.  

“We don’t yet have evidence with respect to the new strain, whether it is susceptible to the antibodies generated by the vaccine,” said Cooke at the EMA press briefing. 

“However, we have quite broad knowledge around the fact that this vaccine is capable of generating neutralizing antibodies that can neutralize the different variants with mutation within the receptor binding domain, which is the key area for attachment to the cells in the human body. 

“So we think that, even if we don’t yet have full confirmation, it is very likely that the vaccine will retain protection, also against this new variant.”

“In principle, what would scare us would be if we see multiple mutations, particularly on this spike protein and on the receptor binding domain that will really alter the antigenic profile of the virus with respect to these vaccines and render them incapable of neutralizing the virus,” said Marco Cavaleri, Head of Anti-infectives and Vaccines, Scientific and Regulatory Management Department at EMA. 

3D print of a spike protein on the surface of SARS-CoV-2, enabling the virus to enter and infect human cells.

“We will need to see the virus changing quite substantially before we can really be in a situation to see…think [about] whether the vaccine has to be somehow rebuilt, incorporating new emerging strains. So, for the time being, we are not too worried.”

Next In Line – Moderna Vaccine  

The EMA is planning on announce its recommendations on a second vaccine, produced by Moderna, on January 6. 

Meanwhile, in the United States,  transportation and delivery of the Moderna vaccine to hospitals and health centres had already begun following its emergency use authorization by the US Food and Drug Administration (FDA) on Friday. 

“With the availability of two vaccines now for the prevention of COVID-19, the FDA has taken another crucial step in the fight against this global pandemic that is causing vast numbers of hospitalizations and deaths in the United States each day,” said Stephen Hahn, US FDA Commissioner, in a press release.

The US Department of Health and Human Services has purchased 200 million doses of the Moderna COVID-19 vaccine, which will provide for continuous delivery of the vaccine through the end of June 2021.  The vaccine, based on the same mRNA delivery technology as the Pfizer vaccine is less temperature sensitive – it can remain stable for long periods at temperatures of -2 -8 C as compared to Pfizer’s -70 C storage requirement. 

Israel’s Prime Minister – First Head of State Immunized in COVID-19 Vaccine Rollout

Meanwhile, while the United States has seen Vice President Mike Pence immunized as well as President-elect Joe Biden, Israeli Prime Minister Benjamin Netanyahu was likely the first serving head of state to publicly receive an approved Pfizer-BioNTech vaccine jab in a televised broadcast Saturday night.

Israeli Prime Minister Benjamin Netanyahu receiving the Pfizer-BioNTech vaccine on Saturday.

“I asked to be vaccinated first, together with Health Minister Yuli Edelstein [Minister of Health], to serve as personal examples and encourage you to be vaccinated,” said Netanyahu. “It’s one small shot for a person and one big step for everyone’s health.”

Netanyahu – with his government crumbling and personally under assault from both the left as well as the right –  has sought to take credit for procuring enough doses of the Pfizer and Moderna vaccines to immunize almost all of Israel’s 9 million citizens.  

The Ministry of Health announced that the vaccine operation would rollout in stages, beginning with health care workers, high risk populations, and those of 60 years of age. According to preliminary reports, approximately 10,000 medical staff members were vaccinated on Sunday. 

“I am pleased to announce that on the first day of Operation ‘Latet Katef [to give a shoulder]’ there is an excellent response by medical staff throughout the country and that starting yesterday afternoon, public pressure to get vaccinated was sensed,” said Hezi Levy, Director General of the Ministry of Health. “We will vaccinate everyone…the Operation progresses on the move.”

The campaign received immediate uptake with appointment hotlines crashing as Israelis clamored to set appointments to be vaccinated. While limited right now to health workers and people over the age of 60, the gates will be opened to everyone over the age of 16 within a couple of weeks.  The rapid timetable set by the government should see some 60,000 Israelis vaccinated a day for coming months – with the hopes of reaching herd immunity of 60% immunized by spring. 

What was less clear, however, was the timetable for vaccinating some 3.5 million Palestinians in the West Bank and Gaza – who are not members of the Israeli health funds that are running the vaccine campaigns. 

In addition, the nearly 2 million Palestinians living in the Hamas-controlled Gaza Strip have  been subject to a longstanding Israeli boycott, making the transport of temperature sensitive vaccines in and out of the Gaza strip even more challenging than usual. 

And even in the more affluent Palestinian West Bank – home to some 3 million Palestinians – there is reportedly only one vaccine refrigerator capable of managing the ultra-cold storage required for the Pfizer vaccine.  

Dr. Ali Abed Rabbo, a senior Palestinian health official, told media that Palestinian Authority will rely largely upon the WHO- supported COVAX global procurement initiative to eventually get vaccines to their communities – which are currently under lockdown due to high COVID-19  infection rates.   Through COVAX, WHO hopes to distribute vaccines to some 10-20% of people in low- and middle-income countries, beginning in the first quarter of 2021.  

At the same time, Israeli Deputy Health Minister Yoav Kisch told the local Kan Radio station that Israel might consider allocating some of its vaccine supply to the Palestinian areas – if sufficient quantities are available after most of Israel’s nine million citizens are vaccinated – a population that includes some 20% Arab Muslim, Christian and Druse minorities.

“Should we see that Israel’s demands have been met and we have additional capability, we will certainly consider helping the Palestinian Authority,” he told Israel’s Kan Radio station. 

Like many other things in the Israeli-Palestinian conflict, the vaccine issue casts into sharp  relief the broader and more global distributional divide between high income and lower or middle income countries vis a vis vaccines – in a particularly up-close way. 

It also illustrates, however, how vaccine sharing may also be, ultimately, in self- interest of higher-income countries – including communities in conflict zones. Since Israeli settlers are scattered across the occupied West Bank, while tens of thousands of Palestinians work in settler-owned enterprises or in Israel proper – in the absence of vaccine sharing with the Palestinians, the goal of herd immunity will be that much harder for Israel to attain.   

 

Image Credits: European Commission, Pfizer, European Medicines Agency, Flickr – NIAID, Youtube – Israeli PM.


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The UK has backtracked on its easing of holiday restrictions, joining a number of European countries spending the season in near-lockdowns. Travel restrictions imposed so close to Christmas are likely to cause upset.

European countries rushed to impose travel bans on UK and South African travellers after both countries reported individual new variants of SARS-CoV-2, thought to be much more infectious than the ones already circulating worldwide.

In the past few days, there have been reports of new variants of the COVID-19 virus in South Africa and the UK, particularly around London. While these variants have developed independently of each other, they are both similar in that they appear to be more transmissible. WHO has reported that the UK’s new variant’s transmissibility is up an estimated increase of between 40% and 70%.

Even so, WHO officials have stressed that there was no evidence that these variants would result in more severe illness or have an impact on vaccine efficacy, during a media briefing on Monday 21 December. The UK reported its variant on 14 December, with South Africa confirming a notable variant was in circulation 4 days later, on 18 December.

Speaking at a press briefing Monday, Dr Maria Van Kerkhove, WHO’s Clinical Lead on COVID-19, said that although the UK had reported in an increase in transmission of this variant from 1.1 to 1.5, scientists “are trying to determine how much of that is associated with the variants itself and how much was related to the behavioural differences in individuals that this variant test affected”.

She added: “The information that we have so far is that there isn’t a change in the clinical presentation or severity from this variant, but again the work is still underway, and they’re looking at a number of factors, including patients who are hospitalised with this variant, as opposed to the wild type.”

The variant identified in South Africa “has one of the same mutations, this 501Y mutation, but it’s a different variant”, she clarified.

“They’ve arisen at the same time so it sounds like they’re linked but this is actually a separate variant,” she said. She confirmed that South Africa is working with WHO ‘s virus evolution group.

Yesterday, WHO Director-General Dr Tedros Adhanom Ghebreyesus said that it is natural for viruses to mutate over time and that the WHO is “working with scientists to understand how these genetic changes affect how the virus behaves”.

“The UK has reported that this new variant transmits more easily but there is no evidence so far that it is more likely to cause severe disease or mortality,” said Dr Tedros. “The bottom line is that we need to suppress transmission of all SARS-COV-2 viruses as quickly as we can. The more we allow it to spread, the more opportunity it has to change.

“I can’t stress enough – to all governments and all people – how important it is to take the necessary precautions to limit transmission right now.”

Dr Tedros Adhanom Ghebreyesus, WHO Director General, at the WHO press briefing on Monday.
New Wave Of Travel Bans Hit Holiday Season

Throughout Europe, countries slapped travel bans on both South Africa and the UK in an effort to head off the spread of the more infectious viral strains – just ahead of the Christmas holidays as well as the pending initiation of mass vaccination campaign.

Ireland, Italy, Switzerland and Belgium banned arrivals from the UK, with France suspending travel for 48 hours. In the latter’s case, this resulted in the closure of the Eurotunnel, which is used by freight lorries. The UK Transport Secretary stated, however, that this would not impact vaccine distribution. Switzerland  has banned arrivals from South Africa while Germany is considering such a ban.

Outside of Europe, Israel was one of the first countries to react to the new virus variant by closing its borders to all foreign nationals who are non-residents, another blow to already muted celebrations of the upcoming holidays in the holy land.

Facing a rapid domestic rise in infections, Israel already had closed its skies to travelers from Britain, Denmark and South Africa yesterday. Now, returning Israelis will also be forced to go into quarantine in designated coronavirus hotels once they arrive.

This mutation could be coronavirus two,” Prime Minister Benjamin Netanyahu told reporters on Monday. “Therefore, I decided last night – and we implemented today – to close the skies of the State of Israel. Foreign nationals will not enter the country, other than exceptions such as diplomats.”

The new orders, coming into effect on the day before Christmas Eve, could have a particular severe impact on Christian communities in Israel and in the Palestinian Authority.

Extended family members living abroad often return to the region via Israel’s Ben Gurion Airport for the holiday season, but many lack the Israeli residency or citizenship documents guaranteeing them entry under the new policies.  It was unclear if returning Palestinians could still enter from Jordan via the West Bank’s Allenby Bridge. The Palestinian Authority has currently placed areas in its jurisdiction under a strict lockdown as a result of soaring Palestinian infection rates.

UK government U-Turns

U-Turns in domestic policies in the UK and other countries were also evidence of the deepening COVID-crisis sweeping Europe.

In the weeks building to Christmas, the UK government, like many of its counterparts on the continent,  had announced an easing of COVID restrictions almost unheard of since March 2020: for a five-day period, up to three households would be able to meet indoors, with permitted travel across the country.

UK Health Secretary Matt Hancock.

On Wednesday 16 December, however – 48 hours after Health Secretary Matt Hancock confirmed the appearance of a more transmissible viral variant in the capital – Prime Minister Boris Johnson was forced to backtrack. But it took him another four days before he  cancelled Christmas easings, by which point cases had risen significantly.

Named ‘VUI (Virus Under Investigation) – 202012/01’, the UK variant had infected more than 1,000 people when Hancock first confirmed the investigation was underway.

Similar lockdowns, restrictions and curfews were introduced across Europe last week, in Germany, France and Greece respectively.

Meanwhile, South Africa – already under curfew with restrictions on beaches, in restaurants and on alcohol sales – announced no new measures.

“It is still very early, but at this stage, the preliminary data suggests that the virus that is now dominating in the second wave is spreading faster than the first wave,” said Professor Salim Abdool Karim, co-chair of South Africa’s Ministerial Advisory Committee on COVID-19.

“We would expect it to be a less severe virus, but we do not have clear evidence at this point. We have not seen any red flags looking at our current death information,” he said. It is not clear if the second wave will have “more or less deaths”.

Karim confirmed that in South Africa, this variation accounts for around 80-90% of cases.

South Africa’s Health Minister Zweli Mhize appealed  to the media and medical and scientific community to “focus on the facts and avoid entering into speculation or issue unproven statements and generate panic and disinformation”.

He provided a stark reminder: “Many countries experienced a second wave that was more severe than the first – even where no mutations were reported.”

Behind the Variants: How Do The Two Differ?

Both virus variations are believed to be similar in that they appear to be transmitting far more rapidly than previous strains, with Karim noting scientists had been surprised by how “this variant has become dominant” in South Africa’s second wave.

The appearance of both at the same time in separate countries, has caused some confusion, however. Despite those similarities, and very similar mutations to the key proteins in the virus, there is little doubt that the two are unique in origin.

The COVID-19 Genomics UK Consortium (COG-UK) identified that the virus contains a substantial number of mutations, including an N501Y mutation existing in the spike protein’s receptor-binding domain. This is also true of the South African strain.

This mutation has created a change at the point at which the spike first contacts our bodies’ cells. A mutation here means the virus is more easily able to enter cells, allowing it to spread more quickly.

A more recent UK study has identified up to 16 additional potential mutations. The most notable here is a “H69-70” spike deletion. The study notes it has “been described in the context of evasion to the human immune response”, noting that it has also occurred a number of times in other variants, like the one discovered in mink populations in November.

WHO: PCR Tests Reportedly Less Effective

Given the relative novelty of the variants, advice provided by WHO is somewhat limited, with the Organization urging countries to be transparent, to share epidemiological, virological and full genome sequence information, to assess levels of local transmission, and to continue taking a risk-based approach.

It did flag a reported loss of performance in PCR assays that target the spike protein, however. If this is the case, a country’s detection capacity could become limited, with potentially severe consequences: all the more concerning as the variant appears to be quickly becoming the dominant strain in regional epidemics.

Laboratories using commercial kits for which the targeted viral genese are not labelled or identified should contact the manufacturer, WHO advised in a statement on Tuesday.

“Laboratories using in-house PCR assays that target the S gene of the virus should also be aware of this potential issue,” it said. “In order to limit the impact on the detection capacities in the countries, an approach using different assays in parallel or multiplex assays targeting different viral genes is also recommended to allow the detection of potential arising variants.”

Image Credits: Nathan Rupert, WHO.

Migrants, who constitute a significant proportion of the global health workforce, struggle to access appropriate healthcare in the midst of the pandemic. Of those surveyed who did not seek healthcare, 35% cited financial constraints and 22% reported fear of deportation.

Despite the “enormous” contributions that migrants have made to society, they still face discrimination, social exclusion, and struggle to access health services even years after migrating, especially during the current pandemic, the first survey ever of migrant health during COVID-19 has found.

The report, which was led by Ghent University and the University of Copenhagen in collaboration with WHO, highlights an urgent need to include refugees and migrants in countries’ COVID-19 response plans, especially in upcoming vaccination campaigns.

WHO director general Dr. Tedros Adhanom Ghebreyesus.

These preliminary findings, based on self-reports of 30,000 refugees and migrants around the world, were published on International Migrants Day, just a week after May Parsons, a Filipina nurse in the UK, was the first to administer a coronavirus vaccine developed by a Turkish couple in Germany: the mRNA-based Pfizer/BioNTech vaccine.

“It is indeed critical that we join forces to ensure that migrants, refugees and asylum seekers internally displaced persons, and in general, people on the move, are not left out of our global efforts to fight back against the COVID-19,” said António Vitorino, director general of International Organization for Migration, at a press conference on Friday.

“I want to take this opportunity to call on governments to count and include all migrants present in their territory, no matter their legal status in their national vaccination plans.”

WHO’s director general Dr. Tedros Adhanom Ghebreyesus added: “Investing in the health of migrants is not just the right thing to do – it also has long term benefits for social cohesion and economic development. Exclusion is costly in the long run, but inclusion pays off for everyone.”

Migrants Contribute To Innovation & Lifesaving Work, But They Lack Access To Basic Services Despite High Need

Despite the innovation that migrants can bring, and the lifesaving work they undertake in a range of sectors – particularly in healthcare – they remain outsiders in their adopted communities, especially undocumented migrants, said Dr. Tedros.

In countries like the US, migrants account for almost a fifth of the health workforce, with numbers rising rapidly. In the last decade, the number of migrant doctors and nurses working in Organisation for Economic Co-operation and Development (OECD) countries has increased by a stunning 60%, according to WHO.

“To be honest, what I have found particularly intolerable in this current crisis is that while being so often left behind, migrants have also been on the front line of the response to the pandemic, taking personal risks for everyone’s well being,” added Vitorino. “And this is across many critical sectors, not just the healthcare sector, but also transport, food, retail, research.”

Half Of Migrants Surveyed Struggle With Depression, Worry, Anxiety And Loneliness

The new survey also found that migrant health was most affected in the European, American, Southeast Asian and Western Pacific WHO regions, triggering depression, worry, anxiety, and loneliness in more than half of migrants and asylum seekers surveyed. The report also found that one in five migrants had increased their intake of drugs and alcohol compared to the start of the pandemic.

12% of those surveyed lacked access to healthcare and 10% were not entitled to healthcare.

Migrants are also generally less likely to access high-quality healthcare, found the report, despite their worse health outcomes. Of those who did not seek healthcare, 35% cited financial constraints and 22% reported fear of deportation. Additionally, 12% lacked access to healthcare and 10% were not entitled to healthcare, among other barriers.

“One of the crucial issues is that migrants sometimes are suspicious to look for health care because they are afraid of contacting health services,” said Vitorinio. “They [fear being] detained or even deported.”

The survey, which closed on 31 October, was based on around 30 self-reported questions in almost 40 languages. However, given the online nature of the report, it is likely that these trends underestimate the struggles faced by migrants, as it could not account for participants without access to technology.

Health Policies Must Be Inclusive To The Diverse Needs Of Migrants And Refugees 

Countries can take several measures to include refugees and migrants in their COVID-19 response plans, noted Dr Tedros on Friday.

They should de-link access to care from a migrant’s legal status, remove financial barriers to access, improve internet access for migrants, offer health information in multiple languages, and foster mutual trust between public health services and migrants, he said.  This is especially important as the world gears up for what is likely to be the largest vaccination campaign in history.

Before the pandemic, only 40% of all countries offered universal health coverage to all migrants, irrespective of their legal status, Vitorino flagged. On the upside, several countries have introduced new policies or relaxed requirements to bolster access to healthcare ever since the pandemic struck.

“Health for all means, all, including migrants,” said Dr Tedros. “That means increasing investments in health, especially in primary healthcare to create health systems that are sensitive to migrants needs, their language and their health problems.”

 

Image Credits: Flickr – EU Civil Protection and Humanitarian Aid, MSF/ Sophia Apostolia.

At least 1.3 billion of the 2 billion donor-funded vaccine doses secured will be distributed in the poorest economies.

The WHO-led COVAX Facility announced Friday that it has now secured some 2 billion vaccine doses and distribution of vaccines will begin in the first quarter of 2021 – ensuring that at least some vaccines will begin to reach the 92 low-income countries that are largely dependent on global philanthropy to access sufficient vaccine supplies.

That would be roughly enough vaccines to immunize a little more than one-eighth of the global population: most of the vaccines procured so far require two doses.

At least 1.3 billion of the 2 billion donor-funded doses secured will be distributed in the poorest economies, said the heads of Gavi, the Vaccine Alliance and the World Health Organization (WHO) at a press conference on Friday.

They said that the COVAX facility – co-sponsored by WHO and GAVI – would push ahead to acquire more doses, so that all countries worldwide could reach 20% population coverage of the highest risk groups by the end of next year.

“We have secured access to the first 2 billion vaccines and these will be delivered in the first quarter of next year,” said Seth Berkley, head of Gavi, The Vaccine Alliance, at the press conference on Friday.

“This is fantastic news and a milestone in global health,” WHO’s Dr Tedros Adhanom Ghebreyesus, at the event. “Images of people receiving vaccines are giving us hope, but it must be hope for all, not hope for some.”

The announcement was made jointly with leading pharma companies that had just sealed deals with COVAX.

Paul Stoffels, head of Johnson & Johnson, said the firm had signed a memorandum of understanding (MOU) to market some 500 million courses of its one-dose vaccine candidate through the facility, if the vaccine wins regulatory approval.

“We are reaching the end point in a large clinical trial, likely by the end of January,” Stoffels said in the briefing. “Following regulatory approvals, we hope to be delivering vaccines in the course of the next year.”

Dr Paul Stoffels, head of Johnson & Johnson.

In addition, Pascal Soriot of AstraZeneca, announced a deal with the COVAX facility for some 170 million doses of the AstraZeneca/Oxford vaccine.

The new deals come in addition to previously announced pre-purchase agreements with India’s Serum Institute, which has signed agreements with COVAX to provide at least 200 million doses – with options for up to 900 million doses more – of either the AstraZeneca/Oxford or Novavax candidates. This is as well as an agreement, in principle, for 200 million doses of another vaccine candidate by Sanofi/GSK.

AstraZeneca’s Soriot said that the company hopes to be geared up to produce up to 3 billion doses of its vaccine, following approval. As one of the cheapest and most durable, it is expected to play a major role in immunization drives in lower-income countries.

US$ 2.4 Million More in Donations – Vaccine Sharing Plans Also Unveiled

The purchases will be funded by US$2.4 billion in donor funds made available over the past two weeks, WHO said in a press release. This includes new pledges from Norway, Canada, Kuwait, Denmark, New Zealand, the Netherlands, Singapore and Estonia.

But the biggest influx of funds has been in the form of a combined European Commission grant and European Investment bank loan totaling €500 million.

At the press conference, Canada’s Minister of International Development, Karina Gould, and France’s Stephanie Seydoux, also said that their countries would consider making donations from their pre-reserved vaccine stockpiles to the COVAX facility, for use in low- and middle-income countries (LMICs).

With pre-orders for around 10 vaccine doses per capita, Canada has one of the largest stockpiles of pre-orders: far more than it can use domestically.

Karina Gould, Canada’s Minister of International Development.

“The idea [is] to be ready to start sharing vaccines as early as possible, that is what we are considering … in conformity with the sharing principles that COVAX and WHO issued today,” said Seydoux.

Their announcement coincided with the release of a WHO paper on Principles for Dose-Sharing. Under this, higher-income economies could donate surplus doses they have procured through direct deals with manufacturers to the COVAX facility’s low-income countries. The framework “opens another potential source of vaccines – supporting the overall goal of equitable access”, WHO said in a press release.

“France will rely on this framework to consider sharing doses, as early as possible to enable vaccination against COVID-19 low priority populations,” said Seydoux, encouraging countries belonging to the G7 and G20 to follow suit.

It remains to be seen if other countries will indeed choose to donate surpluses to the global COVAX initiative – or share directly with other close neighbors and allies.

For instance, New Zealand, an ostensibly strong supporter of the COVAX initiative, announced a plan this week to share its vaccines with its Pacific region partners using any surplus that it acquires.

At the same time, it also committed NZD 10 million this week to the COVAX global scheme this week.

Pfizer and Moderna Vaccines Noticeably Absent on Stage

The Pfizer and Moderna vaccines – which have been the first to secure regulatory approvals in the United Kingdom and by the United States Food and Drug Administration (US FDA) – do not appear in the COVAX vaccine portfolio.

Moderna’s absence is even more striking, since it received funding for Phase 3 of its clinical trials from the Oslo-based Coalition for Epidemic Preparedness Initiative (CEPI), which is funded by a number of governments as well as philanthropies and other public partners.

Moderna’s mRNA vaccine received overwhelming approval from an advisory panel to the US FDA, on the same day as the COVAX announcement.

Since these vaccines are also going to be the first to reach markets – it also means that high income countries in North America, Europe and elsewhere, will inevitably be the first to have their high-risk populations immunized en masse. This process has already begun in the UK and US. Other countries, such as Israel, begin next week with immunizations.

While there are some objective reasons why the Pfizer vaccine would be difficult to deploy – namely, its ultra-cold -70 C temperatures required for storage – Moderna’s vaccine, with its -2C to -8C storage, is much easier to handle.

CEPI’s CEO Richard Hatchet made no mention of the absence, saying only at the briefing: “Science has given us the tools to fight the pandemic. But equitable access is what will enable us to win in the pandemic” 

COVAX Dose Distribution To Be Pro-rated by Population

In terms of the COVAX organized rollout, WHO’s Chief Scientist Soumya Swaminathan said that a pro-rated number of doses would be distributed to countries based on their population.

It would remain up to the countries to prioritize the distribution, but she said that she expected most to go along with WHO guidelines calling for health workers, older people and other high-risk groups to be vaccinated first.

“In the first year, when we have limited supplies, we would distribute them by tranches, based on the country’s population, understanding that most countries are prioritizing their health care workers and vulnerable workers,” said Swaminathan.

Dr Soumya Swaminathan, WHO’s Chief Scientist, WHO.

Executing the initiative will still be a massive logistical task, however, and global health leaders at the briefing said that helping health systems prepare to receive the vaccines would be the next step. To support its plan to transport 850 tonnes of vaccines a month, UNICEF’s Henrietta Fore said that the organization is aiming to install 70,000 cold chains fridges fridges in lower-income countries by the end of 2021, almost half of which will be solar powered.

“As we’ve learned with routine immunisation vaccines don’t save lives, vaccination does,“ said Dr Kwaku Agyeman Manu, Minister of Health for Ghana said in a statement. “This means we need the health infrastructure in place – from supply chain and logistics to well- trained health workers – to ensure the effective and streamlined distribution of vaccines.

“For this we call on governments, manufacturers and the private sector to make urgent and necessary investments in COVAX so that no one is left behind.“

While COVAX was designed as a vaccine pool for countries at all income levels, with a self-financing arm as well as an arm for donations, as more and more high- and middle-income countries make bilateral deals, the focus of the facility has shifted to supplying shots to the world’s 92 LMICs that traditionally rely on donor aid for other vaccine campaigns.

That has left COVAX heavily reliant on voluntary donations to make the system work. Currently, 86 of the 92 LMICs eligible for COVAX have submitted vaccine requests.

On Friday 11 December, WHO director-general Dr Tedros Adhanom Ghebreyesus issued a plea to world leaders to “honour their pledges” to fund the scheme.

Regulations and Readiness: Plans for a 2021 Rollout With Health Workers In Mind

A press release by GAVI said that the first wave of doses, expected to be delivered in the first half of 2021, should be enough to protect health and social care workers.

Prioritising health workers should help these countries keep infection rates low and health systems functioning in the interim period between production waves. Healthcare staff have constituted about 15% of the global COVID-19 case toll: they account for only 3% of the world’s population.

As the rollout continues beyond this initial group, COVAX will aim to support the immunization of up to 20% of a given country’s population.

But a successful global campaign such as this is also dependent upon national regulatory approvals, cautioned Swaminathan. She said that WHO has been working with LMICs to ease the process in countries outside of the European Union and other developed regions.

World Trade Organization IP Waiver For COVID Health Products – Opponents Ask Countries To Explore What Are the Barriers In Use Of Current Rules

Meanwhile, WTO spokesperson Keith Rockwell said that the debate over a South African and Indian proposal to issue a WTO “waiver” for IP related to COVID medicines, vaccines and other tools would be continued in January 2021, following the impasse reached in the meetings held over the past two months.

He spoke at a press briefing just as the WTO’s General Council was wrapping up two days of meetings in Geneva on Friday that had examined the issue – after the WTO TRIPS Council (Agreement on Trade-Related Aspects of Intellectual Property Rights) had failed to come to any agreement over the far-reaching proposal.

WTO spokesperson Keith Rockwell said the discussion surrounding the WTO IP waiver will resume in January.

“There was no decision in the offing. This conversation is going to continue,” said Rockwell, speaking after the discussion in the General Council. “I would say it was a very important conversation, and it was not a conversation that was vitriolic or acerbic.

“The conversation will continue in January. In the TRIPS Council … there was support for continuing the conversation,” he said.

He said that while all WTO members agreed that it was important for low- and middle-income countries to be able to acquire essential health technologies, opponents of the waiver say that existing TRIPS flexibilities for health emergencies already allow governments to take unilateral measures to produce essential drugs and other health products – through measures such as “compulsory licensing” to domestic producers for the manufacture of patented products.

Rockwell suggested that among the countries that oppose the waiver, “there was a strong view expressed by many of them to try to use these discussions to identify where there may be imperfections in the TRIPS agreement that do not make it easy for the members to access these flexibilities, particularly as they pertain to compulsory licensing”.

In the General Council discussions, the UK’s WTO Ambassador Julian Braithwaite, along with Singapore’s Tan Hung San, both said that the recent agreements between India’s Serum Institute and AstraZeneca and South Africa’s Aspen Corporation had indicated and existing flexibilities are working, in terms of vaccine distribution.

On the other hand, proponents of the waiver say that “the flexibilities that are available are cumbersome and difficult to implement.”

Rockwell said progress on this and other health related WTO disputes have suffered from the lack of a new WTO Director General. This follows the impasse over the final appointment of the leading candidate, Nigeria’s Ngozi Okonjo-Iweala, which was opposed in October by one sole WTO member, the United States.

So far “a consensus remains elusive” on the new DG appointment, said Rockwell. While there is now a possibility that the incoming US administration of Joe Biden may withdraw its opposition to Iweala clearing the way for her appointment early next year, Walker made no reference to the pending change in the US administration in Washington, saying only:

“It has not been an easy year. We need to do all we can to get a director general here. This is something that really has to be taken care of, hopefully soon. At the end of a long and difficult year for everyone around the planet, we will use the break to pause and reflect and see what the best way forward will be when we come back.”

Image Credits: CDC Global/Flickr, World Economic Forum, UNICEF Ethiopia, Moderna, World Health Summit, APEC 2013.

Moderna’s COVID-19 vaccine received 20 votes of confidence with only 1 abstention.

Moderna’s COVID-19 vaccine was set to be approved by the US Food and Drug Administration (FDA), following a near-unanimous endorsement by an expert panel that reviewed its clinical trial results.

Meanwhile, at US$ 18 per dose, the Moderna vaccine will also be the most expensive vaccine to go on the market soon, according to a tweet by Belgium’s secretary of state, listing prices per dose of the six vaccines procured by the European Union. The post was quickly deleted, but not before going viral.

In the FDA review, the vaccine candidate from the Boston-based firm received 20 votes in its favour, with a single abstention and no opposition, a stark comparison to the 17-4 vote delivered for the European Pfizer and BioNTech vaccine.

The four votes against the Pfizer/BioNTech vaccine were largely centred on the lack of evidence as to how safe the vaccine may be for people aged 16-17 years old.

Michael Kurilla, the director of clinical innovation at the National Center for Advancing Translational Sciences, who was the only panel member to abstain against the Moderna emergency use authorization (EUA), claimed that approving the vaccine for all people over 18 years old was “far too broad”.

The critical difference, however, appeared to be the sheer volume of trial data provided by Moderna. University of Michigan microbiologist, A Oveta Fuller, cited the biotech company’s transparency as being highly impressive. She had voted against the Pfizer candidate

Moderna enrolled more than 30,000 participants in its placebo-controlled trial. Several weeks after the participants’ second dose (7 November) there were only 5 cases of COVID-19 in the vaccine group, with 90 in the placebo group. This gave an efficacy of 94.5%.

In the new data, published yesterday by the FDA, the efficacy was revealed to have decreased by a statistically inconsequential amount, to 94.1%.

The data also seems to suggest Moderna’s mRNA vaccine is more effective (if only slightly) in younger people, with an efficacy of 95.6%, compared to 86.4% in those over 65 years old.

Stanford professor Hayley Gans noted at the hearing that the emergency approval of the Moderna vaccine – the second vaccine approved for public administration – would “finally provide a safe and effective way to get herd immunity”.

The current volumes of the Pfizer/BioNTech vaccine, approved just last week, are not, on their own, “sufficient for mass vaccination needed to address a pandemic in the US,” said Doran Fink, deputy clinical director of the FDA’s vaccine division, at the hearing.

The US is currently seeing its deadliest surge yet of infections, with unprecedented daily records of new infections and around 3,400 deaths recorded on 16 December alone.

EU’s Vaccine Prices Leaked in Tweet

Meanwhile, a Belgian politician’s tweet of the image of a spreadsheet detailing the price-per-dose paid for the six leading vaccines that the European Union has pre-ordered was picked up widely on the web – by media and public advocates hungry to see how the prices of the leading vaccine candidates compare.

Such information is usually a closely guarded secret by companies who require even public procurement agencies, such as health ministries and governments, to sign non-disclosure agreements about the prices that they pay for medicines and vaccines.

The tweet by Eva De Bleeker, Belgium’s Secretary of State, has now been deleted but not before the Belgian news site HLN captured and published a screenshot. She has claimed the post was a mistake on behalf of the communications team.

The screenshot indicates that Belgium will spend €279 million on around 33.5 million vaccines, broken down as below:

  • Oxford/AstraZeneca: 7.7m units at €1.78
  • Johnson & Johnson: 5.1m units at $8.50
  • Sanofi/GSK: 7.7m units at €7.56
  • Pfizer/BioNTech: 5m units at €12
  • CureVac: 5.8m units at €10
  • Moderna: 2m units at $18

Despite long standing lobbying by medicines access groups, as well as some European members of parliament (MEPs) who claim that prices paid on goods purchased with taxpayers’ money should be disclosed, the practice seems unlikely to change. The European Commission  declined to comment about the incident.

Speaking at a parallel event, Seth Berkley, head of the public-private Gavi, The Vaccine Alliance, said that Gavi also would not disclose the prices paid for large scale purchases of vaccine for the WHO co-sponsored COVAX vaccine facility. The facility aims to help all countries, and particularly low- and middle-income countries, cover some 20% of their population with COVID-19 vaccines over the course of 2021.

Berkeley said that details on vaccine purchase deals by COVAX would not be disclosed “given the nature of these types of commercial and legal agreements.”

Reuters reported that the table briefly published by De Bleeker showed the Belgian government paid 12 euros ($14.7) per dose to buy about five million shots of the Pfizer/BioNTech vaccine. Sources familiar with the matter have told Reuters the EU agreed to pay 15.50 euros ($18.34) per dose for the Pfizer/BioNTech vaccine.

The Belgian price does not factor in unrefundable downpayments of hundreds of millions of euros that the EU has made to many vaccine makers to secure their shots, one EU official told Reuters.

Image Credits: Moderna.

The events of 2020, as well as longer term trends wrought by climate change and rural-urban migration have created a perfect storm for drastic increases in malnutrition, child wasting and stunting and maternal anemia.

The launch of the Nutrition for Growth Year of Action aims to combat global hunger, exacerbated by COVID disruptions and climate change.

After a year marred by huge setbacks for global food security, a group of governments and nutrition organisations this week launched a forward-looking initiative for 2021 to address the global hunger and nutrition crisis.

The Nutrition for Growth (N4G) Year of Action is a year-long effort to mobilise new commitments to improve food security and follows a series of huge setbacks – wrought by the coronavirus pandemic as well as repeated onslaughts of crop-devouring locusts across large parts of Africa and Asia.

Over $3bn in financial commitments was announced by a variety of actors at the kick-off event earlier this week,  led by Canada, Bangladesh and Japan and Pakistan in partnership with UNICEF, the World Bank and World Vision International.

“The 2021 Year of Action is the perfect time to form new powerful alliances with champions in the food system, climate, biodiversity and social protection communities. Strong nutrition outcomes help everyone to build forwards better in this Covid era,” said Lawrence Haddad, executive director of the Geneva-based Global Alliance for Improved Nutrition (GAIN), speaking at the launch.

2020 was a “Perfect Storm” for Nutrition Crisis 
A woman holding her young malnourished baby queues for food at the Badbado camp for Internally Displaced Persons (IPDs). has been declared in two regions of southern Somalia – southern Bakool and Lower Shabelle.

The events of 2020, as well as longer term trends wrought by climate change and rural-urban migration have created a perfect storm for drastic increases in malnutrition, child wasting and stunting and maternal anemia.

“This year, because of the impact of the COVID-19 virus, a potential 270 million people are facing food insecurity. The most vulnerable are those who were food insecure or malnourished before the pandemic – largely women and children,” said Karina Gould, Canada’s minister of international development, speaking at the launch event.

The Year of Action will culminate in the Nutrition for Growth Summit in Tokyo in December 2021. A kick-off event in Tokyo, held on the eve of the opening ceremony of the Olympics aims to be a “springboard” moment to secure more high level commitments from countries to insure universal access to safe, affordable and nutritious food by 2030.

Prioritising nutrition post-pandemic
10539101196_a58b7b02bb_k-1024x683.jpg
A malnourished child is weighed at a clinic in the Abu Shouk camp for Internally Displaced Persons, North Darfur. Credit: Flickr – UN Photo.

Speakers at this week’s event emphasised the need for countries to make nutrition a centrepiece of their COVID-19 response, recovery and resilience-building plans. Good nutrition can contribute to lessening the effects and risks of COVID-19, as well as “improving health, increasing education and lifetime earnings, and promoting gender equality and women’s empowerment,” said Gould.

Actions recommended by the Nutrition for Growth movement include: keeping food markets working, providing aid for malnutrition, leveraging social protection to stimulate nutritious food production and consumption, and forming alliances with climate and biodiversity organisations.

Already prior to the pandemic, malnutrition – usually a result of unhealthy diets that lead to  deficiencies, imbalances or excesses in nutrient intake – was the underlying cause of nearly half of all children’s deaths annually. Poor diets, overly reliant on cheap starches, processed foods or fast foods, which also drive obesity, were the number one cause of preventable death worldwide.

“The pandemic has dramatically affected families’ lives and livelihoods, disrupting: access to nutritious, affordable diets; essential nutrition services; and child feeding practices in many countries around the world,” said Henrietta Fore, UNICEF executive director.

She announced UNICEF’s commitment to an annual investment of US$700m in nutrition programmes over the next five years at the launch event.

Women and children in poorer countries hit hardest
Women and children are hit the hardest by the nutrition crisis.

The nutrition crisis has an important gender dimension, as women are often involved in planting food, working the field, harvesting crops, and cooking meals. More than one billion women and girls suffer from malnutrition and they are twice as likely as men and boys to be malnourished. The worst consequences of the disruptions to the agricultural industry, economies, and nutrition services will fall on women and girls.

A new pre-print study published in Nature Research estimates that by 2022, COVID-19 could result in an additional 9.3 million wasted and 2.6 million stunted children, 2.1 million maternal anemia cases, 168,000 more child deaths. Over the next two years, another 153 children may die every day from COVID-related malnutrition alone, says Save the Children.

COVID, climate change and locusts – a revolving door of impacts

COVID-related border closures, trade restrictions, confinement measures, and job losses have prevented agricultural workers from harvesting crops and selling their produce. ood supply chains have been disrupted and led millions of individuals to lose the ability to feed themselves or their families.

These problems have also been compounded by massive swarms of desert locusts – 400 times usual numbers – that have plagued agricultural communities in the Horn of Africa, Arabian Peninsula, and Southwest Asia over the spring and summer.

New swarms forming in Ethiopia and Somalia, threaten to reinvade northern Kenya, Eritrea, Saudi Arabia, Sudan and Yemen, the Food and Agriculture Organization said Wednesday. Hotspots of locust activity already have led to high levels of hunger and undernourishment.

The pandemic has added to difficulties  by hampering preparation efforts to contain the spread of the insects. Additionally, climate change is an important driver of locusts – since warmer weather leads to more rainfall, stimulating the growth of larger swarms.

405799278_highres.jpg
Locusts swarm near a farm in Kenya. Credit: EPA / Dai Kurokawa
Huge investments required

Recent pledges made by global leaders to invest some $3bn in nutrition programmes over the next four years, is significant, but not enough, experts say.

According to the new Nature Research study, produced by the Standing Together for Nutrition consortium, an additional investment of $1.2bn annually is needed for the next two years just to mitigate the immediate damage caused by Covid-19.

A joint report by the WHO, UNICEF, UN Food and Agriculture Organization, and World Food Programme published in July estimated that even more – some $2.4 bn – is needed immediately to prevent and treat both undernutrition as well as parallel epidemics of overweight and obesity caused by unhealthy diets. These are in addition to the estimated $7bn annually already required to achieve the World Health Assembly Global Nutrition Targets for 2025.

Immediate actions needed

Key immediate strategies include vitamin A supplementation, promotion of breast-feeding, nutritious school meals and improved health screening for malnutrition, leaders of the initiative say. Other important strategies include: protein supplementation; counselling on diets for young children; and treatment of severe acute malnutrition.

This requires scaling up existing health services, and particularly nutrition interventions aimed at women and young mothers. Investment in better data collection on population dietary intakes, for example, is also critical.

“We know that to solve the complex problem of malnutrition, worsened by the COVID-19 crisis, interventions need to span across health, economic and food systems, and social protection programmes,” said Saskia Osendarp, executive director of the Micronutrient Forum, following Monday’s launch.

Added Haddad: “2021 is a make or break year for nutrition. Nutrition is the foundation of human survival, and how we treat our most vulnerable groups during crises…says much about our values as a society. By making the next year one of action for nutrition we can save nearly 10 million infants from a life of deprivation, destitution and even death.”

Published in collaboration with Geneva Solutions, a new non-profit platform for constructive journalism covering International Geneva

Image Credits: Christine Olson/Flickr, Flickr: UN Photo/Stuart Price, Flickr: Noor Khamis/Department for International Developmen.

One-year-old Shukulu Nibogore sits on her mother’s lap while Athanasie Mukamana, a PIH community health worker in Rwanda since 2005, measures her arm for signs of malnutrition.
One-year-old Shukulu Nibogore sits on her mother’s lap while Athanasie Mukamana, a PIH community health worker in Rwanda since 2005, measures her arm for signs of malnutrition.

Indian lockdowns, telehealth in California, a “sin tax” on alcohol and cigarettes in the Philippines – three public health advocates reflect on how these and other events have shaped the narrative around non-communicable diseases (NCDs).  The three included Apoorva Gomber, a medical doctor; Gina Agiostratidou, a philanthropic donor; and civil society leader Katie Dain, found time to meet in a virtual “coffee table” conversation during a busy week for global health.  In a year dominated by news of the COVID-19 pandemic, they took stock of trends and responses to the “parallel pandemic” of NCDs – which the world must confront to achieve the goal of universal health coverage.

The week began with: the launch of the NCD and Injuries (NCDI) Poverty Network, a framework building on the recent findings of the Lancet NCDI Poverty Commission. Mid-week, on 9 December 2020, WHO released dramatic new data showing that 7 out of the top 10 major causes of death globally are now NCDs – including diabetes for the first time ever.  The week concluded with the commemoration of Universal Health Coverage (UHC) Day, 12 December, in which public health leaders worldwide reviewed progress towards the goal of ensuring worldwide access to quality, affordable health services by 2030.

Apoorva Gomber
Gina Agiostratidou
Katie Dain

The interlocuters: Apoorva Gomber, is an Indian medical doctor and public health advocate living with Type 1 diabetes; Gina Agiostratidou, is a programme director at the US-based Helmsley Charitable Trust; and Katie Dain is CEO of the NCD Alliance.  Drawing on their doctor, donor and advocate roles, Apoorva, Gina and Katie’s conversation covered topics ranging from person-centred approaches to prevention and treatment to better integration of NCDs within other global health priorities. 

Katie Dain: Even before the systemic shock of COVID-19, living with a chronic NCD was already a huge challenge. But now there are added delays in diagnosis and accessing essential treatment; there’s the fear of just going outside, as you’re so vulnerable to getting seriously ill with COVID-19. This has had a huge impact on how people living with NCDs have accessed healthcare.

Since 2007, the National Cancer Institute (INCAN) of Mexico has offered free treatment and care to all women against breast cancer.
Since 2007, the National Cancer Institute (INCAN) of Mexico has offered free treatment and care to all women against breast cancer.

Apoorva Gomber: Yes, the pandemic means we’re all more alone. But for people with NCDs, it’s even worse, as many have been forced to manage their diseases alone.

Gina Agiostratidou: It is important to add that the economic impact of people living with NCDs being isolated and struggling to access care is not just faced by the person but also by the government and health care providers. 

Katie: Yet, despite all this, NCDs have been put on the backburner. WHO reports disruption to NCD services in about 70 per cent of countries. It’s not high income countries versus low income countries. This is a global challenge – income irrespective – borne of a lack of preparedness and investment in public health. 

Through the NCD Alliance’s new report ‘Protecting everyone’, which includes eight case studies on integrating NCDs in UHC during the pandemic period,  we saw the countries that have coped better with COVID-19 are those who were already integrating NCDs into UHC. For example, Rwanda already had decentralization, task-shifting [tasks are moved from highly specialized to less specialized health workers] and made sure screening, diagnosis and treatment for NCDs was covered by health insurance. 

PIH staff care for Hodgkin's Lymphoma patient Wilson Ngamije at Butaro District Hospital in Rwanda.
Partners In Health staff care for Hodgkin’s Lymphoma patient Wilson Ngamije at Butaro District Hospital in Rwanda.

Earlier investments in prevention and resilience have also brought dividends. For example, Australia’s anti-tobacco efforts since the 1980s have helped protect its population from COVID-19 in 2020. We’ve seen that smokers are at higher risk, so a population with a lower proportion of smokers is better protected.

Apoorva: Whereas in India, draconian measures were imposed, without planning, which left people with less than 24 hours to procure supplies, food and medicine. People were forced to ration insulin or to buy it on the black market. The government said it was an essential medicine but provided no support to people to access it. 

As doctors, we felt helpless. We told people with ketoacidosis complications not to come in to the hospital. There were huge lines of people, some even sleeping outside, as they had a dire need for services and didn’t have internet or phones to access them another way. 

Gina: You’ve raised a key issue, sourcing and addressing the concerns of health care workers is vital. In the US, at the beginning of the crisis, Helmsley sent a letter to health facilities asking: what do you need? They came back with requests for insulin pens and glucose monitoring devices. We then reached out to companies and lots provided supplies at cost or free. 

Diverse stakeholders can come together to make change happen. 

Apoorva: Healthcare has also since become more collaborative in India, with more public-private partnership. Private doctors have started alternative ways to use telemedicine in their daily practice though it’s still in its nascent phase. 

The government for its part has worked to increase uptake of telehealth services and motivated patients to take care of their own health.  

Gina: Helmsley has supported Project ECHO [using videoconferences to connect generalists with teams of specialists for training and support for treating patients] to provide tailored care beyond major cities like LA or San Francisco and to save people driving three hours to access specialised care. It has been really impactful and ECHO is looking to expand in India.

We have to meet people where they are, not just in terms of where they’re located but also in what they’re going through. It should be about a holistic approach centered on the person. It shouldn’t be about typing people based on their condition but understanding the totality of people’s lives and the interacting web of health, economic and social challenges they face. 

Voices of NCDI Poverty – trailer from VoicesofNCDIPoverty on Vimeo.

I’ve had the opportunity to meet with young people living with type 1 diabetes in Rwanda, wanting to see though their eyes, what it means to have the condition. One young man in Rwanda was diagnosed on time because his local district hospital, which was five mins away, offered PEN-Plus [an expansion of the WHO Package of Essential Noncommunicable Interventions for Primary Care (PEN)]. Were it not for this hospital, he might well not be alive today. 

Katie: Those kinds of stories were previously a missing piece of the NCD movement, which is why NCD Alliance launched the ‘Our Views, Our Voices‘ initiative which seeks to meaningfully involve people living with NCDs in the NCD response. 

As well as listening to communities, the pandemic has also shown the importance of civil society in building trust with communities, which is absolutely essential. 

Apoorva: Completely. A lot of people in India don’t trust their doctors and go with alternative therapies instead because they don’t want that lifelong dependence on insulin. Trust can really help with compliance, as diabetes is not a case of treat today and “I’m fine!” tomorrow. 

That personal touch can make all the difference. The maternal and child health system in India has achieved lots of wins because community health workers go door to door. We can use that model to expand NCDs services and in turn UHC, even with smaller investments. 

Gina: Can we be agnostic and build coalitions across diseases? HIV is a chronic disease at this point. There are lessons for the NCD community to learn from the HIV community and vice versa. 

Community Health Workers attend a training session on HIV accompaniment in Kirehe, Rwanda.
Community Health Workers attend a training session on HIV accompaniment in Kirehe, Rwanda.

Katie: Speaking of HIV, the Global Fund is developing its new strategy at the moment. There is a real case to be made as to why NCDs should be factored in, as so much of that supports and orientates health systems in LMICs. For too long, global health has worked in siloes, which completely ignores the reality that a lot of people live with several chronic conditions, for example diabetes and TB, or HIV and cardiovascular disease. As we said before, it’s time to look at the whole person, and all the conditions they’re living with, including their mental health, and not just one disease at a time.

NCDs are very much left behind, as indicated by only 1-2% of development assistance spent on addressing them in LMICs. COVID is a moment to both rethink financing and going back to tried and tested models. The ‘Protecting everyone’ report gives some excellent examples of countries with different economic contexts integrating NCDs into UHC. For example, Philippines finances UHC in part via its taxation on unhealthy commodities such as tobacco, alcohol and sugar sweetened beverages.

Apoorva: Yes, COVID has unleashed crisis but also opened windows of opportunity. The same logic is seen behind the ACT-Accelerator [the global collaboration to accelerate development, production, and equitable access to COVID-19 tests, treatments, and vaccines] could be used for NCDs. 

Gina: COVID-19 vaccines will have to travel globally in freezers – a huge operation. Can we use this infrastructure to distribute essential medicines, for insulin delivery, now and into the future?

As important as addressing type 1 diabetes is to Helmsley, COVID is also giving us a chance to have an impact beyond just the one disease. We’ve been thinking about health systems, resilience. For people to be healthy, we need all the factors to come together. Integration is key.

________________

Apoorva Gomber is a doctor and youth advocate living with type 1 diabetes, who has been working in hospitals in India during the COVID-19 pandemic. Twitter: @ApoorvaGomber.

Gina Agiostratidou is the program director for the Helmsley Charitable Trust’s type 1 diabetes program, which aims to advance research, treatments, technologies, and services that improve the lives of people with type 1 diabetes. Twitter: @GinaAgios

Katie Dain is CEO of the NCD Alliance, a global network of civil society organisations dedicated to transforming the fight against NCDs. Twitter: @katiedain1

This conversation has been edited for clarity, flow and focus. 

 

Image Credits: Cecille Joan Avila / Partners In Health, PAHO/Sebastian Oliel.

Fresh seafood market in Wuhan, China. Some of the fhe first SARS-CoV-2 virus clusters emerged around the market, but its now unclear if the virus first lept from animals in the market to humans, or the market was merely an “amplifier” for an infection that came from elsewhere.

Following months of delay, and delicate backdoor negotiations, WHO now says that it “hopes” an international team has been mandated by the World Health Assembly to investigate the sources of the SARS-CoV2 virus can travel to China in January to begin their fieldwork.  

“The International team is currently working on logistical arrangements to travel to China as soon as possible. We hope the team will be able to travel in January,” a spokesperson at WHO told Health Policy Watch on Wednesday in response to a query.  

While the investigation was mandated by the WHA in May, China has delayed for months the visit to “ground zero” in the virus emergence in Wuhan China.  And even now in the WHO press announcement, Wuhan was not specifically mentioned as a place that the team would visit.

“It’s really not about finding a guilty country,” said Fabian Leendertz, a biologist on the team of ten that would be traveling to China. “It’s about trying to understand what happened and then see if, based on those data, we can try to reduce the risk in the future.” 

Dr Leendertz said the aim of the mission, expected to last four to five weeks, is to find out when the virus began circulating and whether or not it originated from Wuhan.

In the early days of the virus emergence, a Wuhan seafood market was believed to have been the place where the virus first lept from an animal source, to humans.  Wuhan’s live animal market, like many others across China, sold cats, pangolins and other species that could have been infected, acting as an intermediate host for the virus – which comes from a family of coronaviruses believed to have been circulating naturally in bat populations living in another region of the country, hundreds of miles away. 

However, it was later discovered that a number of Wuhan’s first cases had occurred in people who had no known contact with the live animal market.

That has led to speculation that the market was merely an “amplifier” for the infection that began somewhere else.  Some reports have also suggested that it was the result of a biosecurity accident at a Wuhan virology lab – and that the virus – while of natural origins – escaped from the lab while it was being researched there. 

US State Department cables, which were made public in the spring, suggested that the US embassy had been worried about biosecurity at the laboratory. While intelligence officials discounted the theory that the virus had been man-made or genetically modified, they had investigated the possibility that the virus had escaped from the lab, or infected laboratory workers in contact with animals housed at the laboratory.

China has released no details about the research underway at the laboratory,  and few details about the wild market, which sold seafood and vegetables, as well as varieties of wild animals.  The lack of transparency, along with rigid state censorship of Chinese research and the tightly controlled nature of visits by foreigners, raise doubts about how much evidence the WHO investigative team will really be able to collect- once it finally hits the ground. 

Chinese government media have also recently attempted to suggest that the coronavirus may have originated from a source outside of China – including in Italy – where surveys of blood samples found evidence of infections as far back as September.

At a recent WHO press conference, state controlled Chinese media tried to suggest that alternative narrative in questions posed to WHO’s Executive Director of Health Emergencies, Mike Ryan and WHO Director General Dr Tedros Adhanom Ghebreyesus. 

But that narrative has been dismissed by most experts. As Ryan pointed out in his reply, the SARS-CoV2 virus, which belongs to a family of coronaviruses that circulates naturally in Chinese bat populations, has no known animal host or source in Europe. 

“I think it’s highly speculative for us to say that the disease did not emerge in China. What we do know is the first clusters of human cases that were detected, were in Wuhan and China, there was a massive response to containing that disease there,” said Ryan.  “It is clear from a public health perspective that you start your investigation from the place where the cases first emerge,” he added, recalling that it was Chinese clinicians who had first picked up the cluster of acute pneumonia cases in the city of 10 million people.

In addition, there is also concrete evidence that the virus was circulating in Wuhan as early as August 2019 – with the first cases on record reported by Chinese doctors in September.

In light of the very extensive network of Italy-China business and tourism connections; the infections circulating Italy in the autumn of 2019 likely resulted from the tourism or business traffic back and forth between the two countries – but simply passed under the radar until China finally acknowledged, and reported to WHO, about the first infection cluster of the virus in Wuhan in January 2020.  

Analysts say the Chinese media attempts to sow reports about a foreign source for the virus origins reports not only are without foundation, they are damaging to the country’s international reputation to portray itself as an honest broker in its management of the pandemic. Ditto for the delays that have been seen in China’s approval for the investigative team visit. 

As Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University told the South China Morning Post “rapid and full access to the market” could have helped in the fight against the outbreak.

“China has done many things right with the Covid-19 response,” he said. “But its failure to allow a full and independent investigation into the origins of the outbreak was a major failure of transparency and international cooperation.”

See our recent Health Policy Watch on the debates over the virus origins here.

Image Credits: Arend Kuester/Flickr.