Healthcare’s overreliance on single-use products and equipment contributes to its carbon footprint

Failure to align the global recovery from COVID-19 with an equally powerful climate response could threaten the worldwide effort to limit the average global temperature increase, public health experts have said.

In a convention in 2015 now known as the Paris Agreement, the United Nations Framework Convention on Climate Change (UNFCCC) established its aim to pause the increase in global average temperature by “well below 2 degrees Celsius above pre-industrial levels and to pursue efforts to limit the temperature increase even further to 1.5 degrees Celsius”.

To achieve that, a global effort is required to decrease greenhouse gas emissions by 7.6% each year across five years. This number falls further out of reach each year without action.

“The reality is that the next five years are going to be pivotal,” Dr Renee Salas, Harvard T.H. Chan School of Public Health, said during a webinar from the Lancet Countdown last week.

The 2020 Report of the Lancet Countdown on Health and Climate Change was published in December, and addressed the converging crises of the COVID-19 pandemic, healthcare systems and climate change.

“Healthcare has to show us how we can decarbonize and decarbonize our healthcare system,” she said, adding that it “is truly the embodiment that climate action is a prescription for health”.

COVID Has Outlined Healthcare Systems’ Flaws

The COVID-19 pandemic has highlighted healthcare’s overreliance on single-use products and equipment, the panel said. Additionally, as using personal protective equipment (PPE) has become a greater necessity, use of disposable products has been extended.

The health system in England is responsible for an estimated 4-5% of the country’s carbon footprint, for example.

NHS carbon footprint is mostly comprise of procured items from the health supply chain

The United Kingdom’s National Health Service listed crutches as accounting for nearly 70% of the carbon footprint for items it procured in 2020.

Additionally, the traditional model of outpatient care doesn’t strictly align with the nature of chronic illnesses, which requires patients return for unpredictable emergency treatment. 

Unpredictable treatment directly leads to increased road traffic and increased air pollution. NHS traffic accounts for 5% of road traffic in England alone.

Quantified in terms of environmental, financial, and health outcomes, this means that 753 deaths can be attributed to NHS traffic, and £650 million in NHS expenditure are lost a year.

“When [evaluating] the value offered in the delivery of a healthcare service, we need to start capturing data that looks at these consequences, thinking beyond the financial and individual patient outcomes,” said Jennifer Isherwood, a National Medical Director’s Clinical Fellow at the Royal College of Physicians, London.

“It’s becoming clear that COVID is not going to be the last pandemic that we see,” Isherwood added. “It may be … disruptive to start addressing challenges of different pathways to different care, but it’s the right tool to start future-proofing our healthcare systems.”

Hiten Patel, Senior Strategy Advisor for Greener NHS, said: “There’s always something else happening in healthcare systems that’s [considered] a priority. It’s about how we can try to make carbon emissions and climate change more of a priority within healthcare systems.” 

Concluded Dr Jodi Sherman, Yale University and Lancet Countdown author, said: “Everything we do in healthcare is through the lens of patient safety. Protecting public health is a matter of patient safety and needs to be integral to everything that we do.” 

Supply and Services Compose Four-Fifths of Overall Healthcare Carbon Footprint
The health supply chain comprises four-fifths of US healthcare carbon footprint
The health supply chain comprises four-fifths of US healthcare carbon footprint

While the COVID pandemic has flagged some key flaws in the world’s healthcare systems, what is still unclear are the direct and indirect carbon emissions of the healthcare sector, and the implications these emissions have on health.

Direct emissions are established and well understood products of the sector: gas exhausts from ambulance tailpipes to fumes emitted from waste incinerators.

But indirect emissions – offsite power generation, the provision of medical supplies and pharmaceuticals, and even research and testing – make up a larger percentage of emissions associated with the healthcare sector.

The United States alone spends more than US$3 trillion on healthcare a year. As healthcare expenditures increased, so too did the carbon footprint from goods and services. Around 7% is due to direct emissions from healthcare facilities, and another 10% from offsite energy.

But four-fifths of the footprint is the supply chain, composed of key sectors that include food, pharmaceuticals, and chemicals.

Dr Matthew Eckelman, Northeastern University, Boston and Lancet Countdown author, called on the health sector to take accountability for its immense carbon footprint.

“It’s very clear that buying renewable energy is not the only solution. You really have to work on reducing carbon emissions in the supply chain, as well.”

Lower the Infection Risk and Financial Losses by Reducing Health Waste

Speakers also addressed how vital it is not to risk patient safety in trying to reduce or cut expenses.

Healthcare-acquired infection – when a patient becomes infected while in care – affects hundreds of millions of patients globally each year. This leads to significant morbidity and mortality that incurs financial losses for health systems, in addition to excess pollution.

As a result, prevention is essential.

“While we do want to reduce waste and reduce costs, we certainly don’t want that to be at the expense of increasing infections,” said Dr Sherman.

Dr Sherman also acknowledged, however, that infection prevention methods often contribute to the excessive use of single-use disposable devices, like masks and gloves.

Using only disposable laryngoscopes would increase costs for hospitals
Using only disposable laryngoscopes would increase costs for hospitals

In a greenhouse gas emissions and cost analysis study comparing reusable and disposable laryngoscopes, Dr Sherman and Eckelman found that disposables – whether plastic or steel – outweigh the reusable in terms of greenhouse gas emissions. Using purely disposables would increase costs by up to US $700,000 a year, for one hospital department.

Recycling these disposables would only reduce a small portion of emissions, especially since the laryngoscope cannot be recycled entirely. “In other words, we can’t recycle a way out of this problem,” Dr Sherman said. 

“The answer isn’t that we should use disposables. It’s that we should clean up our supply.” There needs to be a balance between the “indirect disease burden from all the materials thrown away and lowering the infection risk curve.” 

The greatest causes of healthcare acquired infections, said Dr Sherman, have to do with staff discipline, such as hand washing, and patient health status, and exposure to infection. But simple hand washing and using more and more disposables is not the solution.

Image Credits: Flickr: Marc A. Hermann / MTA New York City Transit, The Lancet Countdown.

A new report has found that current R&D is primarily geared towards COVID-19, with next to no efforts to address other pathogens with the potential pandemic risks like Zika and Sars.

With ten of the world’s most infectious diseases not catered by drug firms, pharmaceutical giants remain unprepared to tackle future pandemics, a new report has said.

The report, published on Tuesday, found that though current medicine and vaccine research and development is primarily geared towards the COVID-19 pandemic, there are next to no efforts to address other pathogens with the potential pandemic risks: namely Nipah, Zika, and Sars.

The Access to Medicine Index evaluates 20 global pharmaceutical companies – including AstraZeneca and Pfizer – and compares how far each goes in fulfilling the role of developing urgently needed health products and improving equitable access to them. The companies’ performance is ranked every two years.

Pfizer joins top 5, while GSK retains its number one position, yet only slightly ahead of Novartis. Pfizer moves into the top five. Johnson & Johnson complete the top five companies. Eight of the top ten companies, including the leaders, are setting a new best practice of systematic access planning during R&D.

“The state of infectious disease research today is, if I can put it mildly, on thin ice,” said Dr Jayasree Iyer, executive director of The Netherlands-based Access to Medicine Foundation, in an interview with DW.

COVID-19 has emphasized the need for both the private and public sectors to actively engage in emerging infectious disease research well before the next pandemic breaks out.

It has also shown that ending a pandemic requires suitable products to be developed and equitably distributed: much of the responsibility for which lies with pharmaceutical companies.

Without their sustained commitment to pandemic preparedness, the report suggests, the world world will remain vulnerable to pandemics.

Increased R&D for COVID-19, but Other Pandemic Risks Unaddressed
Pharmaceutical companies are not targeting priority pathogens with epidemic potential through R&D. Excluding coronavirus, pathogens with pandemic potential where pharma companies are active in R&D show very small pipelines in 2020. Out of 16 pathogens, 10 have empty pipelines.

Even for pathogens under scrutiny, research activity remains low. With most research focused on coronavirus, there are just 13 R&D projects across five non-COVID-19 diseases (Ebola, Zika, Chukungunya, Marburg, and non-polio enterovirus) and zero for the remaining ten of 16 infectious diseases.

Emerging infectious disease (EID) research is concentrated among a few companies. In 2020, 17 companies targeted coronavirus, while nine companies are targeting other EIDs: Bayer, Eisai, Gilead, Johnson & Johnson, MSD, Merck, Roche, and Takeda.

This figure shows the number of R&D projects and companies identified by WHO and Policy Cures as emerging infectious diseases, and how this has changed since 2018.

What 2020 has highlighted is that large pharmaceutical companies have a critical role to play in preparing for the next pandemic, but that these companies have so far delivered a range of responses: some of them apparently shortsighted.

Small biotech companies and academic groups may be able to pioneer new ideas, but it is the big players that are responsible for rapid development and access to vaccines, therapeutics and diagnostics, with the capacity to scale-up both manufacturing and distribution capabilities.

Poorer Countries Lacking Access to More Than Half Key Products Covered By Pharma Companies

However, the pharmaceutical industry only mobilized against COVID-19 once it became clear that the outbreak affected rich as well as poor countries.

“Even in light of COVID-19, there were very few commitments from the pharmaceutical industry last year,” said Iyer.

Other than projects developed within the Access to COVID-19 Tools (ACT) Accelerator, there was little evidence in the first months of the pandemic response that there structures in place to ensure access and distribution to COVID-19 vaccines in poorer countries.

This has once more shown that the Global South still does not benefit significantly from access strategies implemented by big pharma. Less than half of key products controlled by 20 large companies are being offered in countries classified as either lower-middle income countries (LMICs) or low-income countries (LICs).

Low-income countries are most consistently over-looked by access strategies, particularly for products that need to be administered by healthcare practitioners.

The response is even more profound in LICs, which are consistently overlooked despite being home to almost 700 million people. Currently, only eight of the 60 – or 13% – critical products that need to be administered by healthcare professionals, like injectable treatments for cancer, are covered by access strategies in at least one LICs. Self-administered medicines such as pills have 26%.

The numbers jump slightly in LMICs, and even more so in upper-middle income countries (UMICs), with approximately half of critical products covered by access strategies in UMICs. The greatest number of people also benefited from both healthcare professionals administered medicine and self-administered medicine in UMICs.

Many industry access arrangements do not go far enough, with many of the world’s most vulnerable and marginalized not receiving the life-changing medicines they need.

Solving the access to medicine problem requires the pharmaceutical industry to take large-scale action, reaching more people with more products across a wider range of the world’s poorest countries.

“I believe the past year has demonstrated the pivotal importance of supplying affordable medicines for the many, rather than premium-priced products for the few,” said Iyer.

“By investing in fair access to medicine for the poorest and most vulnerable among us, we are also investing in a fair, peaceful and prosperous global community.”

Eight Pharma Companies Paving Way Towards Equitable Access
Top 6 companies with access planning, with percentage of R&D projects with access plans

There are positives: eight companies have taken the lead to integrating systemic access planning into their development processes. Novartis was noted as the first to begin mainstreaming access in the previous Index, and joining them in 2021 are AstraZeneca, GSK, Johnson & Johnson, Merck, Pfizer, Sanofi, and Takeda.

Though the 20 companies in the Index have 394 projects in late-stage development that target either global health priorities (114) such as coronavirus, malaria, tuberculosis or HIV, or offer benefits to low- and middle-income countries (280), the majority of these are not supported by an access plan.

An access plan can include a wide range of activities – prioritising countries with the highest disease burden to strengthening supply chains to ensure all populations have fair access.

To have maximum impact, the Index advises that access plans have a broad geographic focus, explicitly aiming to reach a majority of people affected by a disease or in need of a vaccine or diagnostic tool.

The 20 companies in scope have 394 R&D projects in late-stage development that either target established global health priorities or offer clear public health benefits for low- and middle-income countries. The majority of these are not yet supported by an access plan.

If this happens, people living in low- and middle-income countries, especially those in resource-limited or remote settings, will no longer be left behind for pharmaceutical innovations.

Concluded Iyer: “The power of science to help humanity – whether through new vaccines for common pathogens or novel drugs for rare diseases – is remarkable. But these breakthroughs will only truly deliver for the world if they reach all those who need them.”

Image Credits: Access to Medicine Foundation , Access to Medicine Foundation .

Meirav Eilon Shahar, Israel’s ambassador to the United Nations in Geneva, speaking to the WHO Executive Board.

For the second time in as many years, WHO member states have voted down a proposal by Israel to remove a standalone item from the agenda of the 74th World Health Assembly – devoted exclusively to a report on health conditions in the Occupied Palestinian territories – and consider it as part of WHO’s overall health emergencies agenda.  

Saying that the agenda item unfairly singles out just one country for criticism, as compared to every other nation in the world, Israel on Tuesday proposed to the WHO Executive Board, which fixes the WHA agenda, that the report be considered as part of the overall discussion on WHO’s work in health emergencies when WHO member states meet in May. 

In a lengthy and unusual voting process on the closing day of the 10-day EB session, the proposal was rejected in a vote of 15 to seven – with 9 abstentions and 3 countries absent. Those supporting Israel’s position included the United Kingdom, Germany and Austria, joined by the United States, Australia and Colombia. EB members that were opposed included Oman, China, Russia, and Tunisia. 

Israel’s delegation said the report was a “political” item that does not reflect reality and will not change the situation on the ground.

“Item 25 is a political item with only one purpose – to attack Israel and to politicize an otherwise professional organization [WHO]. This must be changed…What I’m asking you to do today is to ensure that the World Health Assembly maintains its focus on health and the truth,” said Israel’s ambassador to the United Nations, Meirav Eilon Shahar.

“Regardless of what takes place in Geneva, we, Israel, will continue to work with the Palestinians and with WHO and we’ll continue to work on any problem and assistance intended to improve the health conditions for the Palestinians,” she added. 

The Palestinian representative, Ibrahim Khraishi, Ambassador of the State of Palestine to the UN, which holds observer status in the World Health Assembly, retorted that: “The [health situation in the occupied territories] is catastrophic and dire…Israel is finding it easy to renege on its responsibility, for example, it is not meeting its requirement…when it comes to vaccination.

“When we look at the rate of vaccination for [Israeli] citizens, the figure exceeds two and a half million, whereas not one single Palestinian citizen has had the jab because of Israeli practices,” he said. 

Khraishi cited the WHO report from the 73rd WHA in November 2020, which he said shows that infant mortality of West Bank Palestinians is six times higher, and maternal mortality nine times higher than that of the 600,000 Israeli settlers living side by side with Palestinians in the Occupied West Bank. The report also describes barriers Palestinians from the West Bank and Gaza face in accessing more health services, such as the more specialized services in Jerusalem, which is directly under Israeli rule and to which access is tightly-controlled. 

Ibrahim Khraishi, Ambassador of the State of Palestine to the UN and Palestine’s representative to the Executive Board.

After the vote among member states, Israel disputed the vaccination claims, saying that Palestinian inmates have received vaccinations and the PA has been provided with emergency supplies for 100 essential health workers – but the overall responsibility to vaccinate the roughly 5 million Palestinians living in the West Bank and Gaza lies with the Palestinian Authority (PA), not Israel. 

“We are very happy to extend assistance in facilitation of those vaccines in entrance to Israel,” said Eilon Shahar, referring to the expected arrival of PA-purchased vaccine supplies from Russia. PA health officials have not, in fact, officially requested vaccines from Israel, but rather are awaiting the arrival of Russian Sputnik vaccines within the coming two weeks.  However, human rights groups have underlined that Israel still holds the ultimate responsibility for health under international law insofar as it still occupies the West Bank,

The largely technical issue of where on the WHA agenda the report on Palestinian health conditions should be reviewed, was subject to a lengthy and unusual voting process (most EB decisions are made by consensus).  The United States, Australia, and the United Kingdom explained their support of Israel’s proposal, saying that no other country in the world has been singled out in such a way by the WHO.

“We’re concerned that the World Health Assembly does not consider the many other difficult health situations around the world in the same way,” said the UK’s delegate. “This item remains the only country specific item at the WHA…We fail our duty to serve people around the world who have vitally important health concerns if we allow WHO to become politicized in this way.”

The UK’s delegate to the Executive Board.

Australia went a step further, expressing concerns about the introduction of political issues into the WHA through the existence of the stand alone item – and calling for negotiations to permanently remove the item, not only as a stand-alone item but altogether from the agenda. 

The delegations from Oman and the Syrian Arab Republic countered the arguments made by the UK and US, claiming that the agenda item does not single out Israel.

“This is not a country-specific item. This is an item which [reflects] a specific situation, a situation of people under occupation and addresses the legal obligations of the occupying power,” said Syria’s delegate. “The politicization is coming from attempts to go around these facts.”

The Palestinian representative concluded the discussion at the closing session of the Executive Board meeting on Tuesday by urging member states to encourage Israel to “shoulder her responsibilities and do her duty towards all citizens for which she is responsible, particularly those in the occupied Syrian Golan, the Gaza Strip, and the other occupied territories.”  The Gaza Strip has been under Israeli blockade as a result of repeated Israeli confrontations with the fundamentalist Hamas, which wrested control of the Strip from the PA-supported Fatah in 2007,  two years after Israel unilaterally uprooted its settlements and withdrew from the Strip. Israel captured the Golan Heights from Syria in the 1967 Six Day War, and extended Israeli citizenship to the predominantly Druse residents of the Heights who remained after the war.  

Image Credits: WHO.

Victoire Tomegah Dogbé, Prime Minister of Togo

The World Health Organisation (WHO) Thursday released a new road map for reducing by 90% illnesses related to neglected tropical diseases (NTDs) by the year 2030. The plan proposes ambitious targets and a more integrated and holistic approach to tackle 20 diseases which affect more than a billion people worldwide, mainly poor, and which thrive in areas where access to quality health services, clean water and sanitation is scarce.

The 2030 global targets of the roadmap would firstly reduce by 90% the number of people requiring treatment for NTDs, to enable at least 100 countries to have eliminated at least one NTD, and to eradicate dracunculiasis and Yaws on a global scale. The roadmap also aims to reduce by 75% disability adjusted life years – e.g. healthy life-years lost – as a result of NTDs. 

Speaking at the virtual launch event for the road map, Dr Tedros Adhanom Ghebreyesus, WHO Director-General, said the plan was developed through an extensive consultative process and was approved in November 2020 by the World Health Assembly – as well as being shared with the Executive Board again last week. The WHO DG noted that it sets global targets and milestones for prevalence control, elimination and eradication of 20 NTDs in a more integrated manner. 

“By shifting away from single business programmes to an integrated approach, it aims to improve coordination and collaboration,” Dr Tedros said. 

The road map also aims to see a reduction by more than 75% in the number of deaths from vector-borne NTDs such as dengue, leishmaniasis and others, promote full access to basic water supply, sanitation and hygiene in areas endemic for NTDs and achieve greater improvement in collecting and reporting NTD data disaggregated by gender, including tracking 10 cross-cutting and disease specific targets.

Tedros said the roadmap also promotes cross sectoral action in areas such as health, education, nutrition and One Health. 

“The roadmap also addresses stigma, discrimination and mental health conditions which are often neglected consequences of disability,” he said. 

While noting that tackling NTDs is a challenge for countries, Tedros said it also presents an opportunity to address the health inequalities that undermine economic and development progress. In the end, the roadmap is only a guide, he emphasized. 

“We can only reach the destination with country ownership. That means, national and local governments, working in partnership with communities and youth. Accountability is key. By working together, we can prevent suffering and save lives. This roadmap shows us the way,” Tedros concluded.

According to the WHO, NTDs that affect over 1 billion people globally have imapcts well beyond health – leaving lasting social and economic consequences for individuals and societies: “They prevent children from going to school and adults from going to work, trapping communities in cycles of poverty and inequity. People affected by disabilities and impairments caused by NTDs often experience stigma within their communities, hindering their access to needed care and leading to social isolation,” stated WHO in a press release.

By integrating and mainstreaming approaches and actions within national health systems, and across sectors, the roadmap sets out a more innovative approach to disease control programmes that once were confined to distinct silos, health experts say.

“At its core, this road map aims to put people first. It involves working across sectors in delivering programmes for all the 20 NTDs and promoting equity and country ownership,” said Dr Mwelecele Ntuli Malecela, Director, WHO Department of Control of Neglected Tropical Diseases. “To do so programmes have to be sustainable with measurable outcomes, backed by adequate domestic financing.”

WHO Director General Dr Tedros Adhanom Ghebreyesus
Partners align with the new roadmap

Besides lifelong disability, NTDs also lead to stigma inequality and discrimination with huge mental health implications, said Amina Mohammed, Deputy Secretary-General of the United Nations, in an address at the launch. 

While increasing access to diagnosis and treatment is essential, partnerships wll be key to advancing cross sectoral interventions, she added:  

“The new NTDs roadmap is innovative and offers a powerful contribution to the Sustainable Development Goals, especially universal health coverage, it also addresses vulnerability and by doing so, it promotes inequality. But these ambitious targets cannot be achieved unless we unite and act together with ambition.”

Even though COVID-19 continues to attract more attention in global health than other issues, West African countries have also found creative ways to successfully tackle COVID-19 and NTDs at the same time, providing examples of a way forward, said Victoire Tomegah Dogbé, Prime Minister of Togo. 

“Togo has seen tremendous success in the past few years with the elimination of filariasis and other diseases. Thanks to the technical and financial assistance of our partners, we have been able to help thousands of our citizens to overcome these diseases that have impacted their lives every day. Successes give us more confidence in the future and allow us to remain optimistic as we are confronted with the current pandemic, and we try to conduct our actions despite it,” the Prime Minister said.

NTDs are anchored in poverty
Muhammad Ali Pate, Global Director for Health, Nutrition and Population, World Bank

Speaking on a panel at the launch of the roadmap, Muhammad Ali Pate, Global Director for Health, Nutrition and Population (HNP) at the World Bank said NTDs are anchored in poverty and lock people into a cycle of ill health, poor education and lack of opportunities. 

Positioning NTDs as a key threat for building a country’s human capital and for progressing towards personal health coverage, can help place NTDs at the centre of political plans, along with ending extreme poverty and creating a more inclusive society. 

“NTDs have long term consequences that can cause visual, and physical impairments, leading to disabilities that place an overwhelming financial burden on households, and the loss of productivity, which becomes a burden on national economies. This is an impact, due to the costs of seeking health care, which not only include out-of-pocket spending on consultations, laboratory and medicines, but also transportation costs and informal payments to providers,” Pate said.

Much of the World Bank’s work has been focused on ensuring equity of access to essential health services, building robust health systems and expanding financial protection for the poorest people as the most cost effective strategies. 

“These cannot be any more important than with regards to neglected tropical diseases. NTDs affect the most vulnerable and marginalized and poorest people in our societies. Since 2015, our efforts are concentrated in supporting countries to increase sustainable domestic financing to strengthen their primary health care systems,” Pate added. 

Long road ahead

In the past decade, substantial gains have been made, resulting in 600 million fewer people at risk of NTDs than a decade ago and with 42 countries eliminating at least one NTD, and some countries defeating multiple NTDs. Furthermore, global programmes treated more than 1 billion people annually for 5 consecutive years between 2015 – 2019.

But the WHO warned that significant challenges remain, including climate change, conflict, emerging zoonotic and environmental health threats, as well as continued inequalities in access to healthcare services, adequate housing, safe water and improved sanitation. 

“There are also major gaps in current intervention packages of diagnostics, treatment and service delivery models,” WHO stated.

Travel restrictions aiming to limit the importation of variants should be based upon a systematic testing policy and not geographic or national origins, Africa CDC Director Dr John Nkengasong has said.

IBADAN – Five African countries have now confirmed cases of the SARS-CoV-2 501Y.V2 variant, which first appeared in South Africa, and there is concern that the variant is circulating undetected elsewhere on the continent. The Gambia and Nigeria have seen cases of the variant B.1.1.7, first identified in the United Kingdom, said WHO’s African Regional Director today, Dr. Matshidiso Moeti, at a press briefing.

Meanwhile, Africa CDC Director, Dr John Nkengasong, called for a “common approach” to COVID testing to oil the wings of international air travel – and halt the wave of new travel restrictions that countries have been imposing based on people’s national origin or the origins of flights – including people and flights arriving to Europe and the United States from South Africa.

Researchers now believe the variants may be both more infectious but also more deadly than the COVID virus strains that were prevalent until just recently. Researchers also fear the variants could also elude COVID tests and be more resilient to vaccines just being rolled out now – although many unknowns remain.

The countries where 501Y.V2 is circulating include: Botswana, Ghana, Kenya and Zambia, as well as South Africa. Beyond Africa, the variant has been confirmed in 24 countries globally. And there’s concern, it is circulating undetected in other countries in Africa,” Moeti told the press briefing.

Dr. Matshidiso Moeti, WHO’s African Regional Director.

“We are seeing more and more cases of variants and 501Y.V2, which was first identified in South Africa now, cropping up in other countries,” Moeti said. “The evidence suggests that these variants are more transmissible and emerging evidence indicates that the UK variant may cause more severe illness than other common strains, although more research needs to be done.”

These variants in conjunction with “the aftermath of year-end gatherings”, Moeti said, “risk powering a perfect storm and driving up Africa’s second wave and overwhelming health facilities”.

The continent saw a 50% rise in infections between 29 December 2020 and 25 January 2021, when compared with the previous four weeks, while deaths doubled.  Last week, more than 6,200 deaths were reported across Africa, said the WHO.The past week saw a small dip in cases in South Africa, but 22 other countries continued to see numbers surge.

Existing COVID-19 vaccines remain effective against the variants, Moeti said. But Professor Tulio de Oliveira, of the University of KwaZuku-Natal, South Africa, noted that these or other emerging variants may likely require individuals receiving booster doses of the vaccine.

WHO’s African Region is meanwhile setting up a new surveillance network with Africa CDC to track the spread of the virus mutations and variants across Africa and beyond, Moeti added.

“The variant which was first detected in South Africa has spread quickly beyond Africa and so what’s keeping me awake at night right now is that it’s very likely circulating in a number of African countries,” said Moeti. “Africa is at a crossroads. We must stick to our guns and double down on the tactics we know work so well. That is mask wearing, handwashing and safe social distancing. Countless lives depend on it.”

WHO’s African CDC Calls for Common COVID Testing Approach For International Travel

Dr John Nkengasong issued his call for a rethink of travel policies after several foreign countries, including the United States, are considering or have already banned flights originating from South Africa. Travel restrictions aiming to limit the importation of variants should be based upon a systematic testing policy – and not geographic or national origins, said Nkengasong.

“We should not be banning people because of their geographical origin, but we should be encouraging people to travel with negative tests and facilitate the testing process so that people can travel with a negative test,” Nkengasong said.

“If I were to go to Kenya and I show up at the airport with a valid negative test, I pose no threat to the country of Kenya, and that way so you shouldn’t just ban me because I’m coming from a certain country. They should be looking at that test, is your test valid,” Nkengasong added.

Dr John Nkengasong, Director of the Africa CDC.

Up until now, the World Health Organization has resisted recommending pre-travel COVID testing, ostensibly due to fears that it would put an unnecessary onus on poor countries.

In fact, however, many of the poorest African and Asian countries have been requiring pre-flight COVID tests for all incoming passengers – which are paid for privately. Some counties, such as the Democratic Republic of Congo, also demand arrivals briefly quarantine until a post-flight test is completed as well, paid privately as well.

Paradoxically, it is wealthier European and American countries that first issued a rash of orders banning passengers of certain nationalities or flights from certain destinations as a result of variant scares – although more developed countries, most recently Switzerland on Wednesday, have adopted testing requirements.

Senegal’s Pasteur Institute – At Center Of New Genetic Surveillance Network

At the outset of the pandemic, most countries in Africa lacked adequate testing capacity for COVID-19 but this was gradually surmounted as new testing facilities were added.

Now, however, the identification of new variants of the virus will require more advanced capacities for gene sequencing that several countries in Africa have yet to obtain.

To address this vacuum, the Africa CDC, the WHO and member countries have created a network that enables existing labs with gene sequencing capabilities to collect samples from countries that lack such.

One of the labs in the network is the Dakar-based Institut Pasteur de Dakar in Senegal. Its CEO, Dr Amadou Sall, said in addition to providing gene sequencing services for Senegal, the institute is now supporting other countries, Cameroon and Equatorial Guinea notably. Others include Mali, Burkina Faso Guinea-Bissau, Côte d’Ivoire, Niger, Verde, and of course, Guinea.

“With the partnership we have with Africa CDC and WHO, we have the possibility of sequencing 500 genomes per week. And we’re trying to increase this capacity and to make these capacities available in different countries,” Sall said.

Key to the success of COVID-19 genomic surveillance in Africa, Sall said, will be the willingness and openness of African countries to share information.

“We need to be able to share information data and the Pasteur Institute is at the center of a global platform and we’re able to share information; to exchange information rapidly, if countries are willing to do so,” he said.

Knowing When to Raise the Alarm

While noting that identification of new variants is a significant feat, genomic experts warned that alarm should not be raised every time a new strain is identified.

Professor de Oliveira, who heads the KwaZulu-Natal Research and Innovation Sequencing Platform, said attention is raised when new strains are being confirmed in increasing numbers of cases with the new variant and not when just one case has been confirmed.

Describing the impacts that variants have on the epidemiology of the pandemic in South Africa, Oliveira said in some regions, the new variant has become the prominent type. But beyond this, he said South Africa is also worried about the variants from elsewhere getting into the country and circulating among its populations.

“Today, we just reported the first important case of the B.1.1.7, the variant of concern that is circulating in the UK. And it’s quite common that in addition to our main variant that is dominating, we’re going to still have introductions of new lineages,” Oliveira said.

“And in the case they begin to spread very fast, then we will communicate it and then highlight that could be a variant of concern.”

He said that while no one can know for sure about the possibility of third or fourth waves of the pandemic in Africa, the variants are highlighting the need for the entire world to globally control the transmission of  SARS-CoV-2 as a global community.

“We have to really decrease transmission to avoid the next waves and more worry that emergence of new variants of concern will transmit too fast or evade immune response,” he said.

“The appearance of these variants in the African continent, but also in South America and Europe really means that more than ever, it is the time that we don’t leave any continent behind, especially on vaccination,” Oliveira said.

Silver Lining In Cloud – Variants Also Impetus For Cooperation

But within Africa itself, Sall said the various SARS-CoV-2 variants constitute a new impetus for cooperation between countries, to be able to track and measure the circulation of the virus, and to enhance diagnostic capacities that he said will soon be available across Africa.

“The new variants are the object of a very thorough study, and the path of our countries is very clear: obtain maximum information and adapt the strategy to contain the transmission,” he said.

Moeti enjoined countries and individuals to strive to overcome COVID-19 fatigue and return to the fundamental actions that have been found to be effective against these variants. These measures, she said, need much more emphasis that news that the virus is much more transmissible.

“The vaccine is a tool that’s going to make a huge difference all over the world,” she said.

But she reminded that “having a corner of the world not protected, the way the world’s economies and peoples are connected, will have negative economic impact even in those countries that managed to vaccinate the entire population. We really are all in it together, and we have to work to support each other to overcome this global crisis.”

Image Credits: Paul Adepoju/HealthPolicyWatch, Africa CDC.

The Oxford/AstraZeneca vaccine is 2 months behind schedule due to an issue in manufacturing.

AstraZeneca has joined Pfizer in announcing delays in deliveries of COVID-19 vaccines to countries in Europe, leading furious EU officials to plan for a system of tighter monitoring of vaccine exports. 

The British-Swedish pharma company that developed its COVID-19 vaccine with researchers at Oxford University, informed the European Commission on Friday that there would be a 60% shortfall in vaccine deliveries this quarter due to a manufacturing issue at a production plant in Belgium. 

The company is reportedly two months behind schedule with regard to vaccines destined for European countries. Since vaccine deals with the United States and the United Kingdom were signed earlier on, and are based around manufacturing sites in those countries, the company has had a headstart in resolving “glitches” in those supply chains, pharma officials said.

But the Commission had its doubts over this given explanation.

Following an EU-requested investigation into AstraZeneca’s Belgian-based production facility on Wednesday, the European Commission has said it would establish a new mechanism that grants national regulators the power to refuse exports of vaccines.

The mechanism – the criteria for which is expected to be published on Friday – could throw the security of the UK’s 40m-dose deal with Pfizer/BioNTech.

The investigation, a spokesperson for the Belgian health ministry said, was to “make sure that the delivery delay is indeed due to a production problem on the Belgian site”.

AstraZeneca ‘Scaling Up’ Doses, As EU Leaders Question Pharma Company
Pascal Soriot, CEO of AstraZeneca

“We are scaling up to hundreds of millions, billions of doses of vaccines at a very high speed. A year ago we didn’t have a vaccine. When you do that, you have glitches, you have scale-up problems. Therefore, the yield varies,” said Pascal Soriot, CEO of AstraZeneca, in an interview with la Repubblica, an Italian newspaper, on Tuesday. 

News of the delays was met with frustration by EU officials and leaders, who were expecting to receive 80 million doses by the end of March. 

“This new schedule is not acceptable to the European Union,” said Stella Kyriakides, European Commissioner for Health and Food Safety, in a statement released on Monday. “The European Union wants to know exactly which doses have been produced by AstraZeneca and where exactly so far, and if, or to whom, they have been delivered.”

Stella Kyriakides, European Commissioner for Health and Food Safety, at a press briefing on Wednesday.

Soriot disputed suggestions that the company sold the doses elsewhere for a higher price, claiming that “there is a lot of silly talk going on right now about all sorts of things,” and the response from the European Commission and EU member states is because “there are a lot of emotions running in this process right now.”

“The suggestion [that] we sell to other countries to make more money is not right because we make no profit everywhere…That’s the agreement we have with Oxford University,” said Soriot. 

“Governments are under pressure. Everybody is getting kind of…aggravated or emotional about those things. But I understand because the Commission is managing the process for the whole of Europe,” he added. 

In late August, the EU made an upfront payment of €336 million to the company to secure 300 million doses of the vaccine. EU officials have disputed AstraZeneca’s explanation of production issues, claiming there are no excuses for the delay. 

“The flimsy justification that there are difficulties in the EU supply chain but not anywhere else does not hold water, as it is of course no problem to get the vaccine from the UK to the continent,” said Peter Liese, an EU parliamentarian from Germany’s Christian Democratic Union.

Currently AstraZeneca is producing 17 million doses per month. That number will reach 100 million doses from February onwards, according to Soriot, meaning 1.2 billion doses per year. And Europe will receive 17% of the global production in February for a population that represents 5% of the world’s population. 

The Oxford/AstraZeneca vaccine is in the final stages of the approval process with the European Medicines Agency (EMA) and is expected to receive the recommendation for market authorization on Friday. After being approved, the company plans to deliver three million doses immediately. 

Meetings between EU officials and AstraZeneca have done little to resolve the issue, with Kyriakides announcing on Twitter: “Discussions with @AstraZeneca today resulted in dissatisfaction with the lack of clarity and insufficient explanations. EU Member States are united: vaccine developers have societal and contractual responsibilities they need to uphold.”

The EU Steering Board, the body that oversees vaccine deals, plans to meet with AstraZeneca again on Wednesday at 6:30pm CET and hopes to “resolve this in a spirit of collaboration and responsibility,” according to Kyriakides. 

The Italian government plans to take legal action against Pfizer and AstraZeneca over their delays in deliveries, according to an announcement made by Foreign Minister Luigi Di Maio on Sunday. 

“This is a European contract that Pfizer and AstraZeneca are not respecting and so for this reason we will take legal action,” Di Maio said on RAI state television. “We are activating all channels so that the EU Commission does all it can to make these gentlemen respect their contracts.”

According to Soriot, however, the vaccine deal signed with the EU was not a contractual commitment but a best effort, so there is no feasible basis for legal action. 

EU to Establish a Vaccine Export Transparency Mechanism

The Oxford/AstraZeneca vaccine is also considered one with global potential – due to its ability to be stored at refrigerator temperatures. Amidst some countries’ suspicions that countries outside Europe are receiving priority for vaccines produced at the Belgium plant, the European Commission announced plans to establish an export transparency mechanism for vaccines to ensure clarity on transactions and to protect its investments in the R&D that led to development of vaccines like AstraZeneca’s.

AstraZeneca is also a major supplier of the WHO COVAX global distribution initiative – which has pledged to begin distributing vaccine doses to the 92 lowest-income countries in the world within the next two months. Although most of the COVAX supplies were reportedly to be produced by India’s Serum Institute or in the Republic of Korea, the exact supply lines remain unclear. 

“Europe invested billions to help develop the world’s first COVID-19 vaccines…And now, the companies must deliver,” said Ursula von der Leyen, President of the European Commission, at the World Economic Forum on Tuesday. “They must honor their obligations. This is why we will set up a vaccine export transparency mechanism. Europe is determined to contribute to this global common good. But it also means business.”

Ursula von der Leyen, President of the European Commission, speaking at the World Economic Forum on Tuesday.

“In the future, all companies producing vaccines against COVID-19 in the EU will have to provide early notification whenever they want to export vaccines to third countries,” said Commissioner Kyriakides. 

The aim of the proposed system will be to monitor, but not block, exports, officials said. And humanitarian deliveries would be anyway exempt from this oversight mechanism. 

EMA Yet To Issue Final Approval – Insufficient Data on Vaccine in Older People

Meanwhile, the EMA has yet to issue its final regulatory approval for the two-dose Oxford/AstraZeneca vaccine, and is reportedly considering limiting the age range to people under the age of 65 – due to a lack of data on effectiveness in older people. Unlike mRNA counterparts produced by Moderna and Pfizer, the AstraZeneca/Oxford vaccine uses a disabled, modified version of a chimpanzee adenovirus that can enter human cells but cannot replicate or cause the disease, as a vector to deliver a fragment of SARS-CoV2 spike protein, stimulating COVID-19 immunity. 

According to data shared by the company, only 10% of participants in the vaccine clinical trials were over the age of 65 because it was first waiting for sufficient safety data in the 18 to 55 age group before vaccinating older individuals. 

“We don’t have a huge number of older people who have been vaccinated,” said Soriot. “But we have strong data showing very strong antibody production against the virus in the elderly, similar to what we see in younger people.”

The results of an ongoing, larger Phase 3 clinical trial with 30,000 participants being conducted in the United States are expected to provide insight into the protection the vaccine provides to older individuals and ethnic minorities populations –  groups that were not very well represented in previous trials. 

In addition, scientists are exploring whether a half-dose of the first vaccine would reliably yield a higher efficacy rating of 90% that was seen in initial trials. The other regime, involving two full doses was only 62% effective, according to the results released by the company in late November and reviewed by an independent Data and Safety Monitoring Board. That still meets key global benchmarks for efficacy, but is significantly lower than the 94-95% efficacy results for the Moderna and Pfizer mRNA vaccines.

The AstraZeneca vaccine has, however, already been authorized in the UK, is already being used in British vaccination campaigns, including for people over 70 years old.

Image Credits: AstraZeneca, AstraZeneca, Twitter, Twitter.

Member States and non-state actors alike have expressed dissatisfaction with the current system, albeit for different reasons, according to WHO.

The World Health Organization (WHO) aims to make its engagement with non-state actors (non-state actors) more meaningful and efficient with a new proposal to establish a number of NSA fora that would allow exchange with WHO and member state representatives outside of official meetings.

The new proposal — which will be tested during the 74th World Health Assembly (WHA), 24 May to 1 June — would offer multiple side events in which non-state (NSA) actors could engage more informally with member state representatives as well as a forum for exchange between NSAs and WHO regional and technical staff.

But at the same time, non-state actors will be allotted a more limited number of constituency statements in formal governing body meetings – and like-minded groups of actors will be asked to combine their official statements together.

Non-state actors include civil society groups such as non-governmental organizations, international business and professional associations, and philanthropic foundations. More than 70 non-state actors are recognized as being “in official relations” with WHO, and thus contribute in formal meetings such as the EB and the WHA.

However, EB and WHA members have complained that the civil society interventions have become bogged down by too many lengthy, individual statements – and NSAs acknowledge that the statements often had limited impact in member state debates.

More informal meetings ahead of the formal meeting dates would help engender more meaningful interaction, WHO said in its proposal for the reform, which was reviewed by the WHO Executive Board on Saturday. Informal meetings will also allow non-state actors to organize themselves into constituencies, consolidating their positions into joint statements to be presented at official events.

The new arrangements to be tested in May, will “serve as a trial for potential future virtual informal meetings between non-state actors, Member States and the Secretariat, as a means of enabling more in-depth technical exchanges, as well as discussions on the Health Assembly agenda items,” said the WHO Secretariat, in its presentation to the EB on Saturday.

The COVID-19 pandemic has provided added impetus for reforms that have long been in the making – insofar as the limitations of virtual meetings have also curtailed the interactions between member states and non-state actors.

According to the new proposal, the informal series of meetings with non-state actors will be held just ahead of the WHA, and thus prepare the groundwork for the formal meeting.

Role of Non-State Actors Has Evolved – But Increasing Number of Statements Detracted from Impact

In the discussion over the proposal, WHO officials stressed that the Organization “is and remains a Member State Organisation” — engaging with 77 non-state actors, at global, regional and country levels, who also support the development and implementation of the Organization’s policies and recommendations, technical norms and standards.

But while non-state actors have “served the Organization well for several decades”, the increasing number of non-governmental organizations and other non-state actors participating — often with a greater number of requests to speak — has “not resulted in a more meaningful involvement”.

For example, when civil society representatives speak one-by-one at the end of a discussion, their interventions have little impact on the content or direction of the debate, WHO contends.

Member States and non-state actors alike have expressed dissatisfaction with the current system, albeit for different reasons, says the WHO.

A virtual consultation by WHO further confirmed that non-state actors’ primary interests in attending governing body meetings are to participate in technical exchanges with the Secretariat and the Member States and to attend consultative hearings that feed into decision-making processes.

Meaningful Participation From NGOs Critical, Member States Say

The UK delegate said that it would allow NSAs to exert even more credible influence on member states attitudes and positions. The EB representative from the United States flagged that it is critical to ensure and enhance meaningful participation of non-state actors in WHO governing bodies, while also creating greater efficiency in the governance process.

“Non-State actor participation must be allowed in a transparent and accountable manner with an open door to input from all stakeholders including the private sector,” the delegate noted.

Austria pressed for the Secretariat to provide some more detailed information on the procedure for these meetings.

Other states, like Australia, flagged that the trial is very ambitious given the agenda for the 2021 assembly is already very crowded.

“We suggest that before agreeing to a trial, the number of meetings proposed to be repeated and streamlined,” the representative said.This would “provide reflections to technical areas in advance of the governing body meetings”.

Civil Society Groups Request Clarity and Procedure Details

Bodies like Health Action International asked for details as to how NGOs would participate, and for clarity on the processes governing such meetings.

“It is a remaining concern to those who have witnessed creeping capacity shrinking of NGO space and poor consultation in recent years,” said an HAI statement. The HAI delegate requested that similar procedures be implemented for WHO regional meetings with member states, also asking that  “these informal meetings compliment, but do not replace comprehensive consultations with non-state actors.”

Meanwhile, the European Society for Medical Oncology said the views and expertise of non-state actors should be introduced earlier in the WHO decision-making process; it would be of greater value if delivered at the onset of projects, and when member states are drafting zero draft decisions and resolutions.

“Direct interaction and discussion between member states, WHO offices, and Non-State actors would provide the opportunity for more in-depth exchanges, and partnerships, as the Member States, develop policies and implement actions to fulfill their WHO commitments,” said the ESMO spokesperson.

Silberschmidt stressed that the virtual informal meetings will not replace other channels, but become an additional avenue for interaction – highlighting the fact that Dr Tedros Adhanom Ghebreyesus, WHO Director General, has already established a regular dialogue with civil society groups, to be held every six weeks.

 

Image Credits: WHO / Christopher Black.

The opening press conference of the 4th HIV Research for Prevention Conference on 26 January.

While global attention has fixated on the coronavirus, the forty-year long fight against HIV, which has claimed 33 million lives, is seeing new breakthroughs in preventive tools.

New discoveries of “broadly neutralizing antibodies” as well as novel regimens of pre-exposure prophylaxis (PrEP), could strengthen the world’s toolbox to prevent the disease, announced the International AIDS Society (IAS) at the opening of the 4th HIV Research for Prevention Conference. 

The IAS-sponsored Conference, which is taking place virtually over four days, is the only conference in the world that is exclusively focused on research in HIV prevention. 

“COVID-19 has disrupted research around the world, so it’s especially exciting to see this new progress,” said IAS President Adeeba Kamarulzaman in a press release. “These research advances on options like broadly neutralizing antibodies and injectable PrEP could help significantly strengthen our HIV prevention toolkit.” 

Adeeba Kamarulzaman, President of the International AIDS Society, at the HIVR4P Conference.

The latest results on broadly neutralizing antibodies (bnAb) are particularly promising. In a pair of parallel trials, researchers from the Fred Hutchinson Cancer Research Center found that one of its bnAb’s prevented HIV infection 75% of the time over 20 months, thus providing an important “proof of concept” to prevent sexually-transmitted HIV in the future, said the study’s  authors. In this case, the bnAb’s were developed to recognize the ‘CD4’ binding site of the HIV virus.

In the two parallel trials, researchers injected participants with a placebo or two doses (10mg/kg and 30 mg/kg) of their antibody. In the American arm of the trials, enrolees included men and transgender persons who have sex with men, while the Sub-Saharan arm of the trial recruited cisgender women.

More Practical PrEP Regimens Also On Horizon

Meanwhile, two longer-acting and thus more practical PrEP regimens have been developed. They have the potential to replace common treatments that have to be taken on a daily basis, such as tenofovir/emtricitabine (TDF/FTC), also known as “Truvada”. 

They include cabotegravir, the first long-acting injectable regimen, as well as islatravir, a pill that would only need to be taken once a month.

As well as improving adherence to PrEP, these novel treatments could also bolster global PrEP uptake, which still falls short of the 3 million target set by UNAIDS despite a six-fold increase in uptake over the past four years, found the AIDS Vaccine Advocacy Coalition in a study that was also featured at the conference.

Cabotegravir – Injectable PrEP Regimen Works Better Than Existing Treatment 

Based on a study in over 3,000 women in Sub-Saharan Africa, PreP candidate cabotegravir, was deemed safe and far superior to Truvada, complementing similar findings from another earlier trial in cisgender men as well as transgender women who have sex with men.

In this latest trial, participants received either cabotegravir plus a placebo of TDF/FTC or a placebo of cabotegravir and active TDF/FTC. Alongside daily administration of oral TDF/FTC for five weeks, participants received intramuscular injections every eight weeks.

On a positive note, women in the cabotegravir group were 89% less likely to contract HIV compared to the group that received TDF/FTC, probably because it is easier to adhere to a treatment that’s taken every 8 weeks compared to a pill that must be taken every day, noted researchers.

But more funding is needed to reach global targets to eliminate HIV, warned another study that was also presented at the conference, and presented by St Luke’s University.

Based on over a hundred nationally-representative datasets representing more than 1.4 million sexually active people, the study projected that the probability of reaching the 2030 targets set by UNAIDS is “very low” – ranging between 0% to 28.5% for HIV testing and 0% to 12.1% for condom use.

Unless more attention is given to the disease, the prospects of reaching these bold targets to put a stop to HIV/AIDS are rather slim, concluded the study.  

Africa Should Not Be left Behind in HIV Prevention & Control 

Along with reviewing new research breakthroughs, members at the Research for Prevention Conference examined the state of HIV prevention and control measures – which highlighted key concerns for the African  continent. 

Phuong Nguyen of St. Luke’s International University presented data analysis that showed African countries are largely not on track to reach key UNAIDS targets for HIV testing and condom use by 2030. 

Trends in oral PrEP use globally as countries introduce and scale up PrEP programs.

Relying on 114 nationally-representative datasets representing more than 1.4 million sexually active people, the team estimated coverage of annual HIV testing and condom use at last higher-risk sex for each country and year to 2030, and the probability of reaching UNAIDS testing and condom use targets of 95% coverage by 2030.

They reported that the probabilities of reaching the 2030 targets were very low for both HIV testing (0% to 28.5%) and condom use (0% to 12.1%). 

Within Africa, they predicted that the countries with the highest coverage of annual HIV testing in 2030 will be Eswatini with 92.6%, Lesotho with 90.5%, and Uganda with 90.5%. The countries with the highest proportion of condom use will be Eswatini with 85%, Lesotho with 75.6%, and Namibia with 75.5%.

The researchers concluded that there is little prospect of reaching global targets for HIV/AIDS elimination. They made the case for more attention to funding and expanding testing and treatment in Africa.

On the brighter side, Africa is making progress on expanding access to existing PreP formulations – and that should accelerate with the new breakthroughs just announced. 

Geographic representation of the number of PrEP initiations globally as of late 2020.

AIDS Vaccine Advocacy Coalition’s (AVAC) Kate Segal noted that sub-Saharan Africa  expanded PrEP access from 4,154 initiations in 2016 to 290,981 by mid-2020, comprising 44% of the global total.

She used data from AVAC’s Global PrEP Tracker to identify global and regional PrEP initiation trends from the third quarter of 2016 through the second quarter of 2020. 

“While PrEP initiations have grown exponentially in several countries, global uptake falls far short of UNAIDS’ target of 3 million users, indicating a need for sustained demand creation where PrEP programs exist, and scale up where PrEP is provided by demonstration projects with limited reach,” the study concluded. 

Find out more about the event here.

Image Credits: Flickr, HIVR4P, Global Advocacy for HIV Prevention.

Doctors putting on N95 respirator masks, face shields, gloves and gowns before entering a COVID-19-positive patient’s room in August in San Diego, US.

In the midst of the spread of new SARS-CoV2 virus variants, several European countries have updated their guidance and regulations on masks, to recommend the use of high-filtration medical-grade masks over fabric ones in confined settings. 

France’s health advisory council (Haute Conseil de la Santé Publique) issued new recommendations last week, warning against the wearing of certain homemade masks due to the insufficient protection provided from the more highly transmissible COVID-19 variants. 

“Artisan masks that you make at home, with the best intentions in the world [and] respecting the official advice, do not necessarily offer all the necessary guarantees,” said French Health Minister, Olivier Véran, in an interview with France Inter. 

Joining Germany and Austria, France appears set to recommend “Category 1” masks, which filter over 90% of particles, for use people are in close contact with others. Category 1 masks includes FFP2 filter masks, or their N95 or KN95 equivalents, as well as single-use surgical masks, and certain fabric masks with high filtration levels, France said.

Fabric masks, included under Category 2, only capture approximately 50% to 60% of all respiratory aerosols. 

A study published in The Lancet in June found that N95 masks and masks with similar levels of filtration are associated with a larger degree of protection from viral infection in comparison to reusable cotton masks. These results were supported by a study conducted by Duke University. 

Surgical masks are three times more effective in preventing droplet transmission than homemade fabric masks, found a 2013 study conducted by Public Health England, a UK governmental health agency. The study advised against the use of homemade masks if a supply of commercial surgical masks is available. 

In light of the data on the degree of mask protection and the more highly contagious variants, “the high council for public health recommends, as do I, that the French do not wear masks they have made at home,” Véran said. 

The recommendation has yet to be enforced and officials are expecting some issues with its implementation. 

German and Austria Have Already Tightened Mask Regulations

Germany and Austria have already tightened mask regulations, mandating the use of medical-grade masks – N95, KN95, FFP2, or surgical masks – on public transportation and in supermarkets. 

“If the virus becomes more dangerous, the mask has to get better,” said Markus Söder, the Minister President of Bavaria, Germany’s largest state and the first to begin implementing the new mandate. 

Production of FFP2 masks is scaling up in Germany, but some experts worry that prices could rise if suppliers are unable to meet the new demand. The government has aimed to provide 15 FFP2 masks to 34.1 million citizens over the age of 60 or with a history of illness by the end of January. 

Health officials in Europe are approaching the new mask guidelines differently. While Germany is requiring FFP2 equivalent masks, French health authorities have discouraged the public from using FFP2 masks, which are high grade fitted masks, because they are difficult to wear correctly.

“In most cases FFP2 masks will be ineffective if they aren’t professionally fitted: people will end up breathing through the gap between the mask and face rather than through the designated filter,” said Jonas Schmidt-Chanasit, a Professor of Arbovirology at the University of Hamburg, in an interview with the Guardian. 

United States Experts Begin Touting “Hi-Fi” Mask Alternatives – But US CDC Yet To Update Guidance 

In parallel to European counterparts, a group of Harvard University experts have also proposed a United States “Hi-Fi” initiative to promote public use of higher quality N-95 or KN-95 masks that can protect more effectively against COVID-19 variants.

As a cheaper alternative, some experts, including US President Joe Biden’s Chief Scientific Advisor Anthony Fauci, are recommending wearing a double mask combination- a surgical mask and a cloth mask, if N95 or FFP2 masks are not available. The combination of two masks, if they fit well, could provide a filtration efficacy rate over 90%. 

Fauci, Director of the National Institute of Allergy and Infectious Diseases, could be seen sporting such a combination at the US President’s Inauguration last week.  He later said that wearing a double mask “likely does” provide more protection. 

“If you have a physical covering with one layer [and] you put another layer on it, it just makes common sense that it likely would be more effective. That’s the reason why you see people either double masking or doing a version of an N95,” Fauci told NBC News on Monday. 

Dr. Anthony Fauci, Director of the National Insitute of Allergy and Infectious Diseases, speaking on COVID-19 virus variants and mask wearing.

Despite increasing moves towards medical-grade masks, the US Centers for Disease Control and Prevention (CDC) has so far stuck to its existing guidelines. The CDC continues to recommend the use of masks made with tightly woven fabrics with two or three layers and discourages the public from using medical masks and N95 respirators in order to reserve them for healthcare personnel. 

WHO Also Sticks to Fabric Masks For General Public

The guidance provided by WHO also continues to recommend only fabric masks for the general public under the age of 60 and without underlying health conditions. It advises the restriction of medical masks to people over age 60, those with certain health conditions, including chronic respiratory disease, cardiovascular disease, cancer, diabetes, and immunocompromised patients, and health care workers.

Image Credits: Flickr – County of San Mateo, Flickr – Navy Medicine, NBC.

While very low-income countries have experienced relatively low mortality rates from COVID-19, they can expect higher mortality caused by the knock-on effects of the pandemic on their fragile health systems, according to the Executive Director of the Global Fund to Fight AIDS, TB and Malaria.

Since the pandemic first overwhelmed health systems in early 2020, countries across the globe have reported a reduction in referrals and diagnoses for various diseases.

Peter Sands, Executive Director of Global Fund

“It’s a perfect storm of concurrent social crises which are disrupting health interventions: programmes to fight diseases like HIV, tuberculosis (TB) and malaria,” Peter Sands, Executive Director of the Global Fund, said during a session of the  World Economic Forum in Davos today.

Last year, India, Indonesia, the Philippines — three high-burden countries for TB — reported a 25-30% drop in its case notifications. A Lancet study predicted a 25% reduction in antimalarial drug coverage in 2020 in malaria-endemic African countries, potentially doubling mortality.

And although the pandemic has affected health systems in low- and high-income countries alike, poorer countries with weaker health infrastructure, greater disease burdens, and generally worse access to COVID-19 treatments and vaccines will have the hardest time recovering.

“Particularly, the lowest income countries have very young populations. This kind of demographic means that the mortality rate from COVID is relatively low,” he said. In the poorest countries, the life expectancy is about 18 years lower than the richest.

But these countries could be more vulnerable to the “collateral damage” of the SARS-CoV-2 pandemic, rather than the direct impact of the virus. 

“You’re going to see relatively low mortality from COVID itself, and relatively high mortality from these knock-on consequences,” added Sands.

Diagnosis Deficit: Lower Diagnoses Globally

The COVID-19 pandemic risks shattering countless disease elimination targets, many of which have been set by the World Health Organization (WHO).

Diagnoses and interventions for communicable and non-communicable diseases (NCDs) have both been impacted in 2020, with COVID-19 and related lockdowns affecting patients’ ability to get access to treatment.

The World Hepatitis Alliance found that last year 94% of respondents in its 32-country survey had had their hepatitis services closed. In addition, half of respondents in lower- and middle-income countries (LMICs) could not get their medication, with respondents in India and Nigeria citing pandemic-related travel restrictions as the cause.

“The Task Force for Global Health and the World Hepatitis Alliance [have] all come up with the same figures,” said Charles Gore, Executive Director of the Medicines Patent Pool.

“Diagnosis and treatment are the key areas in [WHO’s] Global Strategy where the world is lacking,” he added. “And unfortunately, the hit is even bigger in LMICs.”

Where access to treatment for a given disease might have been reduced by 40-60% in a high-income country, “we’re talking 60-90% in LMICs”.

“There’s an estimate that a one-year hiatus in [a country’s] national programs from hepatitis elimination will lead to an extra 45,000 liver cancers and 72,000 deaths by 2030,” he said.

The reduction in access to treatments is similarly stark for NCDs.In the UK, lung cancer referrals in August 2020 were down by 26% from the previous year. During the April lockdown — when much of the Western world experienced its first COVID wave — referrals for lung cancer from doctors’ surgeries dropped by 72%.

“Even if they are referred, it’s very difficult to get patients through the system, and get respiratory symptoms investigated so they can start treatments quickly,” said Michelle Mitchell, chief executive of Cancer Research UK.

“This is a time of great worry for patients with lung cancer or other types of cancer.”

Patients will have a much better prognosis if they are diagnosed early. Data observed by Cancer Research UK indicates that nearly 90% of patients diagnosed at Stage 1 survived the disease for at least one year, compared to just 19% for those diagnosed at Stage 4.

“It’s too early to know the impact yet,” she said. “But we do expect there to be a huge impact.”

Build Back Better: ‘Not Ambitious Enough’

The process of ‘building back better’ does not go far enough, Harvard T.H. Chan School of Public Health’s Dean, Michelle Williams, said.

Building back better refers to a process of economic recovery from COVID-19 that avoids destructive investment patterns: namely, investments that endanger biodiversity, which is linked to zoonotic diseases jumping species.

“What COVID has done is really show how weak global public health infrastructure can bring us to our knees,” she said.

“To build back better is [to] first recognise the importance and value of public health and invest accordingly. That means properly investing in global governance of public health leadership [and] making the structure nimble and equipped.”

An interim report by the Independent Panel on Pandemic Preparedness and Response, published last week, determined that WHO’s COVID-19 response was too slow, and was hampered by a lack of resources and a damning lack of authority among its member states.

“We’re not being remotely ambitious enough,” Sands said. “This year we are deploying about US$4.7 billion on HIV, TB and malaria to mitigate the collateral damage … we need another $5 billion. And that’s the Global Fund alone.”

And the global ambition for economic recovery, which is “currently shaped as getting back to [a] pre-pandemic” scenario, is “not good enough”, Mitchell added. “Because we weren’t doing well enough before COVID.”

Image Credits: The Global Fund.