DataSanté training session in Mali

Third in a series –  Even before the coronavirus struck, large swathes of Africa, as well as parts of South-East Asia and Latin America, still relied on fragmented paper-based medical records, making it difficult to track people’s medical history – and thus provide high-quality treatment and care.

The Virtual Innovation Fair, which is a key feature of this year’s Geneva Health Forum, that began Monday, 16 November, shows how digital health innovations are moving countries into a new era of healthcare, with the creation of digitized personalized medical records that will allow for more systematic follow-up care – not to mention far better disease surveillance. The Fair also showcases some new algorithm-based devices for more precise diagnosis of common conditions like childhood pneumonia. The innovation fair, which will be held from Monday to Wednesday between 12:00-12:30 CET, is open to all GHF participants to chat with innovators about their products. 

There are two particularly promising digital health innovations, both of which will be presented at next week’s Geneva Health Forum, that could help healthcare workers save lives, time, and provide better care for their patients. If all goes well, they could even become the bread and butter of primary health care, and replace paper-based data collection methods forever. 

One of those DataSanté, a seemingly simple, yet highly robust solar-powered software that allows healthcare workers to care for patients of all ages through a digital shared medical record. The second one is IeDA, a slick, Swiss-made job aid tool that enhances the diagnosis of childhood disease, and improves the performance of healthcare workers in real-time through artificial intelligence (AI) algorithms. We took a look at both to see how they work and what impacts they might have on patient care and disease surveillance. 

DataSanté -A Shared Medical Record, Created For Doctors By Doctors 

At first glance, DataSanté may seem quite simple, especially to AI-aficionados. Yet, healthcare workers find it “life-changing”, notes French doctor Pierre Costes, who founded the project almost a decade ago in response to his frustration with digital healthcare in France, as well health data fragmentation in west Africa. 

“Data Sante is a tool we created as doctors, for other doctors and healthcare workers, to simplify their day-to-day work,” says Costes. “It’s quite simple and easy to use, yet it has given rise to a new era.”

Before DataSanté materialized, African doctors in Mali and Benin would lose up to three days a month of potentially life-saving work filling out their Monthly Activity Report – a mandatory administrative report that is almost always prepared by hand. It involves an array of tedious aggregations of patient conditions that were treated, ranging from measures of disease prevalence to vaccination coverage levels, and disaggregated by sex and age,. 

About eight years ago, Coste’s team sought to help doctors do their job and to treat patients more efficiently, instead of spending time writing reports for authorities. 

Today, doctors armed with DataSanté can produce their Monthly Activity Report in no less than one click, saving them up to three days of work. Once their report is ready, all they have to do is to copy the report on paper and mail it to the Ministry of Health.

But automated reports represent only the tip of the iceberg in terms of what DataSanté really does. 

DataSanté’s main aim is to centralize a patient’s medical information in one file through the so-called “shared medical record” – allowing healthcare workers to follow tens of thousands of residents in their region throughout their lives. 

The shared medical records can be simultaneously accessed by nurses, doctors, midwives, or lab technicians, each with their own authentication codes and different levels of authorization.

DataSanté user interface

DataSanté also offers healthcare workers a plethora of handy tools that are tailored to their day-to-day needs and troubles. These include diagnostic support tools, severity alarms, prescription support, continuing education, as well as recall for follow-up care, adds Costes.

Pregnancy Due Date Calculator – Useful Tool For Midwives

The “pregnancy due-date” calculator is a particularly useful tool for midwives. Sometimes, pregnant women that come to the clinic are unaware of their last period, making it difficult to estimate their due-date, which comes about 280 days after their last menstruation. 

Instead, midwives can measure a woman’s uterine height and enter it into DataSanté to quickly estimate her last menstrual period – as well as her due-date. Costes notes that midwives can only use the due-date calculator if they have opened a personalized medical record for each woman, thus ensuring that DataSanté is properly used, without corners being cut.

DataSanté also facilitates teamwork and information-exchange at the local level. If healthcare workers face issues during their workday, they simply click the red alert button on the DataSanté platform and summarize their problem in a sentence, thus alerting the clinic’s head doctor within seconds.

In just four to five days of training, healthcare workers can run the DataSanté package on their tablets, smartphones or laptops. According to Costes, DataSanté can function for dozens of years without requiring a single software update. 

The software can be set up in places that lack internet access through a local server and integrated wifi network, which is either powered through solar energy or a mains power supply of 220 volts.

In Mali, almost three dozen healthcare centers are now equipped with DataSanté. In total, a quarter of a million personal medical records have been created in the three years since the platform was established – and demand is increasing every day, says Costes. 

The NGO has also developed a low-energy version of DataSanté, the “Databox”, for regions that lack electricity. The Databox is as small as a matchbox, with the same functionalities as its larger counterpart, except that it can run on 5-volt supplies. So far, 37 ‘databoxes’ have been installed in Madagascar – and the project aims to expand to Burkina Faso and Niger as well. 

Two years ago, Datasante was presented as an award-winning innovation at the 11th World Convergence Forum in Paris. The project is funded by the Agence Française de Développement.

DataSanté consists of a local server, energy source and tablet

IeDA – A Digital Tool To Diagnose Childhood Illness, With A Few Quirks Up Its Sleeve

In some regions of Sub-Saharan Africa, nearly one child in ten dies before the age of five, often because illnesses like pneumonia, diarrhea or malnutrition are misdiagnosed.

In Sub-Saharan Africa, the most widely used guideline to diagnose children under five is the “Integrated Management of Childhood Illness” (IMCI) algorithm, developed three decades ago by the WHO and UNICEF. 

In countries like Burkina Faso, where half of children die in their first two weeks of life, only 15% of children are correctly diagnosed with IMCI, mostly because frontline healthcare workers fail to adhere to the IMCI algorithm. 

For over ten years, Terre des hommes has refined their solution to optimize the diagnosis of childhood illness. Since the NGO began, its product, IeDA, has gone through twelve iterations.  

Healthcare worker in Niger conducts a consultation with the help of IeDA software

IeDA’s idea is in fact quite simple – it’s a digitized version of the IMCI that can be used on tablets in health centres, using mobile network connections. Its intuitive design, combined with short video tutorials, guide healthcare workers throughout their consultations with children, allowing them to obtain a comprehensive picture of a child’s health. 

Heads of clinics can then visualize the data through simple dashboards to improve the performance of the clinic and to increase the quality of care. The datasets are also sent to Burkina Faso’s Ministry of Health to become an important source of vital statistics, as well as national evidence-based decision-making.

As of August 2020, IeDA has helped undertake 7.5 million consultations, or 200,000 clinical consultations every month, according to a massive 3-year evaluation run by the London School of Hygiene and Tropical Medicine. It has also improved adherence to IMCI by 50%, and reduced unnecessary antibiotic prescription by 7-15%, notes Riccardo Lampariello, Head of the Tdh health programme. 

In Burkina Faso, IeDA has been set up in 1,350 healthcare centres, covering almost two-thirds of the country. If scaled-up to cover the remaining one-third of Burkina Faso, 1.5 million CHF could be saved each year as a result of improved diagnosis and healthcare worker performance, says Lampariello. 

Dr. Robert Kargougou, Secretary General for the Ministry of Health of Burkina Faso

“We have drastically reduced the number of incorrect diagnoses thanks to IeDA and the children benefit from better treatment,” said Dr. Robert Kargougou, Secretary General for the Ministry of Health of Burkina Faso, referring to IeDA. 

But Ministries of Health are not the only ones that are thrilled by IeDA. Healthcare workers are pleased to use the tool because it allows them to quickly finalize monthly reports for authorities, according to qualitative analyses of 21 healthcare workers in 10 primary healthcare facilities. As a result, healthcare workers employ IeDA in 8 out of 10 consultations. 

Sometimes, caretakers even request IeDA because they perceive it as the most accurate option available, says Lampariello. And some communities, like the Boussougou District in the Kadiogo region, have even raised their own funds to gain access to IeDA after hearing about its successes elsewhere.

But IeDA has several other quirks up its sleeve.

Using clever AI algorithms, IeDA can improve the performance of healthcare workers in real-time by anticipating common mistakes, or “bizarre combinations of symptoms”, explains Lampariello.

“In many ways, IeDA is a job aid tool that can detect common errors based on existing clinical data,” he says. “If, for example, a healthcare worker reports high levels of anemia in a region that has historically had low anemia, IeDA will send the healthcare worker a friendly message to check whether anemia has been well measured.“

As the pandemic brings with it a new array of challenges, Terre des hommes’s IeDA has responded through a range of online tutorials to raise awareness on coronavirus prevention and management. IeDA has also developed a triage algorithm to identify and follow up suspected cases of Covid-19, in collaboration with the local authorities. Eventually, the data collected by IeDA may help anticipate new outbreaks with “great precision”, says Lampariello.

Soon, IeDa could also be used in synergy with the Pneumoscope, another promising innovation that will be featured at next week’s GHF. Co-developed by Terre des hommes, it can detect pneumonia in less than seven minutes.

With financing from The Global Fund, Terre des hommes is in the process of handing IeDA over to Burkina Faso’s Ministry of Health. The NGO is also piloting IeDA in Niger, Mali, and plans to expand to India’s state of Jharkhand next year. 

Childhood diseases like pneumonia kill nearly 10% of children below the age of five in Sub-Saharan Africa, often due to misdiagnosis

Big Challenges For Digital Health Still Remain – Both Technical & Human 

In past years, smartphone ownership and internet coverage on the African continent has increased exponentially, but there is still a long way to go – especially in rural regions where coverage, bandwidth, and smartphone ownership is still low, note Lampariello and Costes.

For digital health to be successful, considerable ‘human challenges’ also need to be addressed, says Costes. Local leadership is needed, he adds, noting that sometimes, when new heads of clinics are appointed, they are less motivated to use DataSanté, letting their clinic backslide into old-fashioned methods.

Users also need to take ownership of the digital health tools that are created for them – and demand changes when they are needed, so that digital health stays relevant and useful. 

“Some healthcare professionals have not yet taken ownership of this software [DataSanté],” says Costes. “They are not aware that this is their own system. They can, and should ask for changes to keep control of DataSanté. 

If healthcare workers fail to take ownership of digital health tools, national authorities could take over, and instead appropriate DataSanté to serve their own interests, which are sometimes misaligned with those of healthcare workers, warns Costes. 

While DataSanté’s door is “open for dialogue” with health ministries, it can be challenging to harmonize between the priorities of healthcare workers and ministries of health, he adds. 

According to Costes, digital health’s primary objective should be to serve its users. The needs of decision-makers are important, but they should come once the groundwork is laid.

Image Credits: Terre des hommes, DataSanté, DataSanté , Researchgate, Our World in Data.

Smart Scope cervical cancer screening campaign in rural India

Second in a series – On Wednesday, 18 November, at 2pm CET, leading experts at the Geneva Health Forum (GHF) 2020 will provide their take on how to move forward on the recently approved WHO global strategy to accelerate the elimination of cervical cancer, which kills 300,000 women every year, mostly in low-resource settings like India.

The Indian-made Smart Scope, which will be featured at the Forum’s virtual Innovation Fair, could be a key tool in the battle to put an end to cervical cancer. The Smart Scope can detect cervical cancer in less than ten minutes, making it ideal for mass screening programmes in rural settings. The innovation fair, which will run from from Monday to Wednesday between 12:00-12:30, is open to all GHF attendees to chat with innovators about their products.

Cervical cancer is deadliest in low- and middle-income countries.

In India alone, cervical cancer claims the lives of 100,000 women a year, making it the second largest killer of women in the country after breast cancer. Unlike other countries that have set up an organized cervical cancer screening strategy and mass-vaccination against Human Papilloma Virus (HPV), India has remained largely silent on the issue, noted a recent study by the University of Nebraska. 

“There is no organized cervical cancer screening programme and no national policy for HPV prevention in India – screening of asymptomatic females is practically non-existent,” warned researchers.

In 2020, HPV vaccine coverage in India is still low, and prices are out of reach for the average Indian, at $160 for three doses, according to researchers at the University of Nebraska.

Mass screening for cervical cancer is another issue. The most commonly used test, the pap-smear test, is invasive, requires significant expertise to analyze, and out-of-reach for rural Indians, who account for two-thirds of India’s overall population.

Even if women from rural settings are able to reach distant clinics to get their pap-smear, the test takes four to five days to be processed. As a result, many women do not return for follow-up because they cannot afford to take another day off from work.

Periwinkle Technologies, a company based in Pune, India and supported by the nation’s Department of Biotechnology, offers a practical, portable and affordable solution to detect cervical cancer in a single visit – the ‘Smart Scope’.

The Smart Scope is an affordable handheld device that can be linked to a tablet

The Smart Scope is a non-invasive pencil device that can detect cervical abnormalities in less than ten minutes, with the aid of a tablet and an intuitive app. The test result is color-coded and supplemented by a visual report. Users find it “extremely” easy to use and to interpret, says Veena Moktali, founder of Periwinkle Technologies.

Given the device does not require specialized equipment or electricity, it can reach rural communities, especially during mass-screening programmes, which form a cornerstone of the country’s health promotion strategy. In one day, the Smart Scope can screen up to 60 women, says Moktali.

The AI-powered Smart Scope diagnoses cervical cancer with a sensitivity of 80 to 85 per cent, which is almost double that of the pap-smear test in some cases – where laboratory equipment or expertise may be spotty. 

Smart Scope Campaign in Indian clinic

Since March 2019, over a hundred Smart Scopes have been installed in healthcare facilities in various states across India. Together, they have screened more than 5,000 women, of which 5% had precancerous cervical conditions and 30% had benign HPV infections, according to an impact analysis by Periwinkle Technologies, the Tata Memorial Center as well as Deenanath Mangeshkar Hospital. A study of the device’s efficacy has been accepted for publication by Asian Pacific Journal of Cancer Prevention (APJCP).

Earlier this year, the Smart Scope won the Startup Grand Challenge competition organized by the National Health Authority. Last month, the government began a market access programme to expand the Smart Scope’s reach. 

But the Smartscope is much more than a cancer-detection tool. Rather, it offers women a comprehensive assessment of their cervical health because it can distinguish between pre-cancerous cells, cancerous cells, various types of infection, or even other benign abnormalities. In contrast, a pap-smear provides a limited result that is either “normal”, “unclear” or “abnormal”.

The visual aspect of the report enables patients to see their diagnosis with their own eyes, lending the result more credibility, adds Dr. Varsha Singh, who is the Head of Clinical Studies and Institutional Partnership Programs at Periwinkle Technologies. In contrast, the pap smear’s “text-only” result is rather difficult to communicate to patients, and is even ignored in some cases.

With the aid of a visual report, women can also show their results to family members, which is crucial for a disease that is poorly understood and deemed to lead to extra expenses for households.  As a result, the Smart Scope is more likely to bring women back for follow-up and treatment than the pap-smear. 

Why The Smart Scope Works  

Technicians have screened more than 5000 women in India with the Smart Scope

During the design of the Smart Scope, Periwinkle Technologies quickly understood that the speed of diagnosis was essential to their product’s success.

Busy doctors, especially in rural regions, were often “very reluctant” to spend time sterilizing medical equipment through a lengthy process called autoclaving, which can take up to 45 minutes. And during mass-screenings, women seemed unwilling to get tested when procedures were time-consuming or required a second follow-up visit to get their results. 

“When we used to work with the doctors in rural settings, we saw that autoclaving medical equipment was a big hurdle during mass-screening camps,” says Dr. Singh. “ In addition, patients were reluctant to come for screening as it requires a second visit to get the report. Thus, it was from users’ feedback that we found that there is a requirement to do the testing very efficiently and quickly.”

In response, Periwinkle Technologies designed a disposable sleeve that lies between the Smart Scope’s camera and a patient’s cervix. This allowed doctors to quickly dispose of the sheets between consultations, and to serve as many women as possible without the need for a lengthy sterilization process like autoclaving. 

Although the Smart Scope’s makers are technology providers, they are also heavily focused on outreach to improve awareness of cervical cancer and to fight stigma, in collaboration with local partners.

As well as having launched their own blog on gynecological health, Periwinkle Technologies regularly host training sessions, workshops, conferences and online courses for gynecologists, physicians, nurses as well as midwives. So far, 45 training sessions have been conducted, with 50 to 200 participants at each session.

During their outreach, Periwinkle Technologies frame the Smart Scope very carefully. Instead of describing it as a cancer screening device, it is introduced as a tool that ensures cervical health – as any mention of cancer usually scares people away, says Moktali.  Link here to register for the Geneva Health Forum and join the Virtual Innovation Fair

-Veena Moktali and Dr. Varsha Singh contributed to this story.

Image Credits: Periwinkle Technologies, The Lancet.

UNICEF Measles vaccination campaign in Tergol, Ethiopia.

Measles is on the rise globally, with a 50 percent increase in measles deaths from 2016 to 2019 and the highest number of reported cases in two decades, states a new joint report by the United States Centers for Disease Control and Prevention (CDC) and the World Health Organization, published on Thursday.  

The increase in measles cases coincides with the COVID-19 pandemic, which has disrupted health systems, essential service, and routine immunization programs. Some 94 million people have been at risk of missing vaccines because of paused measles campaigns in 26 countries as of November. 

“While health systems are strained by the COVID-19 pandemic, we must not allow our fight against one deadly disease to come at the expense of our fight against another,” said Henrietta Fore, UNICEF Executive Director, in a WHO press release.

Steady progress towards WHO’s goal of global measles elimination was reported from 2000 to 2016, with an 88 percent decrease in incidence of measles. However, the number of reported measles cases then rose by 556 percent within the three subsequent years – from 132,490 cases in 2016, the year with the lowest incidence, to 869,770 cases in 2019. 

In 2019, nine countries – Central African Republic, Democratic Republic of Congo, Georgia, Kazakhstan, Madagascar, North Macedonia, Samoa, Tonga, and Ukraine – experienced large outbreaks. As a result, none of the WHO regions achieved the WHO’s stated objective of eliminating measles by 2020. 

“These data send a clear message that we are failing to protect children from measles in every region of the world. We must collectively work to support countries and engage communities to reach everyone, everywhere with measles vaccine and stop this deadly virus,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

The report points to the failure to vaccinate children with the two doses of measles-containing vaccines (MCV1 and MCV2), on time, as the primary reason for the increases in cases and deaths. In order to control measles and prevent outbreaks and deaths, vaccination coverage rates have to reach 95 percent. However, currently  vaccination coverage of MCV1 is 84 percent and MCV2 is 71 percent. 

“Infections are not only a sign of poor measles vaccination coverage, but also a known marker, or ‘tracer,’ that vital health services may not be reaching populations most at risk,” said Robert Linkins, Measles and Rubella Initiative Management Team Chair and Accelerated Disease Control Branch Chief at the US CDC. 

Experts from the Measles & Rubella Initiative, a global partnership between WHO, US CDC, UNICEF, Gavi Vaccine Alliance, the American Red Cross, and the Bill and Melinda Gates Foundation, called for: the urgent prioritization of measles catch-up immunization programs, actions to regain trust in communities, infection surveillance, rapid outbreak response, and investment in essential health services to mitigate the risk of outbreaks and move towards eliminating measles.

The Immunization Agenda 2030, the global immunization strategy for 2021-2030 that was adopted at the 73rd World Health Assembly, outlines similar strategies to strengthen essential immunization systems and integrate national immunization programs in primary health care systems.

Image Credits: Flickr – UNICEF Ethiopia.

Experts are reluctant to call the increase in cases in Kenya and other African countries a second wave
There has been a fourfold increase in Kenyans testing positive for COVID-19, following the easing of lockdown restrictions in September.

Experts are reluctant to name the increase in COVID-19 cases in African countries a second wave, following lockdown relaxations in South Africa, Kenya, Ethiopia, Angola and Uganda.

It is argued that the disease has so far mostly been an urban outbreak in Africa, and what is now being observed is an increasing spread in rural areas.

“What we are seeing is a likely continuation of the pandemic with cases rising as restrictions are eased,” said Ifedayo Adetifa, a clinical epidemiologist at the KEMRI-Wellcome Trust Research Programme in Kenya.

South Africa, the country with the highest incidence on the continent, has experienced significant increases in new infections throughout October – as have Kenya, Ethiopia, Angola, Algeria and Uganda. These countries each eased lockdown restrictions around one month ago.

In  South Africa, 725 new cases were recorded on 21 September. A month later, the number had jumped to 2,156 new daily cases, according to the global online Corona Tracker.

Meanwhile, Kenya recorded a low of 53 new infections on 28 September but recorded 1,494 new cases on 4 November.

Kenya’s increases could also be because the country has changed its testing strategy, Adetifa also said.

“Testing is now happening more within the population as opposed to testing being carried out among the sick. When this happens you are likely to capture more infected people, including the asymptomatic ones,” said Adetifa, who is also an associate professor at the London School of Hygiene and Tropical Medicine.

WHO puts the total Kenyan COVID-19 cases at 58,587 but, in October, the test positivity rate averaged at 16%. This is in comparison to 4% before restrictions were eased in September, according to President Uhuru Kenyatta.

Lilian Mutua, WHO Kenya Health Promotion Coordinator, reaching out to ensure nomadic communities know how to protect themselves from COVID-19.

Some 730,548 cases had been confirmed in South Africa by 5 November, as well as 19,585 deaths, according to WHO.

The new infections had followed a “different trajectory” when compared to the current trend in Europe, said Dr Ngoy Nsenga, WHO-Africa’s COVID-19 incident manager.

“The virus remains the same and unchanged. There have been no mutations so far and the biology surrounding it has not changed,” he asserted.

But people had started to relax their behaviour and urgent interventions were needed at country and at sub-country levels where incidents were beginning to grow, Nsenga advised.

Kenya Reports Decrease in Bed Capacity

Kenya has already tightened some of the restrictions it had relaxed in September, with President Kenyatta reducing operating hours for bars and eateries, and adding an extra hour to the current curfew. People failing to wear a mask in public also face a fine of up to US$200.

“Our COVID-19 bed occupancy has also gone down by 60% and we had flattened the curve to below the 5% positivity rate recommended by WHO,” said President Kenyatta in an address to the country on 4 November.

“This is what gave us the courage to re-open and ease our COVID measures. But 38 days later, we have experienced a reversal,” he added. “If COVID bed occupancy had gone down by 60%, giving us comfort to re-open in September, the same has now gone up by 140% during the 38 days of easing COVID measures.

“COVID-19 positivity rate has also shot up from 4% in September when we re-opened, to an average of 16% in October. This is four times what the rate was in September. If one person was positive in September, four became positive in October. That is the literal interpretation of these statistics,” he added.

Kenyans seem to have backtracked from their “good’ COVID practices since the September re-opening, he added.

The month of October was the worst for Kenya, with more than 15,000 new infections, according to WHO. Nearly 300 deaths were also recorded according to the National Multi-Agency Command Centre on COVID-19.

‘Heavy Blow’ to African Health Services

Meanwhile, WHO-Africa director Dr Matshidiso Moeti said that the pandemic had dealt a “heavy blow” to key health services across the continent, including immunisations, maternal health care, and malaria treatment.

A preliminary analysis of five essential health service indicators – including outpatient consultation, inpatient admission, skilled birth attendance, treatment of confirmed malaria cases and the provision vaccines in 14 countries – had revealed a sharp decline in uptake of the services between January and September, she disclosed.

The gaps were the widest between May and July when many countries had put in place movement restrictions and other measures to check the spread of the virus.

“During these three months, services in the five monitored areas dropped on average by more than 50% in the 14 countries compared with the same period in 2019,” Dr Moeti said in a statement.

“Now that countries are easing their restrictions, it’s critical that they implement catch-up vaccination campaigns quickly,” said Dr Moeti. “The longer, large numbers of children remain unprotected against measles and other childhood diseases, the more likely we could see deadly outbreaks flaring up and claiming more lives than COVID-19.”

Image Credits: Twitter: @WHOKenya, WHO African Region.

The Year of The Nurse And Midwife, 2020 will be a featured topic at the Geneva Health Forum on Monday, opening day of the conference (16-18 November). Raisa Santos discusses the dilemmas facing nurses worldwide – informed by her own experiences. 

“Why does it take a pandemic for them to suddenly recognize nurses?” says Isabelle, a Labor and Delivery nurse in New York City. “We’re on the front lines all the time.” 

Nurses celebrating Nurses Appreciation Week in May 2020 in New York City; Pictured second from right: Isabelle Santos

This is in fact my mother speaking. My mother who, just like my father, has been on the front line of the healthcare workforce since they came to the United States, back in 1994. The sacrifice my parents have made is two-pronged, for not only have they worked tireless hours on behalf of their patients, in both the night and day shifts, but they sacrificed their livelihood and everything they knew when they left the Philippines. 

Both of my parents were doctors in the Philippines, but when they immigrated to the United States took up work as nurses. “When you’re working the night shift, you have no time to study or read. I’m lucky I passed the nursing exam,” says my father Roberto, an ER nurse, who immigrated first to New York City so my mother could follow. In addition to the lack of time, they cited the numerous educational and administrative hurdles that prevented them from achieving the same medical licenses in the United States.

My parents are part of the estimated 150,000 Filipino nurses in the United States, with some regions accounting for an even larger portion of the nursing workforce. In California, nearly 20% of registered nurses are Filipino. Filipinos are one of the largest groups of internationally educated nurses in the country, and are the second largest Asian community in America. 

“It is not an exaggeration to say we literally would not have survived the COVID-19 pandemic without all of you, our Filipino brothers and sisters,” said New York City Mayor DeBlasio. “You keep our city moving forward, and you keep us progressing during one of the greatest challenges of our time.” DeBlasio honored Filipino Americans, especially those in healthcare, during Filipino American History Month, in October. Acknowledging the contributions of migrant nurses also highlights the need for active support of all nurses and healthcare workers. 

It is paradoxically fitting that the first-year dedicated to celebrating nurses coincides with the biggest pandemic that the world has seen in a century: COVID-19.

The World Health Organization (WHO) declared 2020 the International Year of the Nurse and the Midwife, in honor of the 200th anniversary of Florence Nightingale’s birth. The topic is also a featured item at the upcoming Geneva Health Forum (16-18 November), including presentations by WHO’s Elizabeth Iro and Howard Catton of the ICN, who are presenting on The Year of the Nurse and the Midwife 2020 – a catalyst for change, on Monday, 11:00 – 12:00 CET.

According to the most recent ICN data, 1,500 nurses have died from COVID-19 in 44 countries. They estimate, however, that worldwide healthcare worker fatalities from the virus could be greater than 20,000.

“Nurses and midwives have been on the frontlines of the fight against COVID-19, putting themselves in harm’s way. Many have made the ultimate sacrifice in service of humanity,” said Dr Tedros Adhanom Ghebreyesus, WHO Director General, at his opening speech for the resumed 73rd World Health Assembly last week. “Now more than ever, the world needs nurses and midwives.”

Dr Tedros Adhanom Ghebreyesus, Director-General, WHO on International Nurses Day
Applause without Action 

In fact, even before the pandemic, nurses have suffered, and continue to suffer, from long hours, risky working conditions, a gender-based pay gap, and a global shortage of nurses. 

The largest shortages of nurses are seen in some parts of Latin America, Africa, and Southeast Asia

“Applause without action is no longer acceptable recognition, without rights and proper rumination is not sufficient a resolution, without implementation is not governance,” said HRH Princess Muna al-Hussein of Jordan, in a keynote address at the resumed 73rd World Health Assembly. HRH Princess Muna is a WHO patron of nursing and midwifery in the Eastern Mediterranean Region. “We must invest in fair pay and protection of health and care workers.”

True appreciation for nurses and healthcare workers should be shown in the form of global cooperation that ensures the lives of both patient and provider are protected.

She added: “We must invest in a healthy workforce that will help the world recover. With 70% of the world’s health workers being women. We must truly invest in transformative gender equity and rights policies.”

Global Shortage of Nurses Now and Future 

According to the latest State of the World’s Nursing Report 2020, there is a 5.9 million gap in nurses worldwide – with most of the shortage, or 5.3 million (83%), concentrated in low- and middle-income countries (LMICs).

The report uses findings from analysis of National Health Workforce Account (NHWA) data provided by 191 Member States. 

Among the 28 million nurses working today, 80% are concentrated in countries that account for only half of the world’s population. And while the nursing workforce is expanding, the report projects that the shortage could reach up to 5.7 million by 2030, primarily in the African, South-East Asia, and Eastern Mediterranean regions.

Along with certain areas of Latin America, these regions are where the nursing gap is currently most strongly felt.

These are also regions that have some of the largest populations of migrant nurses.

Projected increase (to 2030) of nursing workforce, by WHO region and by country income

Dr Tedros said: “This report is a stark reminder of the unique role [nurses] play, and a wakeup call to ensure they get the support they need to keep the world healthy.”

Nursing ‘Brain Drain’ from Developing Countries to Train More Nurses 
Physicians and nurses wore adapted theatre gowns and used face shields and face masks when attending to patient during the COVID-19 pandemic, Nigeria

The migration of health professionals to high-income countries also risks worsening shortages in LMICs. The ICN warned that high-income countries must train enough nurses to become self-sufficient at a large scale.

Speaking at the World Health Assembly (WHA), it urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply.

Countries such as the United Kingdom have admitted dependence on health worker migration. 

Sacrifices but no Status For Migrating Nurses 

The millions of migrant nurses around the world, including many from the Philippines, also often face issues with their legal status in the very countries they are serving.

While international recruiters for nurses promise signing bonuses, referral bonuses, and relocation bonuses, the protection they are guaranteed is far less concrete.

In a review led by Kaiser Health News, some travel nursing contracts of international nurses have left a trail of wrongful termination claims, claims of discrimination, harassment or retaliation, wage claims, and claims for violation of federal, state or other laws and regulations.

These often were settled out of court, as constituents of organizations such as the Service Employees International Union, the American Nurses Association and National Nurses United were suspended or fired from traveling worker agencies for speaking to the news media, posting on social media, or otherwise voicing concerns about unfair practices.

Nurse treating a child at a medical center in Baghdad

Carey McCarthy, one of the lead authors of the State of the World’s Nursing Report, calls on countries to use this data to guide policy discussions around nurse mobility and many other problems regarding the global nursing shortage.

In a YouTube interview on World Health Day, she said: “We know that [nurse migration] is increasing. We really need better data from all countries around the world to make sure that migration is managed ethically and responsibly and that we can ensure that our migration of health workers doesn’t exacerbate, and make worse, local health challenges that already exist in terms of providing services to the population.”

Improving Nurses Working Conditions, Advancement & Leadership   

Increasing the number of nursing trainees and graduates, and retaining nurses already employed also requires improved working conditions, and avenues for advancement to ensure that veteran nurses remain motivated.

Nursing leaders and their in-country networks are crucial to this process, and their inclusion in policy dialogue that concerns them is critical, nurse advocates say.

McCarthy, who is also WHO’s Nursing and Midwifery Technical Officer, said: “We are asking governments to look at improving nursing leadership. We found chief nurse officer positions as well as leadership development programs to be highly related to improved working conditions and stronger education regulation within countries.” 

Interview with WHO Expert Carey McCarthy on The State of the World Nursing Report, broadcast 7 April 2020

Of the 191 countries who responded to the surveys informing the Nursing Report, more than 80% reported that strong government or employer regulations regarding their working conditions was one of the major drivers attracting them to job opportunities. 

This includes stronger regulation of working hours and minimum wage.

Overall, LMICs reported weaker regulatory frameworks for nurses, as compared to high-income countries. The presence of a government chief nursing officer position and the existence of a nursing leadership programme were associated with a stronger regulatory environment for nursing. 

Gender Equity in Nursing 

Approximately 90% of the nursing workforce globally is made up of women. Gender-related barriers and discrimination can constrain advancements of the nursing profession, as well as deeply impacting the well-being of female health workers and the standard of care.

Conversely, addressing gender perceptions and barriers in nursing is also important in order to empower nurses to obtain proper working conditions, receive fair pay and equal treatment, and become leaders in healthcare. 

By providing more equitable pay to a predominantly female workforce, providing adequate PPE and funding to all hospital and clinical staff, and creating gender-sensitive leadership and development opportunities for women in the nursing workforce, we can slowly ease away the inequities in healthcare and work towards attaining universal health coverage, a long-time nursing advocate has said.  

“Politicians understand the cost of educating and maintaining a professional nursing workforce, but only now are many of them recognizing their true value,” said ICN President Annette Kennedy. “Every penny invested in nursing raises the wellbeing of people and families in tangible ways that are clear for everyone to see.”

She added that The State of the World’s Nursing Report “highlights the nursing contribution and confirms that investment in the nursing profession is a benefit to society, not a cost. The world needs millions more nurses, and we are calling on governments to do the right thing, invest in this wonderful profession and watch their populations benefit from the amazing work that only nurses can do”.

HRH Princess Muna al-Hussein, keynote address to the resumed 73rd World Health Assembly

Princess Muna, in her presentation on Monday’s opening of the WHA, said: “All countries need a system that delivers public health, primary care preparedness and response, a system that delivers integrated health and care services, and a system that delivers health and well-being for all of its population.”

“The best strategies and plans will not succeed without the people to deliver them,” she added. “Invest in health. Invest in health systems. Invest in well being. Invest in people who are the world’s health and care workers.”

Raisa Santos is studying a Masters of Public Health with a global health certificate at Columbia Mailman School of Public Health. She is also an intern writing for Health Policy Watch.

Image Credits: Raisa Santos , R Santos, WHO, WHO, Community Eye Health/Flickr, International Labor Organization/Flickr, WHO, WHO.

Executive Board Room in WHO Headquarters, Geneva, during the virtual resumed session of the 73rd World Health Assembly.

The close of the World Health Assembly (WHA), Friday, saw the adoption of the first-ever resolution to eliminate meningitis by 2030 – a disease which has its biggest impacts in sub-Saharan Africa, and with a 50 percent fatality rate if left untreated. 

The closing hours of the WHA also saw the approval of a landmark roadmap for reducing the burden of neglected tropical diseases (NTDs) by 90% by 2030 – NTDs refer to some 18 parasitic, helminthic and vector-born diseases that affect over one billion of the world’s poorest people.   

Another resolution to increase treatment and control of epilepsy and other neurological disorders was also approved. 

Neurological disorders are the second leading cause of death worldwide, yet many, including epilepsy, have preventable causes. The approved resolution plans to address the current gaps and research needs to improve prevention, early detection, treatment, care, and rehabilitation. 

Dr Tedros Adhanom Ghebreyesus at the World Health Assembly’s third plenary meeting on Friday.

“You have approved a comprehensive resolution on emergency preparedness, a new road map to defeat meningitis by 2030, a new road map for neglected tropical diseases, a resolution to scale up action on epilepsy and other neurological disorders, and you declared 2021 the international year of health care workers,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, speaking to member state delegates in his concluding remarks for the 73rd WHA. 

“Each of these represents an urgent health priority that affects the lives of millions of people and which increases the demands on and expectations of WHO,” he added. 

Roadmap Aims to Reduce Neglected Tropical Diseases by 90% 

In terms of the action on NTDs, the new roadmap sets ambitious targets to be achieved by 2030. The global targets include: reducing those requiring NTD treatment by 90 percent; eliminating at least one NTD in 100 countries; eradicating dracunculiasis and yaws; and reducing the disability-adjusted life years related to NTDs by 75 percent. 

“The new road map addresses critical gaps across multiple diseases, integrates and mainstreams approaches within national health systems and coordinates action across sectors,” said Mwelecele Ntuli Malecela, Director of WHO Department of Control of Neglected Tropical Diseases, in a WHO press release.

A young girl receives a meningitis vaccine.

As for meningitis, administration of meningococcal vaccines can help prevent  the major bacterial forms of the disease among young children. The new WHA resolution aims to strengthen vaccine coverage as well as disease surveillance in order to eliminate periodic meningitis outbreaks and epidemics. 

In a discussion before the resolution was adopted, member states such as Brunei, told WHA delegates how they had succeeded in integrating meningitis vaccines into their regular basket of health services. 

“Brunei Darussalam has developed a comprehensive program which has been successful in protecting against vaccine preventable diseases, including meningitis, with a high vaccination coverage rate…ensuring high protection against childhood meningitis,” said the delegate from i on Thursday. “Accessibility to meningococcal vaccinations is now provided nationwide.”

Regarding epilepsy, Mexico echoed the resolution’s emphasis on early detection and treatment of patients with neurological disorders. Along with providing essential care, Mexico’s delegate said prevention and diagnosis would help “the fight against the marginalization of these people [with epilepsy and other neurological disorders].” 

“This [epilepsy action plan] will allow the member states to better work with international collaboration and to engage politically on this issue,” he said. 

Health Conditions In Occupied Palestinian Territories 

The Assembly also approved a decision requesting the Director-General to provide health systems support to Palestinians living in Israeli-occuped territories, including for this year’s COVID-19 pandemic. A WHO report on “Health conditions in the occupied Palestinian territory, including east Jerusalem, and in the occupied Syrian Golan” is issued every year for the WHA, sparking an annual cycle of protests by Israel and its allies.  

In this year’s debate, Israel, Canada and the United States opposed the draft decision, noting once more that the Palestinian conflict was receiving special treatment – in comparison to politically charged debates over other occupied and contested territories, which the WHA typically tries to avoid.  

Said the US delegate:  “The United States believes the current draft decision does not meet our shared objective of a World Health Assembly focused purely on public health and that refrains from singling out countries on a political basis. Rather, the draft decision before us perpetuates such politicization.”

Added Israel: “Israel has strengthened its cooperation with the Palestinian Authority in order to prevent, mitigate and address the spread of the virus in the region.” 

Charged Turkey, a co-sponsor of the draft decision on Palestine, said: “12 years of inhuman blockade has had a profound effect on the health sector, as well as on underlying determinants of health. COVID-19 worsened an already dire situation and the health system continues to operate under pressure from shortages of basic supplies.”

Meanwhile, Cuba, another a co-sponsor of the draft resolution, and a member of the  Palestinian observer delegation at the WHA called upon Israel and the US to respect the recommendations by the Director-General in his report. He said Palestinians were keen for  the WHO “to continue to provide technical assistance to Palestine,” while Israel should “respect its obligations as a member of the World Health Organization.”

This year’s WHA session saw several other such disputes creep to the surface – only to be quickly suppressed in debates. Protests by member states over the WHA’s failure to include Taiwan as a observer – due to objections from China – were shut down on the floor of the Assembly – after a closed-door meeting of delegates decided that Taiwan would not be admitted.  Later, the WHA moderator also shut down comments by Armenia, when it accused Azerbaijan of  “ethnic cleansing” of Armenian nationals living in Nagorno-Karabakh – a territory inhabited by ethnic Armenians but internationally recognised as belonging to Azerbaijan, where bloody battles have occurred in recent week. Under a recent Russian-brokered peace deal, Azerbaijan will fully control of the area, forcing Armenian troops to withdraw and, along with them, many civilians.  

Image Credits: WHO, WHO, WHO.

Dr Tedros Adhanom Ghebreyesus speaks at the World Health Assembly’s closing session on Friday, 13 November.

BREAKING – World Health Organization Director-General, Dr Tedros Adhanom Ghebreyesus has proposed the creation of a Swiss-based global repository for sharing pathogen materials and clinical samples related to potential outbreak threats – allowing for the more rapid development of medical interventions. 

The COVID-19 pandemic has shown the urgent need for this kind of system, said Dr Tedros Adhanom Ghebreyesus in his closing remarks to the 73th World Health Assembly.  He alluded to the problems associated with existing WHO-sponsored frameworks for pathogen-sharing, which are based on bilateral agreements between countries, and have no centralized repository. 

“The pandemic has also shown that there is an urgent need for a globally agreed system for sharing pathological materials and clinical samples to facilitate the rapid development of medical countermeasures as global public goods. 

“It can’t be based on bilateral agreements. And it can’t take years to negotiate. 

“We are proposing a new approach that would include a repository for materials housed by WHO in secure Swiss facility; an agreement that sharing these materials in the facility is voluntary; that WHO can facilitate the transfer and use of materials; and a set of criteria under which WHO will distribute them.”

Dr Tedros said that Alain Berset, head of the Swiss Federal Office of Home Affairs [Public Health] had offered his support for the initiative, including a high-security  BSL certified laboratory (biosecurity level 4). The Health Minister of Thailand, Anutin Charnvirakul, and Italy’s Minister of Health, Roberto Speranza, have also come behind the concept, Dr Tedros said. 

Sharing of Samples is Critical to Rapid Response  – But Slow Under Current Arrangements 

Sharing of such biological samples is crucial for the rapid response to an emerging outbreak threat, leading to the faster development of diagnostic tools, medicines and eventually, vaccines. 

Current WHO-mediated arrangements are guided by bilateral Material Transfer Agreements (MTAs), a contract governing transfer of biological materials – that is relevant samples and data– between two countries or parties (e.g. laboratories).  The MTA also defines the rights of the provider and the recipient with respect to the materials and any derivatives.

The current WHO MTA formulas are part of the Organization’s broader Research and Development (R&D) Blueprint for Action to Prevent Epidemics blueprint.

WHO developed and published its first such R&D blueprint framework 2016, which was approved that year by the WHA, following the harsh experiences of the West African Ebola epidemic where a lack of such formalized frameworks hindered response. The Blueprint was updated  again in 2017, following another expert public consultation.

This Framework was scrutinized again as the COVID-19 pandemic was building steam – when WHO convened a major research meeting in Geneva in February 2020. 

The WHO-convened Global Research and Innovation Forum with scientists, researchers and public health experts followed on the heels of WHO’s initial declaration of  COVID-19 as a public health emergency at the end of January, 2020. 

The meeting, 11-12 February, yielded the first COVID-focused research and development blueprint to accelerate global research work on treatments and vaccines, which is part of the WHO’s broader global strategy and preparedness plan. 

At this meeting, the expert participants issued a set of recommendations for “immediate research actions”, saying that virus material, clinical samples and associated data should be “rapidly shared for immediate public health purposes, and that fair and equitable access to any medical products or innovations that are developed using the materials must be part of such sharing.”

Sources in Geneva told Health Policy Watch that while the Swiss Confederation has indeed agreed, in principle, to host such a repository – a more formal framework for the initiative still needs to be developed. If successful, however, such a facility could make a meaningful contribution to global health security, providing an important base for more rapid, initial investigation of emerging disease threats on neutral ground. Indeed, the concept dovetails well with the classic Swiss diplomatic positioning as a “trusted” and “neutral” partner – in the polarized world of global health diplomacy.

Image Credits: Health Policy Watch .

Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries
Limited education and employment capacity in LMICs means has encouraged health workers to move to high-income countries. One in eight nurses globally are migrant nurses.

The migration of health professionals to high-income countries should not lead to a dearth of healthcare workers and services low- and middle-income countries (LMICs), the International Council of Nurses (ICN) has warned.

Speaking at the World Health Assembly (WHA), the council flagged that the global shortage of six million nurses, in tandem with the burden of the COVID-19 pandemic, would continue to drive health worker migration, leading nurses away from LMICs.

One in eight nurses globally are migrant nurses, according to WHO’s 2020 State of the World’s Nursing report, drawing comparison to the limited education and employment capacity in LMICs.

The global shortage of six million nurses continues to drive health worker migration
The global shortage of six million nurses continues to drive health worker migration.

To address this, the ICN said high-income countries must train enough nurses to become self-sufficient at a large scale.

It urged countries to implement a self-sufficiency indicator, presenting their reliance on foreign-trained nurses as a percentage. This would give policymakers insight into the extent of dependence on international nurse supply, it said, and would enable tracking and monitoring of their commitment to the global strategy of human resources for health.

The representative said: “The impact of COVID-19 on the nursing workforce will continue to increase the flow of nurses from low- to high-income countries. High-income countries must train enough nurses to become self-sufficient.”

UK Admits Dependence on Health Worker Migration

The United Kingdom is one of the world’s top destinations for emigrating health professionals.

Workers born abroad have constituted 50% of the increase in the country’s health and social care workforce across the last decade, according to a Nuffield Trust analysis published in December 2019. The analysis also revealed that people born outside of the UK account for nearly a quarter of all staff working in hospitals, and a fifth of all health and social care staff in the country.

The UK spokesperson at the World Health Assembly admitted that the UK’s National Health Service relies to a large extent on international health workers.

“By forging international partnerships, the UK will foster collective efforts across the world to address the global shortage of health workers and provide health workforce-related support and safeguards to countries with the most vulnerable health systems, enabling progress towards universal health coverage and sustainable development goals,” she told the assembly.

She added that in consultation with WHO, the UK has updated its code of practice for international improvement based on the latest advice, due to be published later this year.

Feeling the Weight of Health Workforce Inequality

Evidence points to a direct correlation between the size of a country’s health workforce and its health outcomes, with WHO estimating a projected global shortfall of 80 million health workers by 2030, mostly in LMICs.

A COVID-19 responder in Kenya learns how to properly equip protective gowns in Kenya. The country is experiencing a critical resource shortage during the pandemic.

COVID-19 has piled additional pressure on the healthcare systems in many countries losing health professionals to high-income countries.

This is an especially pressing issue in Kenya. In a 2016 study published in BJPsych International, researchers noted that one in five nurses trained in Kenya applies to emigrate. They also found that up to 40% of the country’s 600 medical graduates leave upon completing their internship every year.

Kenya’s spokesperson said the East African country’s healthcare system is faced with a shortage of critical human resources for health demands. Similar situations occur in many other African countries.

“We continue to experience challenges in managing human resources for health, such as severe shortages of essential workers, inability to attract and retain health workers, and even remuneration among workers,” she told the assembly.

Kenya also urged WHO to establish and regularly update the list of countries with critical health workforce challenges.

Transparency and Accountability

A representative from the United States asked WHO to put more pressure on Member States to report information on international recruitment of health professionals.

She said this would promote fair, equitable and ethical decision-making. She referred to Cuba, which had more than 30,000 doctors working in nearly 70 countries in 2019.

The US called for the investigation of any allegations by health personnel of human trafficking and slave labour conditions. If substantiated those responsible must be held accountable, she said.

Dr Jim Campbell, WHO’s Director of Health Workforce, noted that the global health body will work on the strategic directions on the code of practice, and address the implementation gap.

Image Credits: Tim Kubacki/Flick, UNICEF/Frank Dejongh, Twitter: WHOAFRO.

A scientist at Ethiopia’s National Influenza and Arbovirus Laboratory, in February, equipped to test for COVID-19.

Africa is set to establish a plan of preparedness and to compile influenza data sets with the World Health Organisation (WHO), to expand its surveillance of potential flu outbreaks.

The African region has also called for the integration of influenza surveillance into an all-inclusive infectious disease surveillance system, and for the creation of a necessary mechanism for contributory finance that can make vaccines and control measures affordable and equitable.

Dr Chikwe Ihekweazu, Director General of the Nigeria Center for Disease Control (NCDC), told the World Health Assembly (WHA): “We notice the challenges with influenza preparedness as well as the consequences that recurring pandemics have on health, economies and society – particularly on vulnerable countries with weak health systems, now exacerbated by the COVID-19 pandemic.”

Establishing a plan of preparedness with the Secretariat would “help expand and reinforce the surveillance and diagnostic capacity of the African region in case of influenza outbreaks,” he said.

He also asked WHO to continue to stockpile vaccines in anticipation of influenza outbreaks, so as to support the region’s ongoing plan to expand sentinel sites next year.

Could the Northern Hemisphere Avoid Flu Season?

In the early weeks of the COVID-19 pandemic, WHO and health stakeholders noted that COVID-19 could worsen the seasonal influenza outbreaks around the world.

“Every year, there are up to 3.5 million severe cases of seasonal influenza worldwide, and up to 650,000 respiratory-related deaths,” WHO stated. “Every hospital bed occupied by a patient with COVID-19 is a bed that is unavailable for someone else with another condition or disease, such as influenza.”

As of November, however, trends are less clear.

On the one hand, over the spring and summer, the southern hemisphere registered a sharp drop in flu cases compared to previous years – attributed to COVID-19 restrictions and guidance like social distancing and hand washing.

At the same time, given the unpredictable course of the pandemic, public health officials have warned countries in the north not to let up their guard.

“We cannot assume the same will be true in the northern hemisphere flu season,” WHO stated. “The co-circulation of influenza and COVID-19 may present challenges for health systems and health facilities, since both diseases present with many similar symptoms.”

WHO said it is working with countries to take a holistic approach to the preparedness, prevention, control and treatment of all respiratory diseases, including influenza and COVID-19.

“Many of the same measures that are effective in preventing COVID-19 are also effective for preventing influenza, including physical distancing, hand hygiene, covering coughs, ventilation and masks,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus.

WHO Must Make Sure Africa’s Record-Low Cholera Cases Are Not Undone by COVID-19

African countries, including Zambia, Nigeria and South Sudan, reported an average 59% decrease in the number of cholera cases between 2017 and 2018, as the broader African region experienced its lowest number of cases in the 21st Century. COVID-19’s impact on vaccination campaigns, however, threatens to drive cases back up.

Dr Chikwe Ihekweazu says influenza outbreaks in Africa require improved surveillance
Dr Chikwe Ihekweazu, DG of Nigeria’s NCDC, spoke on behalf of the African region at the WHA on Wednesday.

Despite the successes so far earned by global initiatives – like the Global Task Force on Cholera Control’s 2030 roadmap which aims to reduce cholera deaths by 90% using evidence-based best practices – Ihekweazu noted the urgent need for additional work to ensure these milestones are consolidated.

“We emphasize that despite a significant downward trend in cholera transmission, more effort is needed to sustain the results achieved, especially during this period of the COVID-19 pandemic,” Ihekweazu said.

He also called for support for a privatization of epidemiological and laboratory surveillance, and a multi sectoral approach to strengthening health systems: a sentiment mirrored by a separate committee at the WHA.

Dr Ibrahima Socé Fall, WHO’s Assistant Director-General for Emergencies Response, noted that there was a 64% reduction in cholera deaths between 2019 and 2018 in the African region, and he drew attention to Nigeria and Sudan’s requests for continued investment in laboratory capacity and community engagement.

He said: “We are continuing to work on this with our partners. There are still a number of challenges despite this progress that we’ve made.”

Dr Socé Fall noted that many African countries, including Cameroon, Uganda and Mozambique, are now resuming their vaccination campaigns following COVID closures, with others resuming preventive campaigns. In 2019, the region distributed 23 million oral cholera vaccines.

“We are also seeing preventive campaigns in Zambia, Tanzania and other countries,” he said. “We would encourage countries not to cancel these campaigns.

“COVID-19 measures have been implemented and it is important that we continue to do this to save lives.”

Image Credits: WHO AFRO/Otto B., WHO / WH.

A bavy is given a polio vaccine
A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus is expetced to roll out in Janaury.

Despite the big success this year in the eradication of wild poliovirus in the African region, the COVID-19 crisis has seen a temporary interruption of polio vaccine programmes. This has led to a rise in vaccine-derived polio cases which, are more likely to occur when vaccine coverage is weaker, WHO and African Region health officials told World Health Assembly (WHA) member states in a wide-ranging review of WHO’s massive two-decade polio eradication effort.

The prospect of a forthcoming COVID-19 vaccine, meanwhile, underlines the important role the programme can play, WHO’s Dr Michel Zaffran, director of the Polio Eradication Programme, said at the WHA session. He specified that adapting national polio eradication teams to COVID-19 prevention and eventually immunization was critical.

“Since July … polio immunization campaigns have resumed under strict infection control protocols in endemic impoverished countries,” he noted, adding that “polio staff have rapidly pivoted to support COVID-response activities, helping with disease surveillance, contact tracing, and educating communities on physical distancing and hygiene.”

Zaffran warned, however, that inadequate vaccine coverage in areas at risk of outbreak mean that “risks are high”.

A map indicating the disparity in polio immunization in Africa.

“Last week, UNICEF and WHO issued a global call,” he said, “for the international community to ensure that the financial resources needed to respond to outbreaks are made available.”

WHO’s Sylvie Briand confirmed that WHO is looking at options to ensure the continued cross-fertilizing between polio eradication and the COVID battle.

She said: “We know that innovative partnerships, mechanisms and platforms, developed through the ACT Accelerator can be leveraged for long term investment in pandemic preparedness, including the research, development and availability of innovative influenza pharmaceutical products.

“So … learning from the COVID-19 crisis, we are looking at options to ensure the continent continues cross-fertilising between programmes.”

“There is an opportunity to link the transition of polio-funded assets with COVID-19 recovery efforts to build back better,” said a representative of the UN Foundation, one of the partners in the polio eradication effort.

Integrating Polio Programmes with National Health Systems

Over the longer term, better integration of polio programmes with national health systems remains a key priority, donor states have emphasized.

“Polio programmes have become cornerstones of the national health system, including their response to COVID 19. It is essential that we progress on integration of the project assets into the national health programmes and have polio vaccines integrated,” said Germany’s WHA representative.

The wide-ranging conversation followed WHO’s presentation to member states of a progress report on its eradication effort. A parallel WHO report covers polio “transition planning” – shifting polio staff and resources into broader Ministry of Health vaccines and primary health care activities.

The Global Polio Eradication Initiative (GPEI) is one of the WHO’s and the world’s largest single global health efforts, with a separate budget of US$4.2 billion, that employs teams embedded in the national health systems of countries in Africa, the Eastern Mediterranean region, and the Western Pacific (Asia). Gavi, the Vaccine Alliance has contributed more than US$180 million to the GPEI, and has pledged an estimated US$800 million in support of inactivated polio vaccines (IPV), as part of GPEI’s Polio Endgame Strategy.

The number of polio cases has dropped significantly, but the COVID pandemic threatens this progress.
Polio Programmes: From Downsizing to Repurposing

Only a couple of years ago, the main corridor conversation inside WHO was how to dramatically downsize the polio programme – including termination or transition of polio team members to other positions – as eradication goals were progressively met.

Now, talk has pivoted to a conversation about how to repurpose those same programmes and teams to help deliver COVID-19 vaccines when these become available – a new and equally momentous task.

Along with that, donors and countries are talking about the importance of better, long-term “integration” of the vertically-designed, donor-driven polio programme into countries’ broader immunization plans and national health systems.

De facto, polio teams are already deeply involved in national health services delivery of a much broader array of vaccines – including the 3-in-1 Td/IPV vaccine (protecting against tetanus, diphtheria and polio).

But until the COVID-19 pandemic, the relevance of the polio programme to vaccine services more broadly was not well understood.

Now that COVID has made this more obvious, the challenge of supporting and funding the institutional rea-lignment of resources remains. With this support in place, national ministries and immunization programmes can staff and fully budget for tasks being fulfilled by the polio programme, as part of primary health care systems.

New Low Risk Oral Vaccine Rollout Urged

A new oral vaccine that is expected to have a substantially lower risk of generating vaccine-derived poliovirus (VDPV) cases was also announced to replace a predecessor that had been used until 2016. The new vaccine is expected to be rolled out, beginning in January 2021 and will be deployed under emergency use.

While oral polio vaccines (OPV) are generally safe and effective, on rare occasions the live poliovirus component can cause infection.

But since 2016, when the earlier OPV was withdrawn, some 49 outbreaks of a genetically distinct circulating VDPV have been reported in 21 countries, including in Africa and the Eastern Mediterranean and Western Pacific Regions.

“Unfortunately, 2020 has seen a dramatic increase in outbreaks of circulating VDPV in Africa and Asia,” said Dr Zaffran. Commenting on the deployment of the new vaccine, he added: “This must be complemented by existing tools, including efforts to strengthen routine immunisation with a second dose of IP.”

Increasing Risk of VDPVs in Migrants to Polio-Free Countries

Several countries – including those certified polio-free – reported an increased risk of polio infection in vulnerable populations, caused by COVID-impeded vaccination campaigns.

Malaysia is a country that was declared polio-free in 2000, however it warned that delays in vaccination campaigns pose a risk to newborns and migrants. The representative said that the GPEI and international organisations need to assist countries to “address the issues of highly-mobile, cross-border populations.”

A representative from Iran cited a “growing concern due to illegal immigration” with neighbouring countries. Wild polioviruses still exist in Afghanistan, which sits along Iran’s eastern border, and experienced an outbreak of VDPV type 2 earlier this year.

The Malaysia representative also said: “Undocumented migrants are at an even greater risk of missing not only routine immunisation, but also polio vaccination campaigns. Efforts to address these marginalised populations will benefit polio control.”

Image Credits: UNICEF Ethiopia/Mulugeta Ayene 2018, WHO.