Chronic diseases claim up to 50 million lives a year

On Monday, the Geneva-based NCD Alliance launched the first-ever fund to bolster the efforts of NGOs worldwide fighting chronic diseases alongside the COVID-19 pandemic with some $US 300,000 in initial seed capital. 

The effort is unique in that it links major pharma interests that develop and produce drugs for non-communicable diseases (NCDs) to the support of NGOs in some 20 low- and middle-income countries (LMICs) and regions that are focused on prevention and access to affordable treatment. 

The new fund, the Civil Society Solidarity Fund on NCDs And COVID-19, also tackles a neglected aspect of the COVID-19 pandemic. 

Cardiovascular and lung diseases, as well as cancer and diabetes, make people much more vulnerable to serious COVID-19 illness and death. And mental illness can actually be triggered by the disease itself.

Even so, while donors have responded with billions of dollars to support the pandemic response, funding to NCD groups addressing root causes of those diseases has become all the more volatile. The new fund addresses that gap by supporting NGOs at the grassroots where action can make the biggest difference.   

“This is a first-of-its-kind fund to support NCD civil society organisations respond to COVID-19”, said Katie Dain, CEO of NCD Alliance. “During pandemics, momentum in several health and sustainable development issues, notably HIV/AIDS, Ebola and climate change, have repeatedly reinforced the critical role of civil society organizations and community-led efforts in accelerating action from local to global levels. Civil society are proven campaigners, change agents, experts, implementers, and watchdogs.”

Every year, chronic diseases cause over 50 million premature deaths and affect 1.7 billion people around the world, added Todd Harper, President of the NCD Alliance, at a virtual launch of the fund on Monday.

WHO Director General Dr. Tedros

But a “deadly interplay”’ between chronic diseases and COVID-19 is taking even more lives than before, as underlying conditions increase vulnerability to COVID-19, said WHO’s Director-General Dr Tedros Adhanon Ghebreyesus, who also spoke at Monday’s event.

“We cannot go back to the same health systems model, which has failed the majority of people living with NCDs…We need a paradigm shift to include the prevention, screening, early diagnosis and appropriate treatment of NCDs as a part of primary healthcare for universal health coverage….We need to build back better”.

“In Italy, 68% of the people who died from COVID-19 had high blood pressure, and 31% had diabetes”, said Norway’s Minister of International Development Dag Inge Ulstein.

Even before COVID-19, there was a “huge need” to fund NCDs, Ulstein said, especially in low and middle income countries (LMICs).

Currently, 86% of NCD-related premature deaths (before the age of 70) occur in LMICs, but NCDs still only receive about 1-2% of all global health related development aid.

Massive Disruptions Being Seen in NCD Treatments

The Fund comes as NGOs on the ground scramble to maintain their operations and to secure funding in the midst of the pandemic and a global economic crisis, according to an internal survey conducted by the NCD Alliance in late May.

“In the survey from late May of 40 national and regional NCD alliance groups, some 87-90% of respondents said that disruption of NCD treatment and care operations for people living with non-communicable diseases, less access to healthy food and physical activity; and more increased alcohol and tobacco use, were key issues they face during the pandemic”, said Dain to Health Policy Watch. Also, 70% of organizations experienced difficulties in securing future funding as a result of the pandemic.

Ilona Kickbush, Founding Director The Graduate institute’s  Global Health Centre in Geneva

Massive disruptions in essential services – combined with a “long-time global under-investment in NCD prevention and control” – are contributing to an uptick in chronic diseases around the globe, said Ilona Kickbush, Founding Director and Chair of the the Global Health Centre at Geneva’s Graduate institute, who moderated the launch event. 

“This is not a crisis that’s going to stop tomorrow, and even if COVID-19 stops tomorrow, the impact is going to be with us for years to come”, she added.

“The fund, totalling $300,000, will competitively award grants of up to US$15,000 to national and regional NCD alliances to support them in addressing the critical needs of people living with NCDs during the COVID-19 pandemic”, said the NCD Alliance. “The funds will support: advocacy and communication efforts for the continuity of essential NCD health services; inclusion of NCDs in national COVID-19 response and recovery plans;  and community-led awareness-raising campaigns on the linkages between NCDs and COVID-19”.

The Fund will amplify the voices of people living with chronic diseases, promote advocacy and communications strategies, and spearhead health policy reform through the grants, awarded on a competitive basis, to 20 national and regional NCD alliances around the world – including Brazil, Uruguay, Togo, Benin, Bangladesh, Cambodia, among other countries, said the NCD Alliance.

While the pandemic has created stiff new obstacles to NCD treatment, it also creates a political moment where policymakers are more aware of the need to address underlying conditions that make people more vulnerable to COVID-19.  

“You can’t underestimate the importance of a political moment, and you have to do the work to translate that political moment into an ongoing dividend”, added Jennifer Cohn from Resolve To Save Lives, an initiative launched by New-York based Vital Strategies.

The pharma companies that contributed to the Fund include: Takeda, AstraZeneca, Upjohn (Pfizer), and Access Accelerated – a partnership of some 20 biopharmaceutical companies working on NCD treatments and cures. The US-based Leona M. and Harry B. Helmsley Charitable Trust also contributed.

We Already Know How To Fight NCDs – But Governments Need To Pull Their Weight

While the new fund represents an alliance between the private sector and civil society, it is governments, ultimately, that need to act more assertively on the NCD challenge, said Cohn. 

Jennifer Cohn, Senior Vice President of Resolve To Save Lives

“Who will pay? It will be governments, it will not be an industry…we must use the opportunity to get commitments [and] ensure there’s transparency on these budgets, so that we can hold decision makers accountable”, she said. 

In past decades, public health professionals have tried and tested strategies that can effectively prevent and treat chronic diseases.

“We know very well that the majority of non-communicable diseases can be prevented or treated with smart policy measures and sound investment in universal health coverage”, said Harper.

However, governments needs to make core NCD investments, and adopt smarter policies and regulations. 

“Just like any other epidemics, the costs from NCDs will only grow if we don’t activate [proven] interventions to prevent and treat these diseases”, said Cohn.

Measures that can nudge people towards healthier lifestyles include higher taxes and plain packaging on tobacco products, as well as other policies recommended by the WHO Framework Convention on Tobacco Control, which 181 countries worldwide have ratified.

Processed foods have excess salt, leading to hypertension

As for hypertension, some 100 million lives could be saved over the next 30 years from the deadly effects of high blood pressure – including strokes and heart diseases – mainly by eliminating artificial trans fats in food supplies, reducing dietary sodium intake, and better front-of-package labeling for healthy and unhealthy foods, added Cohn.  

“We can successfully reduce [salt intake] through…policies and legislations that reduce sodium in packaged or institutionally prepared foods,” she said.

Governments also need to invest “a lot more” to prevent children and adolescents from developing NCDs like obesity, added Sir George Alleyne, PAHO’s Director Emeritus, and former UN Special Envoy for HIV/AIDS in the Caribbean:

“It is almost criminally negligent to [let children] become fat. Governments can stop children from becoming fast [by investing] progressively and more aggressively”. 

Last But Not Least – Community Engagement To Synergize With Policy 

Bente Mikkelsen, WHO Director for NCDs

Policy reforms offer a useful starting point to improve chronic disease management, but people with underlying conditions must not be left out of decision-making processes and interventions, added panelists.

“We need to do better…and secure seats at the table for people [with NCDs] because there are big decisions that need to be made”, said Bente Mikkelsen, WHO’s Director for NCDs.

People with chronic illness need to move from passive participation to “active collaboration and action”, added Nupur Lalani, a diabetic and founder of the India-based Blue Circle Diabetes Foundation. 

Sometimes, community engagement can address chronic diseases in ‘relatively simple and ‘relatively cheap’ ways, said Kickbush. 

In a hallmark initiative to slash cervical cancer – the largest killer of women in sub-saharan Africa – groups of young women with HIV were mobilized to support widespread screening for cervical cancer and to fight stigma associated with the disease. 

As a result, in only two years, over one million women with HIV were screened and treated for cervical cancer in 8 sub-Saharan African countries.

UNAIDS Executive Deputy Director Shannon Hadder

“Our lessons from HIV are that it needs to be community-led, community-led, community-led”, said UNAIDS Executive Deputy Director Shannon Hadder. 

Multi-disease screening can also be a game-changer, noted Hadder, describing a UNAIDS supported programme called Project Search – which monitors for diabetes, high blood pressure, eyesight and HIV all at one time: 

“We have seen [these initiatives] deliver sustainability, creativity and agility in ways that continue to serve.”

“Telemedicine is being scaled up in India as a really important intervention that can allow for treatment modifications from a patient’s home”, especially for chronic diseases, said Cohn, adding:

“Telemedicine can actually help us maintain lifesaving and sustainable pathways of care for those with NCDs. And these models can help us scale rational and sustainable and affordable models of care into the future, even when there’s not a global pandemic raging.”

Image Credits: WHO, Resolve To Save Lives.

   Rome, Italy – More people are going hungry, an annual study by the United Nations has found. Tens of millions have joined the ranks of the chronically undernourished over the past five years, and countries around the world continue to struggle with multiple forms of malnutrition.

The latest edition of the State of Food Security and Nutrition in the World, published today, estimates that almost 690 million people went hungry in 2019 – up by 10 million from 2018, and by nearly 60 million in five years. High costs and low affordability also mean billions cannot eat healthily or nutritiously. The hungry are most numerous in Asia, but expanding fastest in Africa. Across the planet, the report forecasts, the COVID-19 pandemic could tip over 130 million more people into chronic hunger by the end of 2020. Flare-ups of acute hunger in the pandemic context may see this number escalate further at times.

The State of Food Security and Nutrition in the World is the most authoritative global study tracking progress towards ending hunger and malnutrition. It is produced jointly by the Food and Agriculture Organization of the United Nations (FAO), the International Fund for Agriculture (IFAD), the United Nations Children’s Fund (UNICEF), the UN World Food Programme (WFP) and the World Health Organization (WHO).

Writing in the Foreword, the heads of the five agencies warn that “five years after the world committed to end hunger, food insecurity and all forms of malnutrition, we are still off track to achieve this objective by 2030.”

The hunger numbers explained

In this edition, critical data updates for China and other populous countries have led to a substantial cut in estimates of the global number of hungry people, to the current 690 million. Nevertheless, there has been no change in the trend. Revising the entire hunger series back to the year 2000 yields the same conclusion: after steadily diminishing for decades, chronic hunger slowly began to rise in 2014 and continues to do so.

Asia remains home to the greatest number of undernourished (381 million). Africa is second (250 million), followed by Latin America and the Caribbean (48 million). The global prevalence of undernourishment – or overall percentage of hungry people – has changed little at 8.9 percent, but the absolute numbers have been rising since 2014. This means that over the last five years, hunger has grown in step with the global population.

This, in turn, hides great regional disparities: in percentage terms, Africa is the hardest hit region and becoming more so, with 19.1 percent of its people undernourished. This is more than double the rate in Asia (8.3 percent) and in Latin America and the Caribbean (7.4 percent). On current trends, by 2030, Africa will be home to more than half of the world’s chronically hungry.

The pandemic’s toll

As progress in fighting hunger stalls, the COVID-19 pandemic is intensifying the vulnerabilities and inadequacies of global food systems – understood as all the activities and processes affecting the production, distribution and consumption of food. While it is too soon to assess the full impact of the lockdowns and other containment measures, the report estimates that at a minimum, another 83 million people, and possibly as many as 132 million, may go hungry in 2020 as a result of the economic recession triggered by COVID-19. The setback throws into further doubt the achievement of Sustainable Development Goal 2 (Zero Hunger).

Unhealthy diets, food insecurity and malnutrition

Overcoming hunger and malnutrition in all its forms (including undernutrition, micronutrient deficiencies, overweight and obesity) is about more than securing enough food to survive: what people eat – and especially what children eat – must also be nutritious. Yet a key obstacle is the high cost of nutritious foods and the low affordability of healthy diets for vast numbers of families.

The report presents evidence that a healthy diet costs far more than US$ 1.90/day, the international poverty threshold. It puts the price of even the least expensive healthy diet at five times the price of filling stomachs with starch only. Nutrient-rich dairy, fruits, vegetables and protein-rich foods (plant and animal-sourced) are the most expensive food groups globally.

The latest estimates are that a staggering 3 billion people or more cannot afford a healthy diet. In sub-Saharan Africa and southern Asia, this is the case for 57 percent of the population – though no region, including North America and Europe, is spared. Partly as a result, the race to end malnutrition appears compromised. According to the report, in 2019, between a quarter and a third of children under five (191 million) were stunted or wasted – too short or too thin. Another 38 million under-fives were overweight. Among adults, meanwhile, obesity has become a global pandemic in its own right.

A call to action

The report argues that once sustainability considerations are factored in, a global switch to healthy diets would help check the backslide into hunger while delivering enormous savings. It calculates that such a shift would allow the health costs associated with unhealthy diets, estimated to reach US$ 1.3 trillion a year in 2030, to be almost entirely offset; while the diet-related social cost of greenhouse gas emissions, estimated at US$ 1.7 trillion, could be cut by up to three-quarters.

The report urges a transformation of food systems to reduce the cost of nutritious foods and increase the affordability of healthy diets. While the specific solutions will differ from country to country, and even within them, the overall answers lie with interventions along the entire food supply chain, in the food environment, and in the political economy that shapes trade, public expenditure and investment policies. The study calls on governments to mainstream nutrition in their approaches to agriculture; work to cut cost-escalating factors in the production, storage, transport, distribution and marketing of food – including by reducing inefficiencies and food loss and waste; support local small-scale producers to grow and sell more nutritious foods, and secure their access to markets; prioritize children’s nutrition as the category in greatest need; foster behaviour change through education and communication; and embed nutrition in national social protection systems and investment strategies.

The heads of the five UN agencies behind the State of Food Security and Nutrition in the World declare their commitment to support this momentous shift, ensuring that it unfolds “in a sustainable way, for people and the planet.”

Image Credits: FAO.

SARS-CoV-2 (green) attacking a human cell (red)

It is still too early to tell how long immunity to SARS-CoV-2, the virus that causes COVID-19, may last after infection, the World Health Organization’s Technical Lead for COVID-19, Maria Van Kerkhove said at Monday press briefing.

Van Kerkhove’s comments came just after the publication of a new study by researchers from Kings College, London, which found that immunity seemed to peak at three weeks after symptoms first appeared, but then waned rapidly afterward.  Previous studies have also suggested that immunity to SARS-CoV-2 may wane within a few months after infection.

“We do expect that people who are infected with SARS-CoV-2, they do mount some level of an immune response…What we don’t know is how strong that protection is and for how long that protection will last,” said Van Kerkhove. 

While not referring specifically to the recent study, Van Kerkhove added that experience with other coronaviruses indicates that it is possible to become reinfected, and  there is data suggesting that immunity to SARS-CoV-2 could wane: 

“From our experience with MERS and SARS1, the virus that spilled over in 2003, we know that people can have an antibody response for maybe a year or even longer. But with the human coronaviruses that circulate regularly, it’s much shorter than that. So it’s an incomplete answer because we don’t have that answer yet,” said Van Kerkhove.

In the antibody study posted on the preprint server MedRxiv, researchers from King’s College London found that levels of neutralizing antibodies, the type of antibodies that can bind to and neutralize the virus, peaked at three weeks after symptoms appeared. 

However, immunity rapidly waned after the three-week mark. 

“Using sequential samples from SARS-CoV-2 infected individuals collected up to 94 days post-onset of symptoms, we demonstrate declining neutralizing antibody titres [levels] in the majority of individuals,” the authors, a group of researchers from Katie Doore’s lab at Kings College London, wrote. 

Those who survived more severe infection had higher levels of neutralizing antibodies at the three week mark. However the time it took for antibody responses to peak was consistent across all study subjects despite differing levels of disease severity.

The study, Longitudinal evaluation and decline of antibody responses in SARS-CoV-2 infection, measured antibody levels between March and June in 96 healthcare workers and patients who had laboratory confirmed cases of COVID-19.

Such studies casts further doubt over the potential of populations to develop broad “herd immunity” to the virus, no matter how widely it circulates, in the absence of a vaccine.  It may also prove to be a complicating factor in vaccine research, insofar as a potential vaccine would need to provoke a more long-lasting response to the virus in order to be a viable candidate for distribution on a global scale.

Dutch Study Finds Strong Link Between Air Pollution & More COVID-19 Deaths

A pig pokes his head out of a barn in Oosterhout, North Brabant, The Netherlands – where air pollution produced by livestock in rural areas is linked to higher rates of COVID-19 deaths.

Meanwhile, a Dutch study has yielded what some observers say may be the best study yet linking higher air pollution levels to higher rates of COVID-19 hospitalizations and deaths.

The peer-reviewed Dutch study is particularly noteworthy because it found the correlations in Dutch rural areas, which have some of the country’s highest air pollution levels – due to ammonia particulate emissions produced by livestock waste as well as farm fertilizers.

The Dutch study thus tends to strengthen the emerging evidence about a direct linkage between air pollution and COVID-19 outcomes. While a correlation between higher air pollution levels and higher COVID-19 death rates was previously identified in two previous studies by a group of researchers at Harvard’s School of Public Health, as well as researchers in Italy, critics had said that those findings might be due to other factors related to the urban environment, such as poverty or other health inequalities – and not directly linked to air pollution exposures per se.  

The Harvard study looked county-wide throughout the United States and found an 8% increase in coronavirus deaths for a single-unit rise in fine particle pollution, while controlling for factors such as obesity and smoking incidence. 

However, the Dutch study analyzed data at the municipal level for some 355 Dutch municipalities, averaging 95 km2 in size, as compared to the US county level, which is over 30 times larger.

This means that researchers could look more granularly at pollution exposures and outcomes, said lead author Matt Cole, in a blog in the journal The Conversation. The Dutch study also uses COVID-19 data up to 5 June 2020, allowing it to capture almost the full wave of the epidemic.

“The correlation we found between exposure to air pollution and COVID-19 is not simply a result of disease cases being clustered in large cities where pollution may be higher,” Cole said. “After all, COVID-19 hotspots in the Netherlands were in relatively rural regions.”

COVID-19 cases per 100,000 people and annual concentrations of PM2.5 (averaged over the period 2015-19) in the Netherlands. (Matt Cole, The Conversation)

The study found the highest air pollution concentrations included rural areas in the south-eastern provinces of North Brabant and Limburg, where intensive pig and chicken production produces large amounts of ammonia particles as a byproduct of livestock excrement, which form a significant proportion of fine particulate matter in air pollution. COVID-19 hospitalization and death rates were similarly clustered in those same regions.

The Dutch study found that an increase in fine particulate matter concentrations of 1 microgram per cubic metre was linked with an increase of up to 15 COVID-19 cases, four hospital admissions and three deaths, on average.

While media reports had suggested that some of the excess deaths seen in that region of The Netherlands may have also been due to the mass gatherings in rural areas for carnival season in February and March, the researchers controlled statistically for those gatherings as well as other factors.

“The relationship we found between pollution and COVID-19 exists even after controlling for other contributing factors, such as the carnival, age, health, income, population density and others” Cole observed.

The Dutch study, co-authored by Ceren Ozgen of the University of Birmingham and Eric Strobl of the University of Berne, is also the first study to have been accepted for publication in a peer reviewed journal – Environmental and Resource Economics.

Image Credits: NIAID/NIH, Flickr: Dutchairplaneshooter.

Healthcare workers dons protective equipment

Ibadan, Nigeria – The World Health Organisation (WHO) is advocating for equitable access to effective COVID-19 vaccines but developments surrounding the race to a vaccine suggest this may be extremely difficult. And health policy leaders in Africa and other low and middle-income countries are increasingly worried about their prospects for being pushed to the back of the line queue.   

While it used to be the pharmaceutical companies racing to be the first to have their vaccine candidates approved, the pandemic has also seen countries lobbying to get quick access to the vaccines, even before they become available, with the United States taking the most aggressive lead.

In the US, Operation Warp Speed (OWS) aims to deliver 300 million doses of a safe, effective vaccine for COVID-19 by January 2021. On 30 March 2020, the US Department of Health and Human Services (HHS) announced $456 million funding for Johnson & Johnson’s candidate vaccine, with Phase 1 clinical trials starting in summer. About two weeks later, HHS made up to $483 million in support available for Moderna’s candidate vaccine, which began Phase 1 trials on March 16 and received a fast-track designation from the FDA. Then on May 21, HHS announced up to $1.2 billion in support for AstraZeneca’s candidate vaccine, developed in conjunction with the University of Oxford. 

Under the agreement, at least 300 million doses of the vaccine will be made available for the United States, with the first doses delivered as early as October 2020 and Phase 3 clinical studies beginning this summer with approximately 30,000 volunteers in the United States.

But the US is not the only country that is striving to engage in COVID-19 vaccine nationalism which is an attempt to get as many doses of the vaccine for a country before others. Europe is also 

Late June 2020, Brazil signed a $127 million agreement for local production of AstraZeneca’s experimental vaccine that has shown promise to fight the COVID-19 pandemic. A similar agreement has also been signed by Moderna with Spain’s Rovi.  France, Germany, Italy and Netherlands are also setting up an “Inclusive Vaccine Alliance” through which they will jointly negotiate with COVID-19 vaccine developers and potential producers. For its 27-member states, the European Union is seeking a mandate to negotiate with the companies for advance contracts and reservations for doses of candidate vaccines.

African Countries’ Limited Choices
Shabir Madhi, Principal Investigator of the South African arm of Oxford University’s COVID-19 vaccine trial

With countries in Africa and other low and middle income countries unable to outbid the economic powerhouses, efforts on COVID-19 vaccine development is not on the same level as that of other parts of the world and the possibility of Africa not getting the vaccine as soon as possible is a major concern to the WHO and African leaders – although this is not new.

“Too often, African countries end up at the back of the queue for new technologies, including vaccines. These life-saving products must be available to everyone, not only those who can afford to pay,” said Dr Matshidiso Moeti, WHO Regional Director for Africa, speaking at a press event Thursday on vaccines for Africa, sponsored by the Geneva-based World Economic Forum. 

Currently, there are a total of 152 vaccines in development, and about 20 are in clinical trials. Out of those, only one is currently recruiting volunteers in Africa. 

Prof Shabir Madhi of South Africa’s Wits University is the Principal Investigator of Oxford COVID-19 Vaccine Trial in South Africa. Officially referred to as the South African Ox1Cov-19 Vaccine VIDA-Trial, it aims to involve 2000 volunteers aged 18–65 years, including individuals living with HIV. Clinical trials for the same vaccine are also ongoing in the United Kingdom and Brazil involving thousands of participants.

African Countries Should Support More Clinical Trials Despite Sensitivities

Madhi noted that one of the ways that African countries can accelerate the availability of COVID-19 vaccines for their citizens is for them to actively participate in clinical trials.

“In the past, it usually takes from 5 to 20 years for already approved vaccines to become available in Africa because of the non-existence of local data from clinical trials. We can reduce that by participating in clinical trials,” he told a press conference on Thursday.

According to Gavi, the Vaccine Alliance,  vaccine trials in Africa are a “sensitive and potentially controversial issue”, because of instances of Western researchers conducting unethical trials in African countries, and scientists undertaking medical experiments on people of African origin in the USA.

In April 2020, efforts geared towards encouraging African countries to participate in COVID-19 clinical trials stalled with the emergence of a video in which two French scientists made racist remarks in referring to Africa as the testing ground for new vaccines. Realising this could erode public trust in the science community, the video prompted a direct rebuke from Dr Tedros Adhanom Ghebreyesus, Director-General of the WHO.

Continent has a Long Record of Successful Clinical Trial Research 

Although Africa only accounts for about 2% of the world’s clinical trials, vaccine trials are not new in Africa. Prof. Pontiano Kaleebu, Director MRC/UVRI and LSHTM Uganda Research Unit told the press conference that while French scientists’ gaffe raised concerns about Africans being used as guinea pigs for clinical trials, the continent has been participating in various vaccine trials including trials for HIV and Ebola vaccines.

“There is no advantage in using Africans as guinea pigs and in my experience, we have not seen anyone going below international ethical standards,” he added.

Pontiano Kaleebu

The African Union is also striving to get more African countries involved in COVID-19 vaccine activities. It has endorsed the need for Africa to develop a framework to actively engage in the development and access to COVID-19 vaccines. 

“Success in developing and providing access to a safe vaccine requires an innovative and collaborative approach, with significant local manufacturing in Africa. We need to support the contribution of African scientists and healthcare professionals. We need to act with urgency,” said AU’s Chairperson, President Cyril Ramaphosa of South Africa.

New African CDC Consortium Aims to Develop Vaccine

The African CDC has also launched its Consortium for COVID-19 Vaccine Clinical Trial (CONCVACT) through which it seeks to mobilise academics, researchers and the private sector “to work together and use all available platforms for the development of COVID-19 vaccine”.

The consortium aims to secure more than 10 late stage vaccine clinical trials as early as possible on the continent by bringing together global vaccine developers and funders, as well as African organizations that facilitate clinical trials. 

“The goal is to ensure that sufficient data is generated on the safety and efficacy of the most promising vaccine candidates for the African population so they can be confidently rolled out in Africa once vaccines are approved,” Africa CDC stated.

Other challenges – Vaccine Production Capacity and Coverage 

While the global vaccination target is 90% coverage, Africa has averaged at 76% according to Moeti who described the bottlenecks of Africa’s immunisation efforts as a possible limitation in ensuring many Africans are able to get vaccinated against COVID-19 as soon as the vaccine becomes available. But there is another problem, that of mass production.

Advocates of equitable access to COVID-19 vaccine are asking the pharmaceutical companies with the promising vaccine candidates not to hold on to intellectual properties, but to share such to facilitate mass production of the vaccine in various parts of the world.

In Africa, Moeti noted that vaccine production capabilities are available in several African countries including Senegal (which is already producing the yellow fever vaccine), South Africa, Egypt, Tunisia, Ethiopia, Morocco and Algeria. But Madhi added there is no facility in Africa that has the capability to mass produce gene-based vaccines and such vaccines are the ones that are declared effective, Africa may have to rely on producers elsewhere for the vaccine.

Study volunteer receives inoculation at Redemption Hospital in Monrovia on the opening day in Liberia of PREVAC, a Phase 2 Ebola vaccine trial in West Africa.
China to the Rescue?

While the United States, Europe and several other regions are choosing to prioritise getting COVID-19 vaccines for their citizens ahead of the rest of the world, China has promised to supply any COVID-19 vaccine to Africa first, and at no cost.

China is leading the COVID-19 vaccine race with more vaccine candidates in the late clinical trial phase than any other country. Out of the three vaccines that are in Phase III trials, two are from China – Sinovac Biotech and China National Pharmaceutical Group (Sinopharm).

In June 2020, China’s president, Xi Jinping, told African leaders that participated in the Extraordinary China-Africa Summit On Solidarity Against COVID-19 that the continent will get China-developed COVID-19 vaccine for free. According to him, a China-developed vaccine will serve as a global public good. He added that African countries will be the first to benefit from the Chinese vaccine.

Expanding Vaccine Production Globally Could Avoid Competition
Vaccines have been tested on the continent before. But scaling up production in Africa could help avoid competition

Microsoft’s co-founder and co-chair of the Bill & Melinda Gates Foundation, Bill Gates believes that the only way to avoid countries competing for vials of the COVID-19 vaccine and leaving developing countries behind, will be to expand vaccine production capacity globally.

“There’s a plan to have multiple factories in Asia, multiple factories in the Americas, multiple factories in Europe, and if we can make over 1 to 2 billion doses a year, then the allocation problem is not super-acute,” Gates said. 

But there will be an impossible problem if the maximum annual production capacity is only 100 million doses a year.

Gates and Gavi CEO Seth Berkley put the cost of immunizing the world at tens of billions of dollars, said in an interview last month.

“The costs of some COVID-19 vaccines could end up ranging from about $4 a dose to potentially $15 a dose. While effort will involve making financial commitments to several vaccine programs, it’s worth it,” Gates said.

But with developed countries offering pharmaceutical companies huge sums of money to secure millions of doses of their COVID-19 vaccine candidates, Doctors Without Borders recently warned that there’s no guarantee that pharmaceutical companies will charge affordable prices.

“Everyone seems to agree that we can’t apply business-as-usual principles here, where the highest bidders get to protect their people from this disease first, while the rest of the world is left behind. Governments must ensure any future COVID-19 vaccines are sold at cost and universally accessible to all across the world,” said said Kate Elder, Senior Vaccines Policy Advisor for Doctors Without Borders’s Access Campaign.

Despite their limited capacity to outbid rich countries, Madhi advises African governments not to expect the vaccines to be given for free. Instead, he said they should engage the manufacturers and be actively involved in initiatives to dialogue and ensure that Africans are not totally sidelined or excluded.

Africa’s options are however limited. While the developed countries have the dual option of paying for millions of doses for their citizens or locally producing the vaccines after securing authorization and guideline from the manufacturers, Africa’s highly limited and largely unused vaccine production capacity make the continent to be largely unable to compete with the developed countries who are positioned as the first in line to procure doses for their citizens.

“Expecting African companies that have not produced vaccines in the past 25 years to now start producing COVID-19 vaccine over a 25-week period is overly optimistic. So we need to be guided regarding what to expect in terms of manufacturing on the African continent. It’s still a long path ahead to get to the few vaccines that will be available. In the meantime, the focus can’t be around vaccines, the focus remains trying to slow the rate of transmission of the virus,” Madhi said.

Image Credits: Twitter: @WHOAFRO, NIAID, Twitter: @WHOAFRO.

Photo Credit: Raul Lieberwirth

The World Health Organization announced a new program on Friday to help more than 1 billion tobacco users – a group at high risk for coronavirus complications – quit smoking during the pandemic.

The project, the Access Initiative for Quitting Tobacco, will be first rolled out in Jordan, where 82.5% of men over the age of 18 used tobacco or e-cigarettes, and 60% of young people between the ages of 13 to 15 were addicted to nicotine, according to a 2019 survey.

“COVID-19 has required us all to don masks, and yet it has also unmasked too many uncomfortable truths. One of those glaring truths is that smoking tobacco in all of its forms – electronic and non electronic – has shown no benefits whatsoever to its users,” said Princess Dina Mired of Jordan. “On the contrary it depletes one’s health one’s heart, and money, and now also puts the user in the highest risk group for not only contracting COVID-19, but also in spreading it, as well as not being able potentially to fight and survive the virus due to higher vulnerability to severe complications.”

Princess Dina Mired of Jordan

Even before COVID-19, smoking killed an estimated 8 million people a year. It’s a large risk factor for many deadly non-communicable diseases, such as heart disease, cancer, and chronic obstructive pulmonary disease (COPD). But during a pandemic of a deadly respiratory pathogen, smokers lungs are even more vulnerable.

“But if users need more motivation to kick the habit, the pandemic provides the right incentive,” added WHO Director-General Dr Tedros Adhanom Ghebreyesus.

The initiative aims to help smokers access nicotine replacement therapy, a tactic used to wean off of tobacco products, and other free resources to help quit smoking. WHO is also rolling out its first ever virtual health worker, eponymously named Florence after the world’s first nurse, to help quitters manage their smoking cessation plan.

The project will be led by WHO and the UN Interagency Task Force on Noncommunicable Diseases and brings together the tech industry, pharmaceutical and NGO partners like the Coalition for Access to NCDs Medicines & Products. Amazon Web Apps and Google, along with New Zealand and Australian companies helped develop Florence.

The pharma company Johnson & Johnson has joined to initiative to donate more than 40,000 patches of Nicorette, a line of nicotine infused products used for smoking cessation.

“We know that one simple patch of nicotine replacement therapy can change the trajectory of the health of a smoker. And this is what we are talking about here, one smoker at a time, but with a commitment to a large scale impact,” said Thibaut Mongon, Johnson & Johnson’s Worldwide Chairman for Consumer Health.

The program comes just a few weeks after the World Trade Organization ruled that Australia’s ‘plain-packaging’ laws for tobacco products did not present barriers to international trade – a major win for public health advocates against smoking.

Thibaut Mongon

Image Credits: Flickr: Raul Lieberwirth.

COVID-19 can be transmitted through tiny airborne particles floating in the air called aerosols

Just three days after almost 240 scientists criticized WHO for downplaying the risks of airborne transmission of tiny SARS-CoV-2 particles, or aerosols, the Organization edged closer to its critics point of view.   

WHO’s latest scientific brief, published Thursday, acknowledges that “short-range aerosol transmission cannot be ruled out”.

The tiny virus particles floating through the air may indeed infect some people, especially in poorly ventilated indoor settings. As a result, the donning of masks among groups of people standing one meter or less from each other would be warranted, WHO concluded. 

“WHO, together with the scientific community, has been actively discussing and evaluating whether SARS-CoV-2 may also spread through aerosols… particularly in indoor settings with poor ventilation”, says the new WHO brief. 

“Thus, a susceptible person could inhale aerosols, and could become infected if the aerosols contain the virus in sufficient quantity to cause infection within the recipient….

“Respiratory droplet transmission can occur when a person is in close contact (within 1 metre) with an infected person who has respiratory symptoms (e.g. coughing or sneezing) or who is talking or singing.”

The WHO revisions come as more and more COVID-19 disease outbreaks have been linked to overcrowded indoor spaces that lack effective ventilation such as churches and choirs, restaurants or fitness clubs. Particularly in such settings, critics have said that stronger WHO advice about the wearing of masks is needed.

“I applaud the WHO for the new brief”, said Professor of Epidemiology at Columbia University Stephen S. Morse. “It is an improvement [that suggests] WHO’s willingness to examine our assumptions, and to clarify some of the confusing definitions.  Science adapts to new information, and it’s to everyone’s benefit to re-examine assumptions.”

He also acknowledged that “WHO is in the difficult position that its advice has to be applicable all over the world, including resource limited settings, and that these recommendations often have to address both the general population, as well as healthcare infection prevention and control, where priorities may be different.”

Stephen S. Morse, Professor of Epidemiology at Columbia University

Critics Say Virus Arc of Travel is 10 Meters – Not 1

Geneva’s citizens wear masks in indoor space to prevent infection spread

But some critics immediately said that the WHO advice remained problematic — because the virus aerosols can in fact circulate much more widely, infecting people up to 10 meters away, at least in indoors spaces where it can linger for longer.

“Peer-reviewed scientific publications clearly demonstrate that particles even as large as 30 µm [micrometres] can move on air currents and travel more than 10 meters indoors”, said Donald Milton, professor of Public Health at the University of Maryland and an expert on respiratory virus transmission, in a tweeted response. “Even droplets as large as 100 µm can be inhaled and lodge in the nose.”

The WHO brief also falls far short of the much stronger recommendations that Milton and others were hoping for on the use of masks. 

“First — the good. WHO included the recommendations to “Avoid … enclosed spaces with POOR VENTILATION;” and that we should “ENSURE GOOD VENTILATION in indoor settings, including homes and offices.” I’m really happy to see this.” said Milton, in a detailed tweet chain analysis.

“But… they only recommend face masks when within one meter of other people. This is very bad advice, especially in “enclosed spaces with poor ventilation,” he added.  

“This terrible recommendation comes from the fundamental problem with the new WHO “scientific brief;” they do not use fact-based science to define “respiratory droplets” and “aerosols.” They only cite their own previous statements, not peer-reviewed scientific literature.”

“The extensive research and tremendous progress in the physics and biology of aerosols since 1940 appears to have had no impact. The contention that “respiratory droplets” in the size range of >5 to 10 µm [microns] in diameter only travel up to 1 meter is absolutely wrong,” he said. 

WHO Still Maintains Aerosols Are Secondary Mode of Transmission

Health personnel cleans surfaces aboard a Swiss train

Even with the revised guidance, WHO also continues to maintain that the virus causing COVID-19 is primarily spread through direct contact or larger respiratory droplets contained in coughs and sneezes  – rather than aerosols produced more routinely by speaking and breathing:

“To the best of our understanding, the virus is primarily spread through contact and respiratory droplets…Current evidence suggests that SARS-CoV-2 is primarily transmitted between people via respiratory droplets and contact routes,” the WHO brief states. 

Critics, on the other hand, have said that aerosols are the ‘most likely’ form of transmission of SARS-CoV-2, as was the case for the virus that caused the 2003 SARS epidemic in Asia.  

“Several retrospective studies conducted after the SARS-CoV-1 epidemic demonstrated that airborne transmission was the most likely mechanism explaining the spatial pattern of infections. “Retrospective analysis has shown the same for SARS-CoV-2”, said Lidia Morowska from Queensland University of Technology and Donald K. Milton from the University of Maryland, lead authors of the critical commentary published in the Journal of Clinical Infectious Diseases on Monday.

Other viruses that have been shown to aerosolize include respiratory syncytial virus (RSV), Middle East Respiratory Syndrome coronavirus (MERS-CoV) and influenza. As a a result, There is “every reason to expect that SARS-CoV-2 behaves similarly” to other viruses, stated Monday’s commentary. And with MERS, there’s evidence that aerosols could have been a source of infection in “at least one case”, said Morse. 

If a “significant portion” of COVID-19 transmission turns out to be through aerosols, then current physical distancing precautions of 1-2 metres are likely to be insufficient, he added.

WHO Should Adopt Precautionary Principle On Aerosols Given Current Evidence

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

WHO’s hesitancy about acknowledging a wider transmission ring of the virus stems from the lack of experience culturing it out of samples in the air, the Organization states, noting: 

“Further studies are needed to determine whether it is possible to detect viable [infectious] SARS-CoV-2 in air samples,” the WHO brief states, adding that transmission in crowded indoor spaces also “could be due” to other routes of transmission, like direct contact between individuals or respiratory droplets from coughing or sneezing.

In the face of unclear data, critics like Milton urged WHO to adopt the ‘precautionary principle’ to save more lives around the world:

“The report points out that SARS-CoV-2 RNA has been detected in air, but that the virus has not been cultured from air – but it ignores that this same argument was made about influenza virus for years – until two groups, one at CDC-NIOSH and one at the University of Maryland demonstrated that influenza virus can be cultured from the air,” he stated.

“It is understood that there is not as yet universal acceptance of airborne transmission of SARS-CoV2; but in our collective assessment there is more than enough supporting evidence so that the precautionary principle should apply.”

“Following the precautionary principle, we must address every potentially important pathway to slow the spread of COVID-19.”

Image Credits: CCO Public Domain, Stephen Morse, HP-Watch/Svet Lustig Vijay, Don Milton, Svĕt Lustig Vijay, National Institute of Allergy and Infectious Diseases, NIH.

WHO experts poised to announce details of independent evaluation of global COVID-19 response

An independent evaluation of the global response to the coronavirus pandemic, including steps taken by the World Health Organization, will be led by former Prime Minister of New Zealand Helen Clark and former President of Liberia Ellen Johnson Sirleaf.

The former world leaders will co-chair and Independent Panel for Pandemic Preparedness and Response (IPPR), the World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus announced Thursday at a virtual meeting of Member States.

The establishment of the panel follows through on a resolution passed at the 73rd World Health Assembly, which called for WHO to initiate an independent and comprehensive evaluation of the international response to COVID-19.

The new IPPR will operate independently of WHO’s Independent Oversight and Advisory Committee for the WHO Health Emergencies programme, which will be continuing its own line of work.

Dr Tedros proposed that the two co-chairs select the other members of the Panel.

A Special Session of the Executive Board be called in September to discuss the Panel’s progress. The Panel will present an interim report at the resumption of the World Health Assembly in November.

In January 2021, the Executive Board will hold its regular session, where the Panel’s work will be further discussed; and in May of next year, at the World Health Assembly, the panel will present its substantive report.

While the IPPR overtakes a comprehensive overview, Dr Tedros said that the agency is already reviewing “low hanging fruit” such as universal peer review, and the binary mechanism for declaring a public health emergency of international concern (PHEIC) under the International Health Regulations.

Critics have claimed that one of WHO’s missteps was declaring a PHEIC days late at the start of the pandemic. the IHR committee had been deadlocked on whether to declare a PHEIC during the first meeting, leading WHO to declare a PHEIC a week later. Even in January, Dr Tedros had proposed moving towards a “stop-light” warning system, rather than maintaining a binary system for declaring a PHEIC.

Testing bacteria for resistance to antibiotics at the Liverpool School of Tropical Medicine

A new Antimicrobial Resistance (AMR) Action Fund will inject nearly US $1 billion into the collapsing antibiotic development pipeline, aiming to bring two to four new antibiotics to patients by 2030.

The investment, organized by the International Federation of Pharmaceutical Manufacturers & Associations and 23 different pharma companies, is the biggest single investment in antibiotic research in four years. It aims to address the rising tide of life threatening infections caused by pathogens that have evolved resistance to antibiotics.

“We must act together to rebuild the pipeline and ensure that the most promising and innovative antibiotics make it from the lab to patients,” said Director General of the IFPMA, Thomas Cueni. “The AMR Action Fund is one of the largest and most ambitious collaborative initiatives ever undertaken by the pharmaceutical industry to respond to a global public health threat.”

AMR infections kill more than 700,000 people every year, a higher death toll than COVID-19 so far, Cueni further added. And the toll of infections extends beyond physical health – AMR could push 28 million more people into poverty at a staggering cost of $ 60-100 trillion, according to the IFPMA.

But investments in antibiotic development are lacking, despite the huge need. New antibiotics are closely rationed to prevent the development of resistance against them, so it is difficult to turn a profit on antimicrobials that have just hit the market.

“Fact of the matter is right now the worst which can happen to somebody who invests in antibiotics is that they succeed, because then they will lose more money than when they just have to write off research expenditure,” said Cueni. Several small biotech firms in antibiotic research have gone bankrupt in the past few years for such reasons.

The investment provides “an urgently needed lifeline for innovators,” said Jeremy Farrar, director of the research foundation the Wellcome Trust, especially for small and medium sized enterprises.

The Fund also “really complements a lot of other initiatives at the European level”, added Nathalie Moll, Director-General of the European Federation of Pharmaceutical Industries and Associations, as she referred to 12 ongoing projects to boost AMR-related R&D in Europe.

The AMR Action Fund synergizes with existing initiatives because it seals the investment vacuum at later stages of R&D, said Denmark-based investor Novo Holdings, which supports early-stage development of AMR therapies through its US $165 million Impact Repair Fund:

“The Impact Repair Fund [of Novo Holdings] is focused on the earlier stages of development”, said Novo Holdings CEO Kasim Kutay. “We were always counting on other investors to take the products into the more complicated and more expensive later stages [of R&D], but with investors having fled the field, we were trying to do both at the same time, which is just not practical.”

COVID-19 Could Exacerbate AMR

electron micrograph of methicillin-resistant Staphylococcus aureus (MRSA, brown), a deadly bacteria resistant to many antibiotics, surrounded by cellular debris

Even before COVID-19, about half of antibiotics were inappropriately prescribed by general practitioners, which either prescribed the wrong antibiotic, or prescribed it unnecessarily, according to the OECD.

But the World Health Organization has warned that the COVID-19 pandemic may even hasten the long looming threat of antimicrobial resistance, as hospitalizations due to the disease ramp up. Healthcare professionals are increasingly likely to prescribe affected patients with antibiotics to ward off secondary bacterial or fungal “co-infections” in hospital settings, which serve as breeding grounds for antimicrobial resistance. 

In one review of 18 studies, over 1450 out of 2010 patients with COVID-19 – or 72% of patients – received antimicrobial treatment although only 10 % had bacterial or fungal co-infections, said researchers from Imperial College London and the UK’s National Health Service in early May.

Over-prescription of antibiotics may be due to some COVID-19 patients presenting with symptoms similar to severe sepsis, a systemic life-threatening bacterial infection, said Priya Nori, Medical Director of the Antimicrobial Stewardship Program (ASP) at New York’s Montefiore Medical Centre.

An increasing appetite for treatments against COVID-19 may also exacerbate AMR, warned Rita Mangione-Smith from Kaiser Permanente Washington, a healthcare and health insurance provider in Washington state. In recent months, both US and Brazil’s political leaders Donald J. Trump and Jair Bolsonaro repeatedly touted the use of an antibiotic, azithromycin, in combination with anti-malarial hydroxychloroquine despite substantial evidence to support their claims.

And as COVID-19 disrupts essential health services all over the world, antimicrobial stewardship programmes – which aim to curb unnecessary use of antimicrobials through routine monitoring – are also likely to be hit, Nori warned, further raising the risk of AMR.

“AMR is a slow tsunami that threatens a century of medical progress,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, in a video message at the AMR Action Fund Launch. “So game changing investments into biotechnology companies around the world are required now.”

Image Credits: DFID/ Will Crowne, NIAID.

Colorized brain scan (Photo Credit: Florey Institute)

First came the dry cough. Then the shortness of breath and fever.

But what Noely, a 32 year old COVID-19 patient in Lima Peru, hadn’t expected, was her lost sense of taste, worsening anxiety, and impaired motor function.

“At first, I had symptoms of atypical pneumonia, with a lot of chest pain, and I lost my sense of taste. When the disease was really bad, I slept for five consecutive days,” she told Health Policy Watch. 

New symptoms appeared, such as an increased agitation around everyday chores like feeding her dogs or while cooking – so severe she had to escape to her bed to calm down. And Noely found that after her bout of illness, she would frequently burst into tears.

“The doctors gave me a muscle relaxant, as I was tense and agitated. Even before I was infected with COVID-19, I wanted to get tested for ADHD, but now I’m sure I’ve developed some condition I didn’t have before…I can’t function normally,” she said. “I felt overwhelmed, I cried and I prayed to get better.”

Over the past few months, a growing body of evidence has painted an insidious picture of SARS-CoV-2, the virus that causes COVID-19, as much more than a simple acute respiratory pathogen. The virus appears to be able to attack multiple organ systems – and patients can be left with long-lasting lung damage, kidney failure, and cardiovascular damage – especially those who are critically ill.

Now, it is becoming apparent that coronavirus can also hit the brain – even in those experiencing only mild respiratory symptoms. 

“Many elderly patients came in with altered mental status, but instead of being lethargic, they were aggressive or combative, and would have COVID-related encephalopathy [damage to the brain]”, according to one emergency medicine physician who worked in the Bronx, the borough with the highest rate of COVID-19 cases in the United States’ original epicentre – New York City.

A handful of COVID-19 patients presented in the emergency room with classic symptoms of stroke, such as being unable to move one side of the body, the physician, who wished to remain anonymous, told Health Policy Watch.

Young Patients Can Also Experience Severe Neurological Complications

Noely, a 32-year old COVID-19 survivor from Peru

But strikingly, younger patients such as Noely are also reporting neurological and psychiatric complications after their initial infection.

Severe neurological symptoms were reported in patients as young as 16 in a study that followed a cohort of 43 COVID-19 patients from UCL Queen Square National Hospital for Neurology, published 8 July 2020 in the journal Brain. 

And some patients with severe neurological symptoms only had mild respiratory symptoms. The study in Brain found that the severity of the neurological symptoms – which ranged from encephalopathy and psychosis to microbleeds in the brain – did not correlate with the severity of patients’ respiratory symptoms.

“”We should be vigilant and look out for these complications in people who have had Covid-19. Whether we will see an epidemic on a large scale of brain damage linked to the pandemic—perhaps similar to the encephalitis lethargica outbreak in the 1920s and 1930s after the 1918 influenza pandemic—remains to be seen,” joint senior author of the Brain study, Michael Zandi, said in a press release.

Additionally, a UK-wide surveillance study published in the Lancet found that “acute alterations in mental status were disproportionately overrepresented in younger patients in our cohort.

“These early data identify that acute alterations in mental status were disproportionately overrepresented in younger patients in our cohort…this symptom typically predominates in older groups,” the authors, from Universities of Oxford, Cambridge, Edinburgh, and Boston, among others, wrote in Lancet Psychiatry.

An Unpalatable Surprise From COVID-19

In late March and April, leading neurologists were surprised by the fact that an unusually high proportion of patients were experiencing an impaired sense of smell and taste. About 40% of patients with COVID-19 had these symptoms, according to systematic review and meta-analysis analyzing data from over 8000 patients from late May.

But the new paper published in Brain describes more serious neurological symptoms such as hallucinations, encephalitis (or dangerous swelling of the brain), and hemorrhagic changes such as microbleeds in patients who experienced varying symptoms.

Most worryingly, there were nine patients with acute disseminated encephalitis (ADEM), a rare but deadly condition where the body’s own immune system attacks myelin – the protective covering around nerves. 

The team saw an average of one case of ADEM per week during the study period. UCL Queen Square National Hospital of Neurology, where the study was done, normally sees only one case of ADEM per month, and the condition usually affects children. 

Seven of the patients also presented with Guillain-Barré Syndrome (GBS), a rare condition where the body’s own immune system attacks the nerves, causing weakness and muscle paralysis. Two of the patients have yet to recover from GBS at the time of the study’s publication.

Ischaemic stroke, a condition caused by blood clots blocking the delivery of oxygen-rich blood to the brain, causing brain cells to die within minutes, was reported in eight patients. The youngest stroke patient was 27 years old.

In late June, a study  in The Lancet identified a “large group” of patients with “altered mental status”, reflecting both neurological and psychiatric diagnoses, such as encephalitis and psychosis in the United Kingdom. 

Out of 125 patients identified with neurological and psychiatric complications across the UK, 77 (62%) had cerebrovascular events – mainly ischaemic stroke or intracerebral hemorrhage. If these complications aren’t treated in time, patients can die, or be left with permanent brain damage due to lack of oxygen to the organ.

The second most common symptom in about a third of patients (39/125) were ‘acute’ alterations in mental status – or changes in personality, behavior, cognition, or consciousness. Of those 39 patients, 16 had some form of encephalopathy and 23 had psychiatric diagnoses like new-onset psychosis, a neurocognitive ‘dementia-like’ syndrome, and an affective disorder.  

However, the Lancet study may have overrepresented critically ill patients, said the researchers, and it is still unclear how common these symptoms are in COVID-19 patients overall. 

Early Warnings Of SARS-CoV-2’s Effect On The Brain

The first warnings of COVID-19’s potential to cause neurological damage came from the original epicentre – Wuhan, China – where the virus first emerged. Over a third of coronavirus patients in a cohort of 200 had neurological symptoms such as acute cerebrovascular events, impaired consciousness, and muscle injury, according to a retrospective study published in early April. 

Later in May, clinicians from University College London (UCL) and the UK’s National Health Service (NHS) identified six COVID-19 patients suffering from acute ischaemic strokes.

“We now know that COVID-19 is not just a disease of the lungs”, said David Werring, Professor of Clinical Neurology at UCL and corresponding author of a letter published in the Biomedical Journal. “Our findings suggest that blockages of large brain arteries in COVID-19 patients are associated with highly abnormal blood clotting.”

But perhaps SARS-CoV-2’s effects on the brain were truly first hinted at by its deadly sister coronavirus – Middle East respiratory syndrome (MERS), which has a case-fatality rate of 35%. In Saudi Arabia’s MERS epidemic five years ago, scientists documented seizures, confusion and encephalopathy in patients struck by the disease.

SARS-CoV-2 Causes Inflammation & Blood Clotting
SARS-CoV-2 (red) attacking a dying cell (tan)

SARS-CoV-2 has a deadly trick up its sleeve – the ability to make the body turn on itself.

In some severe COVID-19 cases, the patient’s own immune system overreacts to the disease,  unleashing a wave of cytokines and inflammatory cells that damage the lungs and can even lead to death. 

This so-called ‘cytokine storm’ could explain how COVID-19 ravages other organs like the kidneys or the brain. Many of the rare neurological conditions seen in COVID-19 patients, such as GBS and ADEM, are caused by an overreaction of the immune system. 

Excessive inflammation could even be the trigger for blood clots that lead to ischaemic strokes, according to a letter by researchers from UCL and the NHS. 

 “The exaggerated inflammatory immune response known to occur in COVID-19 patients stimulates abnormal blood [clotting], including raised [levels of] D-dimer”, wrote UCL’s researchers.

While clinicians can look for evidence of a clot on brain scans, researchers can also measure the level of D-dimer in patient samples, a blood product that’s associated with blood clotting. All six patients that suffered from strokes in the UCL study had “markedly” high levels of D-dimer.

However, researchers warned that their data is not conclusive, as four out of six patients already had a history of hypertension, and two had atrial fibrillation – predisposing them to blood clots.

Preventing Strokes And Blood Clotting: Blood Thinners & Endovascular Treatment
Excessive blood-clotting, leading to thrombosis and stroke is one of the outcomes of serious COVID-19 cases

If used at an early stage of COVID-19 disease, blood thinners “could reduce” the number of people having strokes or blood clots elsewhere in the body, said UCL’s Werring in a statement:

“Early use of anticoagulant [blood thinners] drugs might be helpful, but this needs to be balanced against their brain bleeding risk, especially soon after an ischaemic stroke,” according to Werring. However, he added that more trials would be needed in order to find the best combination of drugs to treat people with COVID-19 related strokes. 

“Clinical studies (ideally controlled trials) are needed to find out the best treatment to reduce the disability caused by ischaemic stroke in people with COVID-19,” said Werring. 

Some researchers have also pointed to the most common and effective method for treating stroke – endovascular treatment – or the removal of a blood clot. Removing the blood clot works for “most people with acute ischaemic strokes,”  irrespective of patient characteristics or geographical location.

However, time is of the essence for this procedure. The earlier a stroke is treated,the less likely it is to cause severe, long-lasting damage, according a Nature opinion written by Johanna M. Ospel and Mayan Goyal in July. 

But lockdowns, combined with shortage of trained healthcare staff, could prevent patients from receiving treatment in a timely manner. 

“Our findings emphasise that even during the lockdown people with suspected stroke must attend hospital immediately to ensure they get the best treatment,” emphasized Werring.

Image Credits: Flickr: Florey Institute of Neuroscience & Mental Health, Varatharaj et al. 2020, NIAID, Cardiovascular and Interventional Radiological Society of Europe.

Donald Trump gives a speech in Arizona, the state with one of the fastest rising coronavirus caseloads in the US, on 23 June 2020.

BREAKING – The United States on Tuesday gave formal notice to the United Nations and the US Congress that it intends to withdraw from the World Health Organization as of  6 July 2021, following President Donald Trump’s announcement after the World Health Assembly on 18 May.

The administration first notified the United Nations, and sent letter to Congress shortly after. Although some senior legal experts have said the move would still require Congressional approval, others have said the question remains “murky”.

“Congress received notification that POTUS officially withdrew the U.S. from the @WHO in the midst of a pandemic,” said US Senator Bob Menendez in a Tweet. “To call Trump’s response to COVID chaotic & incoherent doesn’t do it justice. This won’t protect American lives or interests—it leaves Americans sick & America alone.”

The move was quickly denounced by political leaders and public health experts.

“US withdrawal from WHO is a setback for international cooperation. Global infection dynamics show that coordinated action is required. We need more international cooperation to fight pandemics, not less,” Jens Spahn, Germany’s Minister of Health, tweeted. Spahn added that European states were looking to “initiate WHO reforms.”

“The president of the United States does not represent the interests of the United States nor the world. He only represents his own personal and political interests. This appeases his base. That is all,” said Howard Forman, a professor of public health at Yale University.

Trump had previously said that he was withdrawing from WHO due to its alleged “China-centric” bias in its responses to the COVID-19 pandemic, as well as its failure to recommend stiff measures such as travel bans, in the early days of the virus’ spread.  But political analysts said that the real motive was to divert attention from the administration’s own botched coronavirus response, leading the US to claim the unenviable title as the country with the most COVID-19 cases and deaths in the world.

It’s Unclear Whether Trump Requires Congressional Approval To Withdraw From The WHO
The United States Capitol Building, seat of the US Congress (Photo: Daniel Mennerich)

If, indeed, the move turns out to require Congressional approval, as some senior legal experts contend, then the withdrawal process could be tied up for many more months in controversy, leading up to the US Presidential elections in November.

Lawrence Gostin, director of the O’Neill Center at Georgetown University School of Law, called the move “unlawful & dangerous” in a tweet from May, when Trump first expressed intentions to withdraw from the WHO.

“Let’s start w/ fact that Secretary of State Mike Pompeo sent [the withdrawal] letter to the UN without first notifying WHO or Congress. They weren’t informed until a day later. No press briefing or media scrutiny. This lack of transparency & accountability is exactly the unfounded charge the President of the US made against Dr Tedros,” Gostin tweeted in recent reaction to the official withdrawal announcement.

“Trump cannot unilaterally withdraw from WHO without Congress,” Gostin further tweeted.

“The US entered WHO under a Joint Congressional resolution. [The president] cannot withdraw without consent of Congress. US also owes all past & current WHO dues through July 2021,” Gostin added.

Gostin, along with 749 other experts in global health law, US Constitutional law, and international relations had submitted a letter to Congress detailing that under the US Constitution’s “mirror principle,” the same process used to ratify an international treaty must be used to withdraw from it. Therefore, because Congress had approved the treaty to join the WHO, it must also approve a withdrawal from the agency.

However, other legal experts say the situation is more unclear.

“Legally it’s murky if the President can withdraw. While [the executive branch] has power to sign treaties, ratification follows advice & consent of Senate. Some argue [the executive branch] thus retains power to exit treaties – Others argue it requires Congress consent,” Alexandra Phelan, global health policy expert at Georgetown Law tweeted.

“Politics likely matter more,” she added.

Impacts on the WHO Operations – Funding and Morale
WHO Director-General Dr Tedros Adhanom Ghebreyesus delivers the closing speech for the World Health Assembly

While the US move cuts off a major source of funding to the Geneva-based Organization, particularly for African emergency disease control activities where much of US funds were traditionally directed, in fact the Trump administration had already begun to close the tap earlier this year. Funding for 2020 was only expected to be about one-half of the estimated US$ 553 milllion contributed in 2019.

Fortunately for the Geneva-based headquarters, Germany last month stepped up to the bat with an unprecedented commitment of € 500 million (US$ 561 million) just last month.  However, WHO’s America’s Regional Office, which operates as an independent legal entity, under the name of the Pan American Health Organization (PAHO), remains in dire financial states – with its budget entirely separate from Geneva’s and heavily dependent on funds from Washington as well as Brazil, another big donor.

While WHO insiders say that the United States appears poised to remain part of the PAHO regional office based in Washington DC, and therefore may eventually resume that line of financial support, monies are likely to come with many strings attached. Potentially, that could translate into demands that the fiercely independent PAHO administration treads more in line with US policies on issues ranging from the treatment of rival states such as Cuba and Venezuela, to controversial US positions on access to sexual and reproductive health services.

Meanwhile, other big countries such as Brazil, today the world’s second-largest centre of the COVID-19 outbreak, are also in arrears on payments, exacerbating PAHO’s financial woes.

The situation in PAHO is so dire that a number of the organization’s senior technical advisors took the highly unusual step of publishing a letter about the crisis in The Lancet.

The letter, entitled Financial Crisis at PAHO in the Time of COVID-19: a Call for Action, said, “Due to non-payment of Member States’ contributions, PAHO stands on the brink of insolvency…Health security in the western hemisphere would be severely threatened without a functioning PAHO. Reserve funds will be exhausted by September, 2020.”

Most of the non-payments, the letter says, are attributable to the United States, which accounts for 67% of missed or late payments to PAHO. Along with Brazil, Venezuela, Mexico, Argentina, Colombia, Chile, and others also have late payments totaling US$164·6 million.

 

Image Credits: WHO / Antoine Tardy, Gage Skidmore, Daniel Mennerich.