COVID-19 is on it’s way to becoming the deadliest infectious disease in the world this year, and could cause more deaths worldwide than the current deadliest infectious disease killer tuberculosis.

Currently tuberculosis, one of humankind’s oldest known infectious diseases, takes the lives of some 1.8 million people per year.

Global Deaths Due to Various Causes & COVID-19 – by Tony Nickonchuk. Tuberculosis deaths are not included.

However, Wednesday marked a gain in the fight against TB. Pretomanid, only the third antibiotic to be approved for treating the disease in nearly half a century, was on Wednesday approved for use in India, which has the highest TB burden in the world. The oral drug has a 90% cure rate when used correctly to treat multi-drug resistant TB, according to peer-reviewed studies published by the TB Alliance, who developed pretomanid.

Meanwhile, COVID-19 has killed over 600,000 people since the beginning of the pandemic, already surpassing the number of deaths caused by HIV/AIDS, suicide, and malaria. But experts at a virtual event hosted by the TB Alliance on Wednesday warned that steadily growing outbreaks in hotspots like the United States, Latin America, South Asia, and Africa could lead to a death count higher than that of tuberculosis.

“Tragically COVID-19, which didn’t exist a year ago, may be in a position to match or surpass tuberculosis as the infectious killer this year,” warned Ariel Pablos-Mendez, a founding board member of the TB Alliance. 

“I don’t mean to be melodramatic about it, but it is really, as an infectious diseases person, a public health person, almost your worst nightmare. It’s almost the perfect storm,”  said Anthony Fauci, director of the US National Institute of Allergies and Infectious Diseases. Fauci has become a household name in recent months, emerging as the preeminent expert voice on COVID-19 in the United States, many times countering messages put out by the Trump administration downplaying the seriousness of the virus.

COVID-19 is the “Perfect Storm” – And It’s Not Going Away Anytime Soon
Subway workers in New York City hand out masks to commuters. Even those who don’t show symptoms of COVID-19 can spread the disease if they were infected.

The novel coronavirus has a number of characteristics that make it “particularly formidable,” said Fauci. It causes a wide range of disease severity, and is easily spread between humans.

SARS-CoV-2, the virus that causes COVID-19, has the ability to jump from animals to humans, and is easily spread from one person to the next as a respiratory-borne virus.

Some 20-45% of infected people may never show symptoms. But people without symptoms are still able to pass the disease onwards, although it’s unclear how much of COVID-19’s spread can be contributed to asymptomatic transmission.

“It is spectacularly efficient in spreading from human to human,”  said Fauci. “I don’t see this disappearing the way that SARS1, [the virus that sickened over 8000 in a 2002-2003 epidemic], did. I don’t really see us eradicating it.”

Additionally, the virus causes anywhere from non-existent to critical disease, hitting large swathes of the population like older people and those with common preexisting conditions particularly hard.

“I have never seen an infection in which you have such a broad range of [disease severity],”  said Fauci. “[You have] literally nothing – no symptoms at all – in a substantial proportion of the [infected] population, to some who get ill with minor symptoms, to some who get ill enough to be in bed for week and have post-viral syndromes, to others who get hospitalized, require oxygen intensive care, ventilation, and face death.”

Still, Fauci remained cautiously hopeful.

“I think with the combination of good public health measures, a degree of global herd immunity, and a good vaccine, which I do feel cautiously optimistic we will get, we will get very good control of this,” he said. “Whether it’s this year, or next year I’m not certain. But I think ultimately… we will bring it down to such a low level that we will not be in the position that we’re in right now for an extended period of time.”

Image Credits: Marc A. Hermann / MTA New York City Transit.

More droplet particles may remain airborne and travel further in poorly ventilated spaces

A new study by researchers at the University of Hong Kong (HKU) has documented how poor building ventilation plays a role in indoor transmission of Covid-19. The study looked at the air flow and infection dynamics from three important Covid-19 outbreaks in China and Japan, concluding that spread of the virus was “definitely favored by poor air ventilation”.

“It can be understood that a normally non-long-range-airborne infection turns to long-range airborne in poorly ventilated spaces. Opportunistic airborne transmission can lead to super-spreading events”, said Professor Yuguo Li, Chair Professor of Building Environment at HKU.

“The findings provide evidence that short-range airborne is also a major transmission channel, which in turn suggests that other precautionary measures have to be taken in order to better contain the pandemic.

Why The Hong Kong Study Is Important 

Recently 239 international experts signed a an open letter to WHO asking it to recognize that the SARS-CoV-2 virus transmission is occuring not only via large virus droplets at very close ranges of 1 meter, but via smaller viral particles that become “airborne” and travel a few meters away, particularly indoors. While experts debate ‘droplets’ versus ‘airborne’ particles, the HKU study points to ventilation as the “elephant in the room” that no one is examining closely.

Even WHO admits that some droplets may evaporate into tiny “droplet nuclei” that can become airborne. The HKU study says that in poorly ventilated rooms, viral droplets or particles will remain suspended in the air for longer – and travel further with a greater potential to infect. The HKU study calls this “opportunistic airborne transmission”:

“In short-range airborne transmission of diseases, droplet concentrations in the exhaled jet of air from an infected person continually decrease away from the mouth and the exhaled jet becomes sufficiently weakened to be indistinguishable from the background room air at a distance of approximately 1.5 m. However, if air ventilation is insufficient, the short-range airborne transmission route can be extended to result in a long-range airborne route to infect more people beyond the proximity.”

A Study Of Three Major Outbreaks 

In collaboration with the Guangdong and Hunan Centers for Disease Control and Prevention, Sun Yat-Sen University and Southeast University, Professor Li and his team at the Department of Mechanical Engineering of the University of Hong Kong (HKU) studied three major outbreaks that occurred between January and March 2020: These included outbreaks on Hunan’s bus system (January 22, 2020), where 10 bus passengers sitting as far as 9.5 meters from the infected passenger came down with Covid-19; at the Guangzhou Restaurant (January 24, 2020) where 9 people sitting as far away as five meters were infected by one person; and on the Diamond Princess Cruise ship where some 696 people became ill (January to March 2020).

Guangzhou Restaurant 1.jpgSARS-CoV-2 transmission dynamics in the Guangzhou restaurant

While the team didn’t find evidence of long distance viral transmission via the cruise ship’s air conditioning system, it found clear evidence of transmission beyond the range of 1.5 meters within the Hunan buses and the Guangzhou restaurant. At the restaurant, the ventilation flow rate was only 1 L/s per person. The two Hunan buses studied had a time-averaged ventilation rate of 1.7 L/s. Professor Li:

“In both the Guangzhou Restaurant case and the Hunan buses case, there is evidence that airborne is the probable way of transmission of the virus, given that those infected were sitting at a distance, and quite a number of them more than 2m apart from the index patients, and no other transmission route can explain the spatial pattern of the infection. We found that a poor ventilation rate is a major contributing factor to the virus’ spreading in the environment.”

Air Flow & Ventilation Rate

They concluded that transmission of the SARS-CoV-2 virus in the indoor environment is more likely when the ventilation rate is less than 3 litres/second per person, with a sufficient exposure period. The international standard ASHRAE 62.1 – requires at least 5 liters of air per second per person (or per cubic meter of space). In fact, a 2008 WHO guideline refers to a desired 10 l/s per person for office spaces, for effective infection prevention. That works out to about 36 air exchanges per hour for 1 cubic meter of space. Professor Li:

“Airborne transmission of Covid-19 outbreak in the indoor environment is likely when the ventilation rate is less than 3 L/s per person, with a sufficient exposure period.”

airborne transmissions.jpgPoor ventilation increases the infective range of SARS-CoV-2 virus particles

Mechanistic Airflow Models 

During the SARS epidemic of 2003, Professor Li and a group of mechanical engineering experts at HKU developed an advanced mechanistic airflow model with computational fluid dynamics simulations and detailed thermo-fluid analyses to track and explain the main infection patterns and characteristics of the SARS outbreak at Amoy Gardens and at Ward 8A of Princess of Wales Hospital, where poor ventilation was widely attributed to broader airborne transmission of the virus. Based on these models, they studied the actual data and air flow dynamics from the ventilation sytems in the more recent Covid-19 cases, to reach their conclusions.

Solutions To Airborne Infections

As the major culprit is opportunistic airborne that occur in poorly ventilated areas, the most effective interventions prevent the opportunistic transmission of the virus through effective ventilation and filtration control, the authors conclude:

  • Enhance air ventilation in indoor environments, particularly in restaurants, public transport, bars, gyms, etc.
  • Ensure even higher ventilation rates for more strenuous indoor activities. Avoid social gatherings in an indoor environment where sufficient ventilation is not provided.
  • Install Carbon Dioxide (CO2) sensors as a “proxy” measure of ventilation quality. While not a perfect indicator, a concentration of over 1,000 parts per million (ppm) may indicate that the room is not sufficiently ventilated.
  • Hand hygiene and social distancing remain critical, with the use of masks in indoor spaces as essential barrier measures (handled with clean hands when putting it on and taking it off).

Improved Filtering of Recirculated Air

To ensure effective ventilation, air conditioning systems must include high quality HEPA filters or equivalent portable filtering technologies to capture and prevent the recirculation of viral particles indoors, added Harvard University Professor Joseph Allen, at a university webinar on the ventilation issue on Tuesday.

“Air conditioning in itself is not the [only] problem”, said Allen, founder of the Healthy Buildings Program at the Harvard Chan School of Public Health. “You [also] want to…filter out any recirculated air.”

Another oft-ignored factor in virus travel behaviour is humidity, Allen observed. He noted that viral respiratory droplets are more likely to evaporate into smaller aerosol particles that travel further in the air when the humidity is below 40%. At humidity levels above above 40%, virus particles are more likely to drop to the ground because the air is already saturated with water.

“Less evaporation of droplets [means they will] settle out of the air quicker. It’ll be a heavier, bigger aerosol”, he added. “If it’s drier, you get a higher likelihood of droplet nuclei which can stay airborne for longer periods of time.”

WHO Response

In 2008, WHO published formal guidelines on “Natural ventilation in health care settings” which discussed the fundamental relationship between ventilation and infection transmission in indoor spaces. Annex C, based on a WHO systematic review, talks about the potential of respiratory droplets to become suspended in the air as “respiratory nuclei” in poorly ventilated spaces. Annex D of these guidelines refers to a desired ventilation standard for office buildings, stating:

“In an office, we need a 10 l/s per person ventilation rate.”

Current WHO guidance about Covid-19 management in community settings does not, however, relate to ventilation issues. A WHO spokesperson said WHO had no comment about the Hong Kong study, but conceded that the ways in which poor ventilation may exacerbate virus transmission needs more systematic review:

“Outside of healthcare settings, some outbreak reports suggest the possibility of airborne transmission in indoor crowded spaces with poor ventilation. WHO calls for more systematic research of these kind of settings/outbreaks so we can have more definitive answers, and is activating the R&D Blueprint to accelerate research in this area.”

Svĕt Lustig Vijay contributed to this story.

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Republished from Geneva Solutions. 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 in August 2020. Follow @genevasolutions on Twitter for the latest news updates.

Image Credits: Hong Kong University.

Schools could spawn COVID-19 outbreaks as children can also transmit the coronavirus.

In past decades, Europe has achieved one of the world’s highest water and sanitation coverages, but it is often forgotten that one in ten schools in the 53 countries of WHO’s European region still lack basic hand washing facilities, leaving some 5 million pupils without access to soap and clean water.

All in all, some 31 million Europeans lack access to basic sanitation, even in the form of a latrine, and 16 million lack access to basic drinking-water services that also enable hygiene – mostly in Eastern Europe, Central Asia and the Caucasus.

As students begin filling up schools in attempts to return to the ‘new normal’, these worrying gaps in Europe have potential to spur more Covid-19 outbreaks and to fuel existing inequalities, warned Marta Vargha from Hungary’s National Institute for Environmental Health, at a recent webinar hosted by Geneva Environment Dialogues.

Last Friday, Vargha’s warnings became even more relevant as a South Korean study of 65,000 people showed children between the ages of 10 and 19 can also spread the coronavirus, strengthening the case for improved water and sanitation coverage in all settings – including schools.

“[The] South Korea study means we can’t assume older kids won’t transmit”, said Director of Harvard’s Global Health Institute Ashish Jha, referring to the study by the South Korea’s Centers for Disease Control and Prevention. “Opening schools will need us to focus on suppressing virus transmission”.

As a result of inadequate water, sanitation, hygiene and health (WASH) services, 14 people die every day from diarrhoeal diseases in the WHO European Region.

And within European countries, services are unevenly distributed. In some cases, there is a four-fold difference between urban and rural settings in access to drinking-water and sanitation services, said a WHO spokesperson to Health Policy Watch.

But the burden of water-related disease is most significant outside of Europe, as about 90% of diarrhoeal deaths occur in south Asia and sub-Saharan Africa, acccording to the Global Burden of Disease 2016 Study.

Access to Safe Water – First Line of Defense Against COVID-19

Access to safe water is the first line of defense against the new coronavirus, and is the “primary tool” to prevent infection from any disease-causing organism, emphasized Vargha at a webinar hosted by Geneva Environment Dialogues last month:

“Under the current pandemic, to be really efficient in prevention, safe [water] should be accessible not only at home, but also wherever we go, including schools, healthcare facilities, in workplaces and public settings” like public transport facilities.

A Thirst For Data

The European region lacks basic data on water and hygiene services.

Europe’s nations cannot expand access to safe water to protect against the new coronavirus without reliable data.

Currently, basic data on water, sanitation, hygiene and health (WASH) services remains “limited” in some European countries, especially in healthcare settings and households, said Vargha.

Large regional disparities are also hidden behind national averages in “almost every country”, owing to the fact that basic WASH indicators have not been embedded into national monitoring.

The Protocol on Water and Health – A Unique International Legal Agreement In Europe 

While the problem of water, sanitation and hygiene in schools and other public buildings remains serious, Europe is still better placed than most regions of the world to address it, as 27 countries in the region are signatories to the 2005 Protocol on Water and Health.

Co-administered by the United Nations Economic Commission for Europe (UNECE) and the WHO Regional Office for Europe, the Protocol is the “only” international legal agreement of its kind that links oft-siloed sectors together – sustainable water management and prevention to control and reduction of water-related diseases, said Natalyia Nikiforova, Environmental Affairs Officer for the United Nations Economic Commission for Europe (UNECE), who also spoke at last month’s panel.

The Protocol helps countries set national targets on water sanitation, hygiene and health (WASH) based on their needs – and ensures “long-standing commitments” because they must report progress at national and international levels every three years.

In contrast to other legally binding agreements – like the WHO’s International Health Regulations (IHRs) or its Framework Convention on Tobacco Control (FCTC) –  the protocol’s compliance committee is a ‘very interesting’ alternative because it does not force Parties to comply, said Co-Secretary for the Protocol on Water and Health Oliver Schmoll. Instead, it achieves effective implementation through a “non-confrontational” and “facilitative” framework:

“The consultation mechanism is not a very hard instrument”, explained Nikiforova. “But it’s a very smart instrument to work with countries in order to facilitate implementation in a non-confrontational way through a consultative process, and thereby ensuring implementation.“

In total, twelve countries have already undertaken a self-assessment to address disparities in their populations, especially in rural settings, said Vargha.

In the Republic of Moldova, the self-assessment brought safe drinking water to some 67,000 villagers in rural areas through new infrastructure initiatives. Meanwhile, other countries like France, Portugal, Hungary, Ukraine and Armenia, have amended national legislation to fill gaps in WASH services, each in different ways.

Hungary has improved minimum standards for water safety, while Portugal and France have cheapened the cost of drinking water. And Armenia has incorporated a definition of marginalized groups in their Water Code, ensuring that legislation caters to the most vulnerable. 

Expanding The Protocol To Other Regions 

At the moment, protocol membership is exclusive to the 53 Member States in the pan-European region. However, it is Africa, Asia and slabs of Central and Latin America where WASH services are most needed.

Sanitation facilities are mostly needed outside Europe.

Around the world, some 2 billion people lack access to basic sanitation facilities, and one billion people in 149 countries suffer from neglected tropical diseases, which thrive in areas that lack basic sanitation. Most of these are outside Europe.

In light of unmet needs around the world, it “would make sense” for the Protocol to “open up” to other regions, said Nikiforova, although there is currently no road map for doing so.

Before the Protocol can expand, 26 additional European member states would need to ratify the Protocol first, and “considerable political will” is going to be necessary, added Nikiforova, as she referred to the fact that only 27 out of the 53 Member States in the Region have ratified the Protocol.

27 out of 53 Member States have officially ratified the Protocol on Water and Health

Image Credits: Source: Allison Shelley/The Verbatim Agency for American Education, Martha Vargha, Deep Knowledge Group.

Credit: Jernej Furman

In the largest and perhaps most robust peer-reviewed study to date, A COVID-19 vaccine candidate developed by pharma giant AstraZeneca and Oxford University has been shown to induce strong antibody and T cell responses in healthy volunteers, according to Phase 1/2 trial results published in The Lancet on Monday.

Most studies so far have focused on measuring the level of neutralizing antibodies, or antibodies that can bind to the virus in the blood to prevent it from attacking human cells. However, the Oxford/AstraZeneca vaccine was also able to to induce another type of immune response in a subset of 43 healthy volunteers within 14 days of vaccine – a T-cell response, which is another specialized immune response that can attack cells infected with the virus.

“The immune system has two ways of finding and attacking pathogens – antibody and T cell responses. This vaccine is intended to induce both, so it can attack the virus when it’s circulating in the body, as well as attacking infected cells,” said study lead author and Oxford professor Andrew Pollard in a press release. “We hope this means the immune system will remember the virus, so that our vaccine will protect people for an extended period.”

However, “there is still much work to be done before we can confirm if our vaccine will help manage the COVID-19 pandemic, but these early results hold promise,” added co-author on the study and Oxford professor, Sarah Gilbert.

WHO Health Emergencies Executive Director Mike Ryan shared the same sentiment.

“This is a positive result but again there’s a long way to go. These are Phase I studies; we now need to move into larger scale real world trials, but it is good to see more data,” Ryan told reporters on Monday.

The Oxford/AstraZeneca group tested their vaccine in 1,077 healthy volunteers, making the trial many times larger that of Moderna, which tested their vaccine candidates in only 45 healthy volunteers in Phase I trials. Moderna’s vaccine candidate, developed in collaboration with the US National Institute of Allergies and Infectious Diseases, was the first to have Phase I results released in a peer reviewed journal.

A third COVID-19 vaccine candidate, developed by Chinese biopharma company CanSino Biologics Inc. and the Chinese Academy of Military Sciences, was also able to induce an immune response in a Phase 2 trial that enrolled over 500 healthy volunteers, according to results published in The Lancet on Monday.

However, researchers have previously expressed concerns about the Ad5 vector, the technology used to carry the vaccine, in the CanSino candidate. HIV vaccine candidates using the Ad5 vector had inadvertently increased the risk of HIV infection in previous trials, and it is unknown whether the CanSino COVID-19 vaccine may have similar effects.

While early Phase clinical trail results have shown to be able to induce an immune response in healthy volunteers, it’s still too early to tell whether that immune response will protect against coronavirus infection or disease.

All three vaccine candidates are preparing to enter the final and largest phase of the vaccine testing process, Phase III clinical trials. These massive trials will enroll tens of thousands of volunteers in all age groups in order to test whether the vaccines can protect against infection by the virus and symptomatic COVID-19 disease.

AstraZeneca/Oxford Vaccine Candidate Set to Move Into Multi-Country Phase III Trials

Colorized electron microscope image of SARS-CoV-2, the virus that causes COVID-19

While the Phase 1/2 trial is ongoing, the AstraZeneca/Oxford vaccine, ChAdOx1, will move into further Phase 2 and Phase 3 trials. AstraZeneca has already ordered 100 million doses to be produced by the Serum Institute of India, a major developing world biopharma company and generics producer, for Phase 3 trials.

Volunteers are currently being enrolled in the UK, Brazil, and South Africa, making this the first vaccine candidate to be tested on the African continent.

The authors further noted that the Phase III trial will focus on observing the vaccine in a wider demographic, including those at higher risk of COVID-19 infection or death such as older people, ethnic minorities or marginalized people, people with preexisting health conditions, and healthcare workers. Participants in the earlier Phase 1/2 trial were mostly likely to be young and Caucasian – some 91% of study subjects were white and the average age of participants was 35 years.

None of the participants reported serious adverse reactions to the vaccine. Around 70% of the participants who received ChAdOx1 reported mild adverse side effects such as fatigue and headache, compared to 48% in those who received the placebo meningitis vaccine.

Participants who took paracetamol, a pain common pain medication, at the time of injection had a reduced likelihood of experiencing adverse side effects. Paracetamol had no effect on the immune response generated by the vaccine.

WHO Experts Urge Countries To Step Up Contact Tracing Rather Than Waiting For Vaccine

WHO Assistant Director-General of Emergency Response, Ibrahima Socé Fall

Still, WHO experts on Monday warned against waiting for an effective vaccine to stem the tide of the pandemic, urging countries to step up contact tracing efforts.

“We do not have to wait for a vaccine. We have to save lives now,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “Contact tracing has long been the bedrock of outbreak response from smallpox to polio to Ebola, and now COVID-19.”

“If we look at viruses that are much more fatal than COVID-19, we were able manage and master these epidemics by regularly following [contacts] with high level efficiency,” said WHO Assistant Director-General of Emergency Response, Ibrahima Socé Fall. The 2014-2016 Ebola outbreak in West Africa for example, was largely managed and quashed through contact tracing, before a vaccine was available.

Investing in contact tracing now is even more important, considering “many countries were not very well prepared for contact tracing” at the beginning of the pandemic, according to Fall.

“Developed countries have surveillance systems centered on hospitals, but by the time the patients arrive it’s too late. They’ve already contaminated others in the community,” said Fall.

“Nothing replaces boots on the ground,”  said Dr Tedros. “[Countries must] train workers to go door to door to find cases and contacts, and break the chains of transmission.”

Image Credits: Flickr: Jernej Furman, National Institute of Allergy and Infectious Diseases, NIH.

WTO Headquarters in Geneva

The race for the leadership of the World Trade Organization (WTO) gained traction this week as eight competing nominees presented their pitches to fill Azevêdo’s role to the WTO General Council, and later to the press and public.

The nominees include: Ngozi Okonjo-Iweala, the chair of Gavi, the Vaccine Alliance, and former finance minister of Nigeria; Abdel-Hamid Mamdouh, former director of WTO’s trade in services and investment division; WTO’s founding deputy director-general Jesús Seade Kuri; as well as Kenyan diplomat and cabinet official, Amina C. Mohamed; the United Kingdom’s former trade secretary, Liam Fox; Moldova’s Tudor Ulianovschi; Republic of Korea’s Yoo Myung-hee; and Saudi Arabia’s Mohammad Maziad Al-Tuwaijri.

COVID-19 has triggered the largest ever slump in global trade. Source: WTO
Why The WTO’s Race to the Top is Important

As the COVID-19 pandemic prompts many countries to ban the export of medical supplies, hoard essential healthcare products and conduct backroom negotiations with vaccine developers, it’s becoming clear that WTO’s role as an arbitrator of both intellectual property as well as global trade rules will have immediate repercussions on global health as well as COVID-19 economic recovery.

The Organization also faces deeper challenges to ensure multilateralism can survive in global trade agreements, as well as to ensure trade rules don’t undermine climate and sustainability – as per swelling debates over subsidies for fisheries that are accelerating the depletion of ocean fish stocks.

“The critical importance of trade is now beyond debate, whether for growth, development, job creation, poverty reduction or World Peace,”  said Mamdouh. “And, remember, trade is no more about merchandise crossing borders. It’s also about services and intellectual property.”

Despite the looming challenges, the WTO can be reinvigorated, asserted nominees in their speeches. Here’s a thumbnail of a few comments some of the candidates made:

Global Health and Intellectual Property Rules

In mid-May, about 90 countries had introduced export prohibitions or restrictions on health products, according to the United Nations Economic Commission for Africa. Okonjo-Iweala, a Harvard trained development economist, has stood out as one of the most vocal candidates on that issue, pledging to ensure developing countries aren’t left standing in the queue for COVID-19 health technologies – whilst also respecting intellectual property rights:

“The world should be able to come to the point where mechanisms are put in place to make vaccines available. The world trading system should be a facilitator of that and not an impediment,” said Okonjo-Iweala.

Ngozi Okonjo-Iweala, Nigeria’s former finance minister

“It’s critical that everyone has access to live-saving vaccines. If I became WTO’s DG, I would have a very strong collaboration with the [WHO’s ACT] Accelerator…to make sure there are no barriers, no restrictions on the availability of these vaccines whilst respecting the intellectual property rights of those who have manufactured the vaccines,” she added.

In contrast, Mamdouh took an even sharper stance on intellectual property rights, acknowledging there are ‘still issues’ impeding wider uptake of WTO’s Doha Declaration on the TRIPS Agreement and Public Health – which affirmed that member states can temporarily circumvent patent monopolies, to produce or import generic versions of critical health technologies under ‘emergency circumstances’ like a pandemic.

“The reform agenda will no doubt identify additional items for negotiations. The backlog, including Doha issues, is still there”, said Mamdouh, who was involved in the landmark ‘Doha Round’ of 2001 that made the Declaration on public health.

“You will recall, in Nairobi [in 2015], Ministers disagreed on the Doha framework as a basis for negotiations [over intellectual property rights], but all agreed on the need to address Doha Issues. “

Abdel-Hamid Mamdouh, former director of WTO’s trade in services and investment division

In late July, WTO will hold a special session of the TRIPS council to discuss these unresolved issues, although there have been attempts to delay the meeting by the United States and Switzerland, ostensibly to postpone this very debate, some critics say.

Restore Viability of WTO’s Dispute Settlement Function

WTO’s troubled dispute settlement mechanism has also ‘failed’ to produce significant results since 1995, said Mamdouh. As just one example, WTO negotiations to end harmful fishing subsidies that support the plundering of ocean fish stocks have dragged on for five years – despite a 2015 pledge by countries to prohibit subsidies that contribute to overfishing by 2020.

“Political issues remain to be resolved,” said Keith Rockwell, a WTO official who spoke at a panel on the fishing issue last month as well as moderating this week’s candidate’s press conferences.

There’s also a ‘chronic imbalance’ between the WTO’s dispute settlement function and its negotiating function, or the ‘legislative’ and ‘judicial’ functions of the Organization. This ‘unsustainable’ imbalance needs to be urgently restored to avoid repeating mistakes from the past, said Mamdouh.

“In any legal system, there needs to be a balance between the “legislative” and the “judicial” functions. For the WTO, these are the negotiating and the dispute settlement functions,” Mamdouh said. “What we have seen over the past 25 years was that the dispute settlement function gained strength…while the other functions [like the negotiating function] have subsided completely, and particularly the negotiating function break-down is causing huge difficulties for the organization.”

Rebuild Trust in the Multilateral Trading System

In recent years, trade tensions among WTO members have flared up evermore sharply, “threatening the fundamental architecture” of a multilateral trading system (MTS) that brings shared prosperity and development for everyone. Warns Okonjo-Iweala:

“In recent years, the multilateral trading system (MTS) has been going through difficult and challenging times. But, in my view, the world now needs, more than ever, a reinvigorated WTO [and the MTS].“

“The rules-based MTS is a public good that underpins peace, security, stability and a chance for prosperity in the world. Every effort should therefore be made to safeguard, improve and renew it to enable it effectively address the challenges of the 21st century.”

The Role of Women in Trade

It is “fundamentally wrong” that trade departments around the world are still male-dominated, said British candidate Liam Fox, a medical doctor by training who later became trade and defense secretary of the UK. His plan to upend the status quo:

“I commit to you today that if you give me the honour of becoming the next DG then I will ensure that at least half of the WTO’s most senior leadership team are women.”

Liam Fox, UK’s former secretary of state for international trade

An Existential Crisis at the WTO

Even before COVID-19, the Organization faced a minefield of much-needed reforms as it struggled to respond to the realities and needs of diverse populations, companies and consumers, said candidates on Wednesday. Mamdouh:

“The international trade landscape has dramatically changed, and the WTO system has been unable to update its rule book. In order to prevent the Organization from becoming obsolete and outdated, it is important that mechanisms be adopted to modernize it.”

A Swiss Take on the Bottom Line

Although there are British, European and Korean candidates who could represent the G-7 economies, none of the big trade players seemed to have publicly picked a favorite nominee yet, including the United States, the European Union – or Switzerland.

However, one desired quality in the new WTO DG will be ‘political clout’ – the head of the Swiss Permanent Mission to the WTO Didier Chambovey, declared in an interview with Swiss Info. He was referring to rising tensions within the Organization that have slowed down the Organization’s progress.

Said Chambovey, “We need a personality with managerial skills who can carry out WTO reform, which is a tall order, and who is able to listen to Member States and build a consensus.”

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Republished from Geneva Solutions. 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 in August 2020. Follow @genevasolutions on Twitter for the latest news updates.

Image Credits: WTO.

UN Under-Secretary General for Humanitarian Affairs and UN Emergency Relief Coordinator, Mark Lowcock

The United Nations has requested US $10.3 billion to help lower income countries struggling to deal with the direct effects and aftershocks of the COVID-19 pandemic, doubling its ask from May, according to a new UN Humanitarian Response Plan launched today. 

The ask comes just as Finance Ministers and heads of central banks of the G20, who represent the world’s most developed countries and largest economies, are set to meet via video conference for the third time this year on Saturday. UN Emergency Relief Coordinator Mark Lowcock directed the ask at the G20 countries, specifically referencing the upcoming Finance Ministers’ meeting. 

“I do have to say that… wealthy nations [have rightly] thrown out preset fiscal and monetary rulebooks to protect their people and their economies. Their response has been grossly inadequate when it comes to helping out the poorer countries, and that is dangerously short-sighted,” said Lowcock.

Rich countries would need to invest less than 1% of the trillions of dollars they have already put into their countries’ own coronavirus responses in order to protect poorer countries from more drastic effects of the virus, according to Lowcock.

“I want to contrast between the global response to the 2008-2009 financial crisis, where there was good coordination and real stepping up by better-off countries, through the G20, particularly in reinforcing the International Monetary Fund, the World Bank to help the poorer countries,” he added. “It’s an unfortunate contrast to what we’re seeing now.

“It is a much bigger crisis, and every country is affected by it. But unfortunately, we don’t yet have a commensurate from the wealthier countries in support of the poorer countries.

“Our advice is that needs to change if the whole world does not want to look back in 2-3 years time after multiple, cascading crises and wonder why we didn’t address them better.”

Pandemic Could Cause New Conflicts To Erupt
A child holds up bullets collected from the ground in a village near North Darfur, Sudan. Many people from the area have been displaced by surges of violence.

“An additional 13 countries are projected to experience new conflicts between 2020 and 2022 relative to pre-pandemic forecasts. If that materializes, global instability will reach a new 30-year high,” Lowcock told reporters, citing an analysis prepared by Oxford University and Lowcock’s team. “Conflict is expensive.

“The minimum cost incurred during an average civil war to both host and neighboring countries has been estimated at approximately $60 billion.”

The pandemic could induce the first rise in global poverty levels in three decades, and cause new refugee outflows.

“At least 70 to 100 million people could be pushed back into the extreme poverty category. In addition, an extra 130 million people could be pushed to the brink of starvation,” he said.

UN Plan Will Help Conflict-Affected & Poor Countries Recover From Pandemic
Volunteers at Bidyanando Foundation, a local NGO in Bangladesh, distribute cooked food.

Some 63 fragile countries facing unrest and conflict in the background of the COVID-19 pandemic will benefit from the funding, according to the costed plan. A draft of the plan was published earlier this week by The New Humanitarian. 

Approximately US $8.4 billion will be directed towards country-level responses, and US $1.8 billion will be directed towards “global requirements,”  said Lowcock. Some US $1 billion alone will be used for transporting aid workers and supplies.

An additional US $300 million will be allocated for NGOs directly, and US $500 million will be used for famine prevention.

“COVID-19 and the associated global recession are about to wreak havoc in fragile and low-income countries,” said Lowcock.

“My message today… to rich nations is that, unless we act now, we should be prepared for a series of human tragedies, more brutal and more destructive than any of the direct impacts of the virus itself in action,” he added, speaking at a press briefing Friday hosted by the World Health Organization. 

Fragile countries will need an estimated total of US $90 billion to recover from the direct and indirect effects of the COVID-19 crisis, and the UN ask for US $10.3 billion represents merely a fraction of the total amount required.  

However, even US $90 billion would be less than 1% of the stimulus packages wealthy countries have already passed to shield their own citizens from COVID-19 related shocks, Lowcock said. 

So far, the UN has raised US $1.7 billion to fund the plan, leaving a shortfall of US $8.6 billion. The humanitarian needs have increased at a faster rate than funding is rising.  

“The gap between the need and the funding is growing. And we’re seeing another compounding problem, we’re seeing more countries under economic distress and being dragged down to the level of requiring humanitarian aid,” said Lowcock.

Image Credits: UN Photo/Mark Garten, UN Photo/Albert Gonzalez Farran, UN Women.

Ebola response workers in the Western DRC

Just as the nearly 2 year long Ebola outbreak that ravaged the eastern Democratic Republic of the Congo has drawn to a close, a new cluster of cases is growing in the Mbandaka area of Equateur province, an area in the DRCs northwest region.

Some 56 cases have been reported since the first case in the province on 1 June. More than half of the cases were reported in just the past three weeks, and the outbreak has since spread to six health zones. As of July 14th, 21 people have died, according to the WHO DRC country office.

Amidst a massive redirection of global health financing towards containing the COVID-19 pandemic, funding for containing the DRC’s eleventh Ebola outbreak is running dangerously low. WHO has mobilized US $1.75 million for the response, which is estimated to last only a few more weeks.

The United States, which was one of the largest funders of the WHO’s Ebola response in the 2014-2015 West Africa epidemic and the more recent Eastern DRC epidemic, has remained quiet on the current situation.

The Trump administration had previously supported the Ebola response in the Eastern DRC as one of its major global health priorities, with Health and Human Services Secretary Alex Azar himself meeting with DRC President Felix Tshisekedi in Kinshasa in September 2019. However, since Trump announced the United States’ withdrawal from the WHO, the administration has not made any public comment regarding the most recent Ebola outbreak in the Western DRC.

The DRC is also battling it’s own COVID-19 epidemic at the same time, with more than 8000 cases so far reported.

Since the coronavirus pandemic has gripped global attention, regular information on the most recent Ebola outbreak has been difficult to find. While the WHO DRC country office Twitter page releases regular updates on case numbers, the agency has not been releasing more comprehensive regular disease outbreak notices or situation reports. The last official WHO situation report on Ebola was dated 23 June, the day the Eastern DRC outbreak was declared over.

“Responding to Ebola in the midst of the ongoing COVID-19 pandemic is complex, but we must not let COVID-19 distract us from tackling other pressing health threats,” said WHO Regional Director for Africa Matshidiso Moeti in a press release. “The current Ebola outbreak is running into headwinds because cases are scattered across remote areas in dense rain forests. This makes for a costly response as ensuring that responders and supplies reach affected populations is extremely challenging.”

Over 12000 people have been vaccinated so far in this outbreak. Community engagement has been a pillar of the response, largely thanks to lessons learned from communities’ and responders’ experience in containing a 2018 outbreak in the province that sickened 54 people. Some 90% of vaccinators are from affected locales.

Image Credits: WHO AFRO.

A notorious hacking group with ties to Russia’s intelligence network has been targeting COVID-19 vaccine developers, according to the United States, United Kingdom, and Canadian government.

APT29, also known as ‘The Dukes’ or ‘Cozy Bear,’ has been organizing cyber attacks in an effort to steal confidential information regarding COVID-19 vaccine development and research, according to an advisory released by the UK’s National Cyber Security Centre (NCSC), Canada’s Communications Security Establishment (CSE), and the US National Security Agency.

The advisory warns that the group has been deploying spearphishing, a tactic used to trick email users into disclosing personal credentials, and custom malware called “WellMess” and “WellMail” to target organizations involved in coronavirus research. “WellMail” has not been previously named on public servers, meaning it may be a newly recognized type of malware.

“It is completely unacceptable that the Russian Intelligence Services are targeting those working to combat the coronavirus pandemic,”  said UK Foreign Secretary Dominic Raab in a press statement. He labeled the cyber attacks “selfish” and “reckless.”

NCSC Director of Operations, Paul Chichester, further denounced the attacks:

“We condemn these despicable attacks against those doing vital work to combat the coronavirus pandemic,” said Chichester in a statement. “We would urge organisations to familiarise themselves with the advice we have published to help defend their networks.”

The advisory urges organizations to review cybersecurity systems and protocols to avoid being compromised by the hackers. It provides “Indicators of compromise” (IOCs) – or lines of codes used to identify hacks – for the common attacks used by the group of hackers.

While APT29 has never been claimed by the Russian government, the NCSC is “almost certain (95%+) that APT29 are part of the Russian intelligence services.” However, the advisory declined to name specific organizations that had been targeted by the group.

APT29 has previously been implicated in the 2016 hack of the Democratic National Convention in the US, and the information leak was largely credited with contributing to Democratic candidate Hilary Clinton’s loss in the 2016 Presidential election.

Image Credits: Yuri Samoilov.

Anthony Fauci, the US’ top COVID-19 expert, and director of the US National Institute for Allergies and Infectious Diseases for nearly four decades.

In an unusually frank statement, the United States’ embattled top infectious disease expert, Dr Anthony Fauci, expressed hopes that the US would resolve its conflicts with the World Health Organization. 

Fauci, an expert on the White House Coronavirus taskforce and director of the National Institute for Allergies and Infectious Diseases (NIAID), in an interview with ABC News. The candid interview follows on the heels of a rash of criticism aimed at him by allies of President Donald Trump, as well as indirect jibes by Trump himself, who has not met with Fauci for the past month.

“They are an imperfect organization, they have made mistakes, But i would like to see the mistakes corrected, and for them to be much more in line with the kinds of things we need… So I hope this kind of tension between the US and the WHO, somehow or other, ultimately gets settled in a favorable way. Because the world does need a WHO,”  said Fauci in an interview with ABC News.

Fauci, who has advised six presidents as head of the NIAID, has been weathering increasing attacks from Trump allies, including some calling for his resignation. But the infectious disease veteran told The Atlantic that the “problem [of the pandemic] is too important” to consider resigning.

“I just want to do my job. I’m really good at it. I think I can contribute. And I’m going to keep doing it,”  Fauci told The Atlantic.

White House Deputy Press Secretary Dan Scavino most recently posted a political cartoon deriding Fauci’s comments against in-person school reopenings in the fall, among other issues. The Trump administration has been pushing schools to reopen with in person classes in the fall, and the President has complained that the US Centers for Disease Control recommendations cautioning against full reopenings are too strict. 

White House Deputy Press Secretary posted a caricature of Fauci in another jab at the infectious disease veteranEx

While WHO had no comments on Fauci’s comments per say, the agency did speak out about school reopenings. WHO experts on Monday warned against using school reopenings as “political football.”

“ We can’t turn schools into yet another political football in this game. It’s not fair on our children,” WHO Health Emergencies Executive Director Mike Ryan said on Monday. “So we have to look at this carefully, in light of the transmission in any given country or any given setting. And we have to make decisions that are based in the best interest of our children, either their education interest or their health interest.” 

Image Credits: National Institutes of Health, Dan Scavino Jr..

Some 75 new countries have submitted expressions of interest to join the COVAX Facility, potentially supporting 90 other countries who have already joined the COVAX Advanced Market Commitment initiative created to pool demand and secure lower prices for bulk purchases of a COVID-19 vaccine.

Meanwhile, Moderna is pulling ahead in the COVID-19 vaccine rat race as the first company to publish results from Phase I clinical trials in a peer reviewed journal, the New England Journal of Medicine, on Tuesday. Some 21 vaccine candidates are in human trials, although none have yet been given full regulatory approval.

The COVAX Facility is one initiative to set up a global system to buy and distribute an approved COVID-19 vaccine as soon as it hits the market in an effort to minimize the lag normally experienced between a vaccine receiving regulatory approval, and its deployment to people in need, particularly in low- and middle-income countries. Hosted by Gavi, the Vaccine Alliance, the Facility aims to subsidize lower-income countries’ vaccine purchases with voluntary donations to GAVI’s Advance Market Commitment. 

““For the vast majority of countries, whether they can afford to pay for their own doses or require assistance, it means receiving a guaranteed share of doses and avoiding being pushed to the back of the queue, as we saw during the H1N1 pandemic a decade ago,”  said CEO of Gavi Seth Berkley in a press release. 

“Even for those countries that are able to secure their own agreements with vaccine manufacturers, this mechanism represents, through its world-leading portfolio of vaccine candidates, a means of reducing the risks associated with individual candidates failing to show efficacy or gain licensure,”  he added.

However, some critics have cautioned that the COVAX Facility could inadvertently allow rich countries to buy up vaccines more quickly than poor countries. High-income countries could sign their own deals with pharma companies, and also benefit from allocations from Gavi, without being required to contribute to the Advance Market Commitment, according to Associated Press. 

““By giving rich countries this backup plan, they’re getting their cake and eating it too,” Anna Marriott of Oxfam International told Associated Press. “They may end up buying up all the supply in advance, which then limits what Gavi can distribute to the rest of the world.”

Berkley has dismissed such criticisms.

The Facility’s ambitious goal is to deliver two billion doses of safe, effective COVID-19 vaccines by the end of 2021. So far, the US $300 million of the US $2 billion goal for the Advance Market Commitment has been raised from high-income donors.

Moderna Releases Positive Phase I COVID-19 Vaccine Results in Peer-Reviewed Journal

Colorized electron micrograph of SARS-CoV-2 (yellow) attacking a dying cell (red)

All 45 participants in Moderna’s Phase I COVID-19 vaccine trial developed neutralizing antibodies, the type of antibodies able to bind to the virus and prevent it from infecting human cells.

Two 100 microgram doses of the vaccine spaced 28 days apart were able to induce antibody levels 4.1 times higher than levels seen in recovered COVID-19 patients. The vaccine, mRNA-1273, was also able to induce a Th1-biased CD4 T cell response. Phase II study participants have already been enrolled.

“These Phase 1 data demonstrate that vaccination with mRNA-1273 elicits a robust immune response across all dose levels and clearly support the choice of 100 µg in a prime and boost regimen as the optimal dose for the Phase 3 study,” said Chief Medical Officer of Moderna Tal Zaks in a press release.

Moderna plans to begin testing a 100 microgram dose of the vaccine in over 30,000 volunteers for a Phase III study set to start in late July. The Phase III trial, titled COVE, will measure how well the vaccine protects against symptomatic COVID-19 disease, infection by the COVID-19 causing virus SARS-CoV-2, and severe COVID-19. 

The highly anticipated results from the Phase I trial, a collaboration between Moderna and the United States National Institute of Allergies and Infectious Disease, comes as the US continues to hit sober new highs for the number of new coronavirus cases, with new records set daily for the past week. The US reported more than 67,400 new cases on Tuesday, according to Johns Hopkins University’s COVID-19 cases tracker.

Image Credits: US NIH, NIAID.