Part of a series of stories about how the coronavirus lockdowns and relaxations are playing out in different parts of Africa. For more on this, see our stories on South Africa and Ibadan, Nigeria.

Crowed market scene in Kampala – some wear masks and others do not.

Kampala, Uganda – As Uganda’s coronavirus cases double in only two weeks, the Ministry of Health is considering a second lockdown to control the SARS-CoV2 virus spread. But will another lockdown really curb the number of cases? Does the healthcare system have the capacity to handle the next wave? And what will be the cost in lives of both health workers and the general public? Reflections from an emergency room doctor in Kampala:

Since I am not one of the scientists that advises the President on public health measures like lockdowns, let me leave it to the experts to decide whether a second lockdown would be effective. We know, however, from many countries – such as the USA, Mexico, and Italy, among others – that full-blown lockdowns may not halt transmission of the coronavirus – and it won’t prevent deaths from the disease either.

So far, the death toll in our country has been exceedingly modest, compared to countries in Europe, Asia and the Americas as well as countries on our continent, such as South Africa. Since the first case of the coronavirus was reported in Uganda on March 19, the virus has claimed a little more than twenty lives. However, the situation now is rapidly changing. Over the past  weeks, Uganda’s number of Covid 19 cases has doubled, with its highest number of new cases in just 1 day being 318.

Mask distribution in a village in Uganda.

Our President, Yoweri Kaguta Museveni, has repeatedly appealed to Ugandans to follow the Standard Operating Procedures (SOPs) that his government has put into place. Based on WHO recommendations, they focus on: physical distancing, universal mask-wearing on public transport and in public spaces, as well as basic hand hygiene.

In hospitals and clinics, WHO guidelines call for the continuation of basic health services, while strictly separating COVID-19 cases from others seeking health care. At the same time, health workers need extra protection, so that they don’t become ill and risk infecting others.

Regrettably, even as we now face a serious uptick in new infections – we are falling short both in the public sphere and in our hospitals. Ugandans seem to be either indifferent or unable to follow the president’s directives. And this threatens our entire effort to keep people safe and healthy – including health workers.

Deadly Lockdown Guidelines

Empty road in Kampala, Uganda, during the first lockdown in March – June.

Admittedly we hardly had any COVID-19 cases when the police and other security organs enforced a a strict lockdown between March and June.  But that was also a crude tool with often cruel consequences.

At a time when all transport was shut down, I received a call from a pregnant woman in labour, who was trying desperately to reach a hospital as her baby was in a breech position – which meant she really needed a cesarean.

I knew this because I had examined her myself only a couple of weeks earlier while visiting my hometown in eastern Uganda.

‘’I am 8-months pregnant and bleeding for 2 days now,” the woman lamented over the phone. According to the lockdown guidelines, however, anyone traveling to the hospital had to first get permission from the Resident District Commissioner’s (RDC’s) office in-person.  And the RDC office was too far for her to walk, bleeding alone.

I was working at my hospital in Kampala and thus unable to provide immediate help. She told me that she would try to reach a traditional birth attendant (TBA). When I eventually spoke with her again two days later, she told me she had walked to the neighboring village, and was being cared for by a TBA.

‘’The bleeding has increased and I’m becoming weaker and weaker, I doubt that I will make it this time.’’

My heart sank as she spoke to me in her the voice of someone who was dying. I looked for ways to reach the RDC directly myself, to request an ambulance to save the mother and her child.

Luckily enough, I finally got through to him, and knowing me, he offered us an ambulance. The driver rushed her to Mbale Regional Referral Hospital, where I was already making arrangements so that a team of health workers would be ready to receive her. The doctors performed a successful cesarean, but her baby had died in the womb by the time it was performed.

I’m glad that my efforts at least helped save the mother – because we would have probably lost both mother and infant had we not reached the hospital. I can only imagine the pain she went through.  But if we face another lockdown now, will the same scenes be repeated elsewhere?

Does Uganda’s Healthcare System Have The Capacity To Handle The Next Wave?

Unprotected medical workers lean over the bed of a sick patient in a Uganda hospital – some of whom may be infected with COVID-19.

To cut a long story short, sadly NOT. That’s because very little has changed since the first wave – which was contained by a public lockdown.

The alternative to a lockdown this time around would be strict public adherence to mask, hygiene and social distancing measures as well as a nimble health system response.

But the public remains lax and the health system is still under-funded. We still face the same shortages in human resources, supplies, and crucial infrastructure that would allow for the effective and timely testing, tracing and isolation of COVID-19 cases.  We can’t follow the WHO guidelines for proper management of COVID cases.

Not Enough PPE – Suspected COVID-19 Cases Mixed With Regular Patients

Here’s an example from one recent shift in the emergency room of the hospital where I am working now. A restless, 52 year-old business man with known hypertension came through our doors late one night. He had been suffering with a cough for the past two days, had difficulty breathing, and also had hypoxia, or low blood-oxygen levels – all signs of the SARS-CoV-2 virus.

The internist on night duty, a friend and colleague of mine, contacted the designated COVID-team, which did not hurry to examine him –  initially telling him to first rule out other causes of the symptoms. Finally, he admitted the man, with a diagnosis of suspected community-acquired pneumonia.

The COVID-team, fully gowned with extensive personal protective equipment, came to the emergency ward, collected a nasal sample, and left within 20 minutes. The following day, with the COVID test still being processed, the patient was moved to a general ward, in close proximity to the other patients who were being treated for other, unrelated conditions.

Except for the fully protected members of the COVID-19 team who took the nasal sample, the other medical staff who saw him over the following hours – from senior doctors to internists like myself, nurses, and administrative staff – have access only to a surgical mask and disposable gloves. Including myself. These are the people who must collect patient history, conduct routine exams, connect oxygen, provide treatment, and remain within close proximity of the patients for more than 12 hours a day.

The man died as a team struggled to administer him oxygen – his test results later confirmed that he had COVID-19.

Following that, we all had to be tested – and those among the medical staff who tested positive are now under quarantine. I was among the lucky ones who tested negative. This was particularly reassuring for me.  As a diabetic, I am also at higher risk from COVID-19.

But the reprise is only temporary.  In fact, day after day, virtually all the staff in our wards, and in the whole hospital, are at constant risk of exposure to suspected COVID-19 cases, and thus at risk of exposing other patients, as well as outpatients, to a potentially deadly virus.

And all of the medical staff also return home to their families everyday – or in my case, on the occasional weekend when I manage to make the journey back to my hometown in eastern Uganda.

So what happens when the next patient arrives at our emergency room, with a suspected COVID-19 case?

The COVID team says it lacks the capacity to quarantine and treat suspected COVID patients – even if they are very ill – until a test-confirms their diagnosis. Meanwhile, health workers remain exposed, and are thus exposing everyone around them.

This is the case in most regional referral hospitals. This is where we are as a country.

What is the fate of health workers?

Health workers deaths due to COVID-19 in Africa, Asia and Europe.

As of 13 July, over 3,000 health workers in some 79 countries have died from the coronavirus, according to Amnesty International. And healthcare workers in almost 63 countries have reported serious shortages in PPE.

Like other hospitals in Uganda and many other countries elsewhere, our fate as health workers is uncertain.

On the one hand, vigorous campaigns are underway in the community to introduce Ugandans to masks and reinforce handwashing and hygiene measures.

Health workers demonstrate handwashing to villagers in eastern Uganda – to prevent COVID infection.

But in the hospitals, the basic preventive measures we could take are weak.

We can only pray that patients we manage everyday for community-acquired pneumonia do not have actually have COVID-19. And if they do, which has already happened in past months, we shall all be quarantined.

As case numbers increase, more of us, depending on the degree of exposure, will contract the coronavirus – and many will die.

The senior medical staff who decided to neglect us will be forced to emerge from their administrative offices to treat many of us – while also managing malaria, hypertension and women in labour – COVID or not.

Many will be called heroes. Heroes who were left to die. Heroes who were sent out as sacrifices with no protection. Heroes who had no choice but to work in unsafe environments set out for them.

 Countering The Pandemic

Samson Wamani wearing a non-medical mask that he uses when not on duty.

Still, I refuse to be only a complainer. We can be part of the solution that addresses the issues our country is facing. All we really need to do is to put the lofty rhetoric issued at the top policy echelons into real action in our hospitals and wards.

“Africa can only counter this pandemic through robust policy responses in every single country on our continent, with additional support from our partners around the globe, declared Charles Leyeka Lufumpa, vice president for economic governments at the African Development Bank Group, in an editorial this week.

“In the short-term, African countries should prioritize health care spending to supply us with essential personal protective equipment (PPE) and to accelerate local production of vital healthcare products –  including PPE, vaccine and other medicines,” he added.

Health workers and management must unite and acknowledge existing shortcomings. Let us set out on a journey to solve the problems of the system once and for all. We must stand our ground on the numerous shortfalls in human resources, PPE supply, and health infrastructure.

The Government must invest in the system with appropriate funding, facilities, supplies and human resources.

Just yesterday, ministers and officials from over 40 different Member States across WHO’s Africa region met virtually for the WHO Regional Committee for Africa, and agreed that the pandemic has been a tragic reminder that we must invest more in our health systems.

“The coronavirus pandemic has proven once again the importance of investing in health systems, enhancing equitable access to care and improving readiness to prevent and control outbreaks,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “Recovering from this pandemic will be incomplete without strong measures to bolster health systems. We must seize the opportunity and make the leap for a better tomorrow.”

Let us stop pretending that things are okay. That we are ready to die only due to reckless circumstances. That we are more patriotic than leaders who have paid a deaf ear and blind eye to the obvious problems we’re all facing.

Let us decide to protect ourselves, our patients, our families and country at large by not being part of the system that spreads a disease that’s actually preventable through evidence-based public health measures.

There is still time to save Uganda from a larger wave that’s flooded other countries on the continent, such as South Africa. This war can be won if we stop talking and start doing. The time is now!

  • Postscript: 9 September – Two Ugandan doctors have since died due to corona-related complications, in Lira and Mbarra regional hospitals. The COVID Treatment Unit (CTU) in my hospital is full to capacity. But suspected cases are still being mixed into the general wards unless and until their infection is confirmed by a test.  The government is planning to open schools beginning September 20th – but there are no practical measures put in place to control the spread of the virus.  We are bracing for huge numbers – we only hope that we shall not get many with severe disease.  

________________________________________

The above are my personal opinions.

Dr Samson Wamani is “examined” by one of his young patients – just weeks before the pandemic began.

Samson Wamani, is currently working as a frontline medical doctor in a COVID-19 referral hospital in Kampala, Uganda. He is also the Executive Director of RAIN Uganda, an NGO that offers HIV education and testing in the Mbale area. He previously headed a health centre in eastern Uganda, as well as serving as the health and development officer for the NGO, Innovation Africa. He has a passion for maternal and child health.. 

 

Image Credits: Samson Wamani , Samson Wamani, Ndahiro derrick, Amnesty International, Sasmson Wamani .

An oral polio vaccine is administered to a child.

Brazzaville – The independent Africa Regional Certification Commission (ARCC) for Polio Eradication officially declared on Tuesday that the World Health Organization (WHO) African Region is free of wild poliovirus.

This marks the eradication of the second virus from the face of the continent since smallpox 40 years ago.  And while vaccine derived polio is still circulating in 16 countries, there is a new strategy to tackle that next.

“Today is a historic day for Africa. The African Regional Certification Commission for Polio eradication (ARCC) is pleased to announce that the Region has successfully met the certification criteria for wild polio eradication, with no cases of the wild poliovirus reported in the Region for four years,” said Professor Rose Gana Fomban Leke, ARCC Chairperson.  

The ARCC’s decision comes after an exhaustive, decades-long process of documentation and analysis of polio surveillance, immunization and laboratory capacity of the region’s 47 member states, which included conducting field verification visits to each country.

In 1996, African Heads of State committed to eradicate polio during the Thirty-Second Ordinary Session of the Organization of African Unity in Yaoundé, Cameroon. At the time, polio was paralyzing an estimated 75,000 children, annually, on the African continent.

In the same year, Nelson Mandela with the support of Rotary International jumpstarted Africa’s commitment to polio eradication with the launch of the Kick Polio Out of Africa campaign. Mandela’s call mobilized African nations and leaders across the continent to step up their efforts to reach every child with polio vaccine.

The last case of wild poliovirus in the region was detected in 2016 in Nigeria. Since 1996, polio eradication efforts have prevented up to 1.8 million children from crippling life-long paralysis and saved approximately 180,000 lives.

“This is a momentous milestone for Africa. Now future generations of African children can live free of wild polio,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “This historic achievement was only possible thanks to the leadership and commitment of governments, communities, global polio eradication partners and philanthropists. I pay special tribute to the frontline health workers and vaccinators, some of whom lost their lives, for this noble cause.”

“However, we must stay vigilant and keep up vaccination rates to avert a resurgence of the wild poliovirus and address the continued threat of the vaccine-derived polio,” said Dr Moeti.

Vaccine derived poliovirus continues to circulate

While the eradication of wild poliovirus from the WHO African Region is a major achievement, 16 countries in the region are currently experiencing vaccine-derived polio outbreaks (cVDPV2), which can occur in under-immunized communities.

While rare, vaccine-derived polioviruses cases can occur when the weakened live virus in the oral polio vaccine passes among under-immunized populations and, over time, changes to a form that can cause paralysis. If a population is adequately immunized with polio vaccines, it will be protected from both wild polio and circulating vaccine-derived polioviruses.

The 16 countries in Africa currently affected by circulating vaccine-derived polioviruses outbreaks include: Angola, Benin, Burkina Faso, Cameroon, Central African Republic, Chad, Côte d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Guinea, Ghana, Mali, Niger, Nigeria, Togo and Zambia.

Responding to circulating vaccine-derived polioviruses

To address the growing challenge of circulating vaccine-derived polioviruses, the GPEI’s new ‘Strategy for the Response to Type 2 Circulating Vaccine-Derived Poliovirus 2020-2021’ is focused on working with affected and at-risk countries to control circulating vaccine-derived polioviruses outbreaks ongoing across the African Region.

The first stage of this targeted strategy involved launching a rapid response team specifically to respond to circulating vaccine-derived polioviruses. Formed in September 2019, the team is coordinated from WHO’s Regional Office for Africa in Brazzaville and is composed of 20 experts in operations and vaccination management, epidemiology, logistics, and communications, drawn from GPEI’s core partners.

“Africa has demonstrated that despite weak health systems, significant logistical and operational challenges across the continent, African countries have collaborated very effectively in eradicating wild poliovirus,” said Dr Pascal Mkanda, Coordinator of WHO Polio Eradication Programme in the African Region.

“With the innovations and expertise that the polio programme has established, I am confident that we can sustain the gains, post-certification, and eliminate cVDPV2,” added Dr Mkanda.

“The expertise gained from polio eradication will continue to assist the African region in tackling COVID-19 and other health problems that have plagued the continent for so many years and ultimately move the continent toward universal health coverage. This will be the true legacy of polio eradication in Africa,” said Dr Moeti.

Polio is a viral disease that is transmitted from person to person, mainly through a faecal-oral route or, less frequently, through contaminated water or food, and multiplies inside the intestines.

During the lifespan of the Global Polio Eradication Initiative, polio cases have reduced by 99.9% since 1988, bringing the world closer than ever before to ending polio. The initiative is a public-private global partnership comprising national governments; WHO; Rotary International; the United States Centers for Disease Control and Prevention; UNICEF; the Bill & Melinda Gates Foundation; Gavi, the Vaccine Alliance; and a broad range of long-term supporters.

For more details about polio, see WHO’s press release: Africa eradicates wild poliovirus.

Image Credits: WHO.

Convalescent plasma from recovered patients may help treat COVID-19`

There is insufficient evidence that treating people hospitalized for COVID-19 with blood plasma from recovered patients is safe and effective – and more randomized clinical trials are thus needed, warned the World Health Organization on Monday. 

Evidence overall remains “inconclusive,” said WHO chief scientist Soumya Swaminathan at a WHO press conference on Monday. 

She spoke just a day after the United States Food and Drug Administration (FDA) issued an emergency authorization for use of the antibody-rich cocktail from the plasma of recovered coronavirus patients in people hospitalized with COVID-19.

Swaminathan added that while blood plasma has been used to treat a variety of infectious diseases for over a century, it is still an “an experimental treatment” for SARS-CoV-2, the virus that triggers COVID-19.  

In the US, over 71,000 hospitalized COVID-19 patients have already received convalescent plasma as part of the nation’s Expanded Access Program. However, evidence supporting its use is still “inconclusive” and “very low quality”, said the Organization.

WHO chief scientist Soumya Swaminathan

“There are a number of clinical trials going on around the world looking at convalescent plasma compared to standard of care, and only a few of them have actually reported results, and the results are not conclusive,” said WHO Chief Scientist Soumya Swaminathan, at a press conference on Monday, in response to a question from Health Policy Watch. “The trials have been fairly small [and while some] trials report some benefit…[the evidence] is still very low quality.”

“The most important question really is about its efficacy and safety being proven and randomised trials, and I hope that we get that evidence in the coming weeks.” 

“At the moment, it is still a very low quality of evidence.. So we recommend that convalescent plasma is still an experimental therapy. It should be continued to be evaluated in well-designed randomized trials.

“Of course countries can do emergency use listings, if they feel that the benefits outweigh the risks,” she added, in a nod to the US FDA move. “But that’s usually done while you’re waiting for more definitive evidence.” 

US President Trump Calls Plasma “Beautiful Ingredient” – Others Less Sure 

Despite the expert reservations, Sunday’s FDA authorization of the treatment was trumpeted at a White House press conference, where US President Donald Trump hailed the plasma as a ‘beautiful ingredient’ that would be a game-changer for COVID patients. 

US Health and Human Services Secretary Alex Azar called it a “milestone achievement” while FDA Commissioner Stephen Hahn, FDA Commissioner, said that data from some 70,000 people pointed to as much as a 35% reduction in mortality.  

The largest such study of some 35,000 people, undertaken by Minnesota’s Mayo Clinic, suggests that people given plasma treatment within 3 days of being hospitalized had somewhat better survival rates than others, as did people who received plasma with higher levels of SARS-CoV-2 antibodies.  This was according to preliminary data published on medrxiv.org, which has not been peer-reviewed yet.

“We dream in drug development of something like a 35 percent mortality reduction. This is a major advance,” Azar. 

However, a number of leading US health experts, including Dr Antony Fauci, one of Trump’s top COVID advisors, last week had urged the FDA to hold off on its emergency approval of the plasma treatment, saying that existing data was still not strong enough to support wider plasma use. 

Notably, the Mayo clinic data was gathered only from “observational” studies and not from randomized controlled studies that are the gold standard for evaluating treatment efficacy. 

In a Twitter blast last week, Trump had impatiently blamed the “deep state” for delaying approval of COVID-19 vaccines and therapeutics.  And speaking at Sunday’s press conference, Trump made it clear that he saw the FDA approval as an election issue – suggesting that the authorization might initially have been delayed for political reasons.  

Critics Say Hasty Approval Threatens FDA’s Credibility

After the FDA issued the emergency use authorization anyway on Sunday, some health policy experts blasted it as a move that had been expedited due to politics, not health concerns, in a week where Trump is heading into the Republican National Convention and wants to show fast results in the COVID battlefront. 

The FDA approval threatens to “further damage” the Agency’s credibility at a crucial time, said Rachel Sachs, Associate Professor of Law at Washington University. 

“Given the explicitly political pressure on the FDA to rush the approval of COVID-19 products, authorizing a new product 1) without publishing the evidence and 2) without a supporting randomized trial risks further damage to public trust in the agency.”

“To be clear, some data from observational studies have been released. But because randomized trials have not yet shown a benefit, it’s not clear than opposing observational data can support an emergency use authorization. It will be critical to see more randomized clinical trials.”

Convalescent plasma isn’t the first product to receive emergency approval despite a shaky evidence base. The antimalarial hydroxychloroquine received emergency approval in late March, after it was widely touted by Trump; its emergency use was later revoked in mid-June after the treatment failed to deliver results in patients. 

Convalescent Plasma May Trigger Side Effects And Could Be Difficult To Scale-Up

Although convalescent plasma has been used against infectious diseases for almost 100 years, it is not risk-free, and may not be suitable in all contexts, added WHO experts at Monday’s press conference. 

Most notably, the actual levels of antibodies received cannot be well-controlled since each plasma portion has different antibody titres, said Swaminathan. So even if convalescent plasma proves to be effective and safe, it may be ‘very difficult’ to deliver a standardized therapy to patients.

“One of the challenges with convalescent plasma is each individual may have different titles of neutralizing antibodies after recovery, and it’s very difficult to standardize that”, Swaminathan observed.

She also added that scaling-up convalescent plasma therapy may be difficult in countries or hospitals that lack the necessary facilities to screen, extract and store plasma from the blood of recovered patients.

Given that convalescent plasma contains a range of different antibodies – including the highly specific neutralizing antibodies – it may result in side-effects like mild chills and fevers, as well as “more severe” lung-related injuries, or even circulatory overload, noted Bruce Aylward, WHO’s Senior Advisor to the Director-General. According to the FDA, circulatory overload is the second leading cause of death in people that receive transfusions.

“For that reason, clinical trial results [for convalescent plasma therapy] are extremely important to know that we have here demonstrated efficacy” and safety, he added.

Convalescent Plasma Versus Monoclonal Antibodies  

Usually, extraction of plasma from the blood requires continuous centrifugation and subsequent freezing within a day of collection. Also, any convalescent plasma sample must be screened for blood-borne infectious diseases – like human immunodeficiency virus (HIV), hepatitis B or C, or even syphilis – and clinicians must match suitable blood types together to prevent adverse immune reactions. 

Given the drawbacks of convalescent plasma, some scientists have instead been suggesting that there may be greater potential for developing more specific and standardized monoclonal antibody treatments, as per their use in past outbreaks, such as Ebola. 

“There’s a lack of willingness, so there isn’t enough [convalescent plasma] around, but I think the most important question really is about its efficacy and safety being proven and randomised trials, and I hope that we get that evidence in the coming weeks,” said Swaminathan.

Image Credits: Sarah Chapman / Evidently Cochrane, WHO.

Some 101 public health organizations have called on the International Automobile Federation (FIA) to put an end to all tobacco advertising in connection to the world-famous Formula 1 (F1) races that FIA sponsors. The organizations issued the call in an open letter to FIA President Jean Todt, released by the tobacco industry watchdog STOP last week.

The call follows on the heels of a call by the World Health Organization last year for sporting bodies, including Formula 1, to adopt stringent polices to prevent participants from receiving any sponsorship through tobacco companies, in line with the WHO Framework Convention on Tobacco Control (FCTC).

Currently, the door remains open for tobacco companies to market their products to Formula 1 fans, despite claims by FIA, Formula 1’s lead sponsor, that its organization is FCTC compliant.

In fact, Phillip Morris International (PMI) and British American Tobacco (BAT) spent US $110 million on Formula 1 sponsorships in 2019. A recent report estimated that the two companies will spend over US $115 million on F1 sponsorships in 2020.

Tobacco marketing expenditures were not mentioned in the new Concorde Agreement, the contract between FIA, Formula 1 and all F1 teams wishing to compete, which sets guidelines for the sport through the next five years, including for the recruitment and allocation of advertising revenues.

“The sport represents one of the last vestiges of Big Tobacco’s global marketing to lure young people into addiction through sports,” the open letter stated. ” Continued tobacco sponsorship in Formula 1, and the promotion of tobacco company’s brands, either directly through brand stretching and extensions, on and off the track is a violation of public health laws and United Nations (UN) norms. Federation Internationale de l’Automobile’s (FIA’s) continued tolerance of this situation defies good governance and is inconsistent with the commitments the FIA has made to UN global road safety and climate change initiatives,” states the open letter.

“While it committed to removing tobacco from the sport, under its watch the industry’s spending is on the increase. FIA cannot claim to be the regulator if it cannot control its races and shirk its responsibility by giving excuses,” said Mary Assunta, from Global Center for Good Governance in Tobacco Control, a partner in STOP, in a press release. “FIA represents the last major hurdle to complete a sweeping change that shows tobacco has no place in sports.”

The organizations accuse tobacco companies of taking advantage of Formula 1’s fast growing fanbase under the age of 25 and marketing tobacco products to youth, which is illegal under the WHO’s FCTC. The Convention has been ratified by 182 countries.

The letter also criticizes the FIA Foundation for claiming that it supports the WHO FCTC, as well as participating in a range of other formal UN-sponsored initiatives, while ignoring WHO’s calls for Formula 1 to end tobacco sponsorship.

“FIA’s continued failure to take responsive action to prevent violations could make it complicit with the tobacco industry,” the letter states.

FIA has made official commitments to both UN global road safety and climate change initiatives, and is officially listed on the WHO website as a partner in the “Friends of the Decade of Action for Road Safety 2011-2020. FIA President, Jean Todt, is also the UN Special Envoy for Road Safety.

“FIA’s commitment to protect the planet and promote safety is a sham if it continues to be a vehicle for tobacco sponsorships that contribute to killing people and destroying the planet.” the open letter added.  “Even if FIA manages to reduce Formula 1’s 256,551 tons of carbon footprint (2019), it continues to contribute 845,000 tons of cigarette butts per year. This staggering amount of waste kills animals, pollutes land and sea, slows sustainable consumptionand undermines the basic principles of the UN framework.”

Todt’s own role as a UN Special Envoy for road safety creates a further conflict of interest, the tobacco control groups say.

“There is a conflict between Mr. Todt’s role as President of the FIA, the governing body of a sport that is promoting tobacco industry interests, and his public health commitments as a UN representative. FIA’s claims about being ‘PurposeDriven’ ring hollow when you look at its resistance to ending tobacco industry involvement in the sport,” said Phil Chamberlain from the University of Bath, a partner in STOP, in a separate press release.

“The tobacco industry is a major driver of disease and death; it targets youth, women, minorities and other vulnerable groups; it profits from the exploitation of vulnerable workers in tobacco farming, and it harms the environment.”

Image Credits: Flickr: Indrid_Cold.

A new US $200 million program, financed by the United States Agency for International Development (USAID), aims to strengthen health data systems in developing countries.

USAID is currently developing the scope of this project, including country participation, according to a spokesperson from global health NGO and partner on the project, Vital Strategies.

Strengthening health information systems is particularly important in the context of COVID-19. An effective pandemic response is dependent on pinpointing the communities where the virus is spreading, which can only be done with a fast-reacting health information system.

“All aspects of governments’ responses to COVID-19 should be informed by data, including decisions on tightening or loosening public health and social measures, performance of contact tracing, maintenance of essential health services and opening of schools,”José Luis Castro, president and CEO of Vital Strategies told Health Policy Watch.

“Health information systems can centralize this data and inform policymaking as close-to-real time as possible—both helping governments understand the pandemic’s true human scope and scale, and accelerating the implementation of lifesaving measures,” added Luis Castro.

A well-oiled health information system will also be able to inform decision makers about where the highest health inequities are.

“This is especially urgent given that the pandemic is not impacting all communities equally; Black and Latinx people in the US are twice as likely to die from COVID-19 as white residents, and this is a challenge surfacing globally as well. In every country, we need high fidelity and rapid data to detect and respond to these inequities, and ensure that public health decision-making is reaching our hardest hit communities,” said Luis Castro.

In many countries, health data collection is reliant on paper forms, which must then be reentered into digital health systems. But sometimes, different platforms are used for different disease areas, and health surveillance officers must manage data across a variety of platforms, as well as other responsibilities.

USAID’s Country Health Information Systems and Data Use (CHISU) Program aims to build up and streamline health information infrastructure, as well as support training in using data for decision making at the sub-national and national level.

One of the first projects of its kind in USAID’s portfolio, the program will be led by public health firm JSI Research and Training Institute. in collaboration with Vital Strategies, research firm RTI International, and digital health NGO Jembi Health Systems. A consortium of leading public health academic centers in low and middle-income countries, GEMNet Health, is also a partner in the program.

Image Credits: David Snyder/CDC Foundation.

The World Health Organization and UNICEF have issued new age-specific mask guidance for children, recommending looser masking protocols for younger children.

The agency’s new guidance comes the week after a new study from researchers at the Massachusetts General Hospital found that children infected with COVID-19 had higher virus levels in their nose and throats than adults, despite showing less severe or no symptoms. The findings suggest that children may be “silent spreaders” of the virus, expelling more virus than infected adults despite being less prone to getting symptoms of COVID-19 themselves.

“[Based on preliminary studies] there appears to be a difference in transmission by age group, with the younger children able to transmit less than teenagers, for example, but this data is really limited,” Maria Van Kerkhove, WHO technical lead for COVID-19, told reporters Friday.

Children under the age of 5 should not be required to wear masks, according to the new guidance.

The guidance takes a “risk-based” approach to recommendations for kids between the ages of 6 to 11 years old. They should wear masks if they have adequate adult supervision, they’re able to safely don and doff a mask themselves, or they reside in areas of high COVID-19 transmission. Those 6 to 11 years old should also wear masks if they are interacting with people who have a higher risk of developing severe COVID-19 disease, such as people over the age of 65 or those with preexisting conditions.

Children older than 12 should wear fabric masks under the same conditions as adults – in areas of high transmission, where maintaining physical distancing is impossible, or confined and crowded environments.

“What we understand about transmission in children is still limited,”  Van Kerkhove admitted.

But with the upcoming fall semester beginning all over the world, understanding the role of children in COVID-19 transmission is even more urgent as countries grapple with the decision to reopen classrooms, or pursue remote learning.

Schools are debating between reopening classrooms or continuing remote learning in the fall.

While the risk of severe disease in children is low, public health officials are concerned that children who get infected at school could bring the virus home, potentially exposing older family members or those with preexisting conditions.

Ultimately, the success of controlling the spread of the virus in schools is dependent on controlling the virus’ transmission in the larger community.

“Schools do not operate in isolation. They operate in communities and… if there’s widespread transmission in those communities or intense transmission is possible, the virus can enter the school system,” said Van Kerkhove.

“Just because kids or others have masks does not mean we can forget about the other measures,”  added WHO Health Emergencies Executive Director Mike Ryan. “Wearing a mask is not an alternative to physical distancing. It’s not an alternative to hand washing, and it’s not an alternative to decompressing classes.”

WHO’s current guidance for masking in classroom settings recommends that schools develop a policy on wearing masks or face coverings in line with national or local recommendations.

Children With Few Or No Coronavirus Symptoms May Carry More Virus Than Hospitalized Adults

In a study of 192 pediatric patients at Massachusetts General Hospital and Mass General Children’s Hospital, researchers found that infected children had significantly higher levels of virus in their airways than infected adults.

Levels of virus in the children’s noses and throats were highest in the first two days of symptoms – significantly higher than viral loads in hospitalized adult patients experiencing more severe symptoms.

“I was not expecting the viral load to be so high,” said lead author Lael Yonker in a press release. “You think of a hospital, and of all of the precautions taken to treat severely ill adults, but the viral loads of these hospitalized patients are significantly lower than a ‘healthy child’ who is walking around with a high SARS-CoV-2 viral load.”

The higher the level of virus in the airways, the more likely it is for a patient to transmit the virus onwards. Coupled with the fact that children generally tend to have more mild COVID-19 disease, the study findings imply that children could be a major, unmeasured source of the virus’ spread.

“During this COVID-19 pandemic, we have mainly screened symptomatic subjects, so we have reached the erroneous conclusion that the vast majority of people infected are adults. However, our results show that kids are not protected against this virus. We should not discount children as potential spreaders for this virus,”  said Alessio Fassano, director of the Mucosal Immunology and Biology Research Center at MGH and senior author on the paper.

“Kids are a possible source of spreading this virus, and this should be taken into account in the planning stages for reopening schools,” Fassano added.

Out of the cohort of patients in Massachusetts, some 49 children tested positive for SARS-CoV-2, but only 25 had a fever. Many of the children presented with non-specific symptoms such as a cough or congestion.

The Massachusetts study’s results are more damning than the results of a preliminary report published by the Centers for Disease Control, conducted by researchers at the University of Geneva in Switzerland. The Geneva study compared 12 pediatric patients’ samples to adult samples and found that levels of virus in children and adults were comparable. Still, the Geneva researchers write, their results also show that infected children can transmit the disease.

This story was updated 24 August to reflect new masking guidelines.

Image Credits: Flickr: Jill Carlson, Flickr: Ivan Radic.

House in Bikoro, Équateur, is disinfected following the discovery of a confirmed Ebola case

The Democratic Republic of Congo (DRC) requires “critical” support to fend off a growing Ebola outbreak in the western Province of Équateur, warned WHO’s Regional Director for Africa Matshidiso Moeti on Friday.

Her warnings came as Équateur’s Ebola cases have almost doubled to one hundred in the past five weeks, of which 96 are confirmed and four are suspected.

Only US$6 million of the $40 million required for the Ebola response has been pledged so far, as international donors remain distracted by the COVID crisis. The DRC government has committed $4 million, and WHO has pledged $2 million. 

“Without extra support the teams on the ground will find it harder to get ahead of the virus,” said Moeti. “COVID-19 is not the only emergency needing robust support. As we know from our recent history we ignore Ebola at our peril.”

Since the DRC’s eleventh outbreak was declared on 1 June 2020, it has spread to 11 of the province’s 17 health zones, and claimed the lives of forty-three people, said the WHO Regional Office for Africa in a press release.

Healthcare Worker Strike Complicates Efforts
Ebola vaccination campaign in
Mbandaka, Équateur Province (DRC)

In addition to the havoc triggered by COVID-19, a health worker strike in the area has limited the response.

“The situation has been further complicated by a strike by health workers, which is affecting activities, including vaccination and safe burials. DRC has the best trained workforce in the world of for Ebola – this situation needs to be resolved as soon as possible,” WHO Director-General Dr Tedros Adhanom Ghebreyesus told reporters on Friday. 

Healthcare workers in the Ebola response entered a three day strike last week, demanding the government pay and raise their salaries in light of the dangers of facing the virus. Healthcare workers have experienced a high risk of infection and death in previous Ebola outbreaks, including in the 2014-2016 West Africa outbreak.

However, part of the strike involved blocking off access to Ebola testing laboratories, according to Mory Keita, a WHO Ebola incident manager. A number of samples collected two days prior to the strike were unable to be processed.

“When health workers protest or strike, it should be done in a way that doesn’t affect the service they provide to those who need it most,” said Dr Tedros on Friday.

Significant Logistical Challenges Delay Identification Of New Cases
House in Equateur Province gets disinfected following discovery of confirmed Ebola case.

And responders are grappling with ‘significant logistical challenges’ to respond to the ongoing Ebola outbreak. Not only has Ebola spread across a whopping 300 km area both from east to west and from north to south, most affected communities also live in remote, densely forested areas that take ‘days’ to reach by river boat, increasing the time it takes to identify potential cases.

“There is currently a delay of about five days from the onset of symptoms to when an alert about a suspected case is raised. This is concerning, because the longer a patient goes without treatment, the lower their chances of survival, and the longer the virus can spread unseen in communities,” said Dr Tedros.

“The virus is spreading across a wide and rugged terrain which requires costly interventions and with COVID-19 draining resources and attention, it is hard to scale-up operations”, added Moeti. “With 100 Ebola cases in less than 100 days, the outbreak in Équateur Province is evolving in a concerning way.” 

Since the outbreak began, the DRC Government has led the ring vaccination of over 22,600 people at high risk of contracting the deadly virus. It has also screened about 640,000 across 40 points of control, in collaboration with 90 WHO experts on the ground and about 20 partner organizations.

Image Credits: WHO/Junior D. Kannah, WHO/Junior D. Kannah, WHO.

The World Health Organization Headquarters in Geneva, Switzerland

Germany and France are proposing sweeping reforms to strengthen the World Health Organization and ramp up funding for the agency.

A draft paper circulated by the two countries outlines ten key reforms to boost the WHO’s legal authority and funding, while also increasing oversight of the agency’s emergency operations, according to Reuters, which obtained a look at the document.

“Not only during the current pandemic, it has become clear that the WHO partly lacks the abilities to fulfill its mandate,” the document said. The reforms are clearly “pro-WHO,” a diplomat in Geneva familiar with the negotiations told Reuters.

One key proposed reform is the creation of an independent expert committee to assess WHO’s operations in emergency situations as they unfold.

In previous years, WHO has undergone extensive independent reviews only after pandemics have been beaten back. The ongoing independent review of the agency’s COVID-19 response, headed by former Liberian President and Nobel Prize winner Ellen Johnson Sirleaf and former New Zealand Prime Minister Helen Clark, is the first such review to take place as an emergency is unfolding.

While leaders and Health Ministers of both France and Germany have been upfront about their criticism of the WHO, both countries have also steadfastly stood behind the agency as it has weathered repeated attacks regarding its handling of the coronavirus crisis.

And unlike the United States, which followed up its strong criticism of the agency by withholding funding and announcing its intent to withdraw from the WHO, France and Germany are looking to prop up the Organization. Both countries have upped their contributions to the agency following the US’ withdrawal.

In fact, the draft document appeared to recommend giving the WHO more power to autonomously and independently investigate reports of new outbreaks. Currently, WHO must be invited into a country to investigate any outbreaks, WHO Director-General Dr Tedros Adhanom Ghebryesus previously told reporters.

Additionally, the document urges Member States to provide more unspecified funding to the agency, which currently runs on a shoestring budget of about US$5 billion a year, approximately the same budget size as a large, sub-regional hospital.

More than 80% of the agency’s current budget is also earmarked for specific programs, meaning WHO only has about US $1 billion a year to deploy rapidly in the case of unpredicted emergencies.

Ramping up un-earmarked contributions will give the agency more flexibility to respond to outbreaks of novel diseases early, rather than spend time raising money for an emergency response, according to the document.

The proposed reforms could be discussed at the WHO as soon as mid-September, according to Reuters.

A WHO spokesperson declined to comment on the document.

Image Credits: U.S. Mission Geneva/ Eric Bridiers.

Antoine Flahault, director of the Institute of Global Health at the University of Geneva

Six months into the pandemic, the rapidly evolving science behind COVID-19 has complicated efforts to clamp down on the virus’ rampage around the world. Geneva Solutions asked Antoine Flahault, director of the Institute of Global Health at the University of Geneva, and leading voice on COVID-19 science in the region, how we can take swift action to save lives when science hasn’t yet provided definitive answers.

When we don’t have evidence, scientists need to be transparent, he says. In the meantime, masks for everyone, everywhere, and all the time, are vital to fend off the pandemic.

Geneva Solutions: Earlier this year, you advocated homemade masks out of toilet paper on Twitter, even though there was no scientific backing for your claim. Why?

Professor Antoine Flahault: It’s true that in late January when COVID-19 began its rampage around the globe, there wasn’t enough evidence to suggest that homemade masks actually worked. I made an assumption that any physical barrier was better than no protection at all. Some of my colleagues said it was irresponsible to make claims on homemade masks without scientific data to back them. At the same time, my colleagues weren’t providing any alternatives to fend off the virus, and there was a massive shortage of surgical masks.

 

During a crisis, doing something is better than doing nothing. In the case of masks, wearing a mask is a really low-risk action that has a huge potential benefit in preventing onwards transmission. When the evidence isn’t there, we need to be transparent and mention the lack of scientific evidence and use our gut feeling because the data may take time to collect — and in that time, lives can be saved. And we shouldn’t be stubborn when the evidence comes our way. We should follow it. In the case of masks, evidence eventually came that masks provide very useful and effective protection against the coronavirus.

However, we wouldn’t want to follow our gut in other instances. For instance, we cannot trust that an untested vaccine works. However, in the case of masks, there is very little risk associated with mask-wearing, and a very large potential benefit, but this is not the case with an untested vaccine, which could have dangerous side effects.

GS: There’s a similar lack of clarity on aerosol transmission of COVID-19. Some scientists think aerosols are primary drivers of transmission, while others — including the WHO — maintain that they are not a primary route of transmission. What should we do when the science is unclear?

AF: Aerosols are small viral particles that float around in the air. We think they’re produced when people speak, sing, cough, sneeze or exhale, but the data is still limited. However, our lack of solid evidence shouldn’t nullify the aerosol hypothesis. Maybe aerosols are not the major route of transmission of COVID-19, but we just don’t know yet.

What we can do now is to protect ourselves with masks in closed spaces that lack ventilation. Keeping distance may simply not be sufficient. We need to be sensible and do the best we can with the tools we have — and that means wearing masks.

Masks should be worn everywhere, all the time, and by everyone – including pupils in classrooms.
GS: We are approaching the fall start of schools. Is there a risk that opening up schools could endanger children?

AF: The latest science tells us that pupils, and anyone below the age of 40, is at a very low risk of becoming critically ill and dying from COVID-19, so opening schools will not endanger children themselves. Rather, the issue is that children could transmit the virus to others in their surroundings, particularly vulnerable groups like older people, those with underlying conditions or even school teachers and staff.

GS: Could schools become a breeding ground for COVID-19 transmission?

AF: Definitely. Given that classrooms in schools are often enclosed and poorly ventilated, schools have potential to turn into clusters of transmission that could spill over into the community.

Some epidemiological findings also suggest that children — and even young children — may transmit the virus as well as adults. This is based on evidence that children carry similar quantities of the virus as adults in their noses and throats. However, we’re still not totally sure whether that means they can transmit as well as adults. Given the data is not well ascertained, we need to stay cautious, and take appropriate measures to mitigate the spread of the virus.

GS: Do you see concrete good practice examples that countries could emulate — in Europe and beyond — with regards to smaller class sizes, masks, remote learning, or other measures, to curb the risk of transmission in schools?

AF: There are three measures we can take to win against this virus and allow schools to stay open for as much as possible throughout the year:

  1. The most important measure we can take is to wear masks in schools throughout the day. Wearing masks is possible for any child older than 3 years of age
  2. We need to improve ventilation in schools, and we also need to promote alternative methods of teaching to reduce the number of students in one space at any point in time. We can achieve the latter by spreading out lunch breaks throughout the day so that kids aren’t all eating at the same time. We could even spread out the time for going to school — not for primary schools because younger children are less autonomous, but maybe for children in secondary schools. This may also take the edge off of overcrowded public transportation, and contribute to dampening down transmission.
  3. We could also implement distance learning or mixed approaches in secondary schools. However, we need to stay cautious, because not all parents will be able to stay at home to supervise their children’s learning. Also, not every family will have computers at home, so we need to take the context into account. There’s also the issue of meals at schools. We need to bear in mind that schools may offer more nutritious meals than at home. That’s why we need to carefully consider the context and work accordingly, and to ensure the strategies we adopt are sensible and appropriate.
Remote learning may help curb COVID-19, but it won’t be appropriate in all contexts.
We are seeing a slow, but steady rise in new COVID-19 cases in Switzerland from 100 per week a less than a month ago to over 200 new cases in the past week. Is there anything Switzerland could do to further curb transmission?

There are several measures Switzerland can adopt today, and that’s to recommend wearing masks in all indoor settings, not only in public transportation, but also in workplaces and businesses in the whole nation. These are the next breeding grounds for transmission.

The second measure we can take is to learn from countries like Australia, Taiwan and Japan. They took very targeted approaches to COVID-19 screening. Instead of randomly testing the entire population, their testing is precise, agile and swift. They took a proactive approach to identify superspreaders and clusters of COVID-19 cases. Once they found a cluster, they very quickly started testing and tracing before the cluster went out of hand and spread across the region.

Targeted screening approaches will be particularly important during the cold season, which will bring many people with mild symptoms to hospitals. If we don’t take more targeted approaches, it will be difficult to tease out COVID-19 symptoms from common colds caused by respiratory viruses other than COVID-19.

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Health Policy Watch is partnering with Geneva Solutions, a new non-profit journalistic platform dedicated to covering Genève internationale. In the midst of the Coronavirus pandemic, a special news stream is published at heidi.news/geneva-solutions, providing insights into how the institutions and people in Geneva are responding to this crisis. The full Geneva Solutions platform and its daily newsletter will launch 24 August. Follow @genevasolutions on Twitter for the latest news updates.

Image Credits: Antoine Flahault, UNICEF, Nenad Stojkovic.

UK Health Secretary Matt Hancock announces that Public Health England will be replaced with a new institute.

United Kingdom Secretary of State for Health Matt Hancock’s announcement to replace Public Health England (PHE) with a new agency focused on biosecurity and infectious disease threats has drawn widespread criticism from health experts.

The Health Secretary announced that PHE will be replaced with a new National Institute for Health Protection (NIHP) in a speech on Tuesday, following widespread media reports hinting at the move on Sunday. Ministers, including Prime Minister Boris Johnson, have supposedly been unhappy with the PHE’s handling of the pandemic for weeks.

The NIHP will merge the PHE, the National Health Services’ Test & Trace program, and the Joint Biosecurity Centre (JBC) into a single organization, modeled after Germany’s Robert Koch Institute and focused on protecting the United Kingdom from “new” and “external” infectious threats, according to Hancock.

But critics have called the move a dangerous and distracting play in the middle of the pandemic. They have also questioned how PHE’s other responsibilities, such as managing environmental health or non-communicable diseases, will be taken into account in this reshuffle.

“Where is the evidence, the independent review that has informed such a significant organisational change to the national public health response for England at such a critical time? It takes time to build an organisational culture and the way the tired, hardworking PHE staff heard via a leak at the weekend is shocking,” wrote Gail Carson, deputy chair of the Global Outbreak and Response Network (GOARN).

“Now is not the time to replace Public Health England. The pandemic may have shown us that some changes are needed, but they need to be made at the right time. PHE is playing a key role in keeping the country going, and we really don’t need the upheaval that this move is going to create,” said Andrew Goddard, president of the Royal College of Physicians, in a statement.

Many Uncertainties Remain About New Institute’s Leadership & Responsibilities

In particular, Hancock’s decision to place fellow Conservative Dido Harding, the current head of the widely criticized NHS Test & Trace program, at the helm of the NIHP has sparked ire. Many critics have pointed to the lack of transparency behind Harding’s appointment.

“I was looking forward to applying for the role of Chair of the UK’s National Institute of Health Protection, but somehow I missed the open transparent recruitment process,” Richard Horton, chief editor of the global health journal the Lancet, tweeted.

Similarly, it’s unclear how PHE’s responsibilities in carrying out programs outside the realm of pandemic threats will be managed in the wake of the agency’s dissolution. Outside of COVID-19, PHE managed programs for a variety of health-related issues, including programs focused on curtailing smoking and the harmful use of alcohol, reducing obesity, improving maternal and child health, and managing sexually-transmitted diseases.

“We shouldn’t forget that the overwhelming burden of death and disease in this country is not caused by ‘external threats’ as Matt Hancock put it, such as infections and biological weapons. Instead it is caused by chronic diseases – cancer, cardiovascular disease, diabetes, dementia and others. A significant proportion of these diseases are preventable and Public Health England plays a central role in that through its health improvement functions,” said Linda Bauld, a professor of public health at the University of Edinburgh. “There is a real risk that reorganisation threatens these functions. We don’t yet know how or where they will continue to be delivered.”

And for a coalition of organizations battling a decades-long epidemic at home in the UK, the  institute’s focus on “new” and “external” threats brings out concerns that longstanding domestic health issues will be ignored.

“The announcement made today focuses on “new” and “external” health threats while not acknowledging the public health emergencies that already exist in the UK,” wrote a coalition of UK-based HIV organizations, in a statement. “While attention has rightly been given to the ongoing COVID-19 pandemic, focus must not be lost in tackling long-standing HIV and STI infection rates and reversing sexual health inequalities.

“The Secretary of State’s speech today leaves us with more questions than answers…a knee-jerk restructure of the public health system which is non-transparent, ill-thought through and leads to more fragmentation in accountability structures risks holding us back.”