Nurses preparing a diagnostic test for COVID-19 at a “drive-through” testing center at University of Washington Northwest Hospital & Medical Center

As the COVID-19 crisis seeps into financial markets, corporate board rooms, and global health systems, there may be one silver lining in an otherwise dark cloud.

The 21st century era of digital health, virtual meetings and teleworking is upon us.

Countries as far-flung as the Republic of Korea, Israel and even some forward-looking US health care providers are rushing to adopt tele-health, mobile health and AI solutions to protect their front-line health workers from COVID-19 infection.

Meanwhile in Geneva’s global health policy hub, institutions large and small, including Gavi, The Vaccine Alliance; The Global Fund; The International Committee of the Red Cross; and Medicines for Malaria Venture (MMV), are rapidly shifting into the virtual world of teleworking and video conferencing to keep operations going smoothly.

For others, however, change is at a slower pace, and more painfully reached.

Although the World Health Organization has long been outspoken about the benefits of telemedicine, in the case of virtual meetings and teleworking the Organization has been slower to adopt new practices, its critics say.

It’s also starting from a very low baseline. In 2018, WHO’s carbon footprint, mostly due to travel, was the second highest in the UN system, exceeded only by the World Meteorological Organization.  Its staff teleworking policies, limited to 4 days a month and subject to a paper chain of bureaucratic approvals, are among the most restrictive in the UN system.

But as COVID-19 cases explode across Europe, including in Switzerland, where the first infection of a staff member in a UN-affiliate, The World Trade Organization, was announced on Tuesday, the events on the ground are driving ever more rapid change.

After MMV reported to staff about a “probable COVID-19 case” over the weekend, all staff immediately shifted to teleworking on Monday.

In an internal message to staff on Tuesday, WHO said that to protect its headquarters operations, all external meetings would be cancelled, visitor access restricted, and a transition to virtual meetings accelerated. But the agency has so far held back on any dramatic expansion of  teleworking – saying only that current policies would now be relaxed for staff with confirmed “pre-existing medical conditions”.

Despite such hiccups, some global health influencers have dared to say that a faster shift to virtual channels could be a faint silver lining in the COVID-19 clouds.

“This *could* be the moment when we collectively finally crack videoconferencing on a mass scale, for good,” Wellcome Trust’s Director of Strategy, Ed Whiting, tweeted after the World Bank announced it would shift its annual Spring Meetings to virtual channels.

Can health policy institutions and the systems that they guide and manage use this crisis to make some leapfrog improvements in the use of digital technologies to better protect health workers and patients, slow infection transmission, and also make operations more efficient?

Here’s a rundown of scenes from a fast-changing landscape in hospitals, health clinics and head offices.

A nurse deposits a COVID-19 swab taken from a patient at a “drive-through” COVID-19 testing center at the University of Washington Northwest Hospital & Medical Center

Boosting PPE With Virtual Technologies  

Equipping health workers in countries worldwide with personal protective equipment (PPE) to protect them from the highly infectious virus has been a key priority for WHO since the new coronavirus first became a threat at ground zero, in Wuhan, China. Hundreds of thousands of PPE kits were distributed across China and rushed by WHO to countries around the world – although working in cramped, crowded conditions, health workers still often became exposed.

With just a few weeks of experience behind them, some countries, from Korea to Israel and forward-looking hospitals in the United States are experimenting with creative ways to test, triage and treat coronavirus patients while reducing those exposure risks.

Korea has received acclaim for its “drive-in” testing centers where patients can be tested with a nose swab in their cars – making the vehicle a kind of “isolation chamber” and protecting health workers as well as others waiting for similar tests.

The testing model is proving to be contagious in the United States, which invented the drive-in burger bar, after all.

The first American drive-in testing clinic was piloted at the University of Washington’s Northwest Hospital and Medical Center, a state where a large cluster of cases has emerged. Colorado, another outbreak area, soon followed suit. It opened a drive-through testing center on Wednesday. And Connecticut is now experimenting with the same approach too, reports the Science journal, The Verge.

It remains to be seen how fast the trends will be picked up by other US states, where test shortages and rigid protocols have triggered horror stories about the hurdles some people had to face, just to get tested, while also spending time emergency rooms or health clinics where others could easily be infected.

In Israel, meanwhile, people who suspect that they have the virus don’t go leave their home at all. They call a special emergency number, and a mobile unit visits to administer a swab. That has helped give Israel one of the highest testing rates in the world (401 tests/million), outside of Korea (3,692 tests/million), and Italy (826 tests/million), and Guangdong, China (2,820). It has also kept the number of infections down to about one-eighth of those in Switzerland, a country that has roughly the same number of people spread over twice the land area and is limiting its testing to severely ill patients or those with pre-existing conditions.

Health care staff interact with patients via a robot at Sheba Medical Centre.

At Sheba Medical Centre, in the city of Ramat Gan, doctors and nurses are performing basic checks on hospitalized COVID-19 patients via a robot, to reduce the threat of contagion.  One of the first patients to be hospitalized there after returning from a trip to Italy described it as a “Back to the Future” experience.

The robot can monitor lung function with a stethoscope, said Dr. Galia Barkai, head of Sheba’s Telemed Services. Added Eyal Leshem, director of Sheba’s Travel Medicine and Tropical Diseases unit, and a former scientist at the US Centres for Disease Control: “The robot moves has the capability to reduce the most fearful thing about this disease in health care facilities, which is nosocomial transmission,” Leshem said in an interview with Health Policy Watch.

Patients who are not sick enough to be hospitalized, are given a tiny handheld medical device called a Tyto to take home. It allows a medical professional to remotely check the patient’s lung function, throat, heart rate, temperature, and other vital signs, notes al Leshem, head of the hospital’s Travel and Tropical Medicine Centre.

Checking a child’s temperature at home with a remote Tyto monitor.

“We can monitor vital signs, such as temperature, and then talk with them on a secure telemedicine application,” Leshem said. “We can also save a lot of the unnecessary travel as well as contact with health care workers, which is also a source of a lot of nosocomial infections.”

On the other side of the ocean, meanwhile, the crisis may also be providing a boost to virtual delivery of more routine health care services – to keep uninfected patients away from crowded hospitals or clinics where they could catch COVID-19.

In a landmark measure approved last week by the US Congress, Medicare, the universal federal health insurance system for older Americans, will be allowed to reimburse clients living in COVID-19 outbreak areas for telehealth consultations with their regular care providers.

The decision, part of a US$8.3 billion emergency funding bill, was hailed by telehealth advocates as an important breakthrough in a country where growth in telehealth services has been constrained by Medicare rules that, until now, strictly limited telehealth service reimbursements to people in remote rural areas.

“During these types of outbreaks, you really don’t want to go where people are sick,” Rusty Hofmann, medical director of digital health care integration at Stanford University School of Medicine, told the The Verge. Although, he warned that the new provisions should be expanded further so such reimbursement is not only limited to a patient’s pre-existing health care providers.

The US administration is also said to be looking at ways to develop home-based COVID-19 testing solutions. “When we think of telemedicine and home testing, it reduces the risks, and makes it easier,” particularly for older Americans, who are among those most at risk, said Seema Verma, head of the US Medicare programme, at a televised meeting Tuesday between US President Donald Trump and major health insurance providers.

Virtual Meetings – Reducing the Footprint of COVID-19 & Carbon Emissions  

When the World Bank announced on March 4 that it would put its annual Spring Meetings, which draw tens of thousands of people to Washington DC every year, on a virtual footing, Whiting in a Tweet filled with emojis of airplanes and trees, said “Bring it. Interested how tech steps up.”

On it came. Just two days later, Friday 6 March, the Secretariat of the United Nations Framework Convention on Climate Change (UNFCC) cancelled its planned March-April rounds of negotiations in Bonn. In Geneva, parallel sessions and side events around the annual UN Human Rights Council meeting, which would normally draw hundreds of people to the city, were also cancelled. And Swiss authorities announced that they would also forbid any mass gatherings of more than 1000 people throughout the country.

Despite the ominous signs, in a WHO press briefing on the same Friday, WHO Director General Dr Tedros Adhanom Ghebreyesus refused to speculate about whether the world’s signature global health event, The World Health Assembly might have to shift to a virtual footing if it convenes at the scheduled dates in late May.

He said that virtual meetings should be encouraged to reduce costs and climate emissions, but decisions “should be made not because of COVID now, but when there is no COVID as well.”

Against the mounting tide of Swiss COVID-19 cases, which on Thursday stood at 868 cases and four deaths, a new order by Swiss authorities limiting meetings to under 100 participants seems likely to dramatically change the shape of how the WHO does business in the coming months.

In the internal memo sent out to WHO staff Tuesday evening, a rapid scale-up of virtual meetings was promised to offset the cancellation of all meetings at Headquarters with external experts and partners.

“To support these changes in our ways of working, steps have been taken to increase our bandwidth to accommodate the expected increase in virtual meetings,” said the note to all WHO Headquarters staff.  “In order for the Organization to fully implement virtual solutions, additional support in setting up virtual meetings and relevant training will be provided.”

Some WHO insiders, who have been pressing for years for such changes, see it as none too soon.

With 13.7 tons of CO2-equivalent emissions (tCO2-eq) per capita, WHO’s carbon footprint is the second largest across some 50 UN agencies and affiliates, exceeded only by the WMO footprint (16.4 tCO2-eq) per capita, according to the 2019 report of the UN Greening the Blue initiative.

Some 90% of WHO’s carbon emissions  or 12.64 (tCO2-eq) was attributable to air travel in 2018 – a more than 50% increase over emissions from the year before, of just 8 (tCO2-eq), WHO’s own emissions inventory available on the Greening The Blue website.

There are strong arguments that periodic face-to-face meetings are critical to build trust and facilitate collaboration between professionals from vastly different countries and institutional cultures. But critics say WHO has lagged for years on investments in stronger videoconference facilities that would save costs and carbon – and this will jump start the process.

“It’s true that you can’t have hallway discussions, that is correct,” said one WHO scientist, who asked to remain anonymous. “But how much do hallway discussions contribute in comparison to the damage that you are doing to the climate?

“In the 1960s, when telephones were first installed in homes, they were put high up on the wall. You could only talk standing up, and that meant passing on a short message. Today,  we have a completely different attitude towards the phone. So, I think it is for the most part it’s an attitude problem.”

Teleworking   

Teleworking is another area in which attitudes are now changing rapidly.

Staff at The Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi-the Vaccine Alliance, the two giant public-private partnerships founded two decades ago by the Bill and Melinda Gates Foundation, have been teleworking one or two days a week for some years already.

As the COVID-19 outbreak began to amplify, The Global Fund administration asked its IT consultants to build a scenario in which all staff would be teleworking. Today, after weeks of trial runs at team level, an organization-wide drill of teleworking procedures will be conducted, said Melanie Brooks, Editorial Team Manager.

“Technology is increasingly playing a part in our ability to work effectively in the building. We are providing regular guidance to staff for teleworking, including Q&As, tips for effective working from home, and training on our remote-working teleconferencing system,” said Brooks.

“To ensure our organizational readiness to be able to react to the developing COVID-19 coronavirus situation, this Thursday morning, 12 March, we are undertaking an organization-wide trial of our home-working capabilities. All staff, consultants and interns are required to work normally, but from home, before coming back to the office for the afternoon, from 13.00. Following the successful testing of our offsite working… last week, this Thursday’s exercise will enable us to more fully assess both our system and individual capacity to work effectively from home.”

Gavi, The Vaccine Alliance, which shares The Global Fund campus, right down the street from WHO, has a less formalized teleworking policy, said spokeswoman Frederique Tissandier. But the overall result is almost the same. Already for the past several weeks, employees have been instructed to back up, and take home their laptop computers…. Just in case.

“The approach is to be mindful of our colleagues and the campus. If someone suspects that they are ill, he is free to stay home, to go home, to work from home and quarantine himself automatically and there will be no questions asked,” she said.

Regular teleworking options have been “standard policy,” at MMV for some time, added Dr David Reddy, MMV’s CEO, whose offices are located in a busy hotel complex near Geneva Airport. On Monday, following a report of a “probable case” among a staff member, MMV shifted to a mandatory teleworking protocol for everyone.

“As part of our COVID-19 preparedness plans that we put into place two weeks ago, we then determined two probable scenarios that would lead to flex in that policy,” he said. “First, in a bid to reduce possible transmission, those employees who wished to do so, could work from home full-time for the immediate future.  Second, as the situation evolved with a probable case among our team over the weekend, we implemented mandatory working from home as of Monday.”

Back at WHO, however, teleworking remains limited to 4 days a month. In order to have a request approved, a staff member has to print out a hard copy form, fill it out and have it signed by a supervisor, then scan it, and then send it to half a dozen other emails – in advance of the planned teleworking days.

WHO’s Staff Association has long complained that WHO’s practice is out of line with broader UN policies on Flexible Working Arrangements, which allows teleworking for up to two days a week, in line with two  UN General Assembly member state resolutions supporting a more  “flexible workforce.”

When Dr. Tedros took the helm of the organization in 2017, WHO’s Staff Association attempted to gain his support for a more flexible policy, arguing among others things, it would “help business continuity in case of a pandemic or natural disaster and enable the workforce to work from outside the premises,” according a message shared by multiple WHO staff, who requested confidentiality.  

A 2019 WHO Staff Association message to the WHO Executive Board publicly called for the standard UN policies to replace the existing WHO provisions. But it was never adopted.

On Tuesday, WHO announced more flexibility for with “pre-existing medical conditions” to request broader teleworking privileges for a time-limited period, through the Staff Health and Wellness Services.

“Medical evidence, which will remain fully confidential, will need to be subsequently provided in support of these measures. The recommended duration of teleworking will be determined on the basis of the evolving epidemiological situation and risk in the community,” stated the message. The announcement hinted that more changes might be on the horizon, but didn’t say what:  “Additional general guidance on teleworking arrangements will be issued in the next update.”

Current policies, staff complain, are contradictory with WHO’s Global Influenza’s Programme Guidelines on pandemic and epidemic influenza measures that company’s can take. Those guidelines recommend the adoption of telecommuting and staggered hours saying that it was associated with a median 23% percent reduction in infection incidence – although the recommendation is framed as “conditional” due to the dearth of controlled bio-medical studies

Now that theory has become reality, staff are worried that the current policy makes it almost impossible for them to use teleworking measures to work from home preemptively, in case they feel just a bit ill, or have returned recently from travel. And that forces them to face a hard choice – take a sick day or go to work and risk infecting others. Older staff, who may be healthy but still at risk, due to their age, are also exposed.

Said one senior staff member, who asked not to be named: “We still have a teleworking policy that requires a physical signature. So  if I do decide I have a cold or want to stay home, I still have to go to the office, print out the form, fill out the form, get it signed, and send it to 7 people, and spread the virus in the meanwhile. Or I stay home, and then I waste a vacation day, or I waste public health resources going to a doctor, saying I need a sick certificate.

“I know there are efforts ongoing in WHO to make us technically fit for teleworking. My guess is that they will start an up-to-date and public health appropriate teleworking policy, when either the Swiss government requires it, or when we have proof of WHO inter-office transmission – and then the baby will have already fallen out of the bath.”

Updated 12 March 2020

Image Credits: University of Washington Northwest Hospital & Medical Center, TytoCare , https://www.greeningtheblue.org/.

Iranian healthcare workers in personal protective equipment

As cases of COVID-19 surpassed 120,000 around the world, the World Health Organization on Wednesday declared a pandemic – a move the organization stressed was intended to “trigger” even more aggressive action from governments against the virus rather than surrender to its rapid spread.

In line with current trends, numbers of COVID-19 cases, deaths and number of affected countries will “climb even higher,” Dr Tedros Adhanom Ghebreyesus warned on Wednesday, before they decline.

However, WHO sees this as a “call to action” to spur countries to scale up efforts to contain the virus and slow the spread, and prepare their health systems for an influx of patients, said WHO’s Head of Emergencies Mike Ryan.

“Declaration of a pandemic is not an “escape clause” to mitigation – a strategy focused only on saving lives when uncontrollable spread of a disease is inevitable, Ryan said. “There is a strong element of controllability in this disease.…We have a real chance to bend the curve – and give the health system a chance to save more lives.”

Dr Tedros added that the dramatic decline in new cases in certain countries, and the low numbers of cases in others means that governments still have the chance to stop the virus from spreading further.

“Eighty-one countries have no cases – they should not give any ground for this virus to set foot in their country. Fifty-seven countries have less than 10 cases – they can cut it from the bud,” he said.

‘Bending the Curve’ of Rising COVID-19 Cases

The Republic of Korea has already ‘bent the curve’  of the epidemic with an aggressive testing and containment strategy. In what was two weeks ago the largest outbreak outside of China, the daily new case count has fallen to approximately 30 – 40 per day compared to a peak of over 500 a day just last week.

Increasingly governments across the WHO European region are taking an iron fist to the virus as well, replicating tracts that have succeeded in China, Singapore and the Korea. Italy has locked down the entire country; school classes and mass gatherings across France and Germany are suspended. In Spain – now the country in Europe most affected outside of Italy – daycare centers and schools in key affected areas are closed, flights between Italy and Spain are suspended, and large sporting events have been cancelled.

In the most assertive preemptive moves so far outside of China and the Republic of Korea, Israel announced this week that it will place all Israeli citizens re-entering the country under 14 days of self-quarantine regardless of where they are coming from, and bar the entry of foreign tourists altogether.  So far Israel has reported just 76 cases, mostly among Israelis or tourists arriving from abroad, while there are 26 cases in the Israeli-occupied Palestinian territories; In contrast, Switzerland, a country of approximately the same size, now has 645 people who have tested positive.

Meanwhile, WHO was recommending that countries around the world take a ‘blended’ approach to the battle against the virus – bolstering the capacity of hospitals and health care facilities to prepare for a surge in patients while at the same time, continuing to make containment “the major pillar” of the response, said Tedros.

The trade-offs are challenging. Tracking down contacts of cases and enforcing quarantine measures to slow down transmission of the virus could slow the surge of patients that require hospital care. At the same time, they can be complex and costly to carry out.

“The difficulty is that if you do not try to suppress this, it could be very straining to your health system,” said Ryan. In Italy, for example, some 900 patients were have been hospitalized within intensive care units, who also need to be continuously monitored by health workers wearing full protective gear.

“We’ve had lots of people talking about containment vs mitigation – countries should focus on containing where there is opportunity, and preparing the health system to reduce the impact,” said Ryan.

“There’s a shortage of ventilators, a shortage of oxygen… ” he added, noting that “the caseload, the demand on the healthcare workers, and the risks that come with the fatigue and the shortage of personal protective equipment,” are overwhelming for health systems,  said Ryan. “We need to focus on getting them equipment, supplies, and the training that they need to do the job.

Pandemic Spread; Active Cases Worldwide

European Countries Declaring Emergencies – But Responses Still Lagging Behind Outbreak Curve

European governments are enacting emergency executive powers as the outbreak explodes across the continent – just days after the Prime Minister of Italy locked down the country, applying travel restrictions on its citizens that were unprecedented since the end of World War II.

Along with Italy, Switzerland, Spain, and Israel have activated national emergency rules, which allow federal powers to control aspects of daily life in order to slow the spread of COVID-19.

Spain, which is now the country with the fifth highest number of cases, has taken a “whole of society approach” to the virus – all schools, daycares and university classes are suspended in La Rioja, Basque, and Madrid, while the national government shut down all flights to Italy and canceled sporting events.

Even so, those measures may not be sufficient, Ryan warned, saying: “Countries in the EU and Western Europe should assess whether efforts are good enough to suppress the virus.”

As of noon Wednesday, 645 people in Switzerland have tested positive for the disease, and events of more than 100 people were banned by Swiss Government authorities – striking at the core of Geneva’s economy, host to dozens of UN agencies, the world’s largest global health hub, and among the world’s most popular venues for related international events..

As the case count crept higher, Geneva’s UN agencies and affiliates, as well as other global health and development organizations and non-profits, rolled out aggressive screening measures, policies on telecommuting, and new protocols for potentially sick employees.

Shortage of Hospital Equipment In Iran

Meanwhile in Iran, local and central governments have improved coordination of COVID-19 efforts, said Ryan.

Schools and universities across the country are closed until after Nowruz, the Iranian New Year that falls this year on 20 March. Opening hours of large tourist attractions have been limited, and checkpoints have been established in major cities such as Tehran according to the official state news agency IRNA.

Right now, “the concern is a shortage of ventilators and oxygen” for treating severe cases, said Ryan.

“We’ve seen this in Italy. What happens at this stage is that it generates a lot of cases, that requires a huge effort by health workers,” he added.

Data from The WHO-China Joint Commission report on COVID-19 showed that approximately 14-20% of critical or severe cases will require hospitalization. Patients can require ventilator support for more than two weeks, and must be attended by at least two healthcare workers wearing full personal protective gear at all times.

WHO and China are still supplying the country with diagnostic supplies and protective equipment. WHO shipped 140,000 diagnostic tests to Iran today, following a shipment of 7 tons of personal protective equipment along with other outbreak response supplies sent last week.

Iranian officials are now aggressively tracing contacts and testing suspect cases, as the outbreak escalated to 9000 total cases and reached the highest echelons of government. Some 24 Iranian government officials and Members of Parliament have died from the disease, and many are reportedly ill.

According to Al Jazeera more than 70,000 prisoners were released following reports of a COVID-19 cases in overcrowded prisons with inadequate isolation facilities. Those sentenced for less than five years for non-violent crimes are subject to release.

Image Credits: Twitter: @WHOEMRO.

Electron microscope image of SARS-CoV-2— the virus that causes COVID-19—isolated from a patient in the U.S. Virus particles shown in red with their signature “crown-like” spikes in green.

The Bill and Melinda Gates Foundation, Wellcome Trust, and Mastercard on Tuesday announced a US $125 million commitment of seed funding to a new COVID-19 Treatment Accelerator – whose aim as its name implies, will be to speed up the development of urgently needed drugs to treat people infected with COVID-19.

Just hours later, the Coalition for Epidemic Preparedness Innovations (CEPI), which is engaged in a similar race for new vaccines, announced a $4.4 million investment to advance preclinical and Phase 1 trials of two of the most promising vaccine candidates that it has identified.

As cases shot up in Italy to over 10,000, spurring a nation-wide lockdown; and US Centres for Disease Control officials warned the US public to prepare to move into the “mitigation phase,” of reducing the worst consequences of the disease – rather than containing it, these ‘sister’ initiatives reflect how the global R&D community is racing against time to find game-changing drugs and vaccines. 

The downside, however is this. Neither initiative has enough funding right now to fully finance a drug or vaccine to from end-to-end.

CEPI issued a statement warning that it lacks financial resources needed to continue the next steps in the development process and “deliver the vaccines the world needs.”

Trevor Mundel, president of the Gates Foundation, told STAT News that there is not enough funding for the COVID-19 Treatment Accelerator to take a one all the way from discovery to disbursement into providers’ hands.

Even if new treatments and vaccines are successfully developed, some infectious disease experts worry that the biggest barrier may be scaling up manufacturing capacity of an approved product.

Normally, drugs get stuck in a regulatory bottleneck waiting for approval from agencies like the US Food and Drug Administration (US FDA), Stephen Morse, professor of Infectious Disease Epidemiology at Columbia’s Mailman School of Public Health, told Health Policy Watch.

But this time, he said, “the problem isn’t going to be FDA approval… they’re going to put this on a fast track, they want to have this quickly.

“In this case… the rate-limiting step is producing enough of [a vaccine] in time,” he said. Only “a handful” of large pharma companies have the capacity to produce the quantities of vaccines that would be needed to protect entire populations against the disease – which has infected more than 118,000 worldwide as of Tuesday night.

Out of some 50 different COVID-19 vaccine development programs, only two vaccine candidates are housed by large, multinational pharma companies according to a round-up by Biocentury. The others are being developed by small biopharma companies or academic institutions – the types of organizations which Morse says do not have the manufacturing capacity to scale production by themselves.

New Funding for COVID-19 Treatment Accelerator 

The US $125 million infusion into COVID-19 treatment research will still be able to help push forward treatment candidates stuck at certain stages of development.

“Viruses like COVID-19 spread rapidly, but the development of vaccines and treatments to stop them moves slowly,” said Mark Suzman, chief executive officer of the Bill & Melinda Gates Foundation in a press release.

“If we want to make the world safe from outbreaks like COVID-19, particularly for those most vulnerable, then we need to find a way to make research and development move faster.”

Modeled after CEPI’s vaccine development platform, the new COVID-19 Treatment Accelerator offers funding at all stages of development – including identification of drug candidates, clinical trials, and working with regulators and manufacturers to bring a treatment to patients.

More than 300 trials on COVID-19 are currently registered with WHO’s International Clinical Trial Registry with at least 15 trials testing antiviral treatments, and no treatments have so far been approved. With the abundance of treatment candidates, WHO officials have said they are nailing down a system for prioritizing clinical trials for the most promising treatments.

Many collaborations across borders have been forged. Sixthtone reported that some 60% of academic papers on potential treatments were rapidly disseminated through open-access pre-print servers such as MedRxiv, which allowed researchers to share key findings and exchange knowledge before going through long peer review processes.

“Science is moving at a phenomenal pace against COVID-19, but to get ahead of this epidemic we need greater investment and to ensure research coordination,” said Jeremy Farrar, director of Wellcome.

“The Therapeutics Accelerator will allow us to do this for potential treatments with support for research, development, assessment, and manufacturing. COVID-19 is an extremely challenging virus, but we’ve proved that through collaborating across borders we can tackle emerging infectious diseases.”

The Gates Foundation and Wellcome are each contributing up to $50 million, and the Mastercard Impact Fund has committed up to $25 million to catalyze the initial work of the accelerator.

CEPI Announces US $4.4 Million Investment In Two New Vaccine Candidates, Asks For Additional Funding

CEPI’s additional US $4.4 million investment announced today would fund Phase 1 trials for a COVID-19 vaccine candidate currently in the pipeline of the pharma company, Novavax, along with the preclinical and Phase 1 safety trials of a potential vaccine developed by the University of Oxford. The two new commitments bring the total number of candidates in CEPI’s portfolio to six.

Novavax, a company that has previously conducted vaccines research into MERS and SARS coronaviruses, is using a proprietary technology to create a vaccine that targets the signature (S) spike protein on the surface of SARS-CoV-2 – the coronavirus that causes COVID-19.

The University of Oxford is working on a COVID-19 vaccine using a simian adenoviral vaccine vector, which has been used as a delivery vehicle in vaccines for other viruses like MERS, Nipah, and Influenza.

However, the organization says that donors need to step up funding to help finance the COVID-19 vaccine projects to completion.

Without “immediate additional financial contributions,” the vaccine programs CEPI has begun will “not be able to progress and ultimately will not deliver the vaccines that the world needs,” the organization warned in the press release announcing the new investments.

“Vaccine development is complex and difficult and will require concerted global effort,”  said CEO of CEPI Richard Hatchett. He clarified CEPI was investing in a variety of different options in order to maintain a “balanced portfolio” and “ensure multiple shots on goal.”

“There are no guarantees of success, but we are working as fast and as hard as we can,”  he added, but the organization hopes to deliver a safe and efficacious vaccine for broader use within the next 12-18 months.

The commitments resulted from submissions made to a global call for proposals that CEPI issued in early February, which invited funding applications for proven vaccine technology that could be used to rapidly develop a vaccine against the new coronavirus. Most importantly, the new vaccine must be able to be manufactured at scale and with the necessary equitable access provisions.

The two new investments join the CEPI-funded COVID-19 vaccine development initiatives by Inovio Pharmaceuticals, Moderna and the US National Institutes of Health, Curevac Inc., and the University of Queensland.

Image Credits: NIAID-RML.

The World Trade Organization’s director general Roberto Azevêdo announced on Tuesday that he was suspending all WTO meetings at its Geneva offices, following the confirmation of a COVID-19 case among staff. It was the first publicly-announced case of the novel coronavirus infection at a Geneva-based United Nations or UN-affiliated organization since the epidemic began, which has seen a the recent acceleration of reported cases in Switzerland.

Meanwhile, in a late-night internal circular, the World Health Organization told its Geneva staff that meetings with external participants would also be cancelled until 15 April, Health Policy Watch learned. WHO also announced a series of dramatic new measures to protect staff and the headquarters’ work premises from infection, including:

  • Self-monitoring by staff of their health status (e.g. temperature, cough) before coming to work;
  • Installation of thermoscanners in WHO’s two main entrances (i.e. Main entrance and D-Building);
  • Establishment of isolation areas;
  • Restriction of visitor access to the premises, and access to other doors to emergency staff;
  • Ramping up of virtual meetings, with technologies and support.

The circular said that while there had not been any confirmed COVID-19 cases in the building, the measures were being taken to proactively “to protect Staff as well as the working environment here at headquarters.”

In a press release posted on the WTO website this evening, Director-General Roberto Azevêdo said that he had informed WTO members that, as of 11 March, all meetings at the WTO will be suspended until 20 March. “The decision follows confirmation that one WTO staff member has contracted the COVID-19 virus,” the press release stated.

“We take the health of Secretariat staff and our members very seriously which is why we have taken this unprecedented step,” Azevêdo was quoted as saying. “We are monitoring the situation very closely and will take whatever measures are necessary to protect health and safety. We will monitor the situation constantly and review this decision before the end of next week.”

The WTO has a coronavirus Task Force in place.  In addition, WTO has been coordinating with other UN organizations in Geneva around the COVID-19 crisis, spokesman Daniel Pruzin told Health Policy Watch.

“I can tell you that we have an interagency network in place to monitor and respond to the coronavirus outbreak and that we are in very good contact with the network,” he said.

While not a United Nations or UN specialized agency, as such, the WTO sits on the United Nations Chief Executive Board (CEB), and is therefore part of the constellation of UN agencies, and global health and development NGOs that make up the hub of so-called “International Geneva.”

WHO did not respond last night to Health Policy Watch queries about new protocols for staff safety at its building, or about measures being taken elsewhere in Geneva’s UN system.

A WHO spokesman said only that: “The UN activated a Crisis Management Team (CMT) on the COVID-19 outbreak, led by Dr Mike Ryan, Executive Director of WHO Health Emergencies Programme as the Crisis Manager. The CMT brings together WHO, OCHA, IMO (International Maritime Organization), UNICEF, ICAO, WFP, FAO, the World Bank and others UN entities.”

As of noon Tuesday, some 476 COVID-19 cases had been reported in Switzerland by the Federal Office of Public Health.

New Infections in Italy, Switzerland and Europe Surging – But Republic of Korea Sees Dramatic Reductions 

COVID-19 cases began to spill over into Switzerland over the past week, largely as a result of the traffic between Italy and southern Switzerland’s Italian speaking Ticino region, where many people have work, study and family ties. Infections have gradually spread out throughout the country, including potential clusters of community transmission in Geneva as well as other expanding disease clusters in the Zurich area.

Over the past 24 hours nearly 100 new infections were reported in Switzerland – an increase of about 25%.  France also saw cases rising by about 30% in the last 24 hours to a total of 1,606 reported cases on Tuesday evening.

On Saturday, an employee of the European Organization for Nuclear Research, CERN, which is based just over the Geneva border in nearby France, was also reported to be infected.

“The infected person was in close contact with a small number of colleagues. In accordance with procedures put in place in collaboration with its Host State expert authorities, CERN has implemented measures to quickly identify potential cases and limit the risk of infection on the CERN site,” a press release stated. The agency has suspended all work-related travel for employees, although it continues to host meetings onsite, however, of less than 100 people.

As cases in the UK rose to 382 total, British Health Minister Nadine Dorries announced she tested positive for the coronavirus Tuesday night. Dorries tweeted she was self-quarantining at home with her 84-year old mother – who had just began to cough and is getting tested tomorrow.

In Germany, the increase was more moderate with only about 130 new cases, for a total of 1,281.  Inconsistencies in testing protocols across Europe leave considerable uncertainty about what proportion of cases are actually being identified and reported, although it appears clear that patterns of community-wide transmission are now occurring in all three countries.

Latest COVID-19 data according to Johns Hopkins CSSE as of 6:53PM CET 10 March (1:53PM EST)- Note numbers are changing rapidly, this map has not been updated with the latest Switzerland cases.

In Italy on Tuesday, there were now 10,149 COVID-19 cases, an increase of nearly 3,000 infections over the day before, when the entire country went under lockdown by order of Prime Minister Giuseppe Conte. However in the Republic of Korea, only 35 new cases were recorded overnight, a striking indication that with tough measures, the epidemic could be brought under control.

In Iran, while reported infections still increased by nearly 1,000, that was a slower pace than in days before, offering some hope that the Islamic Republic might soon turn the corner on the epidemic as well.  Globally, there were now over 118,000 cases in 113 countries and self-administered territories.

Some 45 countries have enacted some form of travel restriction on entering and leaving the country. As virus transmission shifts to other global hotspots, more restrictions are being enacted on people transiting from outside of China such as Italy, Iran, S. Korea, Japan, and the United States.

In China, the number of new cases has slowed dramatically to only 20 in the past 24 hours. However, 17 new deaths were reported, indicating that some patients had died even after a long period of hospitalization.

Image Credits: Johns Hopkins CSSE.

Men are more likely to suffer ill-health than women. (Photo Credit: Micha Serra for Global Health 50/50 ‘This is Gender’ Competition)

As the governments around the world struggle to control surging COVID-19 outbreaks, health experts highlighted cracks in global health systems that created conditions ripe for the pandemic.

A report titled Power, Privilege & Priorities released Monday by Global Health 50/50 found that an inequality of health benefits and an inequality of opportunities inside organizations have created a system where the priorities of the biggest global health organizations failed to prioritize gender equality and the most common causes of death and ill-health, leading to weak health systems around the world.

“The world’s attention now is on looking after people at immediate risk, and controlling the spread. This is an extreme pressure on an already-ill-equipped global health system. An escalation of the epidemic is inevitable,” Kent Buse, co-founder of Global Health 50/50 and chief of Strategic Policy Direction at UNAIDS told Health Policy Watch.

“If we continue to apply a gender-blind approach to healthcare I am afraid we will see additional global healthcare crises in the future.”

In the context of COVID-19, the stark gender disparity in mortality rates is an example of how a history of “gender-blind” approaches in global health have contributed to the current crisis, according to Sarah Hawkes, co-founder of Global Health 50/50 and director of University College London’s Centre for Gender and Global Health. In the WHO-China Joint Mission on COVID-19 Report, the case fatality rate in men is reported as nearly double that in women – 4.7% compared to 2.8%.

“We have to ask why more men in China are dying from the COVID-19 virus than women. Why are men more at risk?” questioned Hawkes. “Put simply, men are less healthy than women and we know that people with existing ill health are more at risk of dying.”

“While we don’t have the full picture, we know that within the affected regions more men smoke and hence there may be more men with cardiovascular disease and other non-communicable diseases than women.”

According to the WHO report, the case-fatality rate was much higher for people with pre-existing non-communicable diseases (NCDs) – hovering around 13.2% for those with cardiovascular disease, 9.2% for diabetes, 8.4% for hypertension, 8.0% for chronic respiratory disease, and 7.6% for cancer.

Men have higher rates of harmful use of alcohol, tobacco use, and substance abuse, which are all contributing causes of NCDs, said Hawkes.

Yet, the Global Health 50/50 report found that two-thirds of global health funders and philanthropies do not address NCDs, and the vast majority of organizations do not make distinctions between the health-related risks of women and men – particularly for alcohol, tobacco, and substance abuse.

This “gender-blind” approach to health means that “decision making is often focused on politics rather than on people’s need,” said Hawkes.

“We see the consequence of these as contributory factors to the current crisis.”

Inequality in Global Governance as Other “Cracks in the System”

Along with highlighting the systematic neglect of certain health conditions, the Global Health 50/50 report found that a high number of organizations still do not balance gender in senior leadership roles, and people from low- or middle-income countries are barred from the highest echelons of major global health organizations, despite the majority of global health work happening in those countries.

In a review released on the tail of International Women’s Day that covered 200 organizations across 10 different health-related sectors, the report found that more than 70% of the chief executives and chairs of boards are men, while only 5% are women from low- and middle-income countries. Women continued to be barred from higher leadership positions – with the proportion of women board chairs growing only from 20% to 26% in the past two years.

Over 80% of leaders in these global health organizations are nationals of high-income countries, and over 90% among those in leadership roles completed their education in economically rich countries, despite low- and middle-income countries being home to 83% of the global population. Some 90% of all the organizations surveyed were headquartered in the United States, Switzerland, and the United Kingdom.

Other key findings of the report include:

  • Some 75% of global organizations declare a commitment to gender equality, up from 55% in 2018. Some 60% of organizations have gender equality policies in the public domain.
  • However, only 35% define the meaning of “gender” in their policies, only 44% have policies to advance diversity and inclusion beyond gender, and only 14% have policies available on gender equality, diversity and inclusion in their governing bodies
  • Along with the predominance of men in global health CEO roles, 64% of organizations have more men than women on governing boards. Some 54% have more men than women in senior management roles.

“Power asymmetries continue to define the global health architecture. These are rooted in economic power imbalances, global governance structures and also the fact that the global health system has not shaken the vestiges of its colonial past,” said Hawkes.

Image Credits: Micha Serra/Global Health 50/50.

Health System Overload – Italian Civil Protection volunteers install a triage tent for COVID-19 patients in front of the University of Padua Hospital.

“The world is inching towards a pandemic,” admitted WHO Director General Dr Tedros Adhanom Ghebreyesus in a WHO media briefing Monday, which saw COVID-19 cases more than double over the weekend in France, Germany and Spain, as well as the USA.  In an unprecedented move, Italy’s Prime Minister put the entire country under emergency lockdown Monday night after cases soared from 3860 Friday to 9,172 people infected Monday. Over 100 countries around the world were now reporting infections.   

“But it would be the first pandemic we could control,” Dr Tedros added.

“Of all cases reported 93% come from just four countries,” he said, referring to Italy, Iran and South Korea, which have seen exponential increases in recent days, while cases in China decline.

Other countries and regions, were beginning to respond as they saw case numbers spiral in now predictable ways as the outbreak caught hold. Italy’s Prime Minister Guiseppe Conte expanded the lockdown over Lombardy region to the entire country Monday evening as the country reported another 1797 new cases – closing schools until April 3rd, canceling all sporting events and other mass gatherings, and restricting movement across the country.

“Italy’s future is in our hands. We all do our part, giving up something for the good of the community. At stake is the health of our loved ones, our parents, our children, our grandparents,” Conte tweeted just after signing the ministerial decree.

New York State declared a “disaster emergency” on Sunday, following on from the examples of the states of Washington, California and Maryland, the states that have been driving the increases in cases in the United States where 707 cases have now been reported, likely an underestimate since the national rollout of tests had been delayed both by inadequate tests as well as a severe shortage testing kits.

“Countries that continue finding & testing cases & contacts can affect their countries and what happens globally,” Dr. Tedros said, noting that the Republic of Korea now seems to be on the verge of containing the virus.  Singapore and Japan also seem to have turned the corner, following the experience of China, which has managed to beat back the infection, registering only 84 new cases over the past 24 hours.

The WHO Director-General praised examples such as the Korean “drive through” testing model, which allows easy access to tests for people suspecting that they may have been infected, with little risk to them or health care workers.  He said that the “drive-through” model was helping to “widen the net and catch cases that might otherwise be missed.”

At the same time, WHO Emergencies Head Mike Ryan told the press briefing that the world may only be in the early phases of an erupting epidemic, and so the curve of new cases would likely rise further before it starts to decline.

“We are at the beginning or middle of fighting this virus,” Ryan said. “We are very much in the ‘up’ cycle. But it’s up to us to turn this around,” he said, adding that, “the way in which China, Singapore, Korea and Japan are on the verge of turning a corner gives me hope,” he said. He added that there has also been some speculation that warmer weather might potentially help beat back the virus, but that can’t be relied upon since so little is known about the virus behaviour. Comparatively fewer cases have been seen in some parts of the southern hemisphere, which is in its summer seasons, although the pattern has been inconsistent. 

Latest COVID-19 data as of 3:30PM CET (10:30AM EST)- Note numbers are changing rapidly.

People 80+ have 20% Fatality Rate – New Recommendations Likely On Avoiding Travel & Mass Gatherings  

Meanwhile even as case totals and death rise daily, failing to fight for strong containment measures will effectively sacrifice the lives of millions of older people, as well as people with underlying health conditions, the WHO officials stressed.

The most recently available data from China indicates that COVID-19 fatality rates for people over the age of 80 is above 20%, and that data is still not fully up to date, said Maria Van Kherkove, WHO Emergencies Technical Lead.

Similarly, people with underlying conditions have an outsized fatality rates – averaging around 13% for those who fall ill and have cardiovascular disease, for example, and about 7.5% for those with cancer, she said, citing the findings of a recent WHO-Joint Mission Report.

It would be a lapse in “morality” to abandon wholesale such groups, said Dr Tedros. “Not taking the death of the elderly, our senior citizens, is a serious issue, and even a moral decay. Every human being matters – it pains us when some want to move into mitigation [as compared to containment of the epidemic] because the virus kills seniors or elderly only.”

Added Ryan, public health professionals need to be committed to fighting on behalf of the vulnerable. “When people talk about just letting the wave pass, remember that there are many vulnerable people, for whom this won’t go away. Our elderly, people on cancer chemotherapy are precious members of society.. N=1  – every person matters,” he said.

But Ryan conceded that WHO may need to provide more pinpoint advice to countries for guidance about measures that older people should take – so far it has not.

“Maybe we need to push forward our advice to that elderly group about travel, mass gatherings and meetings,” Ryan said.

However, recommendations to practice “social distancing” should not just be for the “elderly” said Dr Tedros; it should be for all groups, and particularly for people living in countries and regions that are experiencing widespread community transmission of the virus – from contacts that are difficult or impossible to trace.

The United States Centres for Disease Control is already recommending at national level that older adults and other “high risk” groups stock up on supplies, practice social distancing measures and “stay at home as much as possible,” in light of their greater vulnerability.

Social Distancing – New York State Governor Andrew Cuomo taps elbows with Dr Mark Jarret at Northwell Health Center.

Seattle Hospital Sets Up “Drive-Through” Testing – But Many FDA Testing Barriers Remain

States and cities in US hotspots were finally ramping up diagnostic test capacity, after four state governors declared “states of emergency” in their jurisdictions over the weekend. Overall, the number of US cases more than doubled from 239 on Friday to a total of 566 cases by Monday.

The change came after days of pushing the Federal Drug Administration – the US’s governing body for regulating drugs and diagnostics – to allow local testing and bypass the US CDC’s limited testing capacity. As of March 5, a total of just 1583 patient samples had been tested through the CDC.

The loosening of restrictions saw initial use of successful tools like Korea’s model of “drive-through” testing. The University of Washington’s Hospital – at the center of the US’s first outbreak hotspot in Seattle – followed in South Korea’s footsteps and set up a “drive through” diagnostic center where hospital staff with potential COVID-19 symptoms, or contact with confirmed cases, could pull up and get tested, without leaving their car. The “drive through” testing is so far restricted so far only to healthcare workers. According to an article in Nature, however, the virology lab at the University is now testing hundreds of samples a day from healthcare facilities around the state since the federal government allowed academic centers to test for the virus.

At the other end of the scale, however, Northwell Health Center in the New York City area, was still under an FDA limit to perform manual testing of only 75-80 samples a day as state health officials waited for the FDA to allow Northwell to perform automatic testing in order to scale up to testing 1000-1500 samples a day.

New York’s governor Andrew Cuomo followed in the footsteps of Saturday’s declaration’s by Washington State, California, and Maryland declaring a “disaster emergency” on Sunday. This allows state governments to speed up medical supplies procurement, hiring of medical personnel, transfer of suspected patients to quarantine facilities other than hospitals, and allow medical personnel other than doctors and nurses to test for COVID-19.

The declaration also allows the governor to investigate cases of potential price gouging as prices for cleaning products and hand sanitizer soared last week.

However, an emergency room healthcare worker from a New York City public hospital told Health Policy Watch that there does not yet seem to be a clear protocol for public hospitals that primarily serve underprivileged or uninsured communities – hospitals that are already operating above  capacity.

To order a test for COVID-19 in one particular New York City hospital, for example, the patient must first be cleared of having the flu or any other common respiratory virus – then the test can only be ordered after a consultation with an infectious disease specialist.

Patients often wait to be tested in crowded emergency room waiting areas, where they could expose health care workers or other critically ill people to the virus, said the source. Getting test results still takes a couple days, and the 80% of mild cases of COVID-19 that do not require hospitalization are sent home to self-quarantine, where they might still infect others if the proper precautions aren’t taken.

Another problem faced by hospitals is the lack of systems to test and manage health care workers who may have been exposed to the virus over the past several weeks, when testing was largely unavailable. Healthcare facilities, such as University of California-Davis Medical Center, are asking staff to self-quarantine for two weeks if they have been exposed to the virus. However, experts are concerned that will result in a shortage of healthcare workers during the most critical peaks of the outbreak – particularly if many of those staff ultimately test negative.

“It’s just not sustainable to think that every time a health care worker is exposed they have to be quarantined for 14 days. We’d run out of health care workers,” Jennifer Nuzzo, a senior scholar in Johns Hopkins Health Security Program told National Public Radio.

Africa Region Shifts From “Readiness to Response”

With local transmission confirmed in Algeria, and new cases reported in South Africa, Senegal, and Nigeria, WHO is changing from a “readiness to response” mode in the African Region. Two parallel meetings for Francophone and Anglophone countries were convened to establish a regional partner coordination mechanism, a draft joint work plan, and key action items for governments of WHO’s Africa Region’s Member States and Regional Economic Committees.
“These cases should be a wake-up call for governments across Africa.  Governments must do all they can to prepare for an eventual outbreak: time is critical,”  said Matshidiso Moeti, WHO Regional Director for Africa in a press release. As of 9 March there were 32 confirmed cases in the WHO Africa region.
Experts already in those countries with confirmed cases are now focusing on providing technical support to country health workers, rather than providing generalized preparedness advice. Training on case management and infection prevention has also been provided to health workers from the countries.

See here Open WHO knowledge base with emergency resources for policymakers, professionals and researchers.

Grace Ren contributed to this story.

This story was updated 10 March 2020.

Image Credits: Wikimedia Commons/Amarvudol, John's Hopkins CSSE, Kevin P. Coughlin / Office of Governor Andrew M. Cuomo.

[Medicines for Malaria Venture]

Geneva and Liverpool (8 March 2020) – A new collaboration announced on International Women’s Day 2020 aims to help establish pregnancy registries in malaria-endemic countries in Africa to help fill the data gap on the use of antimalarials in one of the most vulnerable populations to malaria.

The study, led by Medicines for Malaria Venture (MMV) and the Liverpool School of Tropical Medicine (LSTM), will set up pregnancy registers to capture data through a prospective observational study on the real-life use of ACTs during all stages of pregnancy, including the first trimester. The study will be conducted in three countries across Africa with the goal of collecting enough safety and exposure data that, if positive, would allow for policy change on the use of ACTs in the first trimester of pregnancy.

“Pregnant women are disproportionately affected by malaria – 29% of all pregnancies in sub-Saharan Africa were infected in 2018,” said Dr David Reddy, MMV’s CEO. “Yet their needs have not been fully addressed. We are delighted to be collaborating with LSTM to establish a pregnancy registry – a clear first step towards collecting the data necessary to support the medical needs of women suffering from malaria, during every stage of pregnancy.”

Artemisinin-based Combination Therapies (ACTs) are the standard of care for malaria, and are recommended by the World Health Organization (WHO) for children and adults including pregnant women who are in their second and third trimester. Even though they are recommended by the WHO, limited data are available in second and third trimester for the more recently approved ACTs. In addition, ACTs are currently not recommended in the first trimester of pregnancy owing to a historic lack of safety data. However, there is evidence that a significant proportion of women seeking treatment for malaria in early pregnancy are treated with ACTs either because they do not know, or are unable to declare that they are pregnant.

The effort will also contribute to healthcare systems strengthening and capacity building, and encourage a sustainable pharmacovigilance culture in resource-constrained healthcare systems. Furthermore, in partnership with researchers and local regulatory authorities that are responsible for pharmacovigilance, a longer-term goal of the project is to develop a standard protocol and a network of sites that will collect safety data for all antimalarials and medicines for infectious diseases (e.g. HIV, TB) circulating in relevant endemic regions.

Professor Feiko ter Kuile, Head of the Malaria Epidemiology Unit at LSTM, said: “This new collaboration with MMV will give us the opportunity to gather much-needed data and provide a robust framework from which policy makers can make informed decisions that will benefit women when they are at particular risk of malaria, during pregnancy. The work will build on our extensive research and clinical experience in the field, and this pregnancy registry should allow us to gather safety data, not only on anti-malarials, but for drugs for the treatment of other infectious diseases that affect pregnancy.”

For more information, see the press release at MMV.

Image Credits: Elizabeth Poll/MMV.

Iranian women healthcare workers in personal protective equipment

As the world surpassed 100,000 COVID-19 infections, the United Nations announced on Friday that a critical round of climate negotiations among member states in Bonn, Germany will be postponed, while some of the sessions scheduled from 6 March to the end of April would be put on a virtual footing.  Africa Climate Week, a parallel policy event, which was supposed to take place 20-24 April in Kampala, Uganda was also put on hold.

WHO’s Director General Dr Tedros Adhanom Gheyebresus, however, sidestepped the question of whether the World Health Assembly (WHA), which brings thousands of people to Geneva for a week in late May, might be held remotely as well – in light of the COVID-19 crisis and the previously-announced World Bank decision to put its annual Spring Meetings on a virtual platform.

Speaking at Friday’s daily WHO press briefing, Dr Tedros said that WHO would have to do a risk assessment regarding the WHA, adding that he supported a broader approach to “virtual meetings”.

“On the Assembly, we still have time, so we will assess the situation. Based on the risk we will decide and let you know,” Dr Tedros said in response to a question by Health Policy Watch.

“Virtual meetings should actually be considered, not because of COVID now, but when there is no COVID,” he added, “We have to challenge all of our meetings, whether we really need to meet in person. In the middle of the COVID-9, now, we [also] have to do the risk assessment.”

Meanwhile, WHO is making contingency plans for how to continue its own operations at its Headquarters in Geneva, Switzerland, should the local outbreak accelerate.

Switzerland is now reporting 214 cases of COVID-19, largely as a spillover effect from the epidemic in Italy. That leaves the tiny mountain country of only 8.79 people among the top ten nations with the greatest burden of COVID-19 infections outside of China, in both absolute and per capita terms.

Said Emergency’s Head Mike Ryan, a key WHO concern will be how to maintain its Geneva global operations, which are badly needed now for COVID-19 emergency response:

“There is a big international community here in Geneva and we have been working with them (Swiss authorities) on how we deal with business continuity going forward. We have our own concerns about how to continue to run our operations in WHO, not only for our normal health programs but to be able to continue running our global operation here, our global nerve center.”

Ryan added that the Swiss were implementing national “preparedness plans” as well as trying to coordinate with other European authorities, but added, “I think that one of the challenges in Europe right now is coordinating across all of the nations of Europe with such open borders, and many having slightly different policies regarding mass gatherings, slightly different criteria regarding testing, and I think that’s caused a lot of people to question why there isn’t one standard approach in every country?

“But that is impossible to achieve,” he added, saying that: “What we need is each country is making its own risk assessment based on the risks it perceives, its openness, its exposure and its own vulnerabilities.”

As for the UN climate talks, the Bonn negotiating sessions were to be the lead-up for the planned COP26 Conference of Parties in Glasgow in November, a critical moment for the world to agree on a more aggressive plan of climate action. The Bonn sessions are important venues for countries to hammer out agreement on a wide range of technical issues that would underpin a stronger climate agreement on issues ranging from reductions pledges to carbon emissions counting and the financing of mitigation and adaptation measures.

Now these talks will be suspended indefiniely, or held virtually.

“I would like to inform Parties, observer States and Observer Organizations that after careful consideration and with considerable regret, the UNFCCC secretariat will not hold any physical meetings in Bonn and elsewhere between 6 March and end of April. This decision is in response to the Coronavirus disease (COVID-19) outbreak, and the evolving situation in Germany,” said the statement by the UN Framework Convention on Climate Change Secretariat (UNFCCC).

“This exceptional measure aims to contain the spread of COVID-19 and safeguard the health and safety of participants attending UNFCCC meetings in Bonn and elsewhere, as well as address the requisite duty of care of and by the secretariat in such circumstances. At the same time, it seeks to ensure that all mandated UNFCCC meetings and events have the necessary transparency and inclusiveness that our process requires.

“The secretariat is now working with the elected officials, members and registered observers of constituted bodies and other mandated events to find suitable alternative arrangements to meetings scheduled during March and April, such as virtual meetings, or postponement.”

Woman On Front Lines of COVID19 Battle – As World Marks International Women’s Day  

Although women health workers are on the front-lines of the battle to contain the infection — far fewer hold senior roles in the policy fora where key decisions on how to do that will be made.

Dr. Tedros made the remark ahead of International Women’s Day, which will be commemorated on Sunday, March 8. WHO also has declared 2020 to be the International year of the Nurse and the Midwife.

“International Women’s Day highlights the role women play in protecting and promoting the health of all people, noted Dr Tedros in his daily COVID-19 briefing, adding that. “Some 70% of the global health workforce are women, but women only hold 25% of senior roles.”

“We are on the verge of reaching 100,000 confirmed cases of COVID 19,” he added, speaking in the afternoon, shortly before that milestone was in fact reached. Still, he repeated his earlier calls for countries to “continue make containment” their key strategy, and to “detect, isolate, test and care for every case.

“Every day we slow the epidemic is another day hospitals can prepare for cases, governments can prepare, and every day we come closer to having vaccines and therapeutics available,” Dr Tedros said.

Around the world, 3793 new cases of COVID-19 were reported in the past 24 hours. The total number of global cases early Friday evening stood at 100,685. About a third of all new cases were reported in Iran, which saw an increase of 1234 new cases in the past 24 hours. There are now 4747 cases in Iran.  In South Korea, the total number of COVID-19 cases increased by 505 cases in the past 24 hours to 6593 total cases. Italy saw a 24-hr increase of 769 cases for a total of 3858 cases.

Latest COVID-19 data as of 5:43PM. CET (11:43AM EST)- Note numbers are changing rapidly.

Case Fatality Rates Assessed From Multiple Perspectives

Among the global hotspots, South Korea has so far confirmed only 42 deaths – suggesting a below-average case-fatality of about 0.6%. That contrasts sharply with the updated global average mortality cited this week by WHO of 3.4%.

Experts quoted by Business Insider suggested that Korea’s low case-fatality may be driven by the country’s quick roll out of “drive through” diagnostic clinics. The diagnostic dragnet has greatly increased the country’s ability to quickly screen a large number of people, both swelling the numbers of reported infections, including mild cases, but also insuring that people get early treatment.

Another modelling study, released Friday, estimated that the true case-fatality for COVID-19 stood at 1.4%.  That would still be about 14 times higher than mortality for seasonal flu, but half as much as the curent WHO estimate.

Gabriel Leung, head of the University of Hong Kong’s School of Medicine and lead author of the study conducted in collaboration with Harvard University, told the South China Morning Press that the model was created based on data from China’s experience, but considers numbers of people with very mild symptomatic infections.

Still, Leung told reporters at a press briefing Friday that COVID-19 could still claim many lives, particularly among older people as well as those with preexisting conditions.

“We must not let [the virus] enter elderly care homes and centres, else the impact would be huge,” he said.

WHO’s Emergencies Head Mike Ryan echoed that, noting that even if average fatality rates prove to be somewhat lower, due to the identification of more mild cases, mortality rates could very well prove to be much higher than the average among older people and those with pre-existing conditions.

“Yes we could add in a whole bunch of younger people and children who may be getting infected but not getting sick and that’s important and the overall CFR (case fatality rate) may drop,” he said. “But that may not affect the experience of older people, and remember within this when you look at the data from China baed on the numbers reported, the actual age specific or condition specific mortality goes up with age and for those with underlyin conditions. So the actual age-specific or condition-specific mortality could be much higher than those numbers..

“Equally, we have the assumption that children may be getting infected or having milder symptoms. IN influenza outbreaks,  for children with low nutrition, in compromised refugee camp -type situations, the mortality rate in children is much higher, their mortality from many common diseases can be much higher, anyone who has worked in refugee camps we know how devasting viral disease can be in those situations. Of course we hope there is a lower overall case fatality…. But We have to look to those around you who are most vulnerable. ,look to people who are older, or have underlying conditions, look to our refugee populations look to those who are undernourished, look to those with long term infectious conditions, and that’s what we need to do  in order to put together the necessary approached to protect and save their lives,

WHO officials have also underlined that the rapidly changing dynamics of the outbreak mean that the case-fatality estimate will change over time – and the most accurate case-fatility rate will only be able to recorded after the outbreak is over.

Among COVID19 Therapies Under Review – Antibody Treatments Hold Most Immediate Promise 

Meanwhile, more than 200 different clinical trials are now underway in China and abroad, according to WHO. They run the gamut from vaccines, testing existing and new drugs, and traditional Chinese medicine as well.

But the first COVID-19 medications to reach patients are likely to be antibody treatments, many experts believe.

Antibodies are naturally produced by people’s immune systems to combat viruses, usually by blocking the binding of the virus to host cells. They can be an effective treatment for infected patients,  as well as helping in prevention – although they cannot be described as a vaccine.

According to SixthTone, a Chinese media review of trending topics, WuXi Biologics, a Shanghai-based biotech company, is collaborating with Vir Biotechnology in California to produce such a  treatment. The two firms expect to begin clinical trials in about three to four months, according to Chris Chen, CEO of WuXi Biologics.

“Using neutralizing antibodies for viral infections is quite safe, because they bind to very specific targets that only exist on the intended viruses,” says Chen.

Another company working on a COVID-19 antibody treatment is Regeneron Pharmaceuticals, which previously developed and tested Ebola antibiodies at very short notice in respone to the 2013-2015 outbreak in West Africa. The New York-based firm is now trying to harvest antibodies by injecting the SARS-CoV-2 virus that causes COVID-19 into mice that are genetically modified to have human immune systems.

Once the right drugs are identified or developed, the next challenge will be making them available to the people who need them the most, said Ryan.

“We have to look beyond the issue of efficacy, of having an effective drug,” Ryan said. “We have to ensure that those who most need the drugs can get them. We have to absolutely focus now on equity and access – we cannot have a situation where people who need the drug don’t get it, and people who don’t need the drug do. We must find ways where we can ensure that, where we can scale up production of drugs that are effective, and that those drugs are distributed on the basis of need and on the basis of benefit. WHO is already working on this with our partners in the north and south.”

 

Image Credits: Twitter: @WHOEMRO, John's Hopkins CSSE.

A young woman vapes an e-cigarette – a type of nicotine delivery device recently labeled by WHO as “undoubtedly harmful.”

As the World Health Organization and WHO member states celebrate 15 years since the signing of the the Framework Convention for Tobacco Control (FCTC), the global uptake in e-cigarettes, as well as targeted advertising aimed at children and adolescents, threatens the worldwide gains that have been achieved in reducing tobacco use.

The convention is the only legally binding international treaty to have been led and negotiated by WHO. Since coming into force in 2005, some 181 UN member states, accounting for over 90% of the global population, have committed to the treaty to rollback tobacco use, which WHO has described as the “only legal drug”  that kills so many users when “used exactly as intended by manufacturers.”

“Tobacco kills more than 8 million people every year, costs the world economy over a trillion dollars annually in medical expenses and lost productivity,” said the Head of the FCTC Secretariat Adriana Blanco Marquizo in an opening statement, at WHO’s 15th anniversary celebration of the FCTC Thursday in Geneva. 

“The case is clear: implementing the WHO FCTC is a powerful means for Parties to improve the lives of their citizens and ensure a better future of their countries.”

Tobacco use has declined by some 60 million users since 2000, driven by more stringent national tobacco control policy measures, stimulated by Convention provisions, as well as sharp declines in use by women. For the first time in 20 years, WHO also released findings in 2019 indicating that tobacco use in men had plateaued, and is now projected to decline by more than 1 million users in 2020.

Since 2005, 90% of all countries that have signed the Convention have implemented bans on tobacco smoking in indoor workplaces, on public transportation, and in other public places. Some 60% of countries have facilitated more accessible and affordable pharmaceutical products for the treatment of tobacco dependence and 64% have prohibited or restricted imports of tax and duty free tobacco products by international travelers. A total of 34 countries have earmarked a proportion of their tobacco tax income for funding tobacco control measures, said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a keynote address at the celebration, which laid out the record of accomplishments. .

However, the progress in tobacco control does not mean that countries can “take their foot off the accelerator,” the Director-General said.

Notably, the unknown effects of long-term e-cigarette use is emerging as one potential threat to global tobacco control efforts. While there has been much debate about the benefits of electronic nicotine delivery systems (ENDS) for adults looking to quite combustible cigarettes, early this month, a WHO  statement released on 5 February stressed that such devices are “undoubtedly harmful, should be strictly regulated, and most importantly, must be kept away from children.”  

“Progress towards reducing tobacco use remains uneven…We’re increasingly concerned by the growing popularity of new products such as e-cigarettes, particularly for children and adolescents,” said Tedros. “Nobody can be left behind if we are to achieve a 30% reduction in tobacco use by 2025.” 

Challenges to FCTC Implementation: Targeting Children & E-cigarette Use

There are still 15 countries that have not committed to the Convention at all.  And many parties to the treaty have not yet fulfilled all of policy commitments made in the treaty. For example, one third of all parties to the Convention have yet to enact a comprehensive ban on all tobacco advertising, promotion and sponsorship.

The tobacco industry remains the “single greatest barrier” to full implementation of the FCTC, Sandra Mullin, senior vice president of Policy, Advocacy and Communication at Vital Strategies, a global health non-profit that works in tobacco control, remarked to Health Policy Watch. 

Industry tactics to counter tobacco control efforts include: lobbying governments through third-party organizations; creating and funding front groups; hiring retired policy-makers and bribing governments; influencing upstream trade policies that create barriers to integrating public health concerns into tobacco trade policies; and producing and disseminating misleading research about tobacco use, according to a report published by Vital Strategies and STOP (Stopping Tobacco Organizations and Products).

Among the greatest concerns is predatory tobacco advertising for “novel and emerging products flooding the markets” – such as flavored e-cigarettes that are often targeted at children and adolescents, said Blanco Marquizo.

Notably, the Convention has defined a specific set of obligations that countries must fulfill to protect minors from tobacco use, including text prohibiting “the manufacture and sale…of tobacco products which appeal to minors.”

Youth tobacco consumption will be the focus of the ninth session of the Conference of the Parties to the WHO FCTC in November 2020, to be held in The Hague, Netherlands. 

According to Dr Tedros, tobacco companies often use “threats of litigation to intimidate governments trying to implement tobacco control policies.”

However, as an international treaty, the FCTC has been used successfully to support legal defense arguments against industry challenges to tobacco control policies. Along with its sister Protocol to Eliminate Illicit Trade in Tobacco Products which came into force in 2018, the FCTC remains the strongest tool to “take on the tobacco industry,” said Dr Tedros.

“We have to keep up the momentum…Together we can reverse the global tobacco epidemic and save millions of lives,” he added.

Image Credits: WHO.

WHO Director General Dr Tedros Adhanom Ghebreyesus urged countries to redouble their efforts on COVID-19 containment, saying that China’s stunning success shows that goal still may be attainable – even as 16,470 new cases of the fatal virus mushroomed elsewhere across the globe in the past 24 hours.

“This not a drill. This is not the time to give up. This is a time for pulling out all the stops….. We need to fight, we need to fight now,” said the WHO Director General. “Our predictions will come true, if we do nothing.”

“This is not a one way street,” he said, “The epidemic can be pushed back.”

While “some countries are stepping forward to face the fire,” others, however, were reacting too little and too late, he warned, adding, “We’re concerned that some countries have either not taken this seriously enough, or have decided there’s nothing they can do. We are concerned that in some countries the level of political commitment and the actions that demonstrate that commitment do not match the level of the threat we all face.”

Against the almost dizzying spiral of cases abroad, China saw only 143 new cases over the last 24 hours, and only 4 new cases outside of Hubei Province, Dr Tedros noted, citing it as proof that containment actions can work.

Three quarters of the new cases seen abroad, meanwhile, were linked just three countries that have become the world’s three largest hotspots, the Republic of Korea, which saw 467 new infections overnight for a total of 6088 cases; Iran, which saw 691 new cases overnight, for a total of 3513; and Italy, which saw 587 cases overnight, for a total of 3089.

Latest data as of 6 p.m. CET – Note numbers are changing rapidly.

Don’t Abandon Containment – Says WHO 

In remarks that alternated between a plea and a call to battle, the WHO Director General appealed to the global community to “not give up on a containment strategy,” saying that not only China but also other countries that seemed to be beseiged by the virus threat, had pushed back aggressively and demonstrated that it could be contained.

Korea, for instance, was seeing fewer new cases in the past 24 hours than either Italy or Iran, which have only about half as many reported infections. While both Italy and Iran have reported 107 deaths each, Korea, with nearly twice as many cases, has reported only 35 fatalities.  While many factors can explain such a variable, it also points to the likelihood that Korea is identifying cases sooner and getting those infected to treatment more rapidly.

“We see encouraging signs from the Republic of Korea,” said Dr. Tedros. “The number of newly-reported cases appears to be declining, and the cases that are being reported are being identified primarily from known clusters.”

Singapore is another such example he cited.  It was one of the first countries outside of China to discover cluster of local infection transmission  But careful contact tracing and other measures seem to be containing further spread to 117 cases so far, with only 12 new cases were reported over the past week.

A total of 115 countries have not reported any cases, Dr Tedros added, 21 countries have reported only one case, and 5 countries that had reported cases have not reported new cases in the past 14 days.

“The experience of these countries and of China continues to demonstrate that this is not a one-way street. This epidemic can be pushed back, but only with a collective, coordinated and comprehensive approach that engages the entire machinery of government. We are calling on every country to act with speed, scale and clear-minded determination.

“If countries act aggressively to find, isolate and treat cases, and to trace every contact, they can change the trajectory of this epidemic,” the WHO Director General said. “If we take the approach that there’s nothing we can do, that will quickly become a self-fulfilling prophecy. It’s in our hands.

“The worst thing that can happen to any country or any individual is to give up,” he added. “Don’t give up, don’t surrender. Do everything we can do to contain it.”

He added that a “whole of government approach” should be used, involving every branch of government, from security and diplomacy to finance, commerce, transport, trade and information sectors:  “Activate your emergency plans through that whole-government approach.

“Educate your public, so that people know what the symptoms are and know how to protect themselves and others. Increase your testing capacity. Get your hospitals ready. Ensure essential supplies are available. Train your health workers to identify cases, provide careful and compassionate treatment, and protect themselves from infection.

“If countries act aggressively to find, isolate and treat cases, and to trace every contact, they can change the trajectory of this epidemic.”

US House Overwhelmingly Approves $US 8.3 billion for Emergency  COVID-19 Response – In Rare Bipartisan Display  

In a rare bipartisan display of support for funding on a health issue, the US House of Representatives approved an US$ 8.3 billion package of funding to support emergency coronavirus response, by a 415-2 vote. That should ensure ready approval in the US Senate as well.

The US is so far only reporting 129 COVID-19 cases officially. But some US experts have warned that significant numbers of cases could have passed under the radar during the past three weeks when testing services were inadequate, and protocols too strict to include tests for people with, and who later proved to be infected.  That has led to patterns of surreptitious community transmission in Washington State, with new clusters also emerging in California and now, the New York metropolitan area.

Notably, New York City reported 9 new cases  overnight that were linked to the city’s first COVID-19 case in a health worker recently returned from Iran. And Los Angeles County, California, declared a state of emergency after identifying 6 new cases.

The draft funding bill, now to go before the Senate, includes about $US 7.7 billion in funds to boost vaccine development, R&D on vaccines and drug therapies, build critical stockpiles of hospital devices and health worker protective gear, and provisions that every state would receive at least US$ 4 million in funding.  The package would also liberalize Medicare rules on telehealth, so that people with chronic conditions or minor illness other than COVID-19 could consult health care professionals remotely, removing risks of exposure to the virus at health clinic and hospital waiting rooms.

After intense debate, congressional leaders also agreed to a provision of $US 300 milllion that would be used to reduce the costs of new vaccines along with language in the draft bill stating that, “the Secretary [of Health and Human Services] may take such measures authorized under current law to ensure that vaccines, therapeutics, and diagnostics developed from funds povided in this Act will be affordable in the commercial market.”

The language was supposed to allay fears that any new COVID-19 treatments and vaccines developed with public funds would be affordable to the millions of Americans who lack even the most basic health care insurance to cover drug and vaccine costs.

However, Knowledge Ecology International’s James Love, described the draft language in the billl as “worse than weak”, and said the fine print could even undermine existing authority that the federal government has to intervene in drug markets.

“The use of ‘may’ rather than ‘shall,’ adds no new authority and no new mandate to protect the public from unreasonable, excessive or unaffordability prices,” Love said, in a blog.

He stressed that another sentence, is even more worrisome. It states that: “in carrying out the previous provision the Secretary shall not take actions that delay the development of such products.”

That clause, Love contends, could in fact undermine existing legal authority that the federal government has to use any patent or have any product manufactured “by and for” the federal government in cases of public need. It could also undermine existing government authority to issue so-called “compulsory licenses” to third parties for production of a patented drug or vaccine, even if federal funds supported the drug development.

“The proposed legislation can blow all of these measures up, by preventing the federal government from undertaking any measure that would ‘delay the development of such products,’ ” said Love.  “Companies can claim that ANYTHING that reduces the price reduces incentives to invest in more rapid development, and under this act, and litigate that issue.”

 

 

Image Credits: Johns Hopkins CSSE.