Smoking increases vulnerability to COVID-19

In light of millions of smokers attempting to quit the vice during the COVID-19 pandemic, the industry has employed ‘very mean’, ‘very subtle’ and ‘very targeted’ tactics to hook young populations to “deadly’ tobacco products, according to WHO experts. 

“The tobacco industry understands what they’re doing, they’re targeting these children and adolescents. And that’s deliberate. It’s not a mistake [and] what they do is deadly,” WHO’s Director of the Health Promotion Department Ruediger Krech, said at a webinar on Thursday’s  “World No Tobacco Day” which drew attention to preventing the 8 million premature deaths from tobacco every year.

Krech presented the WHO’s new toolkit to empower young people to make their own decision on tobacco products.

Now, more than ever, there’s a “huge potential” for the tobacco industry to “hook our children to tobacco products” – mainly through advertising, promotion and sponsorship of tobacco products – which has a “direct impact on tobacco consumption,” said Adriana Blanco Marquizo, Head of the WHO’s Framework Convention on Tobacco Control (FCTC) Convention Secretariat, and another panelist at Thursday’s webinar.

Adriana Blanco Marquizo, Head of the WHO’s FCTC Convention Secretariat

“Every day or every week,” new tobacco products and e-cigarette devices are rolled-out by the tobacco industry – with “more and more flavors and more tactics”, said Krech, as he warned that 9 out of 10 of smokers start consuming tobacco products before they are 18 years old.

And as “hundreds of thousands” of smokers from ‘many countries’ have committed to quit smoking since the COVID-19 crisis began, the tobacco industry is scrambling to find new ways of marketing their products, reported Vinayak Prasad, Coordinator of WHO’s No Tobacco Unit. These countries include Mexico, India, China, Timor Leste, Philippines, Kazakhstan, Tajikistan and Kyrgyzstan.

Since the raging pandemic started, the WHO has noticed new tactics – ranging from tobacco manufacturers emblazoning their trademark on “free masks”, to suing countries like South Africa as they halt tobacco sales in the midst of lockdowns. 

As Tobacco Market Grows, ‘We May Lose Ground In Tobacco Control’ As Industry Is Eager To Hook Adolescents

WHO’s Director of the Health Promotion Department Ruediger Krech

We may lose ground in tobacco control as the industry is looking to hook a younger generation to its products, warned Krech – With a ‘huge increase’ in the number of adolescents that are smoking in past years.

And the market for tobacco products is increasing, apart from a handful of countries: the US, UK, France, and China, said Vinay. 

In Switzerland, young people are 11-times more likely to use e-cigarettes than adults – almost 17% of young people use e-cigarettes compared to 1.5% of adults, said Krech. Globally, around 9% of adolescents aged 13-15 use e-cigarettes, according to global data from 39 countries.

Currently, some 44 million children and adolescents are smokers, though 100 million smokers began before the age of 15, said Krech. And over 14 million young people aged 13-15 have already started to use tobacco.

However, these numbers “don’t even begin to scratch the surface of young tobacco users”, mainly because there is no solid data on children below the age of 13, said Krech. 

And smoking is “obviously not starting at the age of 13,” according to Prasad. In some cases, it starts earlier. 

Every hour, the tobacco industry spends a million dollars on advertising, and $ 9 billion every year, said Prasad on Thursday. 

Heated tobacco products account for about half a percent of the world’s market, 80% of which is in the developing world – with over 400 million smokeless tobacco users In the South East Asian context, said Prasad.

As COVID-19 Rages On, Tobacco Industry Shift Tactics In Efforts To Maintain Sales

Vinayak Prasad, Coordinator of WHO’s No Tobacco Unit

The tobacco industry has a long history of using all sorts of tactics that oppose “all forms of evidence-based measures” to reduce tobacco use, said Prasad – ranging from direct to indirect forms of advertisements, sponsorships or promotions, some of them “very subtle.” 

“They start with slim [cigarettes], they start with mild [cigarettes], they start with filters [although] the evidence base [does not show] that it’s safer or less safe…their aim is to create confusion amongst [tobacco] regulators,” said Prasad.

And as the industry scrambles to maintain profits during the raging pandemic, health experts have seen some of their tactics change.

In South Africa and Bangladesh, the tobacco industry is lobbying lockdowns to lift the existing sale ban on tobacco products. The industry is using ‘all kinds of arguments’ to support their claims – They have even argued that smokers that are unable to get their products are ‘victims’, said Prasad.

In South Africa, the industry is fighting a case in Supreme Court to lift the sale ban on tobacco products since the country imposed a 21-day lockdown in late March. In Bangladesh, a similar challenge is being fought as “the current law has not made it essential to sell tobacco products,” he added. 

The tobacco industry also uses other strategies to entice adolescents to consume their products – a tasty selection of flavors like bubblegum, as well as bringing cigarette representatives into schools to present their products.

On-screen smoking is another common but highly effective tactic to promote smoking in younger populations, warns the WHO.

In a British study of over 5000 adolescents 15-year-olds who saw more films with smoking imagery were almost three quarters more likely to have tried smoking than those who had seen movies where people smoked less. In the USA, almost 40% of all new young smokers begin as a consequence of seeing smoking on TV, reported another study

Pulling out smoking from youth-rated films is “one of the most powerful ways to protect children from the harms of smoking,” said programme manager of WHO’s Tobacco Free Initiative Armando Peruga, in a WHO bulletin from 2016.

WHO’s Toolkit To Empower Youth ‘To Say No’ To Tobacco Products

In light of the tobacco industry’s tactics to promote smoking in teenagers, the WHO has launched a novel, interactive toolkit for youth between 13-17 years of age.

The aim of the toolkit is to provide children with the tools “to say no” to the tobacco and nicotine industry:

“Adolescents and young people can be empowered to protect themselves when they understand the intention of [the tobacco] industry…that really wants them hooked and addicted in order to keep the profits, even if it goes against public health,” said Marquizo.

The toolkit offers different activities for teachers in classrooms, but also for parents at home, either in-person or virtually – ranging from a tobacco mythbuster quiz, a ‘how to sell death’ workshop to expose tobacco industry tactics, or even roleplay for teenagers to practice refusing tobacco products when offered by their peers or others.

The campaign is ‘very much’ based on social media because the tobacco industry’s tactics often hook teenagers through social media, said Krech.

The WHO is also working with media partners like TikTok, Pinterest and YouTube to promote their #TobaccoExposed challenge.

WHO’s Mythbuster Toolkit For World No Tobacco Day 2020

Claims That Tobacco Is Helpful Against COVID-19 Are Unfounded, Warns WHO 

Youth Representative for Students Working Against Tobacco Nicholas Martinez

We [adolescents] are the new lab rats to big tobacco…We don’t know what they’re putting in their cigarettes that might affect us 10-20 years from now…before, tobacco was promoted as a good thing, a healthy thing.” said Youth Representative for Students Working Against Tobacco Nicholas Martinez, who also spoke at Thursday’s webinar. 

“But now, we know the real consequences of it,” he added.

Last month, two linked Parisian studies put forth claims that nicotine in tobacco products could protect against COVID-19 infection, leading to panic buying in Iran -And also a decree by the French government to limit the sale of nicotine products.

However, these studies were ‘not peer-reviewed’ and had ‘huge methodological weaknesses,’ said Krech.

“There is currently insufficient information to confirm any link between tobacco or nicotine in the prevention or treatment of COVID-19. WHO urges researchers, scientists and the media to be cautious about amplifying unproven claims that tobacco or nicotine could reduce the risk of COVID-19,” said a WHO statement from mid-May.

The WHO’s review of the latest evidence ”shows exactly the opposite’ result to the Parisian studies, warned Krech, as he referred to this week’s review of 27 observational studies and 8 meta-analyses published by the WHO.

Not only is tobacco product consumption likely to increase COVID-19 infection, tobacco products may also increase COVID-19 disease severity, warns the WHO – for several reasons.

It has long been acknowledged that smoking impairs lung function and the body’s ability to fight off diseases. It also increases the severity of respiratory diseases – including COVID-19 – according to a review last month by public health experts convened by WHO.

And while the effect of smoking on COVID-19 infection has not been confirmed in peer-reviewed studies, smokers “may be more vulnerable” to COVID-19 infection as the act of smoking increases the likelihood that a virus will transmit from hand to mouth,” warns the WHO – especially because smokers may share products between each other:

“Smoking waterpipes, also known as shisha or hookah, often involves the sharing of mouth pieces and hoses, which could facilitate the transmission of the COVID-19 virus in communal and social settings,” said the WHO in a Q&A on tobacco and COVID-19 on Wednesday.

There is another link between smoking and COVID-19 illness – Non Communicable Diseases (NCDs) like cardiovascular disease, cancer, respiratory disease and diabetes.

Smoking is the ‘single most preventable cause of NCDs’, and people with NCDs are much more likely to die of severe COVID-19 illness. In Latin America, 80% of deaths are due to NCD’s – And worldwide, 75% of deaths are due to NCDs. 

While there are currently no peer-reviewed studies that directly estimate the risk of hospitalization with COVID-19 among smokers, it is likely that smoking worsens COVID-19 outcomes, reports the WHO.

Image Credits: WHO, Smoke Free Movies Initiatives, WHO, NCD Alliance.

As the COVID-19 pandemic continues to ravage the world, hope has been pinned on the development and roll-out of an effective vaccine. But in a global crisis where demand for the vaccine will be everywhere, how can fair and equitable distribution be ensured?

Panelists from the World Health Organization; the Coalition for Epidemic Preparedness Innovations (CEPI); Medicines Law and Policy, the Shuttleworth Foundation, and a former Brazilian diplomat tackled this question in the second webinar in the ‘Global Pandemics in an Unequal World’ series, cosponsored by the New School and Health Policy Watch.

How do we turn the commitment to a universal vaccine from rhetoric to an implementation plan?” posed Sakiko Fukuda Parr, moderator of the discussion and director of the Julien Studley Graduate Programs in International Affairs at the New School.

What we have now is not only a health crisis, but a crisis that shakes your world order. We can’t separate what is going to happen in health from what happens in the global geopolitical situation,” said Celso Amorim, former Brazilian Minister for External Relations.

In the midst of redefining the world order, a new paradigm for ensuring access must emerge in order to roll-out any successful COVID-19 vaccines in an equitable fashion, said other panelists.

“The supply of any successful and safe and efficient vaccine will be limited for several years…[because] the global demand will be everywhere at the same time,” said Elen Høeg, policy manager at the Coalition for Epidemic Preparedness and Innovation (CEPI), which is supporting the development of at least three different vaccine candidates.

Fair allocation of any vaccine should then be based on public health need, rather than countries’ ability to pay, said Mariângela Simão, assistant director-general for Access to Medicines & Vaccines at the World Health Organization.

“We are bound to establish new [allocation] criteria that are unprecedented in the world, based on ethical and moral values. And then we need to make these products accessible and affordable,” she added.

To do that requires the buy-in of major Heads of States, says Amorim, who proposed a United Nations General Assembly Session to put pandemic preparedness and response on the agenda for all Member States.

Like it or not, people are represented internationally by governments and I think we have to have a very broad discussion in the United Nations in a political body,” he said.

But another looming issue is the problem of scale – manufacturing capacity will have to ramp up significantly to meet the global demand, even with equitable access conditions in place.

One solution is to tie access requirements into funding agreements for vaccine development, said Achal Prabhala, Shuttleworth Foundation fellow. 

The EU, the US and the UK could attach some access conditions to the billions of dollars being given to vaccine developers,” Prabhala explained. But he also lamented that this is “the solution that will probably not be implemented.”

Other solutions may be on the horizon.

The panelists spoke just a day before the official launch of the World Health Organization’s COVID-19 Technology pool, which aims to pool all data, technology, and other research necessary to speed development and scale manufacturing of any COVID-19 treatments, diagnostics, and vaccines.

What this whole initiative will do, is create a place where donors can put conditions on spending so that research and development funding comes with conditions regarding sharing technologies that are needed to scale up production worldwide,” said Ellen t’Hoen, director of Medicines, Law & Policy. “I hope that this crisis will lead to increased multilateralism and collaboration, and then we can move away from the kind of vaccine nationalism that we now see around the world.”

(top, left-right) Sakiko Fukuda-Parr, Achal Prabhala, Celso Amorim (bottom, left-right) Elen Høeg, Mariângela Simão, Ellen t’Hoen)
Here are some key remarks from the featured speakers:
Sakiko Fukuda-Parr, director, Julien J. Studley Graduate Programs in International Affairs, The New School

We need a global public good vaccine for COVID-19 that is effective and safe, but also mass produced, priced affordably and distributed widely and equitably. And that would reach all people, especially vulnerable populations and developing countries. There’s an overwhelming support for this idea as an objective, and it’s been endorsed by political and religious and intellectual leaders around the world such as presidents and prime ministers of France, Germany, Canada, China, China, South Africa and others. And there’s also a broad consensus that this is not only an ethical imperative, but an urgent public health priority and that there is a need for international cooperation and multi stakeholder partnership. 

But there is much greater difficulty in achieving agreement on how to get there. How do we go from the business as usual market model upon pharma research and development, financed by charging high prices under 20 year patents and other intellectual property exclusivity with limited distribution focusing on high income countries first, and from that to a people’s vaccine that is patent free mass produced accessible in the global south?

Who will have early priority access to the vaccines or other necessary technologies, who will bear the financial burden, who will benefit from the investments and who will receive the treatments? How can the values of solidarity and multilateralism prevail over nationalism? How can 21st century capitalism address market failures by creating innovative social institutions to protect public health priorities that do not align with just a maximum profit, private profit and revenues? How do we turn the commitment to a universal vaccine from rhetoric to an implementation plan? And in particular, how will low-income people and countries in the Global South have access to vaccines and other treatments so that we can actually end the pandemic?

 Mariângela Simão, assistant director-general for Access to Medicines & Vaccines, World Health Organization

First we live in a globalized world, so anything that happens in one country affects others. Secondly, it’s also shown that the countries are not prepared, no matter how many resolutions were approved in the World Health Assembly. On the other hand, this has been a very democratic virus… It raised an enormous, collaborative effort to try to sort it out, because no one is safe as long as someone else is vulnerable to this virus. 

We cannot let low and middle income countries end up with an unfair allocation of the leftovers. The market cannot work the same way it worked in the past pandemics and it cannot work the same way. We think we should be all applying at least to five principles; transparency, because we have right now we have a situation where you have companies trying to sell products that we don’t have yet to countries in, we have some countries trying to buy products that are not there yet. We are talking about a new normal, where income should not play a role anymore.

We also need flexible regulatory in procurement approaches, we need collaboration among the different stakeholders to produce a safe and effective product in the shortest time possible. But we also need these products to be allocated to address public health needs, with ethical rules informing the allocation. So it’s really super important that we have agreed criteria to allocate products that will enable equitable access. We’ll need to take into account the vulnerability. 

For example, the Bahamas, a high income country. Suddenly last year, they were devastated by a hurricane. And now they get COVID, so their ability to pay is very limited. So income doesn’t play the same role anymore. So we are bound to establish new criteria that are unprecedented in the world, based on ethical and moral values. And then we need to make these products accessible and affordable.

Achal Prabhala, Shuttleworth Fellow in advancing innovation and access to medicines

The thing that strikes me the most over the last 20 years is that access to treatments and vaccines is no longer an afterthought.The model that we followed right through something like one year ago was develop the drug first, get a treatment, and then let’s figure out how to give people access to it. That’s not the model here. But having said that, there are two big threats that confront us. And the first is intellectual property, private monopolies that are owned by corporations. And to provide one quick example of how IP remains a threat, I think one can do no better than to look to Gilead’s license for remdesivir, which is the first US FDA approved emergency use treatment for COVID-19.

They released an access agreement that allows a few production facilities in India to sell generic versions of the drug in 127 countries. But about half the world is left out – every middle income country, so every country in Latin America including Brazil, which is particularly severely hit by the coronavirus. Many of the former Soviet Union countries are completely left out. 

The second trait, however, is nationalism. And I think the perfect example of how nationalism is playing out is when the CEO of Sanofi, which is registered in France, suggested that the US would have first dibs on its vaccine. And of course, this raised a fly in France. Since the French President intervened, and then the chairman of Sanofi had to backtrack those comments. When it comes to vaccines, there are very, very few production facilities around the world that can even make a generic vaccine.

There are solutions that countries are advocating for themselves. Brazil, Chile, Germany, Canada, Ecuador, have begun taking actions to suspend monopolies around Coronavirus related treatments, vaccines and diagnostics, should that be necessary. There are multilateral solutions that have been discussed like the WHO COVID-19 Technology pool. And then finally, we have the solution that probably will not be implemented, which is having the EU, the US and the UK attach some access conditions to the billions of dollars being given to vaccine developers. 

Elen Høeg, Policy Manager, Coalition for Epidemic Preparedness and Innovation (CEPI)

The challenge of ensuring access in a pandemic is fundamentally different from an epidemic in that the global demand will be everywhere at the same time. Hence, the supply of any successful and safe and efficient vaccine will be limited for several years. 

So, as pointed out, then there’s this balance between the national interests and  global solidarity, because I do think we all recognize this is a global challenge that requires a global solution. There will be both development challenges and access challenges. One thing that has become evident is the need to step up and very urgently get in place large scale manufacturing across many geographies to cover the global demand. 

So we must put in place mechanisms for a global procurement and ordering system, both to give predictability for manufacturing and security of investments as well as addressing the regulatory measures. A fair allocation mechanism, which will be led by the WHO, will be established. We see great will from partners to commit to having doses secured for a global pool of vaccines to serve a fair global allocation model. 

Celso Amorim, Minister of External Relations of Brazil (1993-94; 2003-2010), and Minister of Defense of Brazil (2011-2014)

What we have now is the biggest crisis that’s not only a health crisis, but a crisis that shakes your world order. We can’t separate what is going to happen in health from what happens in the global geopolitical situation. I think there are changes that are going to help. I hope it doesn’t lead to conflict at some point; I hope it can lead to new kinds of cooperation in the world which are multipolar in which developing countries can help. 

I think this is basically a political question. Even the Doha Provision only was able to pass because rich countries also saw they needed it. Of course, technical expertise has to come from the WHO. But we really need the involvement of the United States. That’s why we have been proposing the idea of a special session of the General Assembly where all countries would participate. Like it or not, people are represented internationally by governments and I think we have to have a very broad discussion in the United Nations in a political body. You need a big, international conference, Heads of State in order to push for better replies to world problems. The WHO  simply is not enough. We have to have big political support – the General Assembly of the United Nations is the only place where you can have really a big impulse.

Ellen t’Hoen, director, Medicines, Law & Policy

If a vaccine becomes available, the demand will be immediate, it will be global, and it will be enormous. And we need to plan for this. Now, if there’s one thing that we’ve learned from the HIV crisis, it’s the danger of having no plan. The drugs were developed, but it took about a decade before they became available in low and middle income countries. One lesson-learned from that is that you need to sort out the ownership issue. And this is not only about patterns with HIV, there were barriers to the low cost, generic production of drugs on a large scale, and that was largely solved through the Doha Declaration and the establishment of the Medicines Patent Pool (MPP), where patents for antiretrovirals (ARVS) could be pooled [and licensed to generics manufacturers]. All the patent licenses for all WHO-recommended antiretrovirals are available through the MPP. 

In mid-March, Costa Rica, proposed to the WTO to establish a COVID-19 technology pool that brings together all the necessary intellectual property – data, cell lines, know-how, technology – in order for that to be freely shared to advance science and future large scale production of vaccines ,therapeutics and diagnostics. The pooling of such knowledge was endorsed by the World Health Assembly and tomorrow, there will be an announcement with the president of Costa Rica, WHO, and a number of other member states to launch this initiative. What this whole initiative will do, is create a place where the donors funding the research and development of vaccines, drugs, and diagnostics, can put conditions on that spending regarding sharing technologies that are needed to scale up production worldwide.

I hope that this crisis will lead to increased multilateralism and collaboration, and then we can move away from the kind of vaccine nationalism that we now see around the world. The people first in line for a vaccine should be the health care workers of the world, but you need to have agreements for making that happen. 

Upcoming Webinars in ‘Global Pandemics in an Unequal World’

The Tuesday event was the second in a series of four webinars, co-sponsored by The New School and Health Policy Watch, with the Centre for Development and Environment at the University of Oslo joining as a partner. Join us in June and July for the next two webinars, covering these themes:

24 June – Digital technology and Inequality in the COVID-19 response

22 July – COVID-19 inequalities and the environment

 

This story was updated 2 June 2020 to amend a quote by Ellen t’Hoen.

(Top, left-right) Pascal Soriot, CEO AstraZeneca; Emma Walmsley, CEO GSK (Bottom, left-right) Albert Bourla, CEO Pfizer; Paul Stoffels, CSO Johnson&Johnson

The UK-based Pharma firm AstraZeneca and US-based Pfizer announced they are planning to start Phase III trials as early as July for an experimental COVID-19 vaccine in the United States and the United Kingdom. The massive trials would enroll over 30,000 people, and AstraZeneca’s hope is to have an effective vaccine by the end of the year. 

Pfizer is aiming for an even more ambitious timeline to have a vaccine ready for approval by the US Food and Drug Administration and European Medical Agency by October, announced Albert Bourla, chairman and CEO of Pfizer. 

If things goes well, and the stars are aligned, we will have conclusive or enough evidence of safety and efficacy so that we can feel comfortable and the FDA will feel comfortable, and EMA will feel comfortable to have a vaccine around the end of October,” said Bourla, speaking at a briefing by pharma industry leaders, hosted by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). GlaxoSmithKline (GSK) and Johnson&Johnson were also present at the briefing.

Pfizer’s Phase I clinical trials will conclude in June, Bourla added.

AstraZeneca meanwhile is conducting studies in Kenya, in South Africa, in Brazil, with the hope that trials in many other countries will start “anytime soon.”

“The hope is that we will have a [Covid-19] vaccine, hopefully several, by the end of this year,” said Pascal Soriot, CEO of AstraZeneca. 

Not for Profit Approach – But Vaccine Will Likely Be Rolled Out First In Countries With Stronger Infrastructure

Johnson & Johnson, GSK and AstraZeneca executives said that they were taking a “not-for-profit” approach to vaccine development and sale, at least for now.   

“We do it not-for-profit for the pandemic period, as we want to [ensure] equitable access over the world…and especially to get vaccines to make sure we get a stop to the pandemic,” said Stoffels of Johnson & Johnson. 

“We can actually provide this vaccine in a fairly equitable manner to everybody around the world. And finally, just like everybody else, we do it at no profit,” said Soriot.

Said GSK’s CEO Emma Walmsley: “We’re on record saying we don’t expect to profit during this period because we want to invest in short term profit in pandemic preparedness and in donations.”

While Pfizer’s CEO Albert Bourla did not commit to a ‘not-for-profit’ approach explictly, he acknowledged that vaccine pricing will have to approached differently in times of the pandemic:

“Typically the industry is pricing their product based on the value that they bring. And this is impossible to happen right now. In times of pandemic, you can’t have pricing policies that respect [demand and the rules of an open market]…I don’t know what will be the price reduction because I’ve never thought about it.”

Bourla also stressed that the lack of infrastructure would still be a barrier to global rollout of a new COVID-19 vaccine

Albert Bourla speaking at a May 28 press briefing

“Technologies [we are developing] right now require -80 °C,” said Bourla. “The technology is not very convenient for Africa because they will likely lack basic infrastructure…[the vaccine] will come to the Western world first but [in the] second wave, we are working on making sure that we can develop and manufacture products that are not requiring [refrigeration in Africa]”.

“Not all vaccine candidates can go all over the world,” agreed Stoffels, saying this will depend on its features. 

Even so, Bourla said that Pfizer was “absolutely engaged”’ in joining coalitions like the European Union-led ACT Accelerator to ensure equitable access for COVID-19 health technologies. 

Patent Pool Gets Cold Shoulder 

Thomas Cueni speaking at a May 28 press briefing

The pharma leaders spoke just a day before the World Health Organization was to launch a new COVID-19 patent pool, which is supposed to group intellectual property of any coronavirus-related technologies – to ensure accessibility in low and middle income countries. 

IFPMA head Thomas Cueni said he would not be joining Friday’s ceremony, which followed the announcement two weeks ago Costa Rica, Chile and the WHO.

“I don’t quite see what the new initiative adds [in comparison to existing mechanisms] I’m too busy [to participate],” Cueni said.

Cueni and other industry leaders have said that infrastructure shortcomings, manufacturing challenges and supply chains are likely to be bigger access obstacles than patents in the current race to achieve universal access to a pandemic vaccine.

Distribution Bottlenecks Likely

One of the main issues with mass-producing a vaccine is not necessarily the amount of vaccine itself, but getting enough vials, said Soriot. 

“The challenge is not so much to make the vaccine itself, it is to fill the vial. And there’s not enough vials in the world,” he said.

In light of limited vial supplies and the fact that some 15 billion vaccine doses might be needed, said Cueni, pharmaceuticals like AstraZeneca and Johnson & Johnson are trying to squeeze a handful of vaccine doses within each vial to distribute more of the vaccine with less vials:

“Like everybody else, we are looking into five or ten doses per vial,” said Soriot.

And as vial makers scramble to produce more vials, they face an unprecedented challenge as they have never had to produce such quantities – Planning needs to happen ‘now’ to tackle the vaccine distribution issue: “If we go to 15 billion vaccines, that has never been done in history from a filling capacity as well as vials… planning [is not] for next month…we need to start planning now,” he said

Who Gets Priority? 

Reports of some countries signing pre-purchase agreements for COVID-19 vaccines have surfaced in the past few weeks, sparking concerns that some countries will jump the line in the queue for an effective vaccine. 

Last week, the French-based company Sanofi sparked outrage in Europe when they announced that they would first sell the vaccine in the United States – which had invested heavily in R&D at the company’s US locations as well as making pre-purchase agreements. After protests by French government officials, Sanofi’s CEO retracted the statements. 

But so far, the Pfizer CEO said the company had not signed any pre-purchase contracts for their vaccine, currently concluding Phase I clinical studies that will likely yield results by June 2020.  

“We haven’t signed contracts and also I think it is known that Pfizer is not taking any money from any government, the US government or any other government to advance our vaccines. We don’t do that,” said Bourla.

France rolled back recommendations on the use of hydroxychloroquine, a malaria drug, for severe COVID-19 patients, just two days after the World Health Organization suspended its large multinational hydroxychloroquine trial.

Meanwhile, the United Kingdom has authorized the use of remdesivir for severe cases of COVID-19. The drug showed modest potential to shorten the length of infection in a large, US study. 

France had previously recommended hydroxycholoroquine to be used at providers’ discretion for treating patients with severe COVID-19. However, the French Ministry of Solidarity and Health on Wednesday issued a revised recommendation stating, “whether in town or in hospital, this molecule should not be prescribed for COVID-19 patients.”  

The Ministry statement is informed by the High Council for Public Health (HCSP), which earlier in the week also reversed its stance on the drug, no longer recommending it for discretionary use for severe COVID-19 patients.

The working group concluded in a collegial manner that there was no sufficiently robust clinical study demonstrating the efficacy of hydroxychloroquine in COVID-19 regardless of the severity of the infection,” stated the HCSP in a notice posted Tuesday. 

The moves by the WHO and France were prompted by a massive study published in The Lancet that found a much higher risk of cardiac arrhythmias and mortality among nearly 15,000 COVID-19 patients who were given hydroxychloroquine, chloroquine, or either drug plus a macrolide antibiotic, compared to 81,000 who did not receive any combination of the drugs.

However, the jury is still out on use of hydroxychloroquine as a preventative medicine. India recently expanded its recommendations for prophylactic use of hydroxychloroquine based on early results from a small observational study. 

Both President Trump of the United States and  Salvadoran president Nayib Bukele have touted the use of a drug as a prophylactic. In a parallel development, Brazil’s Jair Bolsonaro has also unveiled plans to expand the prescription of chloroquine, a predecessor of the drug, while acknowledging that there is no scientific evidence of its efficacy, however, the situation continues to be monitored in Brazil and globally. 

UK Issues Emergency Use Guidelines for Remdesivir

Hope is turning more towards remdesivir, an antiviral originally developed by Gilead Sciences for treating Ebola, which has shown modest positive effects on speeding recovery. 

“This shows fantastic progress. As we navigate this unprecedented period, we must be on the front foot of the latest medical advancements, while always ensuring patient safety remains a top priority,” said Minister for Innovation Lord Bethell of the UK’s recent remdesivir approval. 

However, the drug is still being studied in ongoing clinical trials, and some experts warn against pinning all hopes on remdesivir.

Whilst this is clearly the most ethically sound approach, it also means that we ought not to expect the drug to immediately act as a magic bullet. We can instead hope for improved recovery rates and a reduction in patient mortality, which we hope will benefit as many patients as possible,”  Stephen Griffin, a professor from the University of Leeds Medical School told BBC.

Thus, countries like the UK, which just released a package of guidance for emergency use of remdesivir, are approaching the rollout of the drug carefully, limiting it to use only to patients with severe disease. 

Merck Joins The COVID-19 Vaccine Race

Merck, one of the largest pharmaceutical companies in the world, has announced deals to develop and manufacture two different COVID-19 vaccines as well as an experimental antiviral compound which is already in early clinical trials. 

The company will be collaborating with IAVI to develop a vaccine candidate against SARS-CoV-2, the virus that causes COVID-19. This vaccine candidate will use the recombinant vesicular stomatitis virus (rVSV) technology that is the basis for Merck’s Ebola Zaire virus vaccine, ERVEBO®, which was the first rVSV vaccine approved for use in humans. Initial funding support for the initiative comes from the Biomedical Advanced Research and Development Authority (BARDA), part of the office of the Assistant Secretary for Preparedness and Response within an agency of the United States Department of Health and Human Services.

Merck also announced on Tuesday it would be acquiring the small biotech company Themis, which is working with the Institut Pasteur on a COVID-19 vaccine candidate delivered using the same technology used to carry the measles vaccine. The Themis vaccine candidate is still in preclinical trials, and will aim to begin clinical trials by late 2020.

According to the World Health Organization’s latest table of COVID-19 vaccines, 124 candidates are at various stages of development with eight different technologies, or platforms. 

Merck has also backed the development of the compound EIDD-2801, which is designed to inhibit viruses with RNA-based genetic material, including SARS-CoV-2. In this regard, the company is collaborating with Ridgeback Biotherapeutics, which has started a safety trial of the compound in healthy patients in the UK. 

Image Credits: Jamie.

WHO Director-General Dr Tedros Adhanom Ghebreyesus unveiled a bold new WHO Healthy Recovery Manifesto – including an unprecedented call to governments to stop subsidizing the fossil fuel industry to the tune of US$ 400 bilion annually – driving both climate change, air pollution, and an epidemic of chronic diseases that also sharply increased mortality risks for people infected with COVID-19.

The move coincided with the European Union;s unveiling of a much anticipated Covid-19 recovery plan with a green investment edge. Named Next Generation EU the €750 billion package aims to address the economic and social fallout of the coronavirus pandemic with direct investments in renewable energy technologies and support to countries to shift to low-carbon economies. 

The six WHO-endorsed manifesto principles include oft-repeated calls for healthier cities, food systems, and clean water.  However, WHO’s blunt call to governments to “stop using taxpayers money to fund pollution” steps out of the Organization’s traditional comfort zone. The manifesto also calls for an end to biodiversity destruction and the “unsafe management and consumption of wildlife”, noting that it is these activities that lead to the transmission of deadly animal pathogens such as COVID-19 to humans, and “increase the risk of emerging infectious diseases.”  

These steps, WHO says, will lead towards healthier societies, more resilient to future outbreaks and epidemics. 

The human cost of COVID-19 has been devastating, & the so-called lockdown measures have turned lives upside down,” said Dr Tedros in a press briefing. “But the pandemic has given us a glimpse of what our world could look like if we took the bold steps that are needed to curb climate change and air pollution. Our air and water can be clearer, our streets can be quieter and safer, and many of us have found new ways to work while spending more time with our families.”

Both the WHO and EU proposals were unveiled just a day after over 40 million healthcare workers issued a call to place climate-friendly initiatives at the heart of COVID-19 economic recovery. 

Turn “Immense Challenge into Opportunity”

“The recovery plan turns the immense challenge we face into an opportunity, not only by supporting the recovery but also by investing in our future: the European Green Deal and digitalization will boost jobs and growth, the resilience of our societies and the health of our environment,” European Commission President Ursula von der Leyen said in launching the plan

The plan would require all 27 EU member states to back it up with concrete investments. It comes as the bloc faces the prospects of a EU-wide recession. However, Member States have remained divided on whether the plan represents the best way forward.

France, Germany, Spain and Italy have welcomed the package, with French President Emmanuel Macron hailing it “a crucial step”.  But Austria, Denmark, the Netherlands, and Sweden — known as the “frugal four” — have protested the proposal, saying the aid should instead come in the form of low-interest loans. As such, the plan in its current form is unlikely to pass in its current form, given that it does not have unanimous support. 

Climate-Friendly Initiatives Core to in the European Union Plan
Urban pedestrian & green space (Photo: CCAC)

One key pillar of the EU plan is “supporting the green transition to a climate-neutral economy.”  A new “Recovery and Resilience Facility” of €560 billion would offer financial support for investments and reforms focusing on green and digital transitions.

The plan also earmarks €91 billion per year in EU grants and loan guarantees to businesses and households that install green technologies such as rooftop solar panels, building insulation and  heating systems based on renewable energy.

The facility also sets aside €5 billion in guarantees for “green mortgages”, tying low-carbon renovations into property sales, giving schools, hospitals, and social housing the priority.

Other climate-friendly instruments include a proposal to strengthen an EU Just Transition Fund, with up to €40 billion to assist economically weaker Member States in accelerating the transition towards climate neutrality, and a €15 billion injection of funds into the European Agricultural Fund for Rural Development, to support a trajectory for rural areas to reach climate neutrality.

The plan has been largely praised for centering on climate-friendly initiatives. However, some advocates have criticised the plan for leaving out ocean health initiatives, and other climate NGOs blasted leaked drafts of the plan for being too lenient towards polluting industries such as automakers and fossil fuel.

“The European Commission’s €1.85 trillion recovery plan is contradictory at best and damaging at worst,” said Greenpeace in a statement“It does not solve the problem of existing support for gas, oil, coal, and industrial farming – some of the main drivers of a mounting climate and environmental emergency. The plan also fails to set strict social or green conditions on access to funding for polluters like airlines or carmakers,” the NGO added.

WHO Manifesto For Green COVID-19 Recovery

The bold new WHO manifesto begins with a comment by Dr Tedros on the intimate links that have been laid bare between viral threats and other emergencies, pollution and climate change and wildlife and biodiversity destruction:

“The pandemic is a reminder of the intimate and delicate relationship between people and planet. Any efforts to make our world safer are doomed to fail unless they address the critical interface between people and pathogens, and the existential threat of climate change, that is making our Earth less habitable,”

The  WHO Healthy Recovery Manifesto includes six key principles, described as “prescriptions” for a healthy and green recovery from COVID-19, which include the following key messages:

1) Protect and preserve the source of human health: Nature

“Human pressures, from deforestation, to intensive and polluting agricultural practices, to unsafe management and consumption of wildlife, undermine these services. They also increase the risk of emerging infectious diseases in humans  – over 60% of which originate from animals, mainly from wildlife. Overall plans for post-COVID-19 recovery, and specifically plans to reduce the risk of future epidemics, need to go further upstream than early detection and control of disease outbreaks. They also need to lessen our impact on the environment, so as to reduce the risk at source.”

Pangolin, Manis javanica – harbors coronavirus infections, and is hunted for its meat and scales

2) Invest in essential services, from water and sanitation to clean energy in healthcare facilities

“Around the world, billions of people lack access to the most basic services that are required to protect their health, whether from COVID-19, or any other risk. Handwashing facilities are essential for the prevention of infectious disease transmission, but are lacking in 40 % of households. Antimicrobial-resistant pathogens are widespread in water and waste and their sound management is needed to prevent the spread back to humans. In particular it is essential that health care facilities be equipped with water and sanitation services, including the soap and water that constitutes the most basic intervention to cut transmission of SARS-CoV-2 and other infections, access to reliable energy that is necessary to safely carry out most medical procedures, and occupational protection for health workers.”

3) Ensure a quick, healthy energy transition

“Currently, over seven million people a year die from exposure to air pollution – 1 in 8 of all deaths. Over 90% of people breathe outdoor air with pollution levels exceeding WHO air quality guideline values.  Two-thirds of this exposure to outdoor pollution results from the burning of the same fossil fuels that are driving climate change. Energy infrastructure decisions taken now will be locked in for decades to come. Factoring in the full economic and social consequences, and taking decisions in the public health interest, will tend to favour renewable energy sources, leading to cleaner environments and healthier people. Several of the countries that were earliest and hardest hit by COVID-19, such as Italy and Spain, and those that were most successful in controlling the disease, such as South Korea and New Zealand, have put green development alongside health at the heart of their COVID-19 recovery strategies.”

Solar panels supply energy for hot water at Bertha Gxowa Hospital in Johannesburg. Photo: Health Care Without Harm

4) Promote healthy, sustainable food systems

Diseases caused by either lack of access to food, or consumption of unhealthy, high calorie diets, are now the single largest cause of global ill health. They also increase vulnerability to other risks – conditions such as obesity and diabetes are among the largest risk factors for illness and death from COVID-19. Agriculture, particularly clearing of land to rear livestock, contributes about ¼ of global greenhouse gas emissions, and land use change is the single biggest environmental driver of new disease outbreaks. There is a need for a rapid transition to healthy, nutritious and sustainable diets. If the world were able to meet WHO’s dietary guidelines, this would save millions of lives, reduce disease risks, and bring major reductions in global greenhouse gas emissions.

5) Build healthy, liveable cities

Cycling in Fortaleza, Brazil – the city strengthened its active transport plans as part of the Healthy Cities Partnership

“As cities have relatively high population densities and are traffic-saturated, many trips can be taken more efficiently by public transport, walking and cycling, than by private cars. This also brings major health benefits through reducing air pollution, road traffic injuries – and the over three million annual deaths from physical inactivity. Many of the largest and most dynamic cities in the world, such as Milan, Paris, and London, have reacted to the COVID-19 crisis by pedestrianizing streets and massively expanding cycle lanes – enabling “physically distant” transport during the crisis, and enhancing economic activity and quality of life afterwards.”

6) Stop using taxpayers’ money to fund pollution – halt US$ 400 billion in fossil fuel industry subsidies

“Financial reform will be unavoidable in recovering from COVID-19, and a good place to start is with fossil fuel subsidies.

Globally, about US$400 billion every year of taxpayers money is spent directly subsidizing the fossil fuels that are driving climate change and causing air pollution. Furthermore, private and social costs generated by health and other impacts from such pollution are generally not built into the price of fuels and energy. Including the damage to health and the environment that they cause, brings the real value of the subsidy to over US$5 trillion per year-  more than all governments around the world spend on healthcare – and about 2,000 times the budget of WHO.

Placing a price on polluting fuels in line with the damage they cause would approximately halve outdoor air pollution deaths, cut greenhouse gas emissions by over a quarter, and raise about 4% of global GDP in revenue. We should stop paying the pollution bill, both through our pockets and our lungs.”

New ‘WHO Foundation’ Aims To Raise More Flexible Funding For The World Health Organization
Dr Tedros (left) and Thomas Zeltner (right) sign an MOU between the WHO and the newly established WHO Foundation

Meanwhile, WHO also unveiled a new initiative Wednesday to address some of its own pressing financial problems – triggered by the temporary suspension of funding from the United States as well as by a longer term decline in “assessed contributions” by WHO member states to the Organization. 

The WHO Foundation was launched today to raise funding from the general public and other  “non-traditional sources” for the Organization. The new foundation will give the agency a source of unearmarked income, providing more flexibility in financing WHO’s General Programme of Work. 

“The creation of the foundation represents a truly innovative approach to diversify WHO’s resource mobilization strategy. This new approach is clearly an urgent need,” said WHO Foundation founder and former Swiss Secretary of State for Health Thomas Zeltner.

“One of the greatest threats to WHO success is the fact that less than 20% of our budget comes in the form of flexible assets contributions from Member States,” said Dr Tedros at the press briefing. “For WHO to fulfill its mission and mandate, there is a clear need to broaden our donor base, and to improve both the quantity and quality of funding we receive – meaning more flexibility.”

WHO is one of the few international organizations that, up until now, has no legal channel for receiving donations from the general public, he noted. 

The success of the COVID-19 Solidarity Fund, which has raised more than US $241 million in a few short months, served as a good proof-of-concept for the WHO Foundation, which aims to raise money for a broader, more flexible and more long-term portfolio encompassing all of WHO health programmes.

Currently, almost 80% of the funding that WHO receives comes in the form of voluntary contributions earmarked for specific programmes, according to Dr Tedros. 

“This means that WHO has little discretion over the way it spends almost 80% of its funds,” he explained.

More flexible funding, channeled through the new WHO Foundation, will allow the organization to address some underfunded programmes that have not caught the eye of other large donors. attention. 

“All funding of the WHO Foundation will help implement WHO’s General Programme of Work. On average, between 70-80% of the funds we raise will go directly to the WHO Secretariat. The remaining 20-30% will be used to strengthen public health globally by working with implementing partners of WHO,” said Zeltner.

Still, money raised by the new Foundation is meant to “complement, not supplement” existing resources available to the agency, clarified Zeltner.

The WHO Foundation will be set up as an independent, non-profit organization under Swiss law. A Memorandum of Understanding between the WHO and the WHO Foundation was signed Wednesday by Zeltner and Dr Tedros to set the framework for how the Foundation will collaborate with the agency.

Image Credits: Twitter: @WHO, Wikimedia Commons, Piekfrosch/wikipedia, Health Care Without Harm, FAO/Shutterstock, City of Fortaleza.

WHO Regional Director for the Americas Carissa Etienne at a regular press conference

As global COVID-19 cases topped 5 million this past week, Latin America has surpassed Europe and the United States in terms of new cases being reported everyday, said WHO Regional Director for the Americas, Carissa Etienne, at a Pan American Health Organization press conference on Tuesday.

There have been almost 32,000 new cases of COVID-19 in Latin America and the Caribbean over the past 24 hours, as compared to 24,000 in the United States and 18,000 in WHO’s European Region – which includes the recently hard-hit Russian Federation and Turkey as well as western European states, such as Italy, Spain and the United Kingdom, which saw a major wave of infections in March and April.

However, the United States and Brazil are now the two countries with the highest cumulative number of reported cases worldwide, added Etienne.  And the Americas region as a whole has seen 2.4 million of the world’s 5.5 million reported cases, as well as 143,000 of the 350,000 deaths. As of Tuesday evening, the United States reached the 100,000 mark for deaths from the novel virus.

The latest data is ‘truly alarming’, Etienne said in light of the fact that non-communicable diseases (NCDs) like diabetes, cancers or other respiratory diseases are “pervasive” throughout the “Americas” region – and those diseases make people more vulnerable to serious illness from Covid-19. 

“We have Never Seen Such a Deadly Relationship”

Prior to COVID-19, about 80% of all deaths in the Americas were already due to such non-communicable diseases and almost 40% of these deaths were premature, as they occurred before 70 years of age, said Etienne. The Americas Region, according to World Health Organization’s definitions, includes Latin America and the Caribbean as well as the United States and Canada.

That means one in four people in the Americas is at an increased risk of poor outcomes if they become infected with COVID-19, said Etienne.

“We have never seen such a deadly relationship between an infectious disease and NCDs”, said Etienne. “One of the most concerning aspects of the COVID-19 pandemic in PAHO is the disproportionate impact of the virus on people suffering from non-communicable diseases.”

Latin America has 62 million people living with diabetes and 1.2 million people living with cancer, and these populations are much more vulnerable to COVID-19.

Diabetics are twice as likely to have severe COVID-19 disease, according to a recent review of 16,000 patients with COVID-19. And in one Chinese study, almost 30% of cancer patients died from the virus, as compared to only 2% on average, said Etienne. 

Smoking increases vulnerability to COVID-19

Smoking prevalence is another risk factor in the Americas that is exacerbating the current crisis. About 15% of adults in the region still smoke, increasing the likelihood of developing severe illness from COVID-19, as smoking reduces respiratory capacity and promotes cancers, heart and lung disease.

For all of these reasons, she said, health systems need to prioritize prevention and control of non-communicable diseases along with supporting the pandemic response –  as treating NCDs can prevent COVID-19 from becoming life-threatening. 

“As cases continue to rise in our region, our efforts to protect those with underlying conditions must intensify,” she said. “We must ensure timely access to care for chronic diseases to prevent them from becoming life-threatening.”

“Fighting non-communicable diseases now is integral to our response to COVID-19. We need aggressive preventive measures to protect people with diabetes, respiratory and cardiovascular diseases from the new coronavirus.”

If measures are not taken now to help people with NCDs, health systems will be faced with a “parallel epidemic” of preventable deaths in persons with those conditions.

The New Epicentre Of Infection – Latin America

There can be ‘no doubt’ that Latin America has become the epicenter of the COVID-19 pandemic, said Etienne at Tuesday’s press conference.

And over the past day, the ‘highest increase’ in cases was seen in Latin American countries like Chile, Brazil and Peru.

While Chile has reported almost 5000 new cases in the past day, a 7% increase, Brazil has seen almost 16000 new cases over the past 24 hours, a 5% increase. Meanwhile, Peru and Mexico have each witnessed a 4% increase in cases over the past day, said Etienne.

Some countries in the region have successfully ramped up testing; Chile, for instance, has reached the milestone of 25,000 tests per million people, comparable with the highest range of testing rates in Europe at the height of the pandemic wave there. But testing is still ‘not sufficient’ in most other countries, said Director of PAHO’s Department of Communicable Diseases Marcos Espinal – The majority of South American nations are still only managing to test less than 5000-6000 people per 1 million, a figure that is much lower than most European countries.

The Americas has 40% of the world’s cases and 40% of total deaths

Image Credits: WHO, WHO.

Solar panels provide electricity to Mulalika health clinic in Zambia. Reliable power supply ensures reliable function of core health programmes. Green energy also creates local jobs and can fuel economic recovery in the aftermath of the COVID-19 pandemic, proponents say.

More than 40 million health professionals from 90 countries worldwide have issued an open letter to G20 leaders and their chief medical advisors, urging them to support climate smart  development in their plans for economic recovery from COVID-19. 

The appeal to the Group of 20  of the world’s most industrialized countries, supported by some 350 professional organizations, including the World Medication Association, says green growth is medically mandated – to save lives both from climate and air-pollution related threats which would also make societies more resilient to pandemics such as COVID-19. 

The call comes just ahead of a critical moment for climate-related investments – the upcoming G7 Summit now planned for the end of June, which is to convene leaders of the world’s seven most advanced economies to discuss pandemic recovery.  In a recent Tweet, US President Donald Trump, who is hosting the Summit, said that he’d like to convene leaders in person at Camp David, outside of Washington DC, sometime around the originally planned date, which was to have been 10-12 June.

“The amount of money governments and central banks are preparing to spend on Covid-19 economic recovery is so massive that it will inevitably shape humanity’s chances of climate survival,” noted a the Covering Climate Now initiative of Columbia Journalism Review and The Nation, in a recent blog. “If those trillions of dollars are invested in shoring up the industries and infrastructure of the incumbent fossil fuel economy, it will lock in rising temperatures for decades to come, ensuring climate catastrophe. If those trillions are instead invested in transforming the world to a zero-carbon economy, they could rescue millions of people from unemployment and poverty and open vast investment opportunities for businesses, while perhaps also preserving a livable planet in the bargain.”

Conflicting Signals in Global Economies

The health professionals’ call came as French President Emmanuel Macron announced an US$ 8.8 billion bailout of the French car industry, prioritizing development of electric vehicles, for which car buyers will receive a 12,000 Euro subsidy each. The United Kingdom has also said it would stress green growth in its recovery plans. And many European cities have created “pop-up” bicycle lanes to ease crowding on public transport systems in the COVID-19 era – a move that has been celebrated by cycle activists.

Cycling has become a more popular way to get around during the COVID-19 pandemic.

However, in many more countries, returning to business as usual seems to be a bigger priority, and fossil fuel power development is still occuring apace across most of the developing world.

China is expanding its coal power capacity at home and in investments in South-East Asia and Africa. Australia is developing the world’s largest open pit coal mine to supply fuel to India. Japanese environmentalists are mounting a campaign against their country’s planned investment in a coal-fired power plant in Viet Nam.

Existing and planned coal power production (carbonbrief.org)

In the Eastern Mediterranean Region, Israel has largely spurned the power of solar in favor of a heavy dependence on its new offshore natural gas reserves.  The equally sun-drenched countries of Turkey, Cyprus, Greece and Libya are bitterly vying for control of other Mediterranean gas reserves. And African countries such as the Democratic Republic of Congo aim to develop untapped shale oil sources, some in sensitive rainforest areas.

Air Pollution – SARS COV-2 Virus Synergies
Pedestrians in Bangladesh cover their faces to keep from breathing in dust and smog. Air pollution takes 22 months off the average life expectancy in Bangladesh. (Photo: Rashed Shumon)

Long before COVID-19 came onto the stage, WHO data reported that air pollution causes some 7 million people to die prematurely every year, as a result of air pollution-related heart attack, stroke, respiratory illnesses and cancers.  

In the COVID-19 pandemic, people with the same heart and lung conditions, as well as cancers, have been dying from the new SARS-COV-2 virus in far greater proportions – thus the link to air pollution, including from fossil fuel sources, and ultimately climate change.  Several studies of mortality from the pandemic also have drawn an even more direct connection, including sharply higher COVID-19 mortality rates among people living in more polluted areas of Italy and the United States. 

“Before COVID-19, air pollution – primarily from traffic, inefficient residential energy use for cooking and heating, coal-fired power plants, the burning of solid waste, and agriculture practices – was already weakening our bodies,” the letter from the health professionals  states.

“It  increases the risk of developing, and the severity of: pneumonia, chronic obstructive pulmonary disease, lung cancer, heart disease and strokes, leading to seven million premature deaths each year. Air pollution also causes adverse pregnancy outcomes like low birth weight and asthma, putting further strain on our health care systems.

“A truly healthy recovery will not allow pollution to continue to cloud the air we breathe and the water we drink. It will not permit unabated climate change and deforestation, potentially unleashing new health threats upon vulnerable populations,” states the letter, referring to these as drivers that have increased the transmission of certain animal pathogens among human populations.

“We have witnessed first hand how fragile communities can be when their health, food security and freedom to work are interrupted by a common threat,” the letter also states. “”These effects could have been partially mitigated, or possibly even prevented by adequate investments in pandemic preparedness, public health and environmental stewardship. We must learn from these mistakes and come back stronger, healthier and more resilient.”

World Medical Associaiton & International Council of Nurses Among Signatories
WHO Tweet supporting the green recovery call to action by health professionals.

The signatories include the World Medical Association, the International Council of Nurses, the Commonwealth Nurses and Midwives Federation, the World Organization of Family Doctors and the World Federation of Public Health Associations, as well as individual health and medical personnel.

“Health professionals are at the frontlines of this emergency, and we are seeing the immense loss of lives because of acting too late,” Miguel Jorge, the president of the World Medical Association, was quoted as saying.

“We know now more than ever that healthy lives depend on a healthy planet. As we walk on the road to recovery, we need to build a system that will protect us from further damage. We need a healthy and green recovery.”

The appeal also was supported by the World Health Organization, which issued a Tweet stating that it, “aligns with this resounding call to action from the world’s health community.”

As Virus Threat Fades – Same Old Polluting Practices Return
The Dhauladhar mountain range of Himachal, visible from 200 km away in Punjab, India, after air pollution drops to its lowest level in 30 years

While COVID-19 related lockdowns in places such as China, India and northern Italy vividly illustrated how ‘blue skies’ can return once pollution is curbed, healthcare professionals fear that as the immediate impacts of the virus fade, the world is resuming the same old polluting practices without having learnt lessons that are critical to a “climate recovery”.

A climate-smart recovery would also reduce the likelihood of future pandemics as well as climate breakdown, they say.

The letter calls for recovery packages to prioritise investments in public health such as in clean air, clean water and low-carbon development, arguing that such investments would reduce air pollution and greenhouse gas emissions while building greater resilience to future pandemics and creating more sustainable jobs. The signatories also warn governments to learn from the failures exposed by the pandemic to tackle vulnerabilities in the economy and safeguard frontline healthcare workers,  pointing out that when human health is compromised, the economy suffers.

Green Recovery Would Be More Profitable

A recent study from Oxford University, for instance, found that green recovery measures – such as conditional bailouts for fossil fuel-dependent industries to encourage them to shift to greener processes, and increased infrastructure to support electric vehicles and bicycles – would yield more jobs and a better return on investments than returning to business as usual.

“A healthy recovery recognises that human health, economic health and the planet’s health are closely connected; the pandemic has demonstrated that economic recovery must be achieved in ways that strengthen our global health resilience,” said  Jeni Miller, executive director of the Global Climate and Health Alliance“This is not the time to go back to business as usual, it is a time to take bold steps forward to create a future that protects both people and the planet,” she added.

The signatories argue that investing in greener economies would be more profitable – as well as reducing air pollution, promoting healthier diets, more walking and cycling, and protecting biodiversity. But clear economic incentives are needed to stimulate the transition:

“To achieve that healthy economy, we must use smarter incentives and disincentives in the service of a healthier, more resilient society,” the letter’s signatories state. “If governments were to make major reforms to current fossil fuel subsidies, shifting the majority towards the production of clean renewable energy, our air would be cleaner and climate emissions massively reduced, powering an economic recovery that would spur global GDP gains of almost 100 trillion US dollars between now and 2050. 

The letter has been sent to all G20 leaders, including the United Kingdom’s Boris Johnson, German’s Angela Merkel and China’s Xi Jinping, who have seen public pressure to adopt greener economic recovery measures, as well as to those leaders who have been criticised for a lax approach to the Covid-19 crisis or for using it as an excuse to weaken environmental protections, including US President Donald Trump, Russian Federation’s Vladimir Putin and Brazil’s Jair Bolsonaro.

Updated 27 May 2020

Image Credits: Shutterstock/TonyV3112, UNDP/Karin Schermbrucker for Slingshot , Rashed Shumon, Twitter: @Deewalia.

COVID-19 responders learn how to properly don and doff protective gowns in Kenya

In contrast to Europe and the Americas, Africa has just 1.5 percent of the world’s reported cases of COVID-19, and less than 0.1 percent of the world’s deaths, World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus noted on Africa Day 2020.

“Africa appears to have so far been spared the scale of outbreaks we have seen in other regions,” said Dr Tedros. “Of course, these numbers don’t paint the full picture. Testing capacity in Africa is still being ramped up, and there is a likelihood that some cases may be missed.”

Still, African countries’ histories of facing outbreaks of infectious disease have played in their favor, said the WHO Director-General.

“Africa’s knowledge and experience of suppressing infectious diseases has been critical to rapidly scaling up an agile response to COVID-19,” he said.

For example, a coalition of African leaders, organized through the African Union chaired by South African President Cyril Ramaphosa, was set up early in the global pandemic to coordinate cross-country preparedness efforts. Infrastructure and knowledge from battling previous outbreaks was used to rapidly scale COVID-19 interventions, as seen in South Africa’s rapid deployment of mobile diagnostic teams, and the Democratic Republic of the Congo’s use of Ebola screening infrastructure for COVID-19 temperature screening.

Additionally, citizens across the continent have largely understood the need for strong lockdown measures, taken early by many African nations. WHO Regional Director for Africa Dr Matshidiso Moeti on Monday thanked citizens for abiding by stay-at-home orders where possible, acknowledging the hardships that many were facing.

“I’d like to very much commend and thank [the citizens]… because we think that it’s thanks to these measures that we have not started to see the kind of evolution of the pandemic in Africa that we were projecting,” said Moeti. “They accepted the need for some of these measures, although many of them recognize that it would be very tough on them in the households, particularly if you take into account the proportion of African people that are in a sector where you need to be out, earning your money in order to be able to put food food on the table.”

Japan Lifts State Of Emergency As Other Asian Countries Seesaw On COVID-19 Control

On Monday, Japan officially lifted its state of emergency in all its provinces ahead of the May 31st deadline, regarding the emergency situation as “no longer necessary” according to the Ministry of Health. The country has been largely praised for its efficient coronavirus response, relying almost solely on quick contact tracing, testing, and isolation of cases.

India also lifted its restriction on domestic air travel effective Monday, although there were mixed opinions on the move. Meanwhile, Philippines President Rodrigo Roa Duterte commanded its government agencies to expedite the repatriation of more than 24,000 overseas Filipino workers (OFW) within the week.

In China, clusters of cases in Jilin province in the northeast have led to officials to lockdown cities only a couple weeks after the original pandemic epicentre Wuhan began relaxing lockdown measures.

Tensions between China and the US remain high. China’s Foreign Minister Wang Yi remarked that a “political virus is spreading in the US, with some politicians ignoring facts and promoting conspiracy” at a video press conference on Sunday. Still, Wang expressed hope that there could be future collaboration between China and the U.S. for addressing global challenges. 

Park rules in Paterson, New Jersey, USA.
New Death Projections in US Cast Somber Outlook If States Are Too Eager To Reopen

In stark contrast to the Chinese approach, states across the US have begun relaxing social distancing guidance even as new cases continue to appear.

And health experts warn that relaxing COVID-19 measures early could lead to a fresh wave of coronavirus deaths. Some 23,000 more people could die if states failed to reimplement social distancing measures, according to a new analysis by epidemiologists at the Columbia Mailman School of Public Health. 

And enacting federal social distancing measures just two weeks earlier could have prevented 83% of the US’ nearly 100,000 coronavirus deaths, according to the same study. 

But experts fear that social fatigue from complying with the stringent measures mean that citizens will be loathe to comply with any renewed measures. As such, the importance of scaling up public health measures to rapidly detect and contain the virus, as well as improve health education, is even more important in the next phase of the fight.

“Our results also indicate that without sufficient broader testing and contact tracing capacity, the long lag between infection acquisition and case confirmation will mask the rebound and exponential growth of COVID-19 until it is well underway,” says lead researcher Jeffrey Shaman, professor of environmental health sciences at the Columbia Mailman School of Public Health in a press release. “Efforts raising public awareness of the ongoing high transmissibility and explosive growth potential of COVID-19 are still needed at this critical time.”

A COVID-19 triage tent in Italy
High COVID-19 Death Rates in Italy & Sweden  

Sweden had a seven-day rolling average of  6.08 deaths per million between 13 May and 20 May, overtaking the UK, Italy and Belgium to have the highest coronavirus per capita death rate in the world regardless of its low population densities and limits in international travel.

In contrast to countries like France and Germany, social distancing implemented in Sweden depending largely on the discretion of individual Swedes, without harsh controls, fines, or policemen.

However,  the high mortality rate has thrown the government’s decision to avoid strict lockdown into further doubt- especially as its neighboring countries such as Norway, Denmark and Finland, where much tighter restrictions are put in place, have seen dramatically lower numbers of deaths over the past month.

Sweden’s decision to keep open schools, bars and restaurants and to continue to allow gatherings of up to 50 people has been praised by many who believe that the country will be better equipped for a “second wave” with certain degree of herd immunity through the relatively relaxed measures. However, WHO experts have repeatedly warned that early antibody surveys are showing that a far higher proportion of the population will remain susceptible to a second wave, casting strong doubt on the ‘herd immunity’ approach.

Meanwhile, a recent analysis of death registry data by two Italian economists shows that Italy had a 40% higher death rate from February to March 2020, as compared to the same time the previous year.

The economists estimated that the virus may have killed 0.1% of the local population in less than 40 days and that its mortality is vastly underreported in official statistics.

But on the bright side, the analysis shows that stringent containment measures were significantly lower in the Veneto region, which has “embraced mass testing, contact tracing and at-home care provision.” Neighboring Emilia-Romagna and Lombardia did not fare as well.

The economists also found that closure of service activities is effective in reducing COVID-19 mortality – a 10% increase in proportion of the service industry closed correlated with a 15% lower death rate in municipalities. In this second paper, the economists draw from daily death registry data on 4,000 Italian municipalities to investigate two policies, namely the shutdown of non-essential businesses and the management of the emergency care system. However, shutting down factories is much less effective. In addition, results also show that morality strongly increases with distance from the intensive care unit (ICU).

Svet Lustig Vijay contributed to this story

Image Credits: Twitter: WHOAFRO, Paterson Great Falls, Servizio Nazionale della Protezione Civile.

Child receives vaccine

Due to COVID-19, polio and measles campaigns have been suspended in 27 countries, and polio vaccination campaigns have been put on hold in 38 countries,  UNICEF’s Executive Director Henrietta Fore has warned. 

Some 80 million infants in at least 68 countries are likely to be affected by the suspension of routine immunization services, said Fore in a joint press conference with warned UNICEF along with the World Health Organization, GAVI – The Vaccine Alliance, and the Sabin Vaccine Institute, on Friday. 

Vaccination campaigns (which seek to vaccinate large parts of the population in a short period of time) have also been badly hit, especially for measles and polio: Measles campaigns have been suspended in 27 countries and polio vaccination campaigns put on hold in 38 countries.

“We fear that COVID-19 is a health crisis that is quickly turning into a child-rights crisis” Fore said in a press statement. We cannot let our fight against one disease come at the expense of long-term progress in our fight against other diseases,” she added. “We have effective vaccines against measles, polio and cholera. While circumstances may require us to temporarily pause some immunization efforts, these immunizations must restart as soon as possible, or we risk exchanging one deadly outbreak for another.”

The reasons for disrupted immunization services range from stay-at-home orders, redeployment of health workers for COVID-19, lack of personal protective equipment – but also delays in air travel to ship vaccines.

Pandemic threatens to Unravel Vaccine Progress

“Immunization is one of the most powerful and fundamental disease prevention tools in the history of public health. Disruption to immunization programmes from the COVID-19 pandemic threatens to unwind decades of progress against vaccine-preventable diseases like measles,” said WHO Director-General Dr. Tedros Adhanom Ghebreyesus, speaking at the press event. 

“This pandemic is threatening to unravel this progress, risking the resurgence of other diseases”, said Seth Berkley, chief executive officer of GAVI. These include illnesses more likely to affect children such as measles and polio – but also diseases that can attack people of all ages including cholera, meningitis, tetanus, typhoid and yellow fever, he said.  

More children all over the globe are now protected against more vaccine-preventable diseases than at any point in history. Basic vaccine coverage in the world’s poorest countries has risen from 59% in 2002 to 81% today, helping reduce vaccine preventable diseases by 70% during that time period, said Berkley.

Even so, before the COVID-19 pandemic, measles, polio and other vaccines were out of reach for 20 million children below the age of one every year.

A 6-month-old baby receives a delayed vaccine shot at a community health centre in Beijing, China.
‘People Reluctant to Come for Immunization Services’

Many countries have temporarily and justifiably suspended preventive mass vaccination campaigns against diseases like cholera, measles, meningitis, polio, tetanus, typhoid and yellow fever, due to risk of transmission and the need to maintain physical distancing during the early stages of the COVID-19 pandemic.  Added one WHO official, “People are reluctant to come for immunization services, out of concern for themselves, and out of concern of course for the healthcare workers.”  

However, in the long-run, vaccinations will save more lives.

“Not only will maintaining immunization programmes prevent more outbreaks, it will also ensure we have the infrastructure we need to roll out an eventual COVID-19 vaccine on a global scale,” added Berkley.

“We need joint concerted efforts to put vaccinations back on track,” Fore added, “and there are many ways we can do that.

“First  countries need to intensify their efforts to track unvaccinated children, so that the most vulnerable populations are vaccinated, as soon as it becomes possible to do so. Second, we eed to address the gaps in vaccine delivery. Third, we need to look for innovative solutions to keep vaccines going. Fourth, vaccines, need to be affordable and accessible to those who need them the most.” 

Despite Lockdowns and Flight Restrictions – Some Countries Offer Creative Examples For Continuing Vaccines

A UNICEF statement from early May cited a 70-80 percent reduction in planned vaccine shipments, leading to a “massive backlog”, as a result of the cancellation of commercial flights and the “exhorbitant cost” of securing cargo space.

However, despite lockdowns and stay-at-home measures, some countries, such as Uganda and Lao PDR, have found creative ways to maintain routine immunization, Fore said.  This includes carrying out vaccines in pharmacies, cars or supermarkets, while incorporating physical distancing in delivery.

She noted that in March, “Lao scheduled a rollout for HPV vaccine [which has] reached more than 70% of the population…. Uganda is ensuring that immunization services continue along with other essential health services, even funding transportation to ensure outreach activities.”  

WHO is due to issue new advice to countries on maintaining essential services during the pandemic, including recommendations on how to provide immunizations safely.

In early June, the United Kingdom government will host the Global Vaccine Summit, which aims to raise “at least” US$ 7.4 billion for Gavi to protect 300 million children in 68 lower-income countries against deadly diseases from 2021-25.  

Substantial pledges have already been received from the UK, the US, Norway, Germany, Canada, Italy, Japan, Saudi Arabia Spain  – But more is needed to reach the target, added Berkley.

“It is vital that GAVI receives the resources we need to continue our work over the next five years,” he said. 

He added that GAVI would also likely be a major conduit for any future COVID-19 vaccine as well – which will be the only real way to build herd immunity and get rid of reservoirs of infection. 

Image Credits: EPA/Francis R. Malasig, UNICEF/Zhang Yuwei.

This story was updated 4 June to reflect the Lancet study’s retraction.

WHO Chief Scientist Soumya Swaminathan provides reasoning behind pausing hydroxychloroquine arm of the Solidarity Trial.

Enrollment of new patients in the hydroxychloroquine (HCQ) arm of the World Health Organization’s Global COVID-19 Solidarity Trial will be put on pause, as the trial’s oversight committee reviews all available data on COVID-19 and hydroxychloroquine, WHO Director-General Dr. Tedros Adhanom Ghebreyesus said on Monday.

The WHO decision on Saturday came just a day after a major observational study published in The Lancet found a higher mortality rate in COVID-19 patients who have received hydroxochloroquine, chloroquine, or a combination of either drug and azithromycin, as compared to COVID-19 patients who did not receive any treatments.

The Lancet paper was later retracted on 4 June by three of the authors due to concerns about the “veracity of the primary data sources.”

“The executive group [composed of experts from 10 countries involved in the trial] has implemented a temporary pause of the hydroxychloroquine arm within the Solidarity trial,” said Dr Tedros speaking at a WHO press conference. “The group has agreed to review a comprehensive analysis and critical reappraisal of all evidence available globally. The review will consider data collected so far in the Solidarity trial, and important, robust randomized available data to evaluate the potential benefits and harms from this drug.”

WHO Experts Clarify Reasoning Behind Hydroxycholoroquine Arm Suspension

Still, WHO experts said that mortality conclusions could not be definitively drawn from an observational study, such as the one reported by The Lancet. WHO’s Chief scientist Soumya Swaminathan acknowledged that unlike randomized controlled trials such as the one WHO is conducting observational studies can yield misleading results.

“We know that the evidence from observational studies, however large they may be, is still subject to inherent bias. What’s really important is to have well-conducted randomised control studies, done in large numbers,” said WHO Chief Scientist Soumya Swaminathan, also speaking at the press briefing.

WHO Emergencies head Mike Ryan also underlined that WHO’s decision to suspend the hydroxychloroquine arm of the WHO Solidarity Trial was not due to any negative preliminary results that had already been flagged in the ongoing WHO study.

Rather, the decision was a “proactive” one made to “err on the side of caution,” said Swaminathan.

“There were also a lot of questions coming from our own principal investigators in countries, and we knew that the regulatory agencies in many countries were also discussing these data…So the steering committee decided that in the light of this uncertainty that we should be proactive, err on the side of caution and suspend enrollment temporarily into the hydroxychloroquine arm,” she told reporters.

As one part of the review, the trial’s independent data safety monitoring board will be analyzing data collected so far to see if there are any “signals” that the drug is failing, and send them to the trial’s advisory committee for further review, said WHO Health Emergencies Executive Director Mike Ryan.

“We will expect that if there is no signal of failing, and we don’t have any problems, we will try to use the drug,” said Ryan.

Dr Tedros highlighted that hydroxychloroquine, which has been widely approved for use for malaria and the autoimmune disease Lupus, is still safe to use in patients with those diseases.

Researchers Criticise The Lancet Study Design
Analysis of HCQ studies finds that randomised control studies (green) are more likely to find the drug has a positive effect on COVID-19, compared to observational studies (red)
(Credit: Didier Raoult et al.)

Other researchers have also criticised The Lancet study’s design. While the study had analyzed a large body of data from 671 hospitals in 6 continents, there could still be bias in the analysis that is obscuring the true effects of the drug.

In smaller RCTs for example, positive results for hydroxychloroquine had been found. Treatment failure had so far mainly been identified only in observational studies, according to an analysis by Didier Raoult, director of the Marseille University Hospital Institute for Infectious Diseases ( IHU Méditerranée Infection).

One major critique is that The Lancet study does not adequately adjust for the fact that many of the patients in the study are more likely to be severely ill, and are already at increased risk of death.

Critics contend that The Lancet study primarily observes patients experiencing more severe disease who began receiving HCQ later in disease progression, while the drug has shown promise when given earlier or used as a preventative treatment. For example, India now recommends the prophylactic use of hydroxycholoroquine to protect against COVID-19 infection in all healthcare and frontline workers, following results from a small observation trial that found the likelihood of infection was lower in those who took the drug.

“Another poorly designed interpretation of a hydroxychloroquine data set for COVID-19. A larger poorly designed “trial” only leads to larger erroneous conclusions,” tweeted Steven Phillips, a Yale-educated internal medicine doctor who specializes in zoonotic infectious diseases.

About two-thirds of the patients in The Lancet study were from North America, where delays in testing mean that patients aren’t identified until 5 to 7 days after they begin showing symptoms, says Phillips.

“HCQ early COVID-19 treatment isn’t embraced in the US. It’s given only to the sickest patients, without contrary evidence in this study. To state that the baseline disease severity between treatment & control is equal was incorrect,” he added.

For example, one measure used in The Lancet study to determine baseline disease severity is the “quick sequential organ failure assessment”(qSOFA) score. There is little difference between qSOFA scores across different disease severities, so the score is “proving a bad stratifier for COVID,” tweeted antimalarial pharmacology researcher James Watson, a lead scientist at the Mahidol Oxford Tropical Medicine Research Unit (MORU).

“So a quick conclusion is that they have just inadequately adjusted for disease severity, which is driving the treatment allocation [of HCQ or no HCQ],” added Watson.

“I agree with one thing the authors said: ‘Randomized clinical trials will be required before any conclusion can be reached regarding benefit or harm of these agents in COVID-19 patients,'” Phillips tweeted in conclusion.

Image Credits: Matthieu Million, Yanis Roussel, Didier Raoult.