The opening press conference of the 4th HIV Research for Prevention Conference on 26 January.

While global attention has fixated on the coronavirus, the forty-year long fight against HIV, which has claimed 33 million lives, is seeing new breakthroughs in preventive tools.

New discoveries of “broadly neutralizing antibodies” as well as novel regimens of pre-exposure prophylaxis (PrEP), could strengthen the world’s toolbox to prevent the disease, announced the International AIDS Society (IAS) at the opening of the 4th HIV Research for Prevention Conference. 

The IAS-sponsored Conference, which is taking place virtually over four days, is the only conference in the world that is exclusively focused on research in HIV prevention. 

“COVID-19 has disrupted research around the world, so it’s especially exciting to see this new progress,” said IAS President Adeeba Kamarulzaman in a press release. “These research advances on options like broadly neutralizing antibodies and injectable PrEP could help significantly strengthen our HIV prevention toolkit.” 

Adeeba Kamarulzaman, President of the International AIDS Society, at the HIVR4P Conference.

The latest results on broadly neutralizing antibodies (bnAb) are particularly promising. In a pair of parallel trials, researchers from the Fred Hutchinson Cancer Research Center found that one of its bnAb’s prevented HIV infection 75% of the time over 20 months, thus providing an important “proof of concept” to prevent sexually-transmitted HIV in the future, said the study’s  authors. In this case, the bnAb’s were developed to recognize the ‘CD4’ binding site of the HIV virus.

In the two parallel trials, researchers injected participants with a placebo or two doses (10mg/kg and 30 mg/kg) of their antibody. In the American arm of the trials, enrolees included men and transgender persons who have sex with men, while the Sub-Saharan arm of the trial recruited cisgender women.

More Practical PrEP Regimens Also On Horizon

Meanwhile, two longer-acting and thus more practical PrEP regimens have been developed. They have the potential to replace common treatments that have to be taken on a daily basis, such as tenofovir/emtricitabine (TDF/FTC), also known as “Truvada”. 

They include cabotegravir, the first long-acting injectable regimen, as well as islatravir, a pill that would only need to be taken once a month.

As well as improving adherence to PrEP, these novel treatments could also bolster global PrEP uptake, which still falls short of the 3 million target set by UNAIDS despite a six-fold increase in uptake over the past four years, found the AIDS Vaccine Advocacy Coalition in a study that was also featured at the conference.

Cabotegravir – Injectable PrEP Regimen Works Better Than Existing Treatment 

Based on a study in over 3,000 women in Sub-Saharan Africa, PreP candidate cabotegravir, was deemed safe and far superior to Truvada, complementing similar findings from another earlier trial in cisgender men as well as transgender women who have sex with men.

In this latest trial, participants received either cabotegravir plus a placebo of TDF/FTC or a placebo of cabotegravir and active TDF/FTC. Alongside daily administration of oral TDF/FTC for five weeks, participants received intramuscular injections every eight weeks.

On a positive note, women in the cabotegravir group were 89% less likely to contract HIV compared to the group that received TDF/FTC, probably because it is easier to adhere to a treatment that’s taken every 8 weeks compared to a pill that must be taken every day, noted researchers.

But more funding is needed to reach global targets to eliminate HIV, warned another study that was also presented at the conference, and presented by St Luke’s University.

Based on over a hundred nationally-representative datasets representing more than 1.4 million sexually active people, the study projected that the probability of reaching the 2030 targets set by UNAIDS is “very low” – ranging between 0% to 28.5% for HIV testing and 0% to 12.1% for condom use.

Unless more attention is given to the disease, the prospects of reaching these bold targets to put a stop to HIV/AIDS are rather slim, concluded the study.  

Africa Should Not Be left Behind in HIV Prevention & Control 

Along with reviewing new research breakthroughs, members at the Research for Prevention Conference examined the state of HIV prevention and control measures – which highlighted key concerns for the African  continent. 

Phuong Nguyen of St. Luke’s International University presented data analysis that showed African countries are largely not on track to reach key UNAIDS targets for HIV testing and condom use by 2030. 

Trends in oral PrEP use globally as countries introduce and scale up PrEP programs.

Relying on 114 nationally-representative datasets representing more than 1.4 million sexually active people, the team estimated coverage of annual HIV testing and condom use at last higher-risk sex for each country and year to 2030, and the probability of reaching UNAIDS testing and condom use targets of 95% coverage by 2030.

They reported that the probabilities of reaching the 2030 targets were very low for both HIV testing (0% to 28.5%) and condom use (0% to 12.1%). 

Within Africa, they predicted that the countries with the highest coverage of annual HIV testing in 2030 will be Eswatini with 92.6%, Lesotho with 90.5%, and Uganda with 90.5%. The countries with the highest proportion of condom use will be Eswatini with 85%, Lesotho with 75.6%, and Namibia with 75.5%.

The researchers concluded that there is little prospect of reaching global targets for HIV/AIDS elimination. They made the case for more attention to funding and expanding testing and treatment in Africa.

On the brighter side, Africa is making progress on expanding access to existing PreP formulations – and that should accelerate with the new breakthroughs just announced. 

Geographic representation of the number of PrEP initiations globally as of late 2020.

AIDS Vaccine Advocacy Coalition’s (AVAC) Kate Segal noted that sub-Saharan Africa  expanded PrEP access from 4,154 initiations in 2016 to 290,981 by mid-2020, comprising 44% of the global total.

She used data from AVAC’s Global PrEP Tracker to identify global and regional PrEP initiation trends from the third quarter of 2016 through the second quarter of 2020. 

“While PrEP initiations have grown exponentially in several countries, global uptake falls far short of UNAIDS’ target of 3 million users, indicating a need for sustained demand creation where PrEP programs exist, and scale up where PrEP is provided by demonstration projects with limited reach,” the study concluded. 

Find out more about the event here.

Image Credits: Flickr, HIVR4P, Global Advocacy for HIV Prevention.

Doctors putting on N95 respirator masks, face shields, gloves and gowns before entering a COVID-19-positive patient’s room in August in San Diego, US.

In the midst of the spread of new SARS-CoV2 virus variants, several European countries have updated their guidance and regulations on masks, to recommend the use of high-filtration medical-grade masks over fabric ones in confined settings. 

France’s health advisory council (Haute Conseil de la Santé Publique) issued new recommendations last week, warning against the wearing of certain homemade masks due to the insufficient protection provided from the more highly transmissible COVID-19 variants. 

“Artisan masks that you make at home, with the best intentions in the world [and] respecting the official advice, do not necessarily offer all the necessary guarantees,” said French Health Minister, Olivier Véran, in an interview with France Inter. 

Joining Germany and Austria, France appears set to recommend “Category 1” masks, which filter over 90% of particles, for use people are in close contact with others. Category 1 masks includes FFP2 filter masks, or their N95 or KN95 equivalents, as well as single-use surgical masks, and certain fabric masks with high filtration levels, France said.

Fabric masks, included under Category 2, only capture approximately 50% to 60% of all respiratory aerosols. 

A study published in The Lancet in June found that N95 masks and masks with similar levels of filtration are associated with a larger degree of protection from viral infection in comparison to reusable cotton masks. These results were supported by a study conducted by Duke University. 

Surgical masks are three times more effective in preventing droplet transmission than homemade fabric masks, found a 2013 study conducted by Public Health England, a UK governmental health agency. The study advised against the use of homemade masks if a supply of commercial surgical masks is available. 

In light of the data on the degree of mask protection and the more highly contagious variants, “the high council for public health recommends, as do I, that the French do not wear masks they have made at home,” Véran said. 

The recommendation has yet to be enforced and officials are expecting some issues with its implementation. 

German and Austria Have Already Tightened Mask Regulations

Germany and Austria have already tightened mask regulations, mandating the use of medical-grade masks – N95, KN95, FFP2, or surgical masks – on public transportation and in supermarkets. 

“If the virus becomes more dangerous, the mask has to get better,” said Markus Söder, the Minister President of Bavaria, Germany’s largest state and the first to begin implementing the new mandate. 

Production of FFP2 masks is scaling up in Germany, but some experts worry that prices could rise if suppliers are unable to meet the new demand. The government has aimed to provide 15 FFP2 masks to 34.1 million citizens over the age of 60 or with a history of illness by the end of January. 

Health officials in Europe are approaching the new mask guidelines differently. While Germany is requiring FFP2 equivalent masks, French health authorities have discouraged the public from using FFP2 masks, which are high grade fitted masks, because they are difficult to wear correctly.

“In most cases FFP2 masks will be ineffective if they aren’t professionally fitted: people will end up breathing through the gap between the mask and face rather than through the designated filter,” said Jonas Schmidt-Chanasit, a Professor of Arbovirology at the University of Hamburg, in an interview with the Guardian. 

United States Experts Begin Touting “Hi-Fi” Mask Alternatives – But US CDC Yet To Update Guidance 

In parallel to European counterparts, a group of Harvard University experts have also proposed a United States “Hi-Fi” initiative to promote public use of higher quality N-95 or KN-95 masks that can protect more effectively against COVID-19 variants.

As a cheaper alternative, some experts, including US President Joe Biden’s Chief Scientific Advisor Anthony Fauci, are recommending wearing a double mask combination- a surgical mask and a cloth mask, if N95 or FFP2 masks are not available. The combination of two masks, if they fit well, could provide a filtration efficacy rate over 90%. 

Fauci, Director of the National Institute of Allergy and Infectious Diseases, could be seen sporting such a combination at the US President’s Inauguration last week.  He later said that wearing a double mask “likely does” provide more protection. 

“If you have a physical covering with one layer [and] you put another layer on it, it just makes common sense that it likely would be more effective. That’s the reason why you see people either double masking or doing a version of an N95,” Fauci told NBC News on Monday. 

Dr. Anthony Fauci, Director of the National Insitute of Allergy and Infectious Diseases, speaking on COVID-19 virus variants and mask wearing.

Despite increasing moves towards medical-grade masks, the US Centers for Disease Control and Prevention (CDC) has so far stuck to its existing guidelines. The CDC continues to recommend the use of masks made with tightly woven fabrics with two or three layers and discourages the public from using medical masks and N95 respirators in order to reserve them for healthcare personnel. 

WHO Also Sticks to Fabric Masks For General Public

The guidance provided by WHO also continues to recommend only fabric masks for the general public under the age of 60 and without underlying health conditions. It advises the restriction of medical masks to people over age 60, those with certain health conditions, including chronic respiratory disease, cardiovascular disease, cancer, diabetes, and immunocompromised patients, and health care workers.

Image Credits: Flickr – County of San Mateo, Flickr – Navy Medicine, NBC.

While very low-income countries have experienced relatively low mortality rates from COVID-19, they can expect higher mortality caused by the knock-on effects of the pandemic on their fragile health systems, according to the Executive Director of the Global Fund to Fight AIDS, TB and Malaria.

Since the pandemic first overwhelmed health systems in early 2020, countries across the globe have reported a reduction in referrals and diagnoses for various diseases.

Peter Sands, Executive Director of Global Fund

“It’s a perfect storm of concurrent social crises which are disrupting health interventions: programmes to fight diseases like HIV, tuberculosis (TB) and malaria,” Peter Sands, Executive Director of the Global Fund, said during a session of the  World Economic Forum in Davos today.

Last year, India, Indonesia, the Philippines — three high-burden countries for TB — reported a 25-30% drop in its case notifications. A Lancet study predicted a 25% reduction in antimalarial drug coverage in 2020 in malaria-endemic African countries, potentially doubling mortality.

And although the pandemic has affected health systems in low- and high-income countries alike, poorer countries with weaker health infrastructure, greater disease burdens, and generally worse access to COVID-19 treatments and vaccines will have the hardest time recovering.

“Particularly, the lowest income countries have very young populations. This kind of demographic means that the mortality rate from COVID is relatively low,” he said. In the poorest countries, the life expectancy is about 18 years lower than the richest.

But these countries could be more vulnerable to the “collateral damage” of the SARS-CoV-2 pandemic, rather than the direct impact of the virus. 

“You’re going to see relatively low mortality from COVID itself, and relatively high mortality from these knock-on consequences,” added Sands.

Diagnosis Deficit: Lower Diagnoses Globally

The COVID-19 pandemic risks shattering countless disease elimination targets, many of which have been set by the World Health Organization (WHO).

Diagnoses and interventions for communicable and non-communicable diseases (NCDs) have both been impacted in 2020, with COVID-19 and related lockdowns affecting patients’ ability to get access to treatment.

The World Hepatitis Alliance found that last year 94% of respondents in its 32-country survey had had their hepatitis services closed. In addition, half of respondents in lower- and middle-income countries (LMICs) could not get their medication, with respondents in India and Nigeria citing pandemic-related travel restrictions as the cause.

“The Task Force for Global Health and the World Hepatitis Alliance [have] all come up with the same figures,” said Charles Gore, Executive Director of the Medicines Patent Pool.

“Diagnosis and treatment are the key areas in [WHO’s] Global Strategy where the world is lacking,” he added. “And unfortunately, the hit is even bigger in LMICs.”

Where access to treatment for a given disease might have been reduced by 40-60% in a high-income country, “we’re talking 60-90% in LMICs”.

“There’s an estimate that a one-year hiatus in [a country’s] national programs from hepatitis elimination will lead to an extra 45,000 liver cancers and 72,000 deaths by 2030,” he said.

The reduction in access to treatments is similarly stark for NCDs.In the UK, lung cancer referrals in August 2020 were down by 26% from the previous year. During the April lockdown — when much of the Western world experienced its first COVID wave — referrals for lung cancer from doctors’ surgeries dropped by 72%.

“Even if they are referred, it’s very difficult to get patients through the system, and get respiratory symptoms investigated so they can start treatments quickly,” said Michelle Mitchell, chief executive of Cancer Research UK.

“This is a time of great worry for patients with lung cancer or other types of cancer.”

Patients will have a much better prognosis if they are diagnosed early. Data observed by Cancer Research UK indicates that nearly 90% of patients diagnosed at Stage 1 survived the disease for at least one year, compared to just 19% for those diagnosed at Stage 4.

“It’s too early to know the impact yet,” she said. “But we do expect there to be a huge impact.”

Build Back Better: ‘Not Ambitious Enough’

The process of ‘building back better’ does not go far enough, Harvard T.H. Chan School of Public Health’s Dean, Michelle Williams, said.

Building back better refers to a process of economic recovery from COVID-19 that avoids destructive investment patterns: namely, investments that endanger biodiversity, which is linked to zoonotic diseases jumping species.

“What COVID has done is really show how weak global public health infrastructure can bring us to our knees,” she said.

“To build back better is [to] first recognise the importance and value of public health and invest accordingly. That means properly investing in global governance of public health leadership [and] making the structure nimble and equipped.”

An interim report by the Independent Panel on Pandemic Preparedness and Response, published last week, determined that WHO’s COVID-19 response was too slow, and was hampered by a lack of resources and a damning lack of authority among its member states.

“We’re not being remotely ambitious enough,” Sands said. “This year we are deploying about US$4.7 billion on HIV, TB and malaria to mitigate the collateral damage … we need another $5 billion. And that’s the Global Fund alone.”

And the global ambition for economic recovery, which is “currently shaped as getting back to [a] pre-pandemic” scenario, is “not good enough”, Mitchell added. “Because we weren’t doing well enough before COVID.”

Image Credits: The Global Fund.

WHO is yet to grant the Moderna vaccine Emergency Use Listing (EUL), but its advice for use is still significant as many member states rely upon these vaccine recommendations as a global reference point.

The Moderna COVID-19 vaccine is safe for most people including those with a wide range of underlying medical conditions, according to the World Health Organization’s Strategic Advisory Group of Experts (SAGE) on immunizations.

However, the vaccine is not recommended for pregnant women or children as it has not been tested on these groups, according to interim recommendations published today by WHO.  The issue of the vaccine in pregnancy is emerging as a bigger issue in light of recent evidence, including from the US Centers for Disease Control, that pregnant women are at higher risk of serious COVID-19, and as new variants of the SARS-CoV2 virus infect more young people, including those of childbearing age.

The WHO approval may also pave the way for Moderna to contribute vaccines to the global COVAX facility, following a final WHO “Emergency Use Listing” approval for the vaccine.

Last Friday, Pfizer announced it was contributing 40 million doses of its vaccine to the WHO co-sponsored COVAX, weeks after WHO approved the vaccine.

People who have severe allergic reactions to any of the vaccine’s components should not receive it, and it should also not be used in countries that do not have the capacity to treat anaphylactic shock, according to SAGE. It also advises caution about administering the vaccine to frail, elderly people near the end of their lives.

The vaccine needs to be administered in two doses 28 days apart, although “the interval between the doses may be extended to 42 days”, SAGE said. All those vaccinated should be observed for “at least 15 minutes after vaccination”, and anyone experiencing an immediate severe allergic reaction should not receive the additional dose.

No Word On Emergency Authorization From WHO

The WHO has not yet issued an Emergency Use Listing (EUL) for the Moderna vaccine, but it has undergone review by the European Medical Agency (EMA), which has authorized its use in the European Union. It has also been approved in the United States, Canada, the United Kingdom and Swissmedic.

Regardless, the WHO advice is significant as many member states – especially low- and middle-income countries (LMICs) – also rely upon WHO for vaccine recommendations as a global reference point.

Dr Kate O’Brien, WHO’s Director of Vaccines, told a media briefing today that the global body was still in discussions with Moderna about the information it needed to issue an EUL, and so did not comment about if or when this would be issued.

O’Brien did add, however, that SAGE’s advice was important as some member states had already made arrangements to procure the vaccine from Moderna.

Dr Kate O’Brien, WHO’s Director of Vaccines.

Moderna and Pfizer/BioNTech are both mRNA-based vaccines, but the Moderna vaccine does not need to be stored at the extremely cold temperatures required by the BioNTech-Pfizer vaccine, which makes it more suitable for LMICs.

In trials, the Moderna vaccine showed an efficacy of approximately 92% in protecting against COVID-19, starting 14 days after the first dose.

Moderna claimed yesterday that its candidate appears to retain its efficacy against the B.1.1.7 and South Africa-identified (B.1.351) variants. In the study, which is yet to be peer-reviewed, researchers looked at blood samples from eight participants who had previously received the recommended two doses during Phase 1 trials.

In the case of the B.1.1.7 variant, they reported the mutated virus posed no significant impact on titers: a means for measuring the amount of antibodies in a blood sample. Tests on B.1.351 showed a “six-fold reduction in neutralizing titers” although “neutralizing titer levels with B.1.351 remain above levels that are expected to be protective”, according to the company media release.

Meanwhile, Moderna also announced that it will “test an additional booster dose of its COVID-19 Vaccine (mRNA-1273)” to see whether it can further increase neutralizing antibodies against emerging strains “beyond the existing primary vaccination series”.

Despite this, O’Brien said that clinical evidence was needed to support this report, and that the blood sera of people who have antibodies against COVID-19 was currently being tested against these variants.

She welcomed how prepared vaccine manufacturers were to “potentially make modifications to the vaccines that they are continuing to develop”.

“The preponderance of evidence at hand, albeit small, is that the vaccines in hand are extremely valuable as part of the toolbox for fighting the pandemic and really crushing this virus, but we will continue to respond to as new scientific evidence comes in,” concluded O’Brien.

Image Credits: Moderna.

Without this fund, the world’s poorest countries would have to pay out legal claims made by people who might suffer serious side-effects after receiving their COVID-19 vaccination.

The global COVID-19 vaccine access platform, COVAX, plans to impose a US 10-cent levy on each vaccine dose to fund a compensation scheme for people who suffer from severe adverse reactions to any of the vaccines it supplies.

The “no-fault” compensation fund is crucial for countries who join COVAX, as one of the conditions of membership is that they agree to indemnify pharmaceutical manufacturers from any legal claims from people who might suffer serious side-effects.

Without the fund, the world’s poorest countries – defined as COVAX’s advance market commitment (AMC) countries – would have to pay out citizens’ claims themselves.

In the past two weeks, the US Centers for Disease Control and Prevention (CDC) reported several cases of people suffering from anaphylactic shock as a result of taking the Pfizer-BioNTech and Moderna vaccines. Anaphylaxis is a severe, life-threatening allergic reaction that occurs rarely after vaccination, according to the CDC.

In the case of the Pfizer-BioNTech vaccine in the US, by 23 December, some 4,393 adverse events had been reported out of 1,893,360 (0.2%). Of these, 21 cases were determined to be anaphylaxis (a rate of 11.1 per million doses administered), including 17 in persons with a history of allergies or allergic reactions.

In Moderna’s case, by 19 December, 4,041,396 first doses of Moderna COVID-19 vaccine had been administered in the US, with 1,266 adverse events reported (0.03%). Of these, 10 cases were determined to be anaphylaxis, nine of whom had a history of allergies or allergic reactions.

COVAX published an indemnification proposal in November, which states that “each country receiving COVID-19 Vaccines through the COVAX Facility, whether distributed under an emergency use authorization or recently licensed, will be required to indemnify manufacturers, donors, distributors, and other stakeholders against any losses they incur from the deployment and use of those vaccines”.

A spokesperson for GAVI, the Vaccine Alliance, which manages COVAX, told Health Policy Watch that the facility had been working with all stakeholders to establish “a comprehensive solution addressing the need for indemnification and the financial obligations this may impose on middle- and low-income countries”.

The compensation fund will be financed “from a $0.10 per dose levy charged by GAVI on the doses to be distributed to AMC countries through the COVAX Facility,” said the spokesperson. “We will be announcing more details, including specific terms around the principles governing indemnity, in the coming days.”

COVAX has also facilitated a common template agreement for AMC-eligible economies, that has been negotiated with, and agreed upon by all manufacturers which will “greatly reduce the legal burden on AMC participants”.

All Medicines Contain ‘Some Risk’ But Not An Excuse For Sub-Par Product, Experts Remind

Professor Brook Baker, an access to medicines expert at Northeastern University in Boston, said that “there are credible arguments for some degree of indemnification, but it should not be a blanket indemnification for harms caused by manufacturer neglect”.

“All medicines contain some risk of known and unanticipated adverse side effects or reduced efficacy. The risks of vaccines in particular are considered significant, not because vaccines don’t meet heightened safety requirements, but because they are given to large populations of otherwise healthy people,” explained Baker.

“Some risks of vaccine administration are unavoidable. Most of them are rare and listed, but others may be truly rare and unexpected. It makes some sense for governments and payers to indemnify against these predictable and inevitable risks – otherwise vaccine manufacturers might charge much higher prices or avoid vaccine R&D and sales altogether,” added Baker.

However, he said manufacturers should not have a “free pass” against adverse outcomes that they could have prevented, such as a sub-standard batch of vaccines or if the manufacturer failed to monitor and report significant side-effects adversely affected particular populations.

COVAX is also proposing a “no-fault, lump-sum compensation” for an adverse event as a “full and final settlement of any claims”, but this won’t preclude a local claim.

However, Baker cautioned that “a lot of people suffer health effects after vaccination that are not causally related to the vaccine – there is correlation but not causation”.

For this reason, some no-fault schemes “get hung up on long, drawn-out investigations of causation”, making the compensation process slow.

In addition, “no-fault compensation schemes can be overly bureaucratic and costly to maintain and administer”, warned Baker. “Resource poor countries with weak regulatory capacity would have particular difficulty setting up and running a no-fault compensation mechanism at the national level.”

Image Credits: CIO Look/Flickr, Bret Bostock/Flickr.

Dr Tedros Adhanom Ghebreyesus, WHO Director General, at Monday’s Executive Board session.

COVID-19 has led to the suspension of polio campaigns in more than 30 countries, and has underscored the importance of the mission to eradicate it, tackle antimicrobial resistance, and ensure the timely sharing of pathogens, said WHO member states at Monday’s Executive Board session. 

Throughout the morning and afternoon sessions, member states reviewed and discussed the Director General’s reports on poliomyelitis eradication, polio transition planning, antimicrobial resistance (AMR), and the public health implications of the implementation of the Nagoya Protocol. 

Afghanistan and Pakistan have already reported outbreaks of both types of polioviruses, making them the last two remaining polio endemic countries. Although polio outbreaks impacted three of WHO’s six regions in 2020, with almost 1,000 cases recorded, 30% of the emergencies were stopped during the year, demonstrating the ability to stop polio outbreaks even in the midst of a pandemic. The pandemic has also disrupted routine immunisation programmes, increasing outbreaks of both wild and vaccine-derived polioviruses.

“Polio is still considered an emergency, and rightly so, because it could become a major international problem again if we’re not careful,” said WHO Regional Director for the Eastern Mediterranean, Ahmed Al-Mandhari. “So we need the resources that are required to keep the public health situation under control and make sure that all countries of our region are doing what needs to be done as it needs to be done.

“This requires resource mobilisation across the region…We’ve got children at risk of being paralysed for life and we must save them from that. That means intensifying our efforts as we get close to the finishing line of efforts to eradicate poliomyelitis.” 

Despite the disruptions of efforts to combat vaccine-preventable diseases, along with projections that the African region could see a 200% increase in the number of districts with polio cases by the end of 2020, WHO officials highlighted the opportunities brought along by the SARS-CoV2 virus. This could particularly be the case for polio transition, which is the adaptation of polio infrastructure for disease surveillance, social mobilisation, vaccine delivery, and care for hard-to-reach populations to other programme areas. 

“Firstly, COVID-19 is accelerating programmatic integration…We are now leveraging the full technical expertise to align polio transition activities with other programmatic priorities and the planning processes,” said Zsuzsanna Jakab, WHO Deputy Director-General. “Secondly, COVID-19 has once again demonstrated the value of the polio network, especially at the community level…Thirdly, COVID-19 underlines the importance and the need for strong and resilient health systems. In countries where there is a strong polio footprint, the polio network is a core component of the essential public health workforce.”

Zsuzsanna Jakab, WHO Deputy Director-General.

The contributions of polio staff, networks, resources and expertise to COVID-19 actions assisted in the pandemic responses in over 50 countries. In the African region, two polio personnel at the national and district levels in country offices in the region are spending more than half of their time on the COVID-19 response. 

In addition, “polio colleagues are the main frontline workers [in the African region] responding to outbreaks of cholera, yellow fever, and meningitis,” said Matshidiso Moeti, WHO Regional Director for the African Region. 

Australia’s delegation echoed some of WHO’s messages, “acknowledg[ing] the ongoing role the GPEI [Global Polio Eradication Initiative] will have in supporting the delivery of COVID-19 health interventions, including vaccinations.”

Polio Eradication Efforts Face “Precarious Financing”

Meanwhile, member states expressed concern regarding the “precarious financing situation” of the Global Polio Eradication Initiative, a public-private partnership with six core partners – WHO, Rotary International, the US Centers for Disease Control and Prevention, UNICEF, the Gates Foundation, and GAVI. 

“We’re concerned at the slow pace with which polio transition plans are being finalised. Given current funding constraints, this work needs to be expedited now more than ever,” said the UK’s delegate. 

“We share concern with regard to the financial gap in GPEI’s budget this year. The way forward is looking for new financial resources, but also focusing on increasing efficiency,” said the delegate representing Germany. 

Burkina Faso, speaking on behalf of the 47 WHO member states of the African region, called upon stakeholders to strengthen the financial mechanisms to fight polio, particularly given the “fragile financial situation.”

Burkina Faso’s delegate at the Executive Board session on Monday.

With the announcement in the Director General’s report of the likely scaling back of resources and presence in countries where poliomyelitis is not endemic, the African region emphasised the need to “mobilise long term financing to allow the region to continue its elimination activities” and “ask[ed] WHO to add financing for poliomyelitis and put it in one of the priorities of the program budget for 2022-2023 and following budgets,” said Burkina Faso’s delegate. 

In an effort to reassure member states, Jakab recognised the need for long term financing to sustain polio assets. “We would like to assure [member states] that this remains a priority for WHO’s programme budget 2020-2023 and beyond.”

“The draft budget presented to the EB reflects our commitment to sustainable financing for the polio network and we are working closely with GPEI and other development partners to develop comprehensive resource mobilisation efforts for future financing,” she added. 

“I encourage partners and donors to continue to support WHO in order to sustain our core functions where polio infrastructure can make the most impact,” said Dr Tedros Adhanom Ghebreyesus, WHO Director General. “These functions are central to reaching the 13th General Programme of Work (GPW) goals of promoting health, keeping the world safe and serving the vulnerable.” 

Antimicrobial Resistance

Also on the Executive Board agenda was AMR, a growing global threat. Essential antimicrobial drugs used to treat common infections are becoming ineffective globally, but the highest rates of resistance are in low- and lower-middle-income countries, found WHO’s progress report on the implementation of the Global Action Plan on Antimicrobial Resistance. 

A risk assessment conducted by the Secretariat indicated that COVID-19 has disrupted planned and ongoing national AMR activities and has heightened the risk of resistance emerging due to the irrational use of antimicrobials to treat patients infected with SARS-CoV2. 

The EU and the Philippines laid out the interplay between COVID-19 and AMR, which included supply chain disruptions of antibiotics, interruptions in the delivery of routine immunisation services, and the misuse and overuse of antibiotics in managing COVID-19 patients. 

“These developments, if not addressed, can push back all the gains in our fight against infectious diseases,” said the delegate representing the Philippines. 

Philippines’ delegate at the Executive Board session on Monday.

“Within the context of the pandemic, implementing the relevant programmes to mitigate and control AMR, such as infection prevention, surveillance, antimicrobial stewardship, and WASH [water, sanitation, and hygiene] have become even more crucial,” said Dr Tedros. “As we continue to tackle the COVID-19 pandemic, we must simultaneously ensure that efforts to stop the spread of AMR are accelerated to control this silent tsunami together.” 

WHO Collaboration to Address AMR

Following the establishment of the Tripartite Joint Secretariat on AMR, a collaboration between WHO, the Food and Agriculture Organisation (FAO), and the World Organisation for Animal Health (OIE), the tripartite Antimicrobial Resistance Multi-Partner Trust Fund was launched in 2019 to support One Health action in low- and lower-middle-income countries.

“In Brazil’s view, the collaboration between WHO and other agencies within the United Nations system [such as through the Tripartite Joint Secretariat on AMR] will be as legitimate and successful as they perform their respective mandates and are accountable to their respective governing bodies,” said Brazil’s delegation. “We also see room for improvements in the way that AMR-related high level bodies connect their work, the wealth of needs and context to member states.”

The Trust Fund was supported by Zambia at the Executive Board session, as “this will ensure sufficient and sustainable AMR funding” through the utilization of multi-fund streams. 

“134 countries have established national plans [on AMR], but a lot of countries lack the necessary financing. As a result, plans won’t have a real impact. We can’t be successful if we don’t have the necessary financing in place to implement activities at the national, regional and local level,” said Professor Hanan H. Balkhy, WHO Assistant Director-General of Antimicrobial Resistance. 

Professor Hanan H. Balkhy, WHO Assistant Director-General of Antimicrobial Resistance.

“We call upon all member states to take the necessary measures to fight AMR by establishing these national action plans and establishing the financing so that they can be implemented in the context of Universal Health Coverage and primary health care,” she added. 

WHO and member states agree upon the need for a holistic and multi-sectoral approach – a One Health approach – to AMR and several announced their support for the One Health Global Leaders Group on Antimicrobial Resistance, a key global governance structure comprised of members states, civil society and the private sector. 

“We applaud the many initiatives that are putting the one health approach in practice at the global level….Germany welcomes the recent establishment of the One Health Leaders Group and is happy to be represented in this group,” said Germany’s delegate. “We trust that it will keep AMR high on the political agenda.”

Mechanisms for Pathogen Sharing in Health Emergencies

Subsequently, member state discussions on practices in the sharing of pathogens and genetic sequencing data commenced, largely focusing on actions taken in relation to the SARS-CoV2 virus and highlighting the importance of rapid pathogen sharing in the context of public health emergencies.

Austria, speaking on behalf of EU member states, underscored the “confusing situation” and legal uncertainty that surrounds the timely access to pathogens in health emergencies. This uncertainty “could cause delays in access to diagnostics, therapeutics and vaccines,” said the Austrian delegate.

Ambassador Elisabeth Tichy-Fisslberger, Permanent Representative of Austria to the United Nations Office at Geneva.

Current arrangements lack clarity, as the distinction between the sharing of biological pathogen samples and genetic sequences is blurry and the implementation of certain provisions of the Nagoya Protocol – an international legal agreement on the fair and equitable sharing of genetic resources – is limited, according to the Austrian delegation.

By contrast, India’s delegate recounted the benefits of the Protocol revealed by the pandemic. “[The Nagoya Protocol] facilitated the rapid sharing of information about the COVID-19 virus and helped in establishing a systematic, organised method of data exchange to prevent any potential breaches in the country’s jurisdiction related to sharing and use of biological data and resources,” said the delegate representing India.

The Chinese delegation recognised the urgent need to establish a fair and equitable benefit sharing mechanism and highlighted China’s efforts to fulfill its obligations to promote access to genetic data under the Nagoya Protocol.

Both China and the US delegations drew attention to the actions of their respective countries during COVID-19.

“Concerning the sharing of the SARS-CoV2 virus, since the outbreak, China immediately mobilised high level, biological security labs with leading experts to conduct a parallel testing for cases and samples. Within a record breaking time period, they identified SARS-CoV2 as the pathogen and immediately shared this genome sequencing,” said China’s delegate.

China’s WHO Executive Board delegate at the session on Monday.

“The genome sequencing shared immediately by China provided the world with important basic information to be used in clinical diagnostics,…vaccine research, origin tracing, [and] virus evolution studies,” he added.

In the US, “the National Institute of Allergy and Infectious Diseases has shared these [SARS-CoV2 virus samples] more than 4,500 times…with diverse stakeholders in at least 49 countries, including government scientists, academics, and private sector companies for any legitimate purpose required to study, rapidly detect, prepare for, and respond to COVID-19,” said the delegate from the US.

The discussion on pathogen sharing practices and pathways to increase the capacity for the sequencing and analysis of genomes globally will resume on Tuesday, prior to the closure of the 148th session of the Executive Board.

Image Credits: WHO / Christopher Black, WHO.

Björn Kümmel, Vice Chair, WHO Executive Board.

Discussions on WHO’s state of financing were addressed by member states during the on-going Executive Board meeting. As we reported last week, WHO is keen on defining independence and sustainability of its financing to be better prepared to address emergencies in the future.

We spoke to Björn Kümmel, Deputy Head of Unit, Global Health, German Federal Ministry of Health and Vice Chair of the WHO Executive Board, who has been actively involved consistently in raising these issues on the organization’s finances. He was also a part of the consultations on the Open-ended Intergovernmental Working Group on Sustainable Financing at the EB last week.

Geneva Health Files: Germany has emphasized the importance of assessed contributions for improving the finances of WHO. Can you please share your reasoning behind an increase in assessed contributions for all member states?

Björn Kümmel: Strengthening of the World Health Organization (WHO) is a key priority for the German Federal Government. In the new Global Health Strategy of the German Federal Government, which has been adopted by the Cabinet of Ministers last October, there is a clear focus on enabling WHO to play its mandated role as the leading and coordinating authority in global health.

The WHO’s budget has grown over the past decades. However, the assessed contributions have remained practically stable since the year 2000. Today, WHO’s overall budget volume foresees roughly 5 billion USD for two years. While in past history, the entirety of the membership fee, the assessed contributions was the main part of WHO’s budget, since 2000, the voluntary contributions have outgrown the assessed contributions.

It is essential to realize, that today, the vast majority of  financial resources (currently roughly 83 %) are contributed on a voluntary and largely unpredictable basis. These funds are provided and steered by a very limited number of generous individual donors on a purely voluntary basis. These donors decide, for which concrete goals WHO may use the funding, and they are free to withdraw the funding as they please. This financial dependency on a very limited number of key donors is seen as one of the key risks for WHO as this leads also to political dependency. Some argue that WHO is often used by donors like an implementing agency, implementing the goals that are a priority for the generous donors.

With only 17 % purely predictable and flexible sustainable finances (assessed contributions), it is practically impossible for WHO to play its envisaged role as a guardian of global health. Through the COVID-19 pandemic it has become obvious: The expectations of the 194 Member States vis-à-vis WHO by far outweigh WHO’s de facto abilities. And while in the WHO governing bodies, Member States keep on adding concrete tasks for WHO, not only but including through adopting World Health Assembly Resolutions that have wide financial implications, within the past decades, the WHO Member States have failed to properly address the key challenge of sustainable financing for WHO. One lesson that will most likely be pointed out in the current lessons-learnt-processes that assess the reaction towards the COVID-19 pandemic will be: This financing challenge needs to be tackled if  WHO should in the future continue to be expected to lead and coordinate the international prevention, detection and response to pandemics.

GHF: Based on the deliberations at the EB, what is your assessment of WHO’s proposal for sustainable financing?

Björn Kümmel: Through its resumed session in November 2020, the World Health Assembly has asked the WHO Secretariat to prepare a paper on sustainable financing for discussion at the Board`s meeting in January. The Secretariat’s report (EB148/26) provides a clear picture about the different sources of financing for WHO with regards to the question whether this financing is sustainable or not. The Secretariat proposed to set up a Member State working group to assess the situation with regards to the sustainability of financing for WHO. Based on this assessment, the working group is supposed to discuss and explore options in order to address this challenge. However, it is clear, that it is not the role of the working group to take final decisions. These would have to be taken by the entire membership of WHO, all 194 Member States together.

The proposed process is promising as it may help to address one of the key structural challenges that has been hindering WHO to fulfil its mandate. During the yearly meetings of the Executive Board in January, the implementation of the current Programme Budget is being discussed. In the relevant discussions, all Member States complain about the fact, that the different programme areas of the WHO are unevenly financed with many so called “pockets of poverty”. These are predominant throughout all WHO’s programme areas and have severe implications for WHO’s day to day work.

It is important to understand: When WHO’s programme budget is being approved by the 194 Member States, it is a largely unfunded budget. The only financing source that is purely certain is the 17 % share of the assessed contributions and some already secured grant agreements by voluntary donors. Therefore, WHO has to raise the vast majority of the needed finances after the approval of the programme budget.

This has led to the fact, that many departments need to spend major parts of their work on fund-raising efforts to make sure that envisaged activities are enabled and staff positions can be paid for. Since the vast majority of WHO’s funding is unpredictable and non-sustainable, many WHO staff members do not work on a long-term basis but even based on contracts covering shorter periods than half a year. In addition, this situation has led to a major increase of the use of “non-staff” contracts, in particular consultants and other agreements that are perceived to be more flexible and cover shorter periods of time. Obviously, this financial reality is hardly reconcilable with the need to ensure the best talent in public and global health in order to be able to lead global health by excellence. Attracting and retaining the needed talents will be a growing challenge due to the human resources consequences of the current financing model of WHO.

The discussion that will evolve based on the Secretariat’s report on sustainable financing and the future work of the working group is of highest importance to make all WHO Member States and the broader public health community aware of this financing challenge. We hope that the different ways that have been tried in the past years to ease this challenge will be assessed including why these options have failed to properly address the given challenge. It would be a great step forward, if, through this process, the WHO’s governing bodies would devote adequate focus on potential future options for long-term solutions.

It is clear, that this will be a lengthy and very complex endeavour. However, the COVID-19 crisis may serve for a new political understanding among the entire membership of WHO, that more sustainable investments are needed to enable WHO to fulfil its mandated role.

GHF: What steps have been taken, or will be taken, in the near future to revitalise the role of the governing bodies?

Björn Kümmel: Germany has been a member of the Executive Board for the past three years. From the start, we shared the view that the role of the governing bodies and in particular the Executive Board indeed needs to be revitalized. The Executive Board has been criticized not to allow for adequate interaction between its members and sometimes not being able to more flexibly shift the focus of its deliberations on the most pressing and decisive questions. It is a fact, that the Executive Board has become to some extent a small World Health Assembly.

While this transparency is a great merit as it allows for full inclusiveness and at least theoretically ensures that the Assembly is well prepared through a consensual process, some argue that this setting sometimes limits the interaction in between the original members of the Executive Board. This leads to reading out only prepared statements and thus reduces the role of the Executive Board to serve as an exclusive steering board.

During the COVID-19 pandemic, some EB members have raised their concern, that the EB has not played its mandated role to provide oversight and guide the work of the Secretariat throughout the pandemic. In order to reflect on this and more generally the role that the Executive Board sees for itself, a retreat of the Executive Board has been proposed. Taking into account the limitations for such a retreat during the ongoing pandemic, members of the Executive Board have called for such a retreat at the earliest possible timing.

Priti Patnaik is the founding editor of Geneva Health Files – a reporting initiative that tracks power and politics in global health.

This interview is a part of a series under a new collaboration arrangement between Geneva Health Files and Health Policy Watch.  

Image Credits: C Black, WHO.

Michael Osterholm – a leading member of the United States President’s coronavirus transition team – has said he is “convinced” by data indicating the UK COVID-19 variant is more deadly, even as United Kingdom officials downplay the limited and “uncertain” evidence.

Meanwhile, Moderna announced today that it will “test an additional booster dose of its COVID-19 Vaccine (mRNA-1273)” to see whether it can further increase neutralizing antibodies against emerging strains “beyond the existing primary vaccination series”.

Late on Friday evening, UK Prime Minister Boris Johnson announced that the SARS-CoV-2 variant, also known as B.1.1.7, “may be associated with a higher degree of mortality”: potentially by up to 30%.

But the government’s chief scientific adviser, Sir Patrick Vallance, was quick to flag that the current data available – published by Nervtag, a government advisory committee – was “not yet strong”.

The report concluded there was “a realistic possibility” that infection with B.1.1.7 “is associated with an increased risk of death”.

Vallance noted: “There’s a lot of uncertainty around these numbers and we need more work to get a precise handle on it, but it obviously is a concern that this has an increase in mortality as well as an increase in transmissibility.”

The variant, which was first detected in September 2020, was previously understood to be around 30-70% more transmissible than the Wuhan strain.

Vallance explained that around 10 in 1,000 men in their 60s infected with the Wuhan strain would be expected to die with the virus. “With the new variant,” he said, “for 1,000 people infected, roughly 13 or 14 people might be expected to die.”

Despite this, Michael Osterholm – epidemiologist and a member of President Joe Biden’s coronavirus transition team – has said he is “convinced” that B.1.1.7 is deadlier after reviewing the UK report.

Osterholm, who has also reviewed other unpublished data, said: “The data is mounting — and some of it I can’t share — that clearly supports that B.1.1.7 is causing more severe illness and increased death.”

The US Centers for Disease Control and Prevention (CDC) has begun reviewing the data, it confirmed to CNN on Saturday: “The CDC has reached out to UK officials and is reviewing their new mortality data associated with variant B.1.1.7.”

The Nervtag report collected data from three independent analyses, led by University of Exeter, Imperial College London, and London School of Hygiene & Tropical Medicine.

Moderna Latest To Claim Vaccine Effective Against Key Variants

Moderna’s clinical development manufacturing facility in MA, USA.

Given this uncertainty, questions have naturally been directed toward those organizations developing COVID-19 vaccines, notably as to whether these candidates can protect against these variants.

As of Monday morning, Moderna — whose mRNA vaccine has so far been approved for emergency use in at least 10 blocs including the UK, the US and the European Union — has claimed its candidate appears to retain its efficacy against the B.1.1.7 and South Africa-identified (B.1.351) variants.

In the study, which is yet to be peer-reviewed, researchers looked at blood samples from eight participants who had previously received the recommended two doses during Phase 1 trials.

In the case of the B.1.1.7 variant, they reported the mutated virus posed no significant impact on titers: a means for measuring the amount of antibodies in a blood sample.

Tests on B.1.351 showed a “six-fold reduction in neutralizing titers” although “neutralizing titer levels with B.1.351 remain above levels that are expected to be protective”, according to the company media release. But the sample size is surprisingly low, with only eight participants and the study is based on an in-house, un-peer reviewed study,

Last week, Pfizer made a similar claim after testing only 16 blood samples: a startlingly low number given the number of participants involved in their clinical trials. Critics had said Pfizer had been overly optimistic in its interpretation of the data.

Meanwhile, Moderna is also “advancing an emerging variant booster candidate (mRNA-1273.351) against the B.1.351 variant first identified in South Africa”.

It aims to test the candidate in preclinical studies and a Phase 1 study in the US “to evaluate the immunological benefit of boosting with strain-specific spike proteins” and “expects that its mRNA-based booster vaccine will be able to further boost neutralizing titers in combination with all of the leading vaccine candidates”.

Image Credits: Moderna.

Vaccine
The economic cost to the world’s advanced economies in the absence of global vaccine access could be up to US$5 trillion, a report has found, compared to the $38 billion cost of funding WHO’s ACT Accelerator.

Wealthy countries that pursue ‘vaccine nationalism’ when their trading partners don’t have access to the COVID-19 vaccine will pay a far higher economic price than if they invest in ensuring all countries have access to vaccines, according to a comprehensive economic modelling study released today by the World Health Organization (WHO).

The study, commissioned by the International Chamber of Commerce (ICC) Research Foundation, projects that the economic cost to the world’s advanced economies in the absence of global vaccine access could be up to US$5 trillion.

In contrast, the entire cost of funding the Access to COVID-19 Tools (ACT) Accelerator, the WHO-led global platform to ensure equitable access to COVID-19 vaccines, tests and treatments, is $38 billion.

“Strikingly, a $27.2 billion investment on the part of advanced economies – the current funding shortfall to fully capitalize the ACT Accelerator and its vaccine pillar COVAX – is capable of generating returns as high as 166x the investment,” according to the ICC.

The researchers looked at the production and trade networks of 65 countries across 35 sectors, modelling three different vaccine access and lockdown scenarios. They concluded that the global loss to GDP if vaccines are not widely available “is higher than the cost of manufacturing and distributing vaccines globally”.

“Our estimates suggest that up to 49 percent of the global economic costs of the pandemic in 2021 are borne by the advanced economies even if they achieve universal vaccination in their own countries,” states the report, which was produced by the Centre for Economic Policy Research.

The study explains that the advanced economies are “tightly connected to unvaccinated trading partners which consist of a large number of emerging markets and developing economies”.

“Thus, the devastating economic conditions in these countries under the ongoing pandemic can cause a non-negligible drag on the advanced economies as well,” according to the study.

Demand for goods would fall in countries badly affected, and their production capacity would be weakened, thus affecting their ability to supply goods and materials needed by advanced economies.

Ṣebnem Kalemli-Özcan, Professor of Economics and Finance at the University of Maryland and an author of the report, said: “No economy can fully recover until we have global equitable access to vaccines, therapeutics and diagnostics. The path we are on leads to less growth, more deaths, and a longer economic recovery.”

Dr Tedros Adhanom Ghebreyesus, WHO Director General.

Meanwhile, WHO Director General Dr Tedros Adhanom Ghebreyesus said that “this research shows a potentially catastrophic economic failure”.

“The progress made by the ACT Accelerator shows solidarity in beating this virus. The longer we wait to provide vaccines, tests, and treatments to all countries, the faster the virus will take hold, the potential for more variants will emerge, the greater the chance today’s vaccines could become ineffective, and the harder it will be for all countries to recover. Truly, no-one is safe until everyone is safe.”

ICC Secretary General John WH Denton added that the research shows that  “ensuring equitable access to COVID-19 tests, treatments and vaccines is not only the right thing to do – to do otherwise is economically irresponsible. International business needs a fully funded ACT Accelerator”.

“This is not an act of charity. This is economic common sense,” said Denton. “If you want to ensure a durable recovery in your economies, you need to step up and actually pay up.”

Countries with open economies stand to lose the most, particularly Belgium, France, Germany, the Netherlands, Norway, Switzerland, the United Kingdom and the US, “who might lose up to 3.9% of their GDPs”.

“No economy is an island,” the report concluded, paraphrasing the John Donne poem. “The economic losses of the pandemic can only be mitigated through a multilateral coordination ensuring the equitable access of vaccines, tests and therapeutics.”

COVAX Deal With Pfizer Is Small But ‘Opens the Door’

Meanwhile, WHO Special Advisor Dr Bruce Aylward defended a small 40 million COVAX deal reached with Pfizer, which had been announced on Friday. The European Union has reserved 600 million doses, with the US securing 200 million.

Alyward said the small number was “a start”, but that the Pfizer vaccine was already recommended by WHO “so this could be launched very, very rapidly and earlier possibly than some of the other products”.

45 out of 50 of the countries rolling out COVID-19 vaccines are using the Pfizer vaccine.

“45 out of 50 of the countries rolling out vaccines are using the Pfizer vaccine,” said Aylward. “Even with a relatively small number of doses …  it was clear that we could make a real difference in protecting some of the most highly exposed, highly at risk health care workers, particularly in some of the [low- and middle-income countries (LMICs)] that the facility serves.

“The other big advantage by putting the framework agreement in place, is that we can then open the door to donations in a much more potentially seamless manner with other countries that currently have contracts with and substantial quantities of the Pfizer vaccine.”

Rapid COVID Tests Ensured For LMICs As Costs Halved

Fragile health systems, remote or decentralised populations, and reliance on global provision in LMICs have created obtrusive barriers to achieving mass rapid testing for SARS-CoV-2.

However, more than 250 million antigen-detecting rapid diagnostic tests (Ag RDTs) will be made available to LMICs for approximately US$2.50 each following a July 2020 call for interest.

The open call for Expressions of Interest (EOI) was launched by Unitaid — a WHO partner — and global nonprofit Foundation for Innovative New Diagnostics (FIND), on behalf of the ACT-Accelerator: WHO’s platform for providing equitable COVID medicines and treatments

Up to 120 million tests will be produced by Premier Medical Corporation, India, in 2021, with a further 130 million tests secured through other, unannounced agreements.

The ACT-Accelerator has estimated that 500 million COVID tests will be needed in LMICs over the next 12 months, with three-quarters necessarily deployed via primary health care.

Image Credits: WHO Afro region, WHO, Pfizer.

Activism against Gender-Based Violence at the National University of Lao, Dong Dok campus. During the pandemic, violence against women had increased by 25% as early as April in countries with formal reporting systems in place.

WHO needs to focus more work on limiting gender-based violence, increase its programmatic emphasis on healthy diets and lifestyles, and contribute to renewed momentum on climate action, said WHO member states at Friday’s Executive Board session.

The member states were reviewing the WHO Director General’s report on “social determinants of health” – in light of the added health impacts of the ongoing global COVID-19 pandemic.

Social determinants of health is a broad umbrella term referring to a range of socio-economic and environmental drivers that can help prevent diseases from ever occurring – or conversely accelerate more disease if neglected. They range from poverty, which can foster more communal violence and addictions, to unhealthy diets leading to malnutrition and obesity, or air pollution that contributes to the development of cardiovascular and respiratory diseases as well as cancers.

COVID-19’s Gender Gap

Amid mounting evidence that the social and economic toll of the COVID-19 pandemic is to being disproportionately paid by women, member states flagged WHO’s need to do more to assist countries’ attempts to limit gender-based violence and discrimination, WHO member states suggested.

A delegate from Kenya highlighted “increased teenage pregnancies, gender-based violence and substance abuse” as results of pandemic related lock-downs and economic stagnation. He called on WHO for an inter-agency plan to support its Member States, as they struggle to mitigate the “severe social shocks of the pandemic”.

A United Nations report, published as early in the pandemic, highlighted that “many women are being forced to ‘lock down’ at home with their abusers” even as support services typically available for victims continue to be “disrupted or made inaccessible”.

That same report flagged that violence against women had increased by 25% in countries with formal reporting systems in place.

Beyond gender-based abuse, the pandemic-related gender impacts also are evident in the greater difficulties when have had accessing healthcare. And the pandemic has exacerbated pre-existing employment inequalities, member states reflected.

“Gender is a key social determinant of health given the impact of gender roles, norms and behaviours, on how people access health services and information,” a delegate from the United Kingdom said. Similarly, gender also determines how health systems respond to individual patients.

With regards to the pandemic, as such, the WHO report staed that the Organization is developing advocacy and engaging with other UN agencies and actors on “on human rights-based approaches” to gender and COVID-19- although it didn’t provide further details.

The report also notes that internally at WHO: “The Gender, Equity and Human Rights team at headquarters and the regional office network are spearheading efforts to mainstream gender issues across the Organization.” In other comments this past week to the EB, Dr Tedros Adhanom Ghebreyesus has noted that while WHO has gender parity among the ranks os its senior management – but male professionals still well outnumber women in certain WHO regional  and country offices – with the most imbalance in the African region.

Diet and Nutrition

During the board meeting, the UK also flagged diet and nutrition as key social determinants: topics scarcely mentioned in the WHO report.

“Healthy diets and malnutrition are an important element of determinants of health,” the delegate said.  “Action is needed to address unhealthy diets and malnutrition in all its forms.”

The WHO report refers to nutrition only vaguely, listing “food insecurity” alongside “poor-quality housing … insecure employment, and poorly regulated care for the elderly” as “examples of social determinants with devastating impacts on individuals and communities affected by COVID-19”.  However, a growing body of evidence, including other recent WHO reports, point to the double burden many low-and middle-income countries are now seeing from undernutrition and malnutrition- the latter related to an over reliance of fast-urbanizing communities on fast or processed foods, cheap starches, and sugar-  and fat-heavy diets.

Despite arguments that addressing diet would help to improve health outcomes and prevent future pandemics, the WHO report on social determinants of health scarcely mentioned nutrition.

Those forms of malnutrition – leading to micronutrient deficiencies as well as to obesity –  are responsible for a significant portion of the Global Burden of Disease, the UK delegate said.  He reminded the EB that “obesity has shown to significantly increase the severity of COVID-19”.

Meaningfully addressing poor diet, the UK argued, would help to improve health outcomes and enter future pandemics better prepared.

The Climate Crisis & Biodiversity

In the decade before the pandemic, awareness of the health impacts of climate change and loss of biological diversity were growing global health concerns, including at WHO. But the sudden and overwhelming emergence of SARS-CoV-2, however, has meant climate-related health policy has mostly been left to stagnate, some delegates observed.

Pedestrians in Bangladesh cover their faces to keep from breathing in dust and smog. Despite significant advancements before the pandemic, environmental health has largely taken a back seat in policymaking.

While there have been a few significant steps made since the first COVID-19 death — such as the UN including climate measures on its Human Development Report, or the UK registering the first death due to air pollution — there is evidence that the pandemic has led national health ministers to push  environmental health risks to the background of their agendas.

This is despite the fact that environmental risks, notably from air pollution, also contribute directly to more chronic cardiovascular and respiratory health conditions, and thus more COVID-related deaths.

The WHO report acknowledges this, indirectly, stating that “increasing urbanization and climate change risk [as] entrenching existing inequalities and further widening the gap in health outcomes”.

However, delegates noted that more attention needs to be given to the routes by which climate change, biodiversity loss and urbanization are contributing to ill health during the pandemic – as well as increasing future pandemic risks.

In the case of SARS-CoV2, for instance, while the exact route by which the virus reached Wuhan and its seafood market where the first human clusters of infection appeared, most scientists agree that the virus hails from a bat coronavirus that leaped the species barrier. In the past, that has happened when wild animals are hunted, captured, caged, transported and sold alive in crowded urban food markets across Asia.

Similar leaps of animal diseases to humans have led to the rise of Ebola and HIV in Africa, where the capture and consumption of  wild animals as “bushmeat” is a traditional practice that became even more common in conditions of conflict and food insecurity, where wildlife areas also are more vulnerable to poaching and plunder by black marketeers.

“The [COVID-19] crisis we are facing is not only a health crisis, but also a social and economic crisis,” the Austrian delegate told the board. But, vitally, she added that “it cannot be fully understood without considering the ongoing ecological crisis.”

“The poorest and most vulnerable have been disproportionately hit,” she said, “and further action to foster health equity and moving beyond the health sector is urgently needed.”

This was also underlined by the UK delegate, who stated it “will also welcome more attention on to the impact of climate change both on people’s health and on national health systems”.

Image Credits: DANHO/Daniel Hodgso, Sven Petersen/Flickr, Rashed Shumon.