The mysterious new pneumonia coronavirus that has emerged in Wuhan, China may also be transmitted between people, health experts in China and Geneva now suspect. Officials are concerned that the outbreak may also spread globally as a new exported cases of the novel virus were confirmed in Thailand on Friday and Japan on Thursday, and local sources reported a second death due to the virus in China.

The outbreak has claimed its second victim, a 69-year old man named ‘Mr. Xiong’ who was reportedly hospitalized on 31 December 2019. The Wuhan Municipal Health Commission said in an official statement that the man’s condition deteriorated on 4 January and died on 15 January at Wuhan JinYinTan Hospital shortly after midnight (translated from Chinese).

The second Thailand case was also in a Chinese national who was found to have fever on arrival at Suvarnabhumi airport on 13th January. Initially hospitalized for mild pneumonia, Thai and WHO officials have since confirmed the man to be positive for the new viral disease.

Earlier in the week, reports surfaced that the coronavirus, dubbed 2019-nCOV, has been confirmed in family clusters, including at least one family member who had not visited the Wuhan seafood and live animal market that is suspected of being the source of the new infectious agent.

On Thursday Japan’s Health Ministry also reported its first case of the virus in a man who fell ill during a visit to Wuhan earlier in the month, although he had not visited the market, said NHK World News. The man was hospitalized upon his return to Japan on 6 January, and was discharged on Wednesday. Later Thursday, WHO confirmed the report of the Japanese case.

Seafood and fresh food market in Wuhan, Hubei, China. Most confirmed cases of 2019-nCoV were traced back to Huanan Wholesale Seafood Market, although at least two confirmed cases have reported never visiting the market. Authorities are concerned that this could mean the source of infection is present in other markets, or the disease could spread directly from person to person.

Chinese authorities and researchers are now struggling to pinpoint the original infection reservoir among the live animal species sold in the market; routes of transmission; and confirm definitively if the disease can be spread by person-to-person contact – possibly in a weakened form.

A commission of technical experts from Hong Kong, Macao, and Taiwan visited Wuhan on 13 – 14 January and found two family clusters of confirmed cases – three male family members living together and a husband-wife duo.

The three men were all believed to have contracted the disease from working at the seafood market, Dr Chuang Shuk-kwan, a commission expert from Hong Kong, was quoted saying at a press conference Wednesday morning in the South China Morning Post. However, the wife with a confirmed case of the 2019-nCoV infection had not recently visited the market where her husband worked as a trader, according to a statement by Wuhan authorities (translated from the Chinese). Chuang Shuk-kwan said this could suggest “limited” human-to-human transmission of the virus is occurring.

In Geneva, a WHO official expressed similar concerns: “From the information that we have, it is possible that there is limited human-to-human transmission, especially among families who have close contact with one another,” Maria Van Kerkhove, acting head of WHO’s Emerging Diseases Unit, told journalists at a briefing.

The possibility that the virus is being transmitted between humans – but resulting in asymptomatic or mild cases that remain undetected by the health system – is an important concern for Chinese authorities as hundreds of thousands of people prepare to travel around the country during the Lunar New Year, the annual holiday that begins January 25.

The number of confirmed cases has risen by 44, and caused two deaths. Three cases have now been reported outside of China, in Thailand as well as Japan. Officials are investigating whether the latest Thai case has had contact with the local seafood market where most cases have been traced. The Japanese case, announced publicly Thursday, was a man who fell ill on 3 January and had been in close contact with some of the Wuhan residents who became infected, although he did not visit the suspect live market. He was hospitalized after returning home to Japan and has since recovered. In Thailand, a case was reported on 8 January in a 61- year old Chinese tourist from Wuhan who became sick while traveling to Bangkok for a vacation; she was immediately hospitalized and is also now recovering, according to WHO.

While that patient reported visiting a local fresh market in Wuhan on a regular basis, she had not visited the Huanan Seafood Wholesale Market, where most of the other cases have been traced. Experts say that this means that the source of the infection could be a live animal commonly sold at other markets as well.

Number of New Ebola Cases Stabilizes

Infectious disease outbreaks, epidemics, as well as increasing drug-resistance among certain viruses and bacteria, are among a list of urgent global health challenges for the next decade, WHO said this week.

And along with the emerging coronavirus in China, the new year of 2020 also opened with the world still battling a stubborn, 1.5 year-long Ebola outbreak in the Democratic Republic of the Congo.

The last embers of the Ebola outbreak in the Democratic Republic of the Congo are still smoldering as the response effort moves into the new decade. The deadly virus resurged in December, after a month of civil unrest and armed attacks on health workers in eastern DRC – the epicenter of the outbreak. Although there were signs that numbers may be stabilizing in the new year. Some 14 new cases were confirmed between 8-14 January, compared to 12 new cases the previous week. Case numbers are down again after a small resurgence of 27 cases in the first week of December 2019.

A Red Cross team demonstrates a safe and dignified burial.

Insecurity and community mistrust have plagued the response, with the International Federation of the Red Cross confirming Wednesday that yet another attack on Ebola responders had occurred at a safe burial conducted in Mambasa. Two Red Cross volunteers were injured.

“Despite an overall improvement in the community’s acceptance, this attack shows that community engagement is crucial to building trust and ending the Ebola outbreak,” IFRC Africa tweeted on Wednesday. On Thursday, WHO reported that several health areas continue to be difficult to reach due to insecurity, including Mandima Health Zone, where there are rumors of several community deaths in Lwemba Health Area.

In 2019, WHO recorded 978 attacks on health care workers and outbreak responders, resulting in 193 deaths. As of 14 January, 3406 Ebola cases have been reported, of which 2236 cases have died.

Story updated 17 January 2020

Image Credits: Arend Kuester/Flickr, IFRC.

More public disclosure and information-sharing about drug prices and their R&D costs, is key to determining a fair price for essential medicines, concludes a series of five articles on fair pricing published Monday in the BMJ. The series, supported in part by the World Health Organization, highlights the increased priority drug price transparency is receiving on WHO’s agenda.

The five articles discuss the barriers to information-sharing between private and public sectors about R&D costs, as well as between health systems in different countries, which typically keep data on real drug purchase prices confidential, which have become a central theme on the transparency agenda over the past year.

But the series also explores some new, win-win approaches to pricing that could help make higher-price medicines more affordable while maintaining incentives for the private sector to invest in R&D and manufacturing, according to the study authors.

“Transparency is a key element to determine what is fair, but there is an absence of reliable data on development costs,” Alison Colbert, technical officer in the Essential Medicines and Health Products Department at WHO wrote in an introductory editorial published in the BMJ for the series. The editorial was co-authored by top WHO officials, including the director and assistant-director of the Essential Medicines and Health Products Department at WHO, Suzanne Hill and Mariângela Simão, along with Soumya Swaminathan, chief scientist at the WHO.

The WHO officials add that “ultimately, there is no simple algorithm that will calculate a fair price for each medicine,” but that transparency and collaboration will ensure that the “right data” are available to the “right stakeholders” to help ensure affordable access to essential medicines.

However, before “fair” prices can be set, the global health community must first agree about what a “fair” price means.

“”For too long, governments and other purchasers of medicines have not had clear frameworks for how to assess the fairness of medicines prices, especially when considering pricing within a global market. We know medicines prices have been climbing year after year, but how can we assess when a high price is too high?” asked Suerie Moon, co-director of the Global Health Centre at the Graduate Institute.

Suerie Moon et al. propose hypothetical price ceilings (ie, the maximum that is affordable to the buyer) and fair prices for countries with different affordability thresholds. Prices below the red line indicate hypothetically “fair” prices.

In the first article in the series, Moon and her colleagues from WHO highlight the differences between what matters to sellers’ and buyers’ in defining a “fair price.” The authors note that both groups have a very different set of parameters.  Buyers may consider a drugs overall value to individuals and health systems;  affordability and financial hardship risks; and supply security. Pharmaceutical companies, on the other hand, are concerned with prices that cover the costs of R&D, regulation, manufacturing, and distribution while generating a profit.

Moon and her colleagues propose a framework that combines both buyers’ and sellers’ concerns in defining a range of fair prices for medications, proposing that price ceilings for medicines could be set by consideration of consumers’ concerns while price floors could be set by manufacturers’ priorities. Public intervention should occur in cases where prices fall outside of this range.

“A key concept here is that companies can earn a fair profit, but the profit should not be excessive and should not come at the cost of affordability to patients,” Moon clarified.

Altogether, the series includes five papers that address issues around medicines prices that could be described as “fair” while still incentivizing the pharma industry to invest, entitled as follows:

While generally, high prices are associated with patented medicines, the second and third papers also explore lesser-publicized issues of high pricing for biosimilars, generic medications, as well as the prices of  off-patent drugs which may have too few manufacturers. The fourth paper argues for a radical shift towards alternate business models that reward the pharma industry for innovation, but not through the vehicle of prices, to spur more development in areas of unmet health need.

Finally, the last paper presents how the WHO’s Market Information for Access to Vaccines database has allowed middle-income countries to share market data and negotiate more equitable prices, highlighting an example of a transparency initiative that has helped increase access to essential vaccines.

The series’ authors include researchers from WHO, the Organization for Economic Co-operation and Development (OECD), the Graduate Institute in Geneva, University of KwaZulu-Natal, and Harvard University, among others.

Image Credits: BMJ, Suerie et al. Defining the concept of fair pricing for medicines.

Chinese authorities have been commended for the speed at which they have identified the genetic make up of a novel coronavirus, 2019-nCoV as the cause of a new pneumonia-like illness in Wuhan, China. The virus has infected 42 people, and is likely transmitted primarily through animals to humans, said a leading infectious disease specialist on Monday.

But while the recent coronarvirus outbreak does not appear to be nearly as deadly as previous ones, such as the 2002-2003 SARS epidemic or the most recent 2015 outbreak of MERS, it is reflective of a new reality that public health officials increasingly face. Deadly infections are leaping the species barrier from animals to human populations with greater frequency, speed or intensity in a globalized world, experts say. And whether the outbreak is in a remote rural area or dense urban landscape such as Wuhan, it can send shockwaves through countries and global economies.

Wholesale seafood and animal market in China.

“The Chinese could be commended for their efforts in containing the outbreak… but now we need to know more about the animal reservoir, so we know to prepare for future outbreaks,“ Michael Osterholm, director of the Minnesota-based Center for Infectious Disease Research and Policy (CIDRAP), told Health Policy Watch.

But “Wuhan shouldn’t have been a surprise, it’s going to happen more and more. The world responded quickly to people flying out of Wuhan [as seen in Thailand]. However, it may have been more complicated if the virus emerged in a more internationally-travelled city such as Beijing or Shanghai,” he said.

“I think that our ability to respond to these emergencies is moving in a more positive response generally… However, worldwide, we still have many areas of social and political unrest; the world is becoming less safe for public health work,” Osterholm added.

On Saturday, WHO’s Director General Dr Tedros Adhanom Gheyebresus also commended the Chinese authorities for “working around the clock” to identify the genetic sequence of the new Wuhan pneumonia virus, dubbed 2019-nCOV. The authorities also transmitted those sequences to WHO. The data will help WHO support global efforts to diagnose and treat other suspected cases of the virus, WHO said.

In a statement on Monday, WHO also confirmed that a “seafood market,” which also also houses an abundance of live animals, some of which are pets while others are slaughtered and eaten, appeared to be the source of the infection.  Further investigations were still underway to identify the actual “animal reservoirs or intermediate hosts“, the agency said.

Cats awaiting sale in a Chinese live animal market.

Dr Tedros was also consulting with WHO Emergency Committee members in terms of the level of health emergency that exists, and WHO said a meeting could be called with the committee on “short notice“.

In his interview, Osterholm added that it is critical for the Chinese to share information about which animals have been investigated already, and the outcomes of such research. Since there is no evidence of human-to-human transmission as no cases have been reported in health care workers attending to confirmed patients, the main route of transmission seems to be from animal-to-human, he explained. So identifying and preventing the animal host from coming into contact with humans is critical for containing the epidemic.

Most of the confirmed infections have come from people who were either business operators or regular shoppers at “Hua Nan Seafood Wholesale Market in Wuhan,” according to the National Health Commission of China. The market has been closed since 1 January for health inspections.

“Although it’s called a ‘seafood’ market, it is in fact a market for general animal species… mostly sold for consumption,” said Osterholm. Many vendors sell bats and birds, as well as other live animals that could be hosts for the novel virus.

However, while public health officials should remain vigilant, there is no need for undue alarm, Osterholm said, emphasizing that the focus should be on learning from this outbreak to prepare for future ones.

“Panic never works period,” he says. “To me it appears that if anything, [the outbreak] is under control… it seems to be over [in Wuhan] as we haven’t seen any secondary transmission.

“Now the question is, if the market opens up again, what will happen. We need an understanding of what, in fact, was the source, and if that source is likely to come back into contact again with humans?”

So far, the outbreak has not been nearly as deadly as previous coronoravirus outbreaks, which have included Middle Eastern Respiratory Syndrome (MERS), emerging out of the Middle East and harbored by camels, as well as SARS, which first infected humans via civet cats infected by bats, both of which are sold in live animal markets to be consumed in parts of China.

As of Monday, the number of confirmed 2019-nCoV cases had actually declined from 59 suspected cases last week to 42 confirmed cases, including just one case in Thailand. One death has been reported, of a 61-year-old who had a pre-existing liver condition. Six patients remain severely ill while seven patients have been discharged from the hospital. So far, no new cases have been reported in Wuhan since 3 January, according to WHO WPRO. Authorities are currently following 763 contacts of confirmed cases, and no related cases have been detected according to an English translation of a press release from Chinese health authorities.

Wuhan, Hubei, China.
Rapid Action To Identify and Contain The Novel Virus

The Chinese National Health Service shared genetic sequences of the novel virus with WHO on 11-12 January; these confirmed the mysterious disease was a new type of coronavirus, according to news updates posted by WHO on Twitter over the weekend.

Genetic sequences obtained have been uploaded to an open-access online gene bank GISAID, which will publish the sequence upon confirming the information. This will enable other countries to rapidly confirm new suspected cases of the disease and institutions to collaborate on researching the disease, as well as prevention and treatment.

On 8 January, a confirmed case of 2019-nCoV was also reported in Thailand. The patient, a traveler from Wuhan, was hospitalized the same day and quarantined. Thai officials reported that the person is now recovering.

WHO said in a statement on Monday that the possibility of cases being identified in other countries was “not unexpected,” and the case in Thailand confirmed the need for “active monitoring” and “preparedness in other countries.”   However, mutations can also occur as a new virus emerges in humans, making them more dangerous and infectious over time.

The episodes underlines the need for emergency preparedness for emerging infectious diseases to remain high on the global health agenda, said Osterholm.

 

Image Credits: Peter Griffin/Public Domain Pictures, lihkg.com, Wikipedia/user: 钉钉.

Neglected tropical diseases (NTDs) can lead to physical disfiguration, stress and stigmatization, which leave lifelong impacts on the mental health of many of those infected, even after the disease itself is cured. 

As the health community prepares to mark the first-ever World NTD Day on 30 January, Nathalie Strub-Wourgaft, director of Neglected Tropical Diseases at the Drugs for Neglected Diseases initiative (DNDi), talked with Health Policy Watch about the need for increased attention and action by the health community around preventing and treating NTD-related mental illnesses. Research into the NTD-mental health nexus could help inform more effective strategies for the treatment of NTDs, which comprise some 20 different parasitic and vector-borne diseases affecting 1.3 billion people worldwide, including the world’s poorest and most marginalized populations.  

Nathalie Strub-Wourgaft, Director of Neglected Tropical Diseases at DNDi.

Health Policy Watch: NTDs are a really varied group of diseases, so which ones do we know, or suspect, cause the greatest mental health burden? And how does this manifest itself in patients?

Strub-Wourgaft: Firstly, we should recognize that there are only about 50 studies looking at this problem spanning from “is there a problem” to “what are the interventions” for these 20 diseases. This shows that the amount of research that has been conducted is very minimal – absolutely lacking.

There have been some studies published recently on podoconiosis and mycetoma, which are visible, and debilitating [parasitic] diseases. A study on cutaneous leishmaniasis* estimates that 70% of individuals with both active and inactive CL will experience some degree of psychological morbidity. So one thing we can say is that in the case of NTDs that affect the skin, which are chronic, cause scarring, disfigurement, and potentially impact the capacity of young women to get married– there has been little focus on how these diseases might be associated with depression, anxiety or other forms of mental distress. For other skin diseases, we know or suspect that they must be associated with some level of depression.

However, mental health is not being studied much in relation to many of the other neglected tropical diseases, and this is a huge problem. Sleeping sickness (Human African Trypanosomiasis), for instance, can cause psychiatric symptoms. These symptoms are very acute and can be very frightening for everyone – the patients and their families. I remember meeting a woman with sleeping sickness – her husband was so sad, anxious, and seemed very depressed to be taking care of his wife, who had become a total stranger to him. She had psychotic symptoms – she couldn’t stop laughing and talking loudly, but not as a normal person. He was unable to recognize her, or bond with her as he did before. And he kept asking me, “Will she get better one day?”

When a patient has onchocerciasis, they have two major clinical symptoms. One is itching and the other is impaired vision progressing to blindness, if not treated. The top priority has so far been to prevent blindness. However, imagine, having severe, constant itching in the absence of any treatment for it, for years. People have been reported to have committed suicide, but the burden has not been measured. The progress we have made in preventing blindness is fantastic, but we need to investigate case-management much more.

In addition, we very rarely measure the impact of these diseases on caregivers. However, we know from some documented cases that there is a mental health impact. For example, with river blindness (onchocerciasis), children often take responsibility for adults who are permanently blinded as a result of the disease, when it is untreated. They must live with someone for whom there is no real cure or solution. All of this also has an impact on the caregiver’s mental health.

We know very little about the mental health burden of some diseases, such as visceral leishmaniasis. For example, what is the impact of patients being double-burdened by being both sick and poor? They are, for example, at a higher risk of contracting the disease because they are poor and live in poor conditions, and then by being sick they become even poorer because they have to travel to get treatment at a hospital, which impacts their income, and also pay for their hospital stay [which can last for a month]. Items such as food are not provided even if the treatment is free. What is the impact of all of these things on patients and family?

Lastly, we know very little about the psychological impact of Chagas disease. If you imagine what it is like for a patient. They are doing well, then they get a diagnosis, and go for treatment. But they have seen people in their families, older people, who have died as a result of -Chagas-related cardiac disease, despite perhaps having been treated for Chagas before. How can this not impair a patient’s mental state to not know what might happen, even if they do get treatment?

A villager’s eyes are being examined for African eye worm, which can cause blindness and is found in some of the same areas endemic to onchorcerciasis (river blindness), by Dr Philippe Urwotho, a medical doctor and Provincial Coordinator of the DRC’s Neglected Tropical Disease National Programme.

Health Policy Watch: You talked a bit about how people with NTDs may be stigmatized. How does stigmatization associated with NTDs exacerbate mental health issues?

Strub-Wourgaft: Exclusion. Stigma leads to exclusion from society, social life, work and growth. This is one of the biggest factors.

Social support and having strong relationships are very important for mental health. If someone is excluded from society, they don’t belong to a group anymore, so they have fewer relationships with people and social interactions. People with NTDs have also been excluded from work. But then how do they get food to survive? How do they get educated and go to school?

Health Policy Watch: Anecdotally, you describe cases of severe mental health impacts, but how do experts measure the impacts scientifically, to derive data on the extent of the NTD-related mental health burden?

Strub-Wourgaft: It is good to ask the question because asking will provoke more research. But I cannot respond very scientifically because we just don’t have the data yet.

As of now, we don’t have an effective way to measure the emotional impact of infection with a neglected disease.

For sleeping sickness, there is a high “disability weight” when calculating disability-adjusted life-years (DALYs) – perhaps accounting for the psychiatric symptoms. However, for other NTDs, the additional mental health impact of disability is not considered in the standard calculation of DALYs lost as a result of the disease. This is one of the problems of existing measures.

It would be helpful to develop an adapted tool to measure mental health impacts and disability at the point of care level. Measuring the mental health burden is not simple– you have to think about questions like, “what is the difference between sadness and depression, between mental distress and emotional suffering, and between depression and the risk of suicide? The tool would have to enable us to not only to measure the burden of mental health-related disability, but also to measure the effect of psychological treatment, or other helpful interventions.  Since NTD care and treatment is being shifted to lower levels of health systems, one has to consider tools that are appropriate for the primary healthcare level.

Currently, I don’t think there is a consensus on a tool [to measure the burden of mental health in NTDs]. I hope that such a tool will be developed, which could be used across all NTDs, exactly for the purpose of measuring the burden, so that in a few years we can come back and respond to this question with numbers. Intuitively we know the burden is there, but we don’t know enough about it.

Health Policy Watch: Going back to your descriptions of what patients may suffer – what is happening to patients right now on the ground? Is mental health incorporated into treatment in any way?

Strub-Wourgaft: No.

When you go into the field, you will not find antidepressants or medications for anxiety. Patients might not even have antihistamines for severe itching. Although there have been efforts to improve this, the problem of access to essential medicines is still huge for patients with NTDs.

For me, this is also part of Universal Health Coverage. When we speak about helping an NTD patient, if we can properly diagnose that patient and address all their co-morbidities – including the mental health component, that is, indeed, the ultimate litmus test for achieving Universal Health Coverage.

Health Policy Watch: Do you have any examples of initiatives that are trying to address the nexus between mental health and NTDs, and how would you envision this issue could be better incorporated into DNDi’s work?

Strub-Wourgaft: There have been efforts in the NTD community to create a taskforce on mental wellbeing and stigma, as reflected in a study by Bailey et al on “Neglected Tropical Diseases and Mental Health: Progress, Partnerships, and Integration”.  However, we need to do more.

For example, if we had a tool for measuring mental health, we could add a clinical scale when we conduct clinical trials for DNDi projects.  At the community level, community wellness and support should also be strengthened.

Health Policy Watch: Are there examples of initiatives in other disease areas that you would like to see replicated for NTDs and mental health?

Strub-Wourgaft: Community education and community engagement in helping people with NTDs is crucial. There is a great program, for example, developed by the Mycetoma Research Centre in Khartoum, which travels to communities and uses videos to develop awareness and also de-stigmatize the disease.

We also need to improve diagnostic and treatment tools. Obviously, the earlier you diagnose, the better options you have to treat and, therefore, avoid the consequences of not being treated well or having chronic versions of these diseases. The other thing is to continue funding R&D so that we do have tools that not only address the vector or the infectious agent, but also patients’ symptoms, case-management, and morbidity. For some diseases like Chagas, where there can be a long lag period before the disease progresses, we need to have effective treatment  to prevent cardiac diseases developing later. This will also help to reduce the mental health impact.

Universal Health Coverage is key. We must ensure that treatments  do not impose a financial burden on patients. We know that being affected by an NTD triggers a vicious cycle of poverty – you’re sick, you’re poor, to get treated you become even poorer. For children much has been written on the growth development, which in turn, impacts economic growth. We need to collectively bring more attention and advocacy, to understand the holistic management of patients, including the social and financial dimensions. We have made progress, but this needs to continue and we also have to explore other dimensions. Again, new treatments, associated with point of care diagnosis are essential to save lives, and reduce all other related morbidities, including mental health.

Health Policy Watch: WHO is developing a 2021 – 2030 Roadmap for NTDs, as the next phase of strategic planning. As an expert in the field, what commitments would you like to see emerge to incorporate the mental health component of NTDs more fully?

Strub-Wourgaft: Addressing mental health has now been identified by the WHO as a cross-cutting issue for all NTDs in the context of health and the Sustainable Development Goals. This is a great step forward because we need to investigate this much more.

In the [WHO] 2021-2030 roadmap, I am looking for a commitment that this issue is being addressed and that it has to be included in the package of care. Measuring the burden is essential, as well as helping to inform and communicate with communities, and to debunk the stigma surrounding these diseases.

But first we must start from ground level zero. We really have to understand the burden and agree that it should be measured. The roadmap will include indicators to measure progress [in reducing the NTD burden], and in that context, we need an indicator on mental health. We need to capture and understand if there is a link with suicide. We need to know how we can help these patients.

Of course, we also need to ensure that we have the all other associated diagnostic tools and essential medicines to address these needs at the point-of-care level. The NTD team at the WHO is aware and vigilant about this need to better connect with mental health. I am quite confident that this will happen, because we in this space all share the same vision, aligned with the SDGs.

*Ref: Cutaneous leishmaniasis and co-morbid major depressive disorder: A systematic review with burden estimates – by Bailey F, Mondragon-Shem K, Haines LR, Olabi A, Alorfi A, Ruiz-Postigo JA, Alvar J, Hotez P, Adams ER, Vélez ID, Al-Salem W, Eaton J, Acosta-Serrano A, Molyneux DH. PLOS Neglected Tropical Diseases 2019, doi: 10.1371/journal.pntd.0007092).

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About the Author: Dr Nathalie Strub-Wourgaft joined DNDi as Clinical Development Director in February 2009 and is now the Director of Neglected Tropical Diseases. Prior to that she worked for over 15 years in the clinical development of new health products in the private sector.

 

 

 

 

Image Credits: DNDi.

Ahead of the upcoming WHO Executive Board meeting 3-8 February, WHO has launched a series of informal consultations this week with member state representatives on key issues that will be coming before the governing body – and ultimately the May meeting of the World Health Assembly (WHA). The detailed consultation agenda, published on the WHO website, covers nearly a dozen topics rangng from proposed new WHA resolutions on strengthening preparedness for health emergencies and the elimination of cervival cancer to initiatives on food safety and “people-centered” eye-care and blindness prevention.

WHO Executive Board meeting, 2019

A new global strategy and plan of action on public health, innovation and intellectual property is another focus of the consultations, with several meetings scheduled to discuss the strategy, which touches on oft-controversial issues around medicines accesss and affordability.  Other member state consultations will review the status of action plans and initiatives on vaccines, road safety, and  the current status of global polio eradication.

There will be a least two sessions discussing WHO’s policies on engagement with so-called “non-state actors”, referring to NGOs and the private sector. This will include a special session devoted to the rules governing their participation in meetings of WHO governing bodies, such as the Executive Board and the World Health Assembly.  WHO has a long roster of civil society actors that are recognized as being in “official relations” with the agency, and are therefore allowed to attend key meetings as observers, may then request to speak on issues as they are debated.

However, last year, WHO’s administration proposed that those rules be tightened so that diverse civil society representatives that are aligned on a given issue might present a set of consolidated remarks, to avoid repetition and save time at key meetings, which often drag into overtime, running late at night and on the weekends. As an alternative, a separate conference or meeting could be scheduled specifically between member states and recognized civil society representatives every year, WHO has suggested.

The closed-door consultations, which began yesterday, will continue throught the end of the month and are open only to WHO member state representatives.   The complete agenda of the upcoming  EB meeting, which is streamed publicly, covers a much broader array of topics.  These include reviews and updates of initiatives planned or underway on specific diseases, such as ending tuberculosis; combatting epilepsy; flu preparedness; and the next phase of action on neglected tropical diseases, as well as cross-cutting initiatives in digital health; healthy ageing; non-communicable diseases; maternal and infant nutrition.  Finally, the EB will discuss the planned follow-up to the UN High Level Meeting on Universal Health Coverage in September 2019, an ambitious global  initiative to insure that everyone worldwide can access quality healthcare by 2030, which is the flagship issue of WHO’s current administration.

The EB is comprised of the designated representatives of 34 member states; each member state is elected by the World Health Assembly to serve on the EB for a three year term. The EB’s annotated provisional agenda is available online here.

Image Credits: William New.

With the death toll from the world’s worst measles outbreak in the Democratic Republic of the Congo (DRC) now exceeding 6000, the World Health Organization (WHO) appealed to donors on Tuesday for $US 40 million more in funding to stop the advance of the disease – which has killed nearly three times as many people as the Ebola outbreak raging for more than a year.

Measles Immunization in DRC’s Kivu region

Meanwhile, Ebola, which had almost been squashed in late November, continued its resurgence, with some 29 cases reported over the last two weeks of December, according to the latest WHO disease news outbreak report. The surge in cases, which had dropped to less than ten a week, occurred in the wake of widespread civil unrest as well as targeted attacks on health workers by militias in the eastern DRC in late November and early December.

The violence interrupted community-based work to contain the epidemic in a few remaining hotspots, restricting the access of health workers to affected communities for the referral of Ebola patients to treatment centres, vaccination of contacts, and safe burials for Ebola victims.

As for measles, lack of funding remains a key barrier to curbing the outbreak, WHO said, calling on donors to step up to the bat with more contributions to measles vaccine efforts in the DRC.

Despite ramped up immunization campaigns in 2019, routine measles vaccination coverage remains low in some areas of the countries, due to weak health systems as well as the ongoing civil unrest. As evidence of that, some 25% of the reported measles cases are occurring in children over the age of five, who are the most vulnerable, said WHO.

Officials said that while $US27.6 million has been mobilized, another US$ 40 million is required for a six-month plan to extend the vaccination to children in the vulnerable age categories of six to 14 years. The plan would also reinforce elements of the outbreak response beyond vaccination, including improving treatment, health education, community engagement, health system strengthening, epidemiological surveillance and response coordination.

“We are doing our utmost to bring this epidemic under control. Yet to be truly successful we must ensure that no child faces the unnecessary risk of death from a disease that is easily preventable by a vaccine. We urge our donor partners to urgently step up their assistance,” said Dr Matshidiso Moeti, WHO Regional Director for Africa.

In 2019, around 310 000 suspected measles cases were reported. In the same year, the DRC Ministry of Health together with WHO, Gavi, the Vaccine Alliance, The European Union’s Humanitarian Aid department and other aid agencies vaccinated more than 18 million children under 5 years of age across the country.  But that has not been enough.

“We recognize the Government’s engagement in the efforts to end the outbreak and we are grateful for the generosity of our donors. But we still need to do more,” said Dr Amédée Prosper Djiguimdé, Officer in charge of WHO’s DRC office. “Thousands of Congolese families need our help to lift the burden of this prolonged epidemic from their backs. We cannot achieve this without adequate finances.”

The measles outbreak in DRC is part of a broader worldwide epidemic – which has hit poor countries where weak health systems are unable to reach vulnerable populations with immunizations, as well as more affluent countries where pockets of “vaccine resistance” exist in some communities. For a country to be safe from measles, 95% of the population must be immune, WHO says. Yet global vaccination rates have remained stagnant for the last ten years – hovering at around 10% below the recommended threshold for the first dose and 25% below the recommended level for the second dose.

Measles case distribution by month and WHO Region (2015-November 2019).

As for Ebola, the 29 latest confirmed cases were reported from eight health areas in four health zones: Mabalako (62%, n=18), Butembo (14%, n=4), Kalunguta (17%, n=5), and Katwa (7%, n=2). As of the end of 2019, a total of 3380 Ebola cases had been reported, WHO said.  This included some 3262 confirmed and 118 probable cases. Among these, 2232 people had died for an overall case fatality rate of 66%.

 

Image Credits: WHO/African Region, WHO/John Kisimir, WHO .

Chinese authorities have ruled out seasonal influenza, avian flu, adenovirus, SARS and MERS as the cause of a mysterious strain of pneumonia that has now stricken 59 people in the Chinese city of Wuhan, according to the latest data from WHO.

The unidentified virus, which has left seven people critically ill, may have emerged from the city’s large fish market, which also includes trade in exotic animals, the agency suggested.

Wuhan, China

“There is limited information to determine the overall risk of this reported cluster of pneumonia of unknown etiology. The reported link to a wholesale fish and live animal market could indicate an exposure link to animals,” stated the WHO report.

Some of the pneumonia victims were operating dealers or vendors in the Wuhan South China Seafood City, according to another report published by Chinese authorities on Friday.  The market has now been provisionally closed for hygiene and sanitation inspections.

Direct contact with animals is a common trigger for the emergence of new viruses in humans. As the infection is propagated, the virus can mutate and become transmissible from human to human, greatly increasing spread.

So far human-to-human transmission of the unidentified virus affecting Wuhan’s population has not been observed, said WHO: “Based on the preliminary information from the Chinese investigation team, no evidence of significant human-to-human transmission and no health care worker infections have been reported.”

The number of reported infections has more than doubled, however, in the week since the appearance of the pneumonia “of unknown cause” in 24 people in Wuhan was first reported to WHO by the Chinese authorities on 31 December.

There were clear concerns that the pneumonia may represent a new form of a coronavirus, which can be particularly deadly if it begins to spread from person to person, but experts said that more time was needed to identify the virus.

“I think we need to give them a couple of days but I want to hear something from a credible source on the investigations that are ongoing,” Marion Koopmans, director of the department of virology at Erasmus Medical Center in Rotterdam, the Netherlands, was quoted by STAT News as saying.

In 2002, a deadly coronavirus, severe acute respiratory syndrome coronavirus (SARS-CoV), was detected in China, after emerging from animal reservoirs such as bats to infect civet cats, which some Chinese consume, and then spreading more widely through human-to-human contact. SARS infected over 8000 people in more than two dozen countries over a period of 18 months before the epidemic was squashed. However, since that time, China’s outbreak detection and response capacity has improved considerably.

Middle East Respiratory syndrome (MERS-CoV), another deadly coronavirus strain, was first identified in Saudia Arabia in 2012 and killed some 851 of the nearly 2500 people infected with a case fatality rate of about 34%, according to WHO.

Coronaviruses consist of single-stranded of RNA genetic material; they belong to a family of viruses that infect both humans and animals.

Wuhan health authorities said that the patients’ symptoms mainly included fever, although some people had developed difficulties breahing and lesions on their lungs.  Some 120 close contacts of the pneumonia victims have been identified and placed under medical observation.  Pathogen identification and the tracing of the causes are underway, along with assessment of environmental sanitation and hygiene in the animal markets where the pneumonia is suspected to have emerged.

WHO said that it had requested more information from the Chinese authorities on laboratory tests that have so far been performed, however officials maintained an upbeat note: “Good to receive update information from #China on #pneumonia of unknown cause in Wuhan city,” declared World Health Organization Director General Dr Tedros Adhanom Ghebreyesus, in a tweet on Monday.

WHO said that it was not recommending any travel restrictions as a result of the mysterious outbreak, noting, “WHO advises against the application of any travel or trade restrictions on China based on the current information available on this event.”

Singapore and Hong Kong, however, both said that they had both set up measures to check travellers from China for signs of illness, following reports that some arrivals had displayed pneumonia-like symptoms. However, none of the suspected cases so far had been confirmed to be infected with the unidentified pneumonia strain, authorities in both cities said.

Wuhan, a city of 19 million people, is the capital of Hubei province.

 

Image Credits: Wikipedia .

[UN News] Kenya, Mozambique and Niger curbed different outbreaks of vaccine-derived poliovirus over the past 24 months which affected 14 children, said a senior WHO official on Monday.

Although wild poliovirus virus has not been detected in Africa since 2016, roughly 12 countries are currently facing outbreaks of vaccine-derived poliovirus.

© UNICEF/Claudio Fauvrelle
Mothers take their babies to receive vaccinations at a mobile unit in Molumbo district, Mozambique.

“Ending outbreaks in the three countries is proof that response activities along with high quality immunization campaigns and vigilant disease surveillance can stop the remaining outbreaks in the region”, said Dr. Modjirom Ndoutabe, coordinator of WHO-led polio outbreaks Rapid Response Team for the African Region.

“We are strongly encouraged by this achievement and determined in our efforts to see all types of polio eradicated from the continent. It is a demonstration of the commitment by governments, WHO and our partners to ensure that future generations live free of this debilitating virus”.

Polio is a highly infectious viral disease that can lead to paralysis.  It mainly affects children under five.

While there is no cure, the disease can be prevented through a simple vaccine.

Polio is transmitted from person-to-person and is spread through contact with infected faeces or, less frequently, through contaminated water or food.  The virus enters the body via the mouth and multiplies through the intestines.

“When children are immunized with the oral polio vaccine, the attenuated vaccine virus replicates in their intestines for a short time to build up the needed immunity and is then excreted in faeces into the environment where it can mutate”, Ndoutabe explained.

Vaccine-derived polioviruses are rare, according to WHO. They only emerge in areas where overall immunization rates are low and sanitation is inadequate, leading to transmission of the mutated polio virus via sources such as contaminated sewage.

Another 12 African countries continue to experience vaccine-derived polio outbreaks, including: Angola, Benin, Cameroon, Central African Republic, Chad, Côte d’Ivoire, Democratic Republic of the Congo, Ethiopia, Ghana, Nigeria, Togo and Zambia.

Weak routine vaccination coverage, vaccine refusal and difficulty in accessing some locations, are some of the risk factors behind these outbreaks, according to WHO.

 

Image Credits: © UNICEF/Claudio Fauvrelle.

The number of cholera cases decreased by 60% in 2018 compared to 2017. Cholera-endemic countries such as Haiti, Somalia, and the Democratic Republic of the Congo saw some of the highest reductions.

Cholera vaccination in Nigeria

“The decrease we are seeing in several major cholera-endemic countries demonstrates the increased engagement of countries in global efforts to slow and prevent cholera outbreaks and shows the vital role of mass cholera vaccination campaigns,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a press release. “The long-term solution for ending cholera lies in increasing access to clean drinking water and providing adequate sanitation and hygiene.”

There were 499,447 reported cases and 2990 deaths in 2018, significantly lower than the 1.2 million cases and 5654 deaths reported in 2017. The country most affected by the ongoing cholera pandemic continues to be Yemen, which reported 128,121 cases and 2485 deaths in 2018, according to data collected by WHO.

However, several cholera-endemic countries saw dramatic decreases in the number of cases – including Haiti, Somalia, DRC, Zambia, South Sudan, United Republic of Tanzania, Somalia, Bangladesh, and Nigeria – thanks to the implementation of new national action plans for cholera control.

“The global decrease in case numbers we are observing appears to be linked to large-scale vaccination campaigns and countries beginning to adopt the Global Roadmap to 2030 strategy in their national cholera action plans,” said Dr Dominique Legros, head of WHO’s cholera programme in Geneva.

“We must continue to strengthen our efforts to engage all cholera-endemic countries in this global strategy to eliminate cholera.”

Nearly 18 million doses of Oral Cholera Vaccine (OCV) were shipped to 11 countries in 2018, financed in part by Gavi, the Vaccine Alliance. However, experts at WHO say that vaccination must be supplemented with efforts to improve access to clean water and sanitation. Vibro cholerae, the bacterium that causes the acute diarrhoeal infection, breeds in contaminated food and water.

Mass vaccination and water and sanitation interventions are recommended as part of the Global Roadmap strategy, which provides a three-pillar framework for national action plans focusing on:

  • Early detection and rapid response to contain outbreaks
  • A multisectoral approach integrating strengthened surveillance, vaccination, community mobilization, and water, sanitation and hygiene to prevent cholera in hotspots in endemic countries
  • An effective mechanism of coordination for technical support, resource mobilization and partnership at the local and global levels.

Image Credits: WHO.