Immunization programs ssuspended by COVID lockdowns have resulted in an increase in vaccine-derived polio cases in Africa.

Africa’s COVID-19 rollout is anticipated for Spring 2021, despite the continent’s low vaccine preparedness, multiple health leaders in Africa have said, as policy advisory groups flag the importance that other successful immunization campaigns will have on COVID recovery.

At a press briefing on Thursday, Dr. John Nkengasong, Director of Africa CDC, said: “Africa may have to wait until the second quarter of 2021 to roll-out COVID-19 vaccines. I have seen how Africa is neglected when drugs are available in the past.” The sentiment was echoed by WHO Regional Director for Africa Matshidiso Moeti, who specified an anticipated March roll-out.

The statements follow calls made by the African Regional Immunization Technical Advisory Group (RITAG) for countries to urgently resume routine and catch-up immunization services, while adhering to strict COVID-19 prevention protocols.

When African countries began to lockdown at the beginning of the pandemic, critical vaccination programs for diseases like polio were suspended for several months. Since the countries began reopening, governments have taken steps to undo the impact the pandemic has had on these campaigns, but the months-long interlude to routine immunizations has left its mark. While Africa was declared wild polio-free in August 2020, vaccine-derived polio cases have increased.

“Collective action to strengthen immunization is needed, now more than ever, as we approach the end of the Decade of Vaccines and COVID-19 limits access to essential health services across Africa,” said Professor Helen Rees, Chair of the RITAG, which is the principal advisory group to the WHO on regional immunization policies and programmes

Resuming routine vaccination could help countries prepare their systems for immunizing adult populations with up-and-coming COVID-19 vaccines.

Currently, African vaccine preparedness appears to be low, warned a WHO group on Thursday – which evaluated self-assessment of vaccine readiness levels in 40 of the region’s 47 countries, only to find that average readiness was only about 33% – in comparison to the WHO benchmark of 80%.

Through COVAX – a program aiming to accelerate the development of COVID-19 vaccines – Africa will be able to access vaccines for up to 20% of its population but at the outset, early dose will only reach about 3% of the population : namely, health workers and the elderly.

Nkengasong added that the continent needs to provide vaccine access to up to 60% of its population before it can achieve herd immunity indicating that additional funding needs to be arranged to extend COVID-19 vaccine coverage in Africa beyond what the continent would get through COVAX. He put the cost at up to US$12 billion.

How COVID-19 has impacted immunisation in Africa

Africa has a regional immunization target of 90% but in 2019, immunization coverage in the region stagnated at 74% for the third dose of the diphtheria-tetanus-pertussis containing-vaccine (DTP3), and at 69% for the first dose of the measles vaccine. WHO and its partners had hoped there would be improvement in 2020.

Moeti stressed that pre-existing gaps in immunisation coverage have been exacerbated in 2020 by the COVID-19 pandemic, putting millions of children at risk for deadly diseases.

An additional 1.37 million children across the African region missed the Bacille Calmette-Guerin (BCG) vaccine which protects against tuberculosis, and an extra 1.32 million children below the age of one missed their first dose of measles vaccine between January and August 2020, when compared with the same period in 2019, WHO said in a statement.

Moreover, immunization campaigns covering measles, yellow fever, polio and other diseases have been postponed in at least 15 African countries in 2020.

“Current outbreaks of vaccine-preventable diseases are an apt reminder of the work that remains to be done,” said Dr. Richard Mihigo, Programme Manager for Vaccine-Preventable Diseases at the WHO Regional Office for Africa. “How we respond to these outbreaks amid the COVID-19 pandemic will be critical to protecting children and communities, and to preventing further disease outbreaks.”

Image Credits: WHO, United Nations Photo.

Young school girls organize themselves before the March to End Gender-Based Violence in Dar es Salaam, Tanzania.  One sign reads: “Refrain from using abusive language for Women and Children”.

Violence against women and girls has been neglected during and worsened by the COVID-19 pandemic, and urgent efforts are needed to protect women, UNAIDS has said.

One in three women likely to experience violence at least once in their lifetime. Evidence indicates that the COVID-19 pandemic has resulted in significant increases in gender-based violence in nearly all countries.

Speaking on International Day for the Elimination of Violence Against Women, 25 November, UNAIDS called for urgent efforts for nations to improve or follow-through on neglected health services and outreach programmes to support victimes of violence or abuse.

“The growing evidence confirms that the impacts of the COVID-19 pandemic are not gender-neutral,” said Winnie Byanyima, UNAIDS Executive Director. “The impacts of lockdowns and travel restrictions imposed in many countries to curb the spread of the COVID-19 pandemic, the failure to designate sexual and reproductive health services and services for survivors of violence as essential services, and the undermining of women’s economic security have compounded the barriers for women and girls experiencing abuse, especially those who are trapped at home with their abusers.”

Ending violence against women is everyone’s business, and it is possible to make a difference during the 16 days of Activism against Gender-Based Violence

The pandemic has both amplified violence against women, as well as currently existing gender inequalities, a panel of representatives from various ministries of health said. Service providers, representing Spain, Argentina, India and Iraq, discussed how their countries have implemented strategies to combat violence against women, including actively searching for cases of violence in COVID-19 patients, improving connectivity between victims and authorities, and creating outreach services.

Argentina – Actively Assisting Victims of Violence Who Do Not Come Forward

Argentina has implemented a program that actively searches out COVID-19 patients in their homes and social circles for cases of gender-based violence, as lockdown measures designed to curb the COVID-19 pandemic have made made it harder to connect with victims.

The country has focused its approach on implementing preventative measures to protect potential victims from future abuse, and has expanded its response to protect LGBTQ+ people. It has also made its sexual and reproductive health services more accessible, with non-discriminatory policies established. There has still been an increase in femicides between January and November, however, with 265 women murdered this year.

“We have learned during this long pandemic that we have to adjust our current mechanisms in place to defend women and combat gender-based violence,” said Argentina Minister of Health Dr. Gines Gonzalez Garcia. Garcia addressed the significant changes that have come with the pandemic – in people’s behaviors and emotional states. Economic changes especially can increase violence against women, and has stated that “there is still more to be done.”

Young Syrian refugees performed a silent play on the importance of education in preventing early marriage in the UN Women-led ‘Women and Girls Oasis’ in District 4 of the Za’atari refugee camp (Jordan) on the occasion of the 16 Days of Activism Against Gender Violence campaign 2015.
Iraq – Addressing the Connection Between Health Emergencies and Gender-Based Violence

Iraq’s Ministry of Health has drafted human rights strategies and action plans to provide protective maternal, newborn, and child and adolescent health policies related to the pandemic. It has also developed education and communication materials and is assessing care provided for gender-based violence during the pandemic.

“COVID-19 showed us the link between health emergencies and gender-based violence,” said Dr. Riyadh Adbul Ameer Alhifi, of the Iraq Ministry of Health, noting that the role of the health system is to address both issues, with many survivors during the pandemic seeking mental health and psychosocial support.

Iraq saw high levels of domestic violence even before the pandemic, and the number has only risen since. At least 46% of married women are exposed to at least one form of spousal abuse, and 57% of them to domestic violence. Gender-based violence is also rooted in child marriages, with 20% of girls aged 15-19, and 5.5% of girls under the age of 15.

“It is important that gender-based violence services are included in the list of essential health services, and health facilities are equipped to properly answer survivors’ emotional, physical, and practical needs.”

Riyadh discussed the need to strengthen the referral system for gender-based violence survivors within the health system, and the need to address the social traditions and beliefs that perpetuate this violence. If these issues are not addressed, this will remain confined to the Ministry of Health – services will not improve and the number of victims will increase.

“Violence against women connot be reduced unless those beliefs and traditions change. This needs a great force in which all sectors in the country must contribute.”

Orange the World 2018 – Uganda
Ugandan police joined with UN Women Uganda, UN in Uganda & SafeBoda for a safe ride to mark the 16 Days Of Activism under the theme ‘Safe ride to end violence against women and girls’. Over 300 boda riders and other participants took part in the activity.
Spain – Facilitating Communication Through Technology and Pharmacies

Spain’s gender-based violance helpline has observed nearly 30,000 requests for assistance during the pandemic: an increase of nearly 60% from 2019. Emotional and psychological assistance against gender-based violence, which was devliered via WhatsApp during the strictest period of lockdown, received 2,500 requests. This service ended in June, when in-person services could be provided again.

As a result, Spain has established a contingency plan against gender-based violence with the Ministry of Equality, following the declaration of a state of emergency. These were strategic measures designed to help, prevent, control, and minimize the negative consequences for many victims of gender violence. While health laws in Spain allow for diagnosis and care for people suffering from violence in both primary and specialized health services, it is a common problem that seriously impacts health, said Dr. Pilar Apracio, Director of the National School of Public Health in Spain.

The government of Spain has taken measures to prevent femicide, facilitating connections through telephone and internet. A network in pharmacies has also been created that allows women who go into pharmacies to contact the pharmacist, connecting the pharmacy to the helpline and authorities.

Added Apracio: “If you facilitate the communication, this contributes to solving problems women have to face in gender violence situations.”

The second wave of COVID-19 indicates the possibility that there will once more be an increase of physical violence in the new phase of the pandemic, and people have been urged to not let their guard down against gender-based violence.

Activism against Gender-Based Violence at the National University of Lao, Dong Dok campus
India – Health Experts Ensuring Safety for Victims of Gender-Based Violence

India has seen a decrease in incidence of domestic and sexual violence reported, due to a lack of transportation during lockdown and fear of contracting COVID-19. The severity of the cases of those victims who have come forward, however, has increased.

The Government Medical College and Hospital Aurangabad has created a section of the hospital for victims of sexual violence, where experts such as gynecologists, pediactricians, surgeons, forensic specialists, and psychiatrists are on staff to console and treat victims. A shelter has also been created in the medical college admission ward to ensure the safety of its patients.

Dr. Shrinivas Gadappa of the Government Medical College brought up the importance of training practitioners to recognize the signs of gender-based violence, especially in the primary healthcare system, citing difficulty in screening for both domestic violence and COVID-19, and called it a “loophole in this pandemic”.

Workshops to train practitioners is very important in increasing sensitivity towards and awareness of gender-based violence, Gadappa added. Primary health care centers should be strengthened to deal with such cases during the pandemic which will, in turn, increase the amount of women reporting instances of violence, he said.

WHO Director General Dr Tedros Adhanom Ghebreyesus, in a final statement, said that countries need to increase accessibility to healthcare that aids women affected by violence, implementing it as an essential service, as well as offering more resources towards training health professionals on how to identify women experiencing abuse, and how to provide first line support.

“All women have the right to live free of violence and coercion, working together, we can build gender responsive, health and social protection systems to keep all women safer and healthier.”

Image Credits: UN Women Tanzania/Deepika Nath, UN Women, UN Women, UN Women/ Martin Ninsiima, DANHO/Daniel Hodgso.

Nairobi.  Africa’s limited cold-chain capacity will constrain the continent’s ability to take up the more cutting-edge Pfizer and Moderna vaccines that are likely to win approval first from regulatory authorities, said WHO’s African Regional Director Dr Matshidiso Moeti on Thursday.

Those same constraints make the AstraZeneca (AZD1222) vaccine the most attractive option, despite its lower efficacy results, so far, which has averaged about 70 %, Moeti observed in a press briefing on Africa’s vaccine preparedness. 

WHO’s African Regional Director Dr Matshidiso Moeti

“The latter vaccine is much better and easier to handle with storage required…  unlike the Pfizer vaccine that would pose a big challenge with distribution,” Moeti said, referring to the ultra-freeze conditions at  -70° C that the mRNA-based vaccine candidate, Pfizer requires. Moderna’s vaccines can be stored at more moderate freezer temperatures of 2-4° C. In contrast, the AstraZeneca vaccine, which relies up an older, adenovirus delivery technology, only requires refrigerator temperatures of 2-8° C.   

“In any case at an efficacy rate of 70% the AstraZeneca vaccine is still good enough,” she added. Most regulatory authorities have said even a bar of 60% efficacy would be acceptable to clear the way for new COVID vaccines. 

Shortly after she spoke, AstraZeneca’s CEO Pascal Soriot told Bloomberg News that the company would run a fresh global trial to test a dosing option that seems to attain much higher, 90% efficacy levels. The higher results were in one arm of the trial already under way in the United Kingdom, the USA, and Brazil, after a serendipitous under-dosing of one group of volunteers under the age of 55 was found to yield better interim results than the 70% average.  

“Now that we’ve found what looks like a better efficacy, we have to validate this, so we need to do an additional study,” Soriot was quoted as saying. Based on its existing results, however, Soriot said that he is also optimistic that AstraZeneca, which co-developed its vaccine with Oxford University, will remain on track to obtain regulatory approval for the vaccine in the United Kingdom and Europe by the end of the year. 

Due to its low cost and modest cold chain requirements, AstraZeneca is expected to be one of the main vaccines to be supplied to many low and middle income countries, including through the COVAX facility global vaccine procurement and distribution facility, co-led by WHO and the Global Vaccines Alliance (GAVI). COVAX aims to support the vaccination of up to 20% of Africa’s population against the SARS-CoV virus by the end of 2021, Moeti said. But doing so is highly dependent on the rollout of cheap and accessible vaccines. 

Under the plans of the COVAX facility, an initial 3% of Africa’s population – mainly health workers and the elderly will be immunized, with hoped for coverage of  20% of the population by the end of 2021, said Moeti.  Following that, Africa Centres for Disease Control (CDC) has said that it will lead another effort that will aim to vaccinate up to 60 % of the population, revealed Dr Moeti.

She added: “the COVAX vaccine will be highly subsidized thanks to donor contributions and will ensure Africa gets vaccines at the same time as everybody else”.

COVAX aims to support the vaccination of up to 20% of Africa’s population against the SARS-CoV virus by the end of 2021
African Vaccine Preparedness – Rates 33% 

Beyond cold chain limitations, Africa’s overall preparedness for COVID-19 immunisation campaigns is low, Moeti said.  She referred to a recent WHO assessment that ranked the countries’ average readiness at only about 33%, significantly lower than the WHO benchmark of 80%, Moeti said at the briefing, where a WHO assessment of the continents “vaccine readiness” was presented.

The low level of readiness is worrying, given that the continent hopes to commence administering vaccines for the disease toward March, 2021, she said. 

The WHO evaluation was based on national vaccine preparedness surveys performed by 40 out of the 47 countries in the WHO Africa Region. The national self-assessments evaluate vaccine country readiness based upon  10 key sets of indicators, including:  planning and coordination, resources and funding, vaccine regulations, service delivery, training and supervision, monitoring and evaluation, vaccine logistics, vaccine safety and surveillance, communications and community engagement.

After seeing the results of the surveys,  WHO held a meeting with ministers of health from across the continent two days ago, to brief them on the urgent need to up their preparedness levels, to ensure Africa was not left out of the global vaccination drive.

“At WHO, we are supporting countries to increase their preparedness levels and we will do everything possible to ensure Africa is not left out of COVID-19 vaccination initiative,” Dr Moeti told a press briefing on Thursday.

“We can say that we are far from getting there, each pillar has a different average that is supposed to be achieved before we can safely deploy vaccines and reach a maximum number of people,” said Dr Richard Mihigo, a WHO Immunization and Vaccine Development officer, at the briefing. 

While cold storage capacity remains a big concern, countries can still rely upon pre-existing infrastructure – built over decades of vaccine campaigns – for vaccine cold storage. WHO is working with governments to support countries fill “cold chain gaps” before the exercise started, he said without providing details.

Information Campaign Also Needed 

Along with that, a systematic media campaign needs to accompany the vaccine drive, to counter misinformation already appearing in social media, said Professor Helen Rees, Executive Director, Wits Reproductive Health and HIV Institute at the University of the Witwatersrand, South Africa.

Recent studies in South Africa have indicated that different socio-economic groups have different perceptions towards vaccines, with men generally less willing to be immunized, and educated members of the society being more willing, she offered. On the other hand, young people feel less vulnerable to the disease like their counterparts around the world, she added.

“For these reasons we need to develop different messages for different groups and be transparent with what we know about the vaccines. For example we need to explain why a vaccine prioritizes group ‘A’ and not group ‘B’, added Rees, who is also the Chairperson of  WHO’s African Regional Immunization Technical Advisory Group (RITAG).

“Vaccines are one of the biggest global health goods we have, and we must ensure they reach as many people as possible,” the professor added.

Ensuring the vaccine reaches as many people as possible can be done through effective media campaigns.
Ongoing Studies Needed To Determine Which Vaccines Are Best For Africa

It was important to have ongoing studies on available vaccines even as vaccinations begin, to see how they respond to the “African situation” said  Professor Pontiano Kaleebu, director Uganda Virus Research Institute (UVRI).

Currently some of the COVID vaccines in various stages of clinical trial appear to be more effective in preventing development of severe disease, while others seem to offer better protection against infection in the first place. 

The latter would be more desirable, over time,  especially in Africa, where more of the cases are mild, he said. He echoed the sentiments of Moeti, that overall, the Pfizer vaccine is untuiable for African conditions, noting that even laboratories have trouble handling samples that need storage at -70 C.

So far Africa is the continent with the fewest infections — around 2.1 million cases and 50,000 deaths. More than 84 % of the infections have been mild or asymptomatic. It has also participated in the fewest number of trials for both drugs and vaccines. Although one major multi-country African trial of COVID-19 drug treatments, supported by the Drugs for Neglected Diseases Initiative (DNDi), just got underway this week

Image Credits: Twitter: @WHO, WHO, Jernej Furman/Flickr, CDC Global/Flickr.

Shelters in Central America overcrowded by hurricane evacuees have increased risk of COVID-19 transmission

New York City. The pandemic has been exacerbated by recent hurricanes in Central America, as a result of outbreaks in overcrowded emergency shelters, as well as travel during the American Thanksgiving season, health leaders said at a Pan American Health Organization (PAHO) press conference.

Last week, saw an increase of 1.5 million cases reported in the WHO “Americas” region, mostly in the USA where new cases are now averaging close to 180,000 a day, but also with climbing numbers in vulnerable populations and among indigenous communities in Central America, who are especially vulnerable due to their remote location and the challenge of access to the health infrastructure.

“Since the start of the pandemic, there have been more than 25 million cases and more than 700,000 deaths due to COVID-19 in the Americas,” said Dr. Jarbas Barbosa, Assistant Director at PAHO.

Back-to-Back Hurricanes Impact Pandemic Response in Central America

Central America’s pandemic surveillance system has been greatly impacted by recent hurricanes Eta and Iota. The number of cases reported has dropped dramatically in Honduras and Nicaragua, which have seen approximately 640 testing centres and other facilities hit by the hurricanes, which have affected more than 8 million people, also leading to widespread evacuations to hurricane shelters. 653,000 people have been evacuated in the region. The Caribbean, Guatemala, and El Salvador have also been similarly impacted.

“Shelters organized to host thousands of people in these countries do not necessarily have the conditions to prevent transmission from COVID-19,” said Dr Ciro Ugarte, Director of Health Emergencies. “This creates a very challenging situation.”

Decreased reporting of cases following Hurricanes Iota and Eta.

In Central America, hospitals and shelters have reported a lack of care personnel and capacity – increasing the risk of transmission of disease – as already vulnerable populations, like the elderly, have been left with limited or no access to healthcare. The region has also seen decreased water and sanitation services, making it difficult to maintain infection, prevention, and control efforts: all important in preventing the spread of waterborne and other communicable diseases like COVID-19. Collapsed roads have also prevented timely humanitarian response.

Ugarte noted at the PAHO conference that the health sector, supported by PAHO and other international NGOS, have been assisting assessment as well as emergency response.

Holiday Season Brings Good News of Promising COVID Vaccines but also Increased Transmission Risk

While Central America is facing increased transmission from a damaged healthcare infrastructure, there is another source also driving increased disease transmission and that is traveling and family gatherings during the holiday season, which began with Thanksgiving celebrations in Canada and this weekend in the United States.

“During an epidemic there is no such thing as a risk free holiday season. Every gathering, every shopping trip, every travel plan, you increase the chance of spreading the virus,” Dr Barbosa warned, advising against large social gatherings, especially indoors. He recommended that any gatherings be held in well-ventilated areas, with masks, or outdoors, and if that is not feasible postponed entirely.

The US CDC also has issued stiff warnings against travel and mixing between households. But on Thursday the United States Supreme Court also issued a stiff blow to authorities’ attempts to curb religious mass gatherings that can be superspreader events. The Court on Thursday ruled that limits which had been imposed by the City of New York on the number of people gathering in churches, mosques and synagogues – were unconstitutional because they impinged on people’s freedom of worship.

Travel Not Risk-Free Even With a COVID Test

Speakers also flagged that many people falsely assume that being tested means safe travels, free of infection. Testing often leads travelers into a false sense of security, as it does not guarantee risk of infection is eliminated. Countries must continually use data on the spread of the virus to reassess their travel guidance to make travel safer, they said.

Although November saw announcements of the very positive interim efficacy results of several potential vaccine candidates announced, with vaccine candidates produced by Pfizer and possibly Moderna, in line for emergency use approval by the US FDA by mid- or end of December, PAHO officials warned that vaccines are still some months off, in terms of reaching the general public.

“Unfortunately, we will not have enough vaccines to vaccinate everyone and stop the transmission,” Barbosa said. Once the vaccine is released, however, its use is still recommended in order to save lives. Achieving herd immunity, in theory, would only be possible if a population reached a threshold of 60-70% immunity, either through natural infection or vaccination.

The total number of confirmed vaccine doses procured, displayed by income level.

Even in the US, which has amassed the largest stock in the world of pre-purchased vaccine supplies from Pfizer, Moderna and others, it is yet to be determined who will be vaccinated first. In addition, officials are concerned about public resistance to vaccines. The most recent US poll showed 51% of people were inclined to be vaccinated, and while that is an increase from previously, it is still far lower than the 90% levels that would need to be achieved.

A much stronger public information effort needs to be undertaken to inform people about the personal and community-level benefits of vaccination against COVID-19, PAHO officials said. And more awareness raising needs to be done to inform the public of how the virus can be transmitted, particularly during the holidays.

Barbosa noted: “The individual decisions we make this holiday season affect the people closest to us. They will also impact our communities. Solidarity has been our region’s response to COVID-19. [Solidarity] is more important than ever, during the holidays.”

Image Credits: PAHO, Duke Global Health Innovation Center.

Winnie Byanyima, Executive Director of UNAIDS.

Far greater investment in global pandemic response is required to ensure that core public health initiatives, like AIDS prevention and treatment aren’t thrown off course by future pandemics, while roll-out of a cheap and accessible “People’s Vaccine” would help get other core public health programmes quickly back on track, UNAIDS has said.

In a message at the launch of the annual World AIDS Day report, Prevailing against pandemics by putting people at the centre, UNAIDS Executive Director Winnie Byanyima also called on the global pharma industry to unlock the secrets to their COVID-19 vaccine technologies to produce a cheap and accessible “People’s Vaccine”.

“Even today, more than 12 million people are still waiting to get on HIV treatment and 1.7 million people became infected with HIV in 2019 because they could not access essential services, said the UNAIDS head in her message. “That is why UNAIDS has been a leading advocate for a People’s Vaccine against the coronavirus. Global problems need global solidarity.

“As the first COVID-19 vaccine candidates have proven effective and safe, there is hope that more will follow, but there are serious threats to ensuring equitable access,” she said. “We are calling on companies to openly share their technology and know-how and to wave their intellectual property rights so that the world can produce the successful vaccines at the huge scale and speed required to protect everyone and so that we can get the global economy back on track.”

Byanyima’s comments followed upon her open letter to the The Financial Times, and published Thursday, which said that media coverage of fast-moving vaccine research has too often ignored “the fundamental problem of the failure of pharmaceutical firms to openly share their technologyand knowhow, and waive their intellectual property rights.

“The Pfizer/BioNtech and Moderna vaccines have received millions in public money, from the US and EU to develop these vaccines,” Byanyima added in her letter, referring to the two companies most likely to win regulatory approval in the next few weeks for the first vaccines against COVID to show efficacy, but which rely upon expensive mRNA technologies that are out of the price range of low- and middle-income countries.

“These vaccines are not private property to be sold for a profit, but public property to be mass produced for the global common good. We would urge all corporations to join the World Health Organization’s Covid technology access pool (C-TAP) and for their rich country backers to insist that they do so, given the huge public subsidy they have received. Only this will enable every vaccine producer in the world to manufacture on the huge scale required to protect everyone, and get our global economy back on track. We cannot let this be a profit vaccine; it must be a peoples’ vaccine,” Byanyima wrote in the FT letter.

Weak Health Systems Left World Unprepared For COVID

The UNAIDS report notes how insufficient investment and action on HIV and other pandemics left the world exposed to COVID-19. State UNAIDS: “Had health systems and social safety nets been even stronger, the world would have been better positioned to slow the spread of COVID-19 and withstand its impact. COVID-19 has shown that investments in health save lives but also provide a foundation for strong economies. Health and HIV programmes must be fully funded, both in times of plenty and in times of economic crisis.”

“The collective failure to invest sufficiently in comprehensive, rights-based, people-centred HIV responses has come at a terrible price,” Byanyima also said. “Implementing just the most politically palatable programmes will not turn the tide against COVID-19 or end AIDS. To get the global response back on track will require putting people first and tackling the inequalities on which epidemics thrive.”

There are bright spots nonetheless, the UNAIDS report notes: “The leadership, infrastructure and lessons of the HIV response are being leveraged to fight COVID-19. The HIV response has helped to ensure the continuity of services in the face of extraordinary challenges. The response by communities against COVID-19 has shown what can be achieved by working together.

But the Organization warned that countries risk repeating the “mistakes” of the early days of HIV response – when millions of people in Africa died as a result of being unable to access expensive new antiretroviral drug treatments that were being rolled out in developed countries:

“The world must learn from the mistakes of the HIV response, when millions in developing countries died waiting for treatment. Even today, more than 12 million people still do not have access to HIV treatment and 1.7 million people became infected with HIV in 2019 because they did not have access to essential HIV services,” said the statement.

“Everyone has a right to health, which is why UNAIDS has been a leading advocate for a People’s Vaccine against COVID-19. Promising COVID-19 vaccines are emerging, but we must ensure that they are not the privilege of the rich. Therefore, UNAIDS and partners are calling on pharmaceutical companies to openly share their technology and know-how and to wave their intellectual property rights so that the world can produce successful vaccines at the huge scale and speed required to protect everyone.”

When asked at a press conference on Thursday about how young people will be considered in this startegy, she flagged that the risks posing young people today are different to those experienced by young people at the start of the AIDS crisis.

“The HIV pandemic is in its second – even third – generation, and the attitudes toward the disease each geneeration keep changing,” she said, citing that Uganda’s younger generation as viewing the disease as “just a chronic illness, like diabetes or hypertension”.

“They have no sense that it kills. They think you just live with it because they never saw the deaths,” she added. “I saw the deaths.” Young people today, in countries with a high number of cases are made more vulnerable by this lack of education, she said.

Countries Falling Way Behind – New 2025 Targets for Getting Back on Track

Modelling of the pandemic’s long-term impact on the HIV response shows that there could be up to 293,000 additional new HIV infections and up to 148,000 additional AIDS-related deaths between by 2022, the new UNAIDS report finds.In its latest report UNAIDS outlined a series of new targets for reducing HIV infections by 2025  – aimed at  getting progress that was admittedly already “off track before the COVID-19 pandemic hit” – back on the rails.

New HIV/AIDS treatment targets set out in the report aim at achieving a 95% coverage for each sub-group of people living with and at increased risk of HIV. By taking a person-centred approach and focusing on the hotspots, countries will be better placed to control their epidemics.

The targets  also focus on a high coverage of HIV and reproductive and sexual health services together with the removal of punitive laws and policies and on reducing stigma and discrimination. They focus on people most at risk and marginalized— including young women and girls, adolescents, sex workers, transgender people, people who inject drugs and gay men and other men who have sex with men.

And the 2025 targets also include the promotion of more ambitious anti-discrimination laws and policies – so that less than 10% of countries have punitive laws and policies vis a vis people living with HIV; less than 10% of people living with and affected by HIV experience stigma and discrimination; and less than 10% experience gender inequality and violence.

Although some countries in sub-Saharan Africa, such as Botswana and Eswatini, have achieved or even exceeded the targets set for 2020, many more countries are falling way behind, the Organization also noted, stating that nonetheless. “The high-performing countries have created a path for others to follow.”

 

Image Credits: UNAIDS.

A sweeping proposal by South Africa and India to suspend the protection of intellectual property (IP) related to COVID-19 health products was presented to the World Trade Organization’s TRIPS Council in October.

South Africa is campaigning for the World Trade Organization (WTO) to waiver intellectual property rights on all products related to COVID-19 for the duration of the pandemic. Mustaqeem De Gama, Counsellor at the South African Permanent Mission in Geneva, is leading the campaign. Kerry Cullinan and Elaine Fletcher spoke to him about the reasons why he sees the WTO initiative as central to efforts to get COVID treatments and vaccines to people worldwide.

 

Health Policy Watch: What kind of support do you have for the waiver proposal, which was discussed at WTO TRIPS Council on Friday? Other than India, it seems that mostly smaller countries support it.

Mustaqeem De Gama: From our consultations, we have a feeling that we have majority support for this proposal. You can actually see it from what happened in the first meeting of the TRIPS Council where we had introduced the proposal on 16 October. There were about 40 interventions. At least 30 to 31 were positive, while 9 said they could not support this. About 12 or 13 countries have no condition on their support, 15 or 16 countries support the waiver but have a few questions, and then the third group said that they could not support our idea.

We also had statements from the African Group, the Least Developed Countries group, and from the Africa-Caribbean-Pacific Group, all favourably disposed to the proposal. I haven’t done a headcount, but I think a big proportion of the 164 member countries would be in support of this proposal.

Mustaqeem De Gama, Counsellor at South African Permanent Mission in Geneva.
HPW: The ball game seems to flip back and forth between the WTO and the COVAX initiative: between the WTO, and big philanthropy, donor-driven models like Bill Gates – which funds a lot of vaccines at accessible prices and pharma agreements for the creation of voluntary licenses for vaccines with generic manufacturers – which gives countries the option to act at national level.

MDG: We are happy to work within the confines of multilateral approaches with, for instance, the ACT Accelerator [Access to COVID-19 Tools (ACT) Accelerator], its vaccine access arm, COVAX, and the COVID-19 Technology Access Pool (C-TAP).

What our waiver proposal says is: let’s make available any drug, vaccine or technology that will help everyone to deal with COVID-19. So from that perspective, the COVAX initiative that could make available vaccines to low and middle-income countries, is welcomed. COVAX is a good start however it is not a long-term solution.

We are also able to work with voluntary licenses given by companies such as AstraZeneca.

Every little bit helps us to achieve the quickest possible access, but these approaches do not result in ramping up the production capacity. They are limited to only a handful of producers.

Look at the volume projections of the Pfizer vaccine for example: 50 million doses before the end of this year and 1.5 billion by the end of next year, with pre-order purchases that have already been put in by rich countries. Even if countries such as South Africa, which self-fund under COVAX, were to try to purchase this vaccine in the open market, there’s no guarantee we could get access to enough within the timelines required to establish effective access.

We are confronted with a situation where, even if COVAX could procure large volumes, there would not be enough vaccines to cover a substantial part of the population. It is projected that, for low- and middle-income countries, only 20% of the population will be covered. But this is not even feasible now, given various issues that have arisen, such as a two-dose regimen. This is now becoming the standard and it effectively halves the number of people who can be vaccinated. There will be limited benefits for the developing world that has limited ability to pre-purchase vaccines.

By the end of 2021, COVAX could possibly come to an end. From that point of view, we think that’s the shortcoming of institutions that are run on the basis of gifting or philanthropy. They are not effective long-term mechanisms because these only have a short-term time horizon. It’s a good idea in principle but is hampered by funding problems and issues around transparency.

Our waiver proposal is supportive of these processes, but we don’t think that they go far enough. Every country should be in a position to take control of the public health challenges that it faces.

HPW: What emerged from the meeting last Friday in the TRIPS Council and what are the next steps? Are South Africa and its allies going to ask for a vote on the issue?

MDG: There has been a lot of focus on a vote. But the WTO works on consensus. We don’t have to go to a vote to get an outcome. We feel that this process could benefit from greater political oversight in the WTO General Council, as opposed to the TRIPS Council. We are working on a report to take to the General Council next month for further consideration and discussion. Then we will rely on the General Council to give further direction, including possible recommendations.

We are also trying to demystify the proposal and build further support. At last Friday’s meeting, there was a good discussion on core issues, but we ran out of time. So we want to use the next few weeks to reach out to both like-minded and opposing delegations to explain our position, and also build a coalition and consensus among like-minded groups.

We want the WTO to show that it is part of the solution to COVID-19, and not part of the problem. This is an organisation that has competence in trade-related matters: this is where intellectual property rights come in. There is a powerful role for the WTO to play to ensure that everyone has access to what they need to try and address the epidemic, whether it is in prevention, diagnosis or treatment.

Africa has so far managed the COVID-19 pandemic exceptionally well, with only an estimated 4% of the world’s cases, but a resurgence of infections being seen right now underlines the fact that the continent is not immune. Ensuring equtiable access to vaccines is vital.
HPW: Are you open to fine-tuning this waiver, and possibly confining it to vaccines, tests treatments, ventilators and PPE –  a more defined set of  the public goods?

MDG: There are four broad categories of intellectual property rights that we suggest could be suspended for the duration of the pandemic: copyright, industrial designs, patents and undisclosed information.

We think that there are good reasons to suspend them. First, COVID constitutes an international emergency, which is part of the requirements to invoke the waiver in the first place. Secondly, the waiver has a specific scope of application. And thirdly, It should be in place until a vaccination or COVID is largely defeated, that is it applies only for a limited time period.

HPW: Are you saying that the problems go beyond patents to also include “trade secrets”, copyright and industrial designs? Can you explain why these are important right now?

MDG: Currently, a lot of patents require disclosure of information when they are filed. Companies get a monopoly if they disclose the ‘new thing’ that they did, and for that they get the right to a 20-year patent, for example.

But many companies are not doing that anymore or rely on other modes of protection. They are going the “trade secret” route – which is a separate category under the TRIPS agreement. In the last four or five years, we’ve seen most industrialised countries upgrade these aspects of their laws that are not necessarily included in the patent application. For example, what doses and combinations work could be considered trade secrets and hence protected. The same applies to test data, medical formulas, in the case of vaccines and other biological medicines: cell lines and genomic information can be held as trade secrets.

There is very limited experience in dealing with trade secrets, I cannot think of any publicly available information where a national authority would have issued a compulsory licence to enable a local manufacturer to produce a product that is covered by a “trade secret”, and the same could be said for industrial designs or copyright. We have to remember that copyright also protects databases, compilations, algorithms and mobile data that can be leveraged for the detection and control of COVID-19. These are novel issues. South Africa requested the TRIPS Council to discuss these issues previously when it submitted a communication entitled: “Beyond Access to Medicines and Medical Technologies Towards a More Holistic Approach to the TRIPS Flexibilities,” dated 17 July 2020, contained in IP/C/W/666.

We have very little experience in how we could apply government measures to force disclosure on some of these if the rules are not clear. So, we thought we should give a little bit of flexibility for things to happen in the interim which would also give governments the ability to access certain types of information in order to scale up production or the address aspects such as detection, prevention and control of the coronavirus.

The proposal has caused a lot of anxiety for many countries, however Mustaqeem De Gama believes there is no need to invalidate half of the TRIPS agreement, as countries fear.
HPW: How will the waiver happen in an orderly and legal fashion? 

MDG: The proposal has caused a lot of anxiety for many countries. They ask if we are saying that we need to invalidate half of the TRIPS agreement. Our answer is a very simple ‘no’. The waiver will be agreed at the level of international commitment and every country will decide on how it wants to benefit from the waiver.

We don’t believe that countries will suspend all the IP rights that are mentioned, nor are they required to do so. They may do it selectively. Some don’t have production capacity but may want to import generic versions of medicines that could be effective, not only for COVID but also for the comorbidities that are associated with COVID. They may import a very narrow range of pharmaceuticals, or they may want to import a vaccine if it is being produced. Other countries may have needs on the diagnostic side. Some countries may have needs in terms of testing, access to buffers, and so forth. The waiver presents a bespoke solution to all countries that need it. If a country decides that it does not need to invoke the waiver, it is free to do so as well.

Countries will have to decide what their greatest needs are and implement the waiver from that perspective. The waiver is not a blank cheque to waive all legitimate IP obligations. That’s why we’ve limited the scope of application to cover on COVID and related products and processes, and left it to the discretion of individual members to invoke aspects that they require.

HPW: But if each country can invoke that part of the waiver that it wants to use, wouldn’t that create a real hodgepodge that undermines an international agreement?

MDG: We have the 2003 waiver decision that creates an exception for countries that don’t have manufacturing capacity, now embedded in Article 31bis of the TRIPS agreement. Countries may invoke this system, known as the paragraph 6 system, however the procedure is fraught with both procedural and substantive hurdles which makes it difficult to use. It has only been used once.

Nonetheless, when this waiver was implemented, certain industrialized countries indicated that they would not use this waiver in any way while other countries said they will only use it in emergency situations. It is no different with this waiver proposal, countries may choose they want to use the waiver and – for transparency purposes – may notify the WTO just as would have been envisaged under the 2003 waiver.

When countries invoke the waiver, the “law of the jungle” will not apply. At a national level, when you issue a compulsory license, there are specific processes that are followed in which the rights of all parties are protected, including the licensor and the licensee. The principle of good faith also applies in this situation.

HPW: You are saying this won’t be the “law of the jungle”. How will that be ensured?

MDG: People are creating this Frankenstein monster about the waiver but this should not be the case. This is an opportunity to have collaborations that will strengthen our ability to deal with future pandemics. The waiver is a short-term solution, it is opening up the possibility for longer-term, more sustainable solutions. We have to build a better system after COVID to ensure resilience in the face of future challenges.

In a pandemic of this nature, it’s unlikely that states will act in bad faith and do things that they are not allowed to do. Once the period for which the license has been granted is over, those rights are fully recovered by the rights holder. But we also believe in the process we could create other avenues for collaboration. It is in our common interest to protect IP, but only to the extent that it respects the balance between rights of holders and the public interest. Thus when such rights are ‘limited’ it is done under conditions of the rule of law and national legal parameters that will ensure that such information is nonetheless protected.

I can’t imagine that my grandmother and her friends will now request the ‘recipe’ for a vaccine, to make it in a kitchen sink. There are only a handful of countries and producers that can do that. The fear of abuse is totally irrational and unfounded.

HPW: AstraZeneca has come out with news that their vaccine is 90% effective, and as well as not requiring freezer storage, that vaccine can be sold at US$3 a dose – isn’t that good news still for low and middle-income countries like South Africa?  

MDG: We have AstraZeneca saying their vaccine is 90% effective, Moderna saying theirs is 95%, and then you have a restatement from Pfizer. There’s no peer review on the exact figures so who is to say that these companies are correct. There is still a way to go with most of these vaccines. We cannot go on the companies’ words. They will have to submit vaccines for regulatory approval. Let’s see whether authorities share the same views as the companies as to the efficacy claim around their vaccines.

We ought also to observe how companies will share data about their vaccines. Will vaccines make less people infectious or will they only prevent severe illness? This is not yet clear from information that companies have made available. Since the SARS-CoV-2 virus accumulates in the upper respiratory tract before causing symptoms, there is the possibility that vaccines will not necessarily prevent people from spreading the virus even if they may be largely immune to the virus. I think there is still a long way to go with COVID-19.

While pricing may be cessional for as long as the pandemic lasts, companies have ultimate discretion on how they will apply these in a highly lucrative market which is estimated to be worth in excess of US$40 billion worldwide. Who will make the decision when the pandemic is over? I think without intervention, profit will prevail over lives.

HPW: What about global production capacity to make a vaccine?

MDG: Many pharmaceutical companies have sold or outsourced their production capacity, including companies such as Moderna and AstraZeneca. This is a problem because they have very little in-house production and are reliant on third-party producers.

This is why they are now licensing to third parties in the developing world, not because they are magnanimous but because they just don’t have the capacity to produce at the rate that is required.

You’ll see more and more of these voluntary licenses, but it’s a throwback to the model that pharmaceutical companies and biotechnology companies would have chosen to advance their agendas. The fact that they entered into these licensing agreements does not indicate it is because they like us: it shows they need us.

HPW: You indicated in your address to the TRIPS Council on Friday that some pharmaceutical companies that had declared that they would operate on a “no profit principle’’, but some of these companies have retained the legal power in their licensing agreements to suspend this principle as early as July 2021. What’s the implication of that?

MDG: Allowing companies to say when the pandemic is over is certainly problematic. The signals of the ‘home country’ is likely to be decisive in such a decision. But as soon as that country declares the pandemic is over in its own territory, companies will invoke provision in  the licensing conditions entitling them to move from no profit to exorbitant profit.

Part of the transparency requirements that we put on the table, asks companies to make available the licensing agreements in full so that we can know what it costs for them to produce their vaccine, as well as disclosing any funding received from governments, whether directly through subsidies or indirect through collaboration with publicly funded institutions. The same logic would apply to disclosure of information regarding the effect of vaccines: how long immunity lasts, whether boosters will be required outside a two dose regimen that frontrunners are signaling. If so, how long? Six months, a year or longer? It’s just too early to tell. COVID-19 seems likely to become endemic.

At present, we don’t even know what the collaboration agreements might mean. Information has emerged of a collaboration agreement with Aspen (a generic manufacturer) in South Africa but we don’t know what the full extent of their license agreement is except to say that 300 million doses will be produced. We are not certain whether some doses will go to South Africa. If so, how many, and what will go to the African continent?

HPW: Why is South Africa one of the countries leading this campaign?

MDG: South Africa’s stance is not new. The country took pharmaceutical manufacturers to court for medicine pricing under President Nelson Mandela’s government, while Dr. Nkosazana Dlamini-Zuma stood accused of trying to steal IP rights because of amendments to health legislation. The positions that we have taken are consistent with the mandates that we have in our Constitution on access to health and the right to life.

Our delegation has raised these issues for at least the last 4 years in the TRIPS Council, but was met with deafening silence. When confronted with issues of access, high pricing, and the unfair competitive practices of pharmaceutical companies, developed countries merely respond that these are not matters for the TRIPS Council and that they should be dealt with somewhere else. But if these matters are raised in the World Health Assemblies, then they say these are IP matters that should not be raised in the World Health Organisation so where should we raise these issues?

 

Mustaqeem de Gama is a Counsellor at the South African Mission in Geneva and is accredited to the WTO and UN. He previously worked at the Department of Trade and Industry in South Africa where he headed the International Trade and Investment Directorate.

Image Credits: WTO, Johns Hopkins University and Medicine.

The Lancet’s Manifesto for Planetary health was one of the first major scientific articles to articulate the concept as a holistic attitude towards life and a philosophy for living.

‘Planetary health’ describes how the limits of natural resources like clean air, water and food production shape our long-term health, with climate change as a “threat-multiplier” for future COVID-19 like crises. Experts at the Geneva Health Forum explored the links, ahead of next week’s launch of the 2020 Lancet Countdown Report on Health and Climate Change.

On Monday 23, US president-elect Joe Biden announced that John Kerry would be his administration’s special climate envoy, indicating that his administration would also rejoin the Paris Climate Agreement.

That represents an about-face in the decision by the outgoing administration of President Donald Trump earlier this month to formally withdraw from the 2015 Paris Agreement. Biden is also expected to rescind outgoing President Donald Trump’s withdrawal from the World Health Organization (WHO) on the day after inauguration – and he has placed tackling COVID-19 among his top priorities.

Climate and Global Health Deeply Interrelated

In fact, as those recent moves might suggest, for policymakers who care about science, climate and global health are deeply interrelated. And in the wake of the pandemic, more and more political leaders from both the developed and developing world are speaking out about the long-term impacts of climate on health – include the prospects that global warming could increase the likelihood of future pandemics.

The concerns have been reflected in a string of recent statements by WHO’s Director General Dr Tedros Adhanom Ghebreyesus, France’s Emmanuel Macron, and other leaders from Europe, Africa, Latin America and the Pacific region at November’s World Health Assembly (WHA), the Paris Peace Forum 2020, and last week’s Geneva Health Forum (GHF). While each forum and speaker may have had different agendas, they agree that climate change poses significant threat to global health.

One key framework for exploring the climate – health connection is ‘’planetary health’’. The concept was discussed in depth in a session at last week’s GHF – ahead of the Lancet Countdown’s launch of it’s 2020 report on health and climate change.

What is planetary health?

The Lancet’s Manifesto for Planetary health was one of the first major scientific articles to articulate the concept, in March 2014 – as a holistic attitude towards life and a philosophy for living.

“It emphasises people, not diseases, and equity, not the creation of unjust societies. We seek to minimise differences in health according to wealth, education, gender, and place,” Richard Horton and co-authors wrote. “We support knowledge as one source of social transformation, and the right to realise, progressively, the highest attainable levels of health and wellbeing.”

The Lancet Countdown reported 220 million heatwave exposures affecting vulnerable populations in 2018.

According to the Planetary Health Alliance, the field is focused on characterizing the health impacts of human-caused disruptions of earth’s natural systems. It encompasses the health of human civilization and the state of the natural systems upon which it depends.

Speaking at the GHF last week, speakers flagged examples of the vicious cycle of climate drivers and health impacts that is becoming stronger by the year. For instance:

  • According to the 2019 report, researchers observed 220 million heatwave exposures affecting vulnerable populations in 2018, increasing risk of heat stress, heart disease, and kidney disease. This was an increase of 11 million since 2015.
  • Regarding wildfires, 152 out of 196 countries saw increases in populations exposed to wildfires from the early 2000s to present day there are also changes in rainfall patterns. According to the report, South America and Southeast Asia have experienced the largest increase in extreme rainfall from 2000 to 2018.

Jessica Beagley, policy manager for the Lancet Countdown report said: “The global impacts of climate change on health are worsening year on year.”

“And there were areas of significantly increased job exposure in all six WHO regions. Parts of Brazil actually experienced the full 12 months of drought and the whole 2018 also seeing impacts on food insecurity,” Beagley added.

Renzo Guinto, chief planetary doctor at the Manila-based PH Lab.

The Lancet reports also connect undernutrition to a changing climate’s impact on crop production especially the productivity of maize and soybean crops. Land degradation further exacerbates climate impacts. Together the two may reduce crop yields by up to 10% globally and up to 50% in certain regions, according to a new report by the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services, released on Wednesday. And food and economic insecurity give rise to migration and conflict in the worst cases, as well as immeasurable mental health impacts.

Renzo Guinto, a Philipino physician and chief planetary doctor at the Manila-based PH Lab, which explores human and planetary health through a similarly holistic lens said: “Climate change is very real in this country, planetary health challenges are very real and raw. People are facing them every day. It’s not just the extreme weather events. It’s also increasing the sea level. The Philippines’ coastlines are also facing the fastest rate of sea level rise in the world.”

He added: “Climate change is very real, just like health challenges. Increasing sea level rise, volcanoes, tsunamis. Then infectious disease pandemic which may not be the last if we don’t put our house together. A planetary health approach is critical.”

Land degradation is a pervasive, systemic phenomenon: it occurs in all parts of the terrestrial world and can take many forms.
Climate Change is a “Threat Multiplier” Leading More COVID-like Crises

COVID-19 and the climate crisis share another common trait: they are both threat multipliers. As the pandemic dominated 2020 news cycles, climate change continued to exacerbate the same risks that often lead to humanitarian crises.

At the GHF, Beagley said: “COVID-19 has shown the extent to which a large scale health threat can jeopardize even the strongest economies and can entirely redefine ways of life.

Jessica Beagley, policy manager for the Lancet Countdown report.

“We really need to start minimizing future health threats that are related to infectious disease or the wider health risks of warming climate.”

According to the United Nations Development Programme (UNDP), 90% of COVID-19 cases are in the world’s cities where people are already experiencing the impact of climate change, pollution, widening inequality, and economic crisis.

In the Philippines, citizens have been dealing with what ReliefWeb has described as “typhoon after typhoon after typhoon”.

“Even by the area’s stern storm season standards, 2020 has been a terrible year. In the past month alone, five storms have hammered the Philippines, from Typhoon Molave (locally named Quinta) on October 25 to Vamco (Ulysses) last week, which came less than a fortnight after the season’s strongest storm, Typhoon Goni (Rolly),” said Minaz Kerawala, Communications and Public Relations Advisor at ReliefWeb.

Climate Impacts Vector-borne Diseases As Well

Aside from its impacts on food production and nutrition, attention has also been drawn to the ways in which climate change can also exacerbate transmission of vector borne diseases. At the recently held resumed session of the 73rd WHA, a representative from Mexico said climate change goals are important in stemming the tide of vector-transmitted diseases.

While WHO has affirmed the direct connection between climate change and health outcomes, it has largely stressed the threats posed to clean air, safe drinking water, nutritious food supply, and safe shelter.

“Climate change has the potential to undermine decades of progress in global health,” the WHO climate change homepage says. “Between 2030 and 2050, climate change is expected to cause approximately 250,000 additional deaths per year, from malnutrition, malaria, diarrhoea and heat stress alone. The direct damage costs to health is estimated to be between USD 2-4 billion per year by 2030.”

More than a decade of science also links climate change to expanded transmission of vector-borne diseases.

In the 2015 paper on ‘Climate change and vector-borne diseases: what are the implications for public health research and policy?‘, the authors said vector-borne diseases are sensitive in different ways to weather and climate conditions such that the ongoing trends of increasing temperature and more variable weather threaten to undermine recent global progress against these diseases.

“For operational health agencies, the most pressing need is the strengthening of current disease control efforts to bring down current disease rates and manage short-term climate risks, which will, in turn, increase resilience to long-term climate change,” the authors reported.

Dilemma for Humanitarian Organizations

Addressing climate change has been regarded as a development issue that should be addressed by development organisations leaving humanitarian establishments to tackle crisis and emergencies.

Peter Maurer, President of the International Committee of the Red Cross (ICRC).

As Mexico stated at the WHA, not only are health and climate change deeply interrelated, but together they impact deeply on people’s fundamental human rights.

Organizations including the International Committee of the Red Cross (ICRC) are increasingly being challenged to get more actively involved in combating climate change. This was on display at the GHF.

Speaking at the 2020 Paris Peace Forum, Peter Maurer, President of the ICRC said climate change is one of the factors that increase vulnerabilities to diseases and outbreaks in societies.

“The vulnerabilities through poverty, climate change, violence, wars and other challenges in societies tend to be overshadowed by the dominant features of fighting the pandemic,” Maurer said.

He warned that the world needs to learn from the experience of past outbreaks that a more robust approach would be required to achieve desired results.

“We have seen in previous pandemics that just focusing on the pandemic and not keeping a perspective on the overall health system delivery is really the thing not to do. It is important to keep a systematic overview. Whether it is health, water, livelihoods, jobs … the situations have to be analyzed specifically in each and every context; and we need to design programs responding to every need,” Maurer added.

Taking Steps That Matter

At the Paris Peace Forum, Justin Trudeau, Prime Minister of Canada admitted that there is a lot to do in fighting COVID-19, and addressing other key global health-linked issues including fighting climate change, building economies that work for everyone, and advancing gender equality.

“We have a lot to do,” he said.

Jacinda Ardern, Prime Minister of New Zealand asked world leaders to come up with urgent global efforts on climate change, she drew attention to the high seas treaty that would protect biodiversity beyond borders.

But with a vacuum in global leadership in addressing climate change, stakeholders are struggling to coherently get the global community in moving in the same direction and this was expressed by the French Minister for the Economy and Finance, Bruno Le Maire.

At the 2020 Paris Peace Forum, he said making progress in addressing climate change has suffered a similar fate that addressing inequalities is facing — no clear way forward.

“So far, we have been unable to find global answers to these two questions: the rise of inequalities and climate change. This means that capitalism has reached its limits,” Le Maire said.

But in her remarks at the GHF, Beagley said deciding the way forward is not hard as numerous actions that have far-reaching effects can be taken easily considering several threats to climate change are also linked to diseases and illnesses that are of importance to global health.

“Anything to reduce greenhouse gas emissions is already going to have the most impacts to human health in the longer term. But in the near term you’ll see co-benefits and emissions reduction. And because many of the sources of greenhouse gas emissions are the same as sources for air pollution,” she said.

Reducing greenhouse has emissions will have the most impacts to human health in the long term.

She said transitioning to more renewable energy, and in particular, phasing out coal, will improve air pollution. Other actions including countries and cities remodeling transport systems, and promoting active transport that will also promote physical activity.

On an individual level, she said that transitioning to a whole plant-based diet will mean less red meat and processed food will improve an individual’s health.

“I think it’s also important to look at the lessons that we can learn from the covid 19 pandemic response, and especially as some governments start to consider recovery. So I really want to emphasize here that climate health and economic objectives are not just mutually reinforcing but are also mutually dependent. We can’t have health where we have poverty and it’s clear that extreme poverty is possible with extreme climate change and public health issues,” Beagley said.

Image Credits: Jason/Flickr, The Lancet Countdown, Geneva Health Forum, THE ASSESSMENT REPORT ON LAND DEGRADATION AND RESTORATION, Geneva Health Foundation, Nadir Hashmi/Flickr.

The manifesto website calls upon other policymakers, health experts and influencers, as well as members of the general public to sign as well, ahead of the moment when political leaders will formalize the frameworks for a new Health Union.

After catching Europe unprepared, the COVID-19 pandemic has created a window of opportunity to create a “European Health Union”. And what was once a long-simmering initiative has picked up steam with a formal endorsement from the European Commission’s President Ursula von der Leyen, as well as proposals to strengthen Europe’s health security.

Ursula von der Leyen, European Commission President.

But a group of policy-minded European health experts want to ensure that the new vision of a European Health Union moves well beyond the realm of health security and pandemic response.

They are calling for a stronger commitment to climate and environmental health, health equity, preventive health – and the policies to achieve them in the context of the new European Health Union. They also want to etch a vision for the continent’s global health role, post pandemic.

The group on Tuesday issued a “Manifesto for a European Health Union” outlining their vision. The manifesto website calls upon other policymakers, health experts and influencers, as well as members of the general public to sign as well, ahead of the moment when political leaders will formalize the frameworks for a new Health Union at upcoming sessions of the European Council and the next Conference on the Future of Europe.

“This will not be the last pandemic. There will also be many other threats to health, including the effects of climate change, antimicrobial resistance, and much else. We cannot continue with life as before. We have to safeguard our societies but in ways that are proportionate to the dangers which threaten them,” the manifesto declares.

“We are happy that for once, at last, after decades, the European Union is putting health so high on the agenda,” Ilona Kickbusch, founding director and chair of the Global Health Centre, and a leading member of the Manifesto initiative, told Health Policy Watch. “But we know how volatile European policies are, and we want to show the Commission that there is broad support out there [for an EHU].”

Ilona Kickbusch, Founding Director of the Graduate Institute’s Global Health Programme in Geneva.

The manifesto sets out a vision of a European Health Union that would:

  • Strive for the health and wellbeing of all Europeans, with no one left behind
  • Strengthen solidarity within and among Member States, based on the principle of progressive universalism, providing support, including universal health coverage, for all, but with particular attention to the needs of those who are disadvantaged
  • Ensure environmental sustainability, by adopting the European Green Deal and prioritising measures to promote One Health, the concept that links our health with that of the animals and plants with which we share this planet
  • Provide security for all Europeans, protecting them from the major threats to health and from the vulnerability that is created by living a precarious existence
  • Enable everyone’s voice to be heard, so that policies that affect their health are created with them and not for them

Among the key measures proposed by the authors include the strengthening of health policies in European Treaties; expanding the EU’s involvement in health research; addressing the uneven distribution of health workers across the continent; and development of a Global Health Policy for the European Union.

Another component of the manifesto includes the creation of a Health Emergency preparedness and Response Authority (HERA) to prevent the delay and floundering seen during the COVID pandemic.

While some of the elements of the manifesto’s proposals could be adopted rapidly and without major changes to EU treaty agreements, others would likely need a stronger legal framework, Kickbusch said, noting, “probably if one is really, really serious about it, one should look at a treaty change in terms of what the European compentencies in health are.  And so we wanted to initiate a debate on the components that we saw as critical.”

The manifesto falls in line with European Commission President Dr Ursula von der Leyen’s proposal, made at her September State of the Union address, for a stronger health union in Europe and greater focus on cross-border coordination.

When work initially began on the manifesto in July, the European Parliament was considering a series of cuts to in the health budget, made by the heads of governments in the European Council.  Although the funding cuts were ultimately rejected by the Parliament, which produced a much higher budget for health, it is important to ensure, going forward, that investments are made holistically, said Kickbusch.

“It seemed important for us to ask what this actually implies,” Kickbusch said, adding that it was important that funds are not allocated solely to pandemic preparedness – “as important as that may be.”

Image Credits: European Health Union, European Parliament, European Health Forum Gastein.

Screening of passengers FOR covid-19 at Maya Maya airport, Brazzaville

Thirteen African countries and an international network of research institutions have joined forces to launch a multi-country clinical trial of COVID-19 drug treatments in Africa for people who are mild to moderately ill.

The new ANTICOV trial, led by the Geneva-based Drugs for Neglected Diseases Initiative (DNDi) aims to respond to the urgent need to identify drugs that can be used for early treatment of COVID-19.

Although Africa has so far managed the COVID-19 pandemic exceptionally well, with only an estimated 4% of the world’s cases, a resurgence of infections being seen right now underlines the fact that the continent is not immune. And what was mostly urban outbreak until now is now spreading increasingly in rural areas.

“Treating mild cases is urgently needed to halt progression to severe disease and prevent spikes in hospitalization that could overwhelm already fragile health systems,” said DNDi’s Bernard Pécoul, speaking about the launch of the new initiative. “The ANTICOV trial brings together African and global science and public health leaders from 26 institutions and will enrol up to 3,000 participants across 13 countries.”

The clinical trial will be carried out at 19 sites by the ANTICOV consortium, which includes 26 prominent African and global research and development (R&D) organizations, coordinated by DNDi, an international non-profit R&D group with extensive partnerships in Africa.

Focus on Repurposed Drugs and Combinations 

ANTICOV will initially focus on examining a series of “repurposed” drugs also used for HIV, malaria and other infectious diseases, and where evidence from a large-scale randomized clinical trial could provide missing data on the efficacy of a drug candidate in mild-to-moderate COVID patients. 

Health Policy Watch if the trial would also include cutting-edge monoclonal antibody treatments such as those recently approved by the US Food and Drug Administration, but DNDi did not comment. The organization stressed that “the goal is to include additional treatment arms in the ANTICOV trial within weeks.”

As of its launch, the trial will test the HIV antiretroviral combination lopinavir/ritonavir (LPV/r) and the antimalarial drug hydroxychloroquine – both of which have been ruled out for seriously ill patients. In the case of mildly ill patients, the jury is still out. 

Various WHO co-sponsored studies, affiliated with the RECOVERY and SOLIDARITY initiatives have concluded that both hydroxychloroquine and LPV/r therapy have no significant efficacy for severe and hospitalized cases. But the ANTICOV trial will explore if either drug might be effective in milder cases, and at different dose regimes. 

“Today, at least 16 African countries (including 7 of the 13 ANTICOV countries) are recommending the use of chloroquine or hydroxychloroquine, even though scientific evidence is lacking,” DNDi noted in a press statement. 

“Several large, randomized trials have shown a lack of efficacy of HCQ as a treatment for COVID-19 in severely ill hospitalized patients, but the drug still needs to be tested in large, randomized controlled trials with mild and moderate cases,” it added, referring to statements by WHO’s Chief Scientist Soumya Swaminathan. In June, she flagged a key gap in knowledge: “Does it have any role at all in prevention or minimizing the severity of the illness in early infection. We need to complete those large trials to have a definitive answer on that.”

As for lopinavir/ritonavir, ANTICOV is exploring a dose regimen that has not been tested in other trials in order to determine if the drug combination, normally used to treat HIV/AIDS, might be effective in the treatment of mild-to-moderate cases of COVID-19, before the inflammatory stage of the disease is reached.

Among the other potential therapeutic options being explored by ANTICOV are medicines currently used to treat malaria, HIV, hepatitis C, parasitic infections, and certain cancers. 

Adaptable Test Pad For Drug Trials 

An ‘adaptive platform’ design will enable several treatment candidates to be tested simultaneously, also allowing for the testing of new therapeutic candidates as they emerge, DNDi said.

The trial is part of the WHO cosponsored ACT Accelerator’s therapeutics arm, which was launched in April 2020 by WHO to ensure equitable global access to innovative tools for COVID-19 for all. Unitaid – one of the principal funders of ANTICOV – is a co-convenor of the Therapeutics Partnership of the Accelerator, together with the Wellcome Trust. All clinical trial data generated by ANTICOV will be shared on an open platform, DNDi said.

The trial, led and managed by African researchers, also aims to provide African-led solutions to the pandemic as well as overcome community concerns and suspicions that have sometimes emerged around the conduct of clinical trials managed by researchers from abroad.

It also makes up for a dearth of clinical trials on the continent of COVID vaccines and treatments. As Dr Borna Nyaoke, DNDI’s senior project manager in Africa told Health Policy Watch in September, among the 1,000 trials underway worldwide for COVID drugs and vaccines, fewer than 70 are taking place in Africa.

Speaking about the ANTICOV trial launch, Monique Wasunna, Director of DNDi’s Africa Regional Office, said: “African countries have proved that they have the skills and expertise to provide local solutions to this global pandemic.”

The trials are also being supported by the German Federal Ministry of Education and Research (BMBF)/KfW, as well as the European & Developing Countries Clinical Trials Partnership (EDCTP) and Starr International Foundation.

 

 

Image Credits: WHO, DNDi.

Norway’s Minister of International Development, Dag Inge Ulstein and South Africa’s Minister of Health Zweli Mkhize issue urgent appeals at WHO press briefing for $US 28 billion in funding for COVID 19 vaccines, tests and treatments.

The vaccine zero hour is approaching. As Norway’s Minister of International Development Dag Ulstein and South Africa’s Minister of Health Zweili Mkhize made yet another urgent plea Monday for some US$4.3 billion right now and another $US23.9 billion in 2021 to massively roll out new COVID19 vaccines, drugs and tests that are now coming on line, it’s increasingly clear that the funds available to support the ambitious worldwide COVAX vaccine procurement and distribution facility planned by WHO and its partners through its ACT Accelerator initiative, is, at present, woefully inadequate. 

And following the lukewarm G20 pandemic commitments at last Saturday’s Summit, which failed to include any new offers of serious vaccine finance, the upcoming holiday season could feature heavy TV coverage of the first Americans getting a freshly-approved Pfizer COVID vaccine – with Europeans, Japan, Australia and other high-income countries next in line – as the rest of the world watches the show. 

“The ACT Accelerator has compiled the world’s largest portfolio of these tools to continue rolling up rapid testing, evaluating new treatments and ensuring access to vaccines as soon as they are licensed. The accelerator urgently needs US$4.3 billion, and the further US$23.9 billion in 2021,” said Ulstein in his appeal on the WHO stage.

“I would argue that this is a no brainer for world leaders. US$23.9 billion sounds a lot, yet the total needed is less than one-tenth, or one percentage point of global GDP. In other words, if G20 countries were to devote just 1% of the current stimulus spending on efforts to alleviate the economic consequences of the pandemic,” he said, “they would actually more than cover the needs of the next generation. I would argue that this is a small price to pay to getting the world back on track.” 

It may be a small price, but there is also much more at stake. Any deadlocked funding also threatens to pit two long standing world views against each other – in much more direct competition than what has been seen in decades.

One, led by the G20 economies, is hugely invested in their pharma industries, and a donor-driven regime of massive vaccine purchases at reduced prices, and distribution for poorer countries. They argue that the private sector confidence that they will reap as a reward for their efforts is necessary to incentivize the expensive investments required for any vaccine R&D, let alone the COVID research effort that has taken place at unprecedented scale and speed. 

R&D at AstraZeneca with robotics-supported technologies

Another vision, led by South Africa and India, is challenging that more fundamentally. They are pressing ahead for an IP “waiver” in the World Trade Organization (WTO) – so that countries would have the discretion to waive, for the period of the pandemic, not only COVID-related patents, but also trade secrets, industrial designs and copyrights associated with prized vaccines, tests or treatment technologies.

This, South Africa, India and its partners say, would greatly expand countries’ own ability to produce, as well as to export and import desperately needed vaccines, tests, and treatments quickly, and at much reduced prices – while bolstering the greater self-sufficiency that has become so important in the pandemic.

“We find that COVAX is a good start, but it’s not the solution,” said a leading South African diplomat, speaking with Health Policy Watch. “We are happy to work with multilateral approaches, of which COVAX is an example, and we are also able to work with voluntary licenses given by countries like AstraZeneca. Every little bit helps.

“But these approaches do not result in ramping up the production capacity, if they are limited to only a handful of producers. There’s no guarantee in terms of the volumes being supplied, within the timelines that are required to establish effective access. And even if we had volumes procured through COVAX that would cover 20% of the population for low- and middle-income countries (LMICs) … then you still don’t reach herd immunity.”

South Africa & Norway – Seeking a Way Forward

To be sure, as evidenced by the joint appearance of Ulstein and Mkhize today at the WHO press conference, both sides are trying to find new modus vivendi for bridging the stark differences between rich and poor countries in the global North and South, and create a practical way forward for sharing the benefits of new technologies more broadly – during a pandemic. 

Ulstein said: “We have a wide portfolio of candidates on the cusp of finalizing Phase 3 trials; we need to make sure that we do not end up with having these tools, but not the infrastructure to make them available at all.” 

Mkhize added: “Global solidarity isn’t just the right thing to do, it’s the smartest thing to do, ensuring that tools are allocated equitably, and not just based on income, but based on universal protection against COVID-19. It is the fastest and most effective way to defeat the pandemic and get our lives and our economies back to normal again.

“The lack of adequate financing for the ACT Accelerator is an existential threat to the economic and health security of all countries and their citizens.”

Whether due to its youthful population, strict preventive measures, or prior experience with dangerous outbreaks and epidemics, African countries have largely succeded in restraining the spread of the pandemic – in a success story that other regions have sometimes envied – but this has also come at a huge economic and social costs. 

Up until now, the entire continent has recorded just 2 million cases and 14,000 deaths – just 2.5% of the global caseload – and a fraction of the 12 million cases and 250,000 deaths see in just one country, the United States, which leads the world in terms of its COVID-19 infections, pointed out Mkhize. 

However, Africa is not immune either, he added, noting a resurgence of the virus underway just now, with a more than 20% increase in cases just over the past week. “The resurgence on the African continent will evolve, and therefore early equal access to vaccines and therapeutics will be critical to mitigating the threat posed,” he said. 

“We must treat access to COVID-19 tools as a global public health initiative: collective efforts to stamp out the virus now would also mean that future virus strains or mutations, that are more difficult to treat, could be avoided. It is clear that every country will need to play a part in financing an end to this crisis, and every leader has a political choice to make.” 

AstraZeneca Vaccine Results Accelerate Access Debate
Vaccine deals by country and for the COVAX pool as of mid-October – by Suerie Moon, Co-Director at Global Health Centre, Geneva Graduate Institute

For LMICs, the promising Phase 3 trial results of 24,000 volunteers, announced by AstraZeneca and its research partner Oxford on Monday – which saw 90% protection from the virus in one stream of dosing strategies, are a beginning, in terms of the concrete possibilities to deliver vaccines that can be handled through the normal supply chains.

WHO’s Chief Scientist Soumya Swaminathan, speaking at the WHO press conference, said the AstraZeneca results are particularly important due to their modest cold chain requirements – refrigerator storage at 2-8 C is sufficient. “This has, of course, huge logistical advantages for transporting and delivering this vaccine to cities and towns and villages and rural areas around the world,” she added.

Soumya Swaminathan, WHO Chief Scientist

Unlike the Moderna and Pfizer vaccines, AstraZeneca’s candidate also is based upon a tried and tested “viral vector strategy” she noted. That means that it uses a weakened form of another virus (a common adenovirus) to deliver the genetic code for a protein that is part of the characteristic a SARS-COV-2 spike – prompting a person’s body to mount an immune reaction. But it also means that the vaccine was developed and can be produced at a much lower cost than counterparts by Moderna and Pfizer that rely upon newly developed mRNA technologies.

Manufacturers like India’s Serum Institute, which have already acquired a license from AstraZeneca to produce its vaccine, have said that they will be able to produce and sell it for as little as US$ 3 a dose (it requires two shots), as compared to a cost of US$25-30 for the Moderna and Pfizer alternatives, which rely upon newer mRNA technology.

The low-cost is also due to the fact that AstraZeneca’s licensing agreements with manufacturers in India, Brazil and elsewhere are on ‘no-profits’ basis until the pandemic is over. Althought that pledge may have its limits in the light of revelations that the company reserved the right to declare an “end” to the pandemic as early as July 2021, according to one agreement made with Brazil’s Fiocruz Institute.

But while AstraZeneca’s deals with the Serum Institute and other similar partners could allow for the production of some 2 billion vaccine doses or more in the coming year, at two doses a person, expected global demand will still be 7-8 times that. 

 

Vaccine pre-orders by COVAX and countries to pharma firm as of mid-October; Suerie Moon, Co-Director at Global Health Centre, Geneva Graduate Institute

And the AstraZeneca commitments only channel about 300 million doses to COVAX, while the lion’s share would still go directly to the countries hosting production, like India and Brazil, as well as middle or high-income countries such as the United Kingdom, the European Commission (400 million doses), and others. Like counterpart vaccines produced by Moderna and Pfizer, middle and high income countries have pre-orders or options to purchase a sizeable chunk of the doses likely to be available next year from manufacturers – not including vaccine candidates being developed by China and Russia, which may open up other alternatives.

As Swaminathan noted, still more vaccines will be needed: “Remember we have to cover a huge number of people, billions and billions of people this is unprecedented. And we will need all the manufacturing capacity in the world, to be able to do that”. 

India’s Serum Institute – India First Strategy & A few Hundred Million Doses for COVAX By July

Speaking at a live “Leadership Summit” last week in India sponsored by the Hindustan Times, Adar Poonawala, head of India’s Serum Institute stressed that the first cut of the Serum Institute vaccines would also go to India and Bangladesh, as part of the company’s national and regional commitments.

The Serum Institute would be positioned to having “a few hundred million” vaccine doses to offer to COVAX by July or August of 2021, he said.

And those commitments already represent the upper limits of production capacity, he added, cautioning, that “we don’t want to partner with anyone [more] right now … We will be committing to more than what we can handle”.

Along with the logistical barriers of production, there remains the barrier of cost – or conversely that of finance – for other vaccine options. 

Poonawala said: “Indian vaccine prices will always be probably half or less than what we are seeing in the West with US$20 and US$30 dollar pricing that Pfizer and Moderna have publicly announced. Ultimately, I don’t know if they will come down on price. They might with public pressure, global pressure which is there.

“If we are talking about a US$10-US$20 dollar vaccine, you will need a budget of US$60-US$70-US$100 billion dollars, which the world doesn’t have for vaccinating everyone.

“Initially there might not be a choice for governments but to just pay these high prices. But eventually, when there is enough supply and alternatives you will see prices coming down drastically.

“Because the world will soon realise that there are other options coming from India and China at more affordable prices.” 

 

With reporting by Kerry Cullinan in Cape Town and Menaka Rao in Delhi, India.

 

Image Credits: AstraZeneca , R Santos/HP Watch, WHO.