Luca Li Bassi holds his transparency award

Former general director of the Italian Medicines Agency (AIFA) Luca Li Bassi was awarded the 2019 “International Transparency in Medicines Policies Awards” by the French civil society watchdog group l’Observatoire Médicaments Transparences (the Observatory for Transparency in Medicines), for his efforts in negotiating a milestone World Health Assembly resolution in May 2019 supporting more public disclosure of medicines costs by countries, which are now generally obliged to keep their purchase contracts with pharma suppliers secret under non-disclosure agreements. French MP Caroline Fiat was awarded the French national prize by the NGO for her efforts to encourage price transparency in the parliament.

Li Bassi navigated the draft resolution on “Improving the transparency of markets for medicines, vaccines, and other health products,” through a complex set of technical barriers and member state objections to final approval during the seventieth-second World Health Assembly.

Following on the WHA resolution, Li Bassi drafted and won Italian government approval for a decree requiring pharma companies to disclose any public contributions that they had received for R&D costs of new drugs, as part of their portfolio submissions for drug reimbursements by the national health system. While the decree was signed by both Ministers of Health and Finance in August 2019, Li Bassi was replaced as head of AIFA in a government reshuffle in last autumn, and the decree is yet to be published in the national gazette, when it would then officially take effect.

“Scientists, policy makers and the public all need to have more and clearer information on the life-cycle of medicines if we all are committed to achieve universal access to treatments,” Li Bassi told Health Policy Watch, regarding his efforts on the transparency issue. “The current asymmetry of information is not helping society to assess the efficiency and effectiveness of the current system and to explore ways to improve it.”

Caroline Fiat holds her transparency award

Caroline Fiat, a Member of the French Parliament for the political party La France Insoumise, was recognized by the Observatory for leading the charge on an amendment to the French Bill on Social Security Funding for 2020, that would require pharmaceutical disclosure of public contributions to R&D costs.

After bouncing back and forth between the National Assembly and the Senate, the amendment was finally adopted in the final version of the Bill, only to be blocked by the French Constitutional Council on a procedural technicality. The legal objection centered around the fact that French Minister of Health Olivier Véran initially had rejected all transparency amendments in the first reading of the bill. That led to the Council’s censoring of the final amendments, even after Véran joined the transparency bloc to co-write the amendment that was adopted by both houses of French legislators. Fiat has continued to push forward the issue by submitting public questions on the implementation of the amendment to the Ministry of Health, which has the authority to override the constitutional objections.

In an oblique reference to Véran’s inaction so far, representatives of the Observatory said in a press release that they are waiting on Véran to publicly confirm his support for the transparency amendment, and “hope to award him with this prize” in the future.

Skyrocketing medicines prices around the world have put transparency higher on the global health agenda, as proponents argued that the secrecy around disclosure of medicines prices and R&D costs puts public health systems at a disadvantage when negotiating medicine prices – combatting pharma industry claims that the information is proprietary and confidentiality is needed to encourage costly medicines R&D.

In its press release, the Observatory said the awards to “pay tribute to critical individual and courageous actions” and “shed light on people occupying institutional positions” that push forward initiatives on transparency in many aspects of their work.

Transparency Legislation Recognized As Team Effort

In his comments to Health Policy Watch, Li Bassi’s view said his reward represented “the result of the efforts made by many delegates at the last World Health Assembly to take a milestone step for global health.”

“While it was indeed challenging to arrive to a consensus on a very contentious topic, the efforts made to reach an agreement were fueled by an incredible motivation in all delegates to do something concrete to improve access to medicines and other health products,” he added. 

The Observatory also paid tribute to all the countries who “co-sponsored” the resolution on transparency, against stiff opposition from a handful of governments. That included Lenias Hwenda, representative of Zimbabwe and vice-chair of the negotiating group, as well as other representatives of countries.

In France, a number of politicians across seven different political parties have supported the transparency amendment. Fiat has also aligned her efforts with hospital and emergency care health workers in France who have been protesting against cuts to public hospitals in staffing, funding, and equipment.

“Major progresses in health policies cannot be attributed to individuals alone,” said the Observatory press release. “Democratic life needs such strong, courageous and concrete actions, from various stakeholders, and cannot content itself with lukewarm actions.”

Image Credits: l'Observatoire Médicaments Transparences.

WHO’s Bruce Aylward shows a graph of the epidemic curve in China, showing how rate of new infections has decreased due to China’s strict outbreak response measures.

COVID-19 can be beaten – but it will take a big mindset shift on the part of the global community to achieve what China has done – which is dramatically curb transmission of the new, mysterious and deadly coronavirus using traditional public health measures for digilent tracing of contacts, isolating those found to be ill; and providing intensive care, including advanced respiratory treatment, for the 20% of serious cases.

That was a key message from Bruce Aylward, the head of a WHO-convened independent commission of experts that just returned from a 10-day trip to China studying the massive public health effort now underway there.

Aylward spoke as new cases in China continued a generally downward trend, with 523 new cases and 71 deaths in the past 24 hours, but cases elsewhere in the world were now exploding.

The latest count included 2573 cases in 39 countries, an overnight increase of 292 infections. The biggest hotspots continue to be: Korea with 977 infections and 10 deaths; Italy, with  322 cases and 11 deaths; and in Iran, 93 cases including the infection of Iran’s deputy health minister, and 16 deaths.  In Switzerland, a 71 year old man was the first to be diagnosed with COVID-19 after visiting Lombardy, Italy 10 days ago for a conference. The fact that the case reports have increased so rapidly in all three countries over just the past few days suggests that other infected people may also be circulating undiscovered and infecting others, repeating a pattern that occured in the first weeks of the coronavirus emergency in China.

“What has China down and how they have done it is extremely important,” said Aylward, speaking to journalists on Tuesday, just hours after his return. “We have escalating outbreaks [even] in industrialized countries.  We have got to try to respond.”

In an unusually fresh, if sometimes rambling, account by a WHO official, Aylward called on countries to undergo a “shift in mindset.”  He used wartime terminology to describe the public health battle that countries will need to mount to effectively fight the virus, while describing the R&D effort required as a modern-day “Manhattan project.”

Aylward also painted a stark picture of the alternative – exponentially expanding infections and health systems becoming overwhelmed and even collapsing with the weight of treating so many seriously ill patients, often requiring advanced respiratory care.

Yet, too many public health officials remain both unprepared and fatalistic about the virus – approaches that will be devastating when cases finally appear on their doorstep.

Health checks at the “Milano Malpenza” airport in Milan, Italy.

“Is this a pandemic or not? Folks this is a rapidly escalating epidemic in different places that we have to tackle really fast.  But what China demonstrates is where this goes is within our control,” said Aylward.

“For the rest of the world, there has to be a shift in mindset. Around the world, people are thinking ‘how do we live with this, and manage all this disaster’, instead of saying: ‘This virus is going to come, we are going to find every case, isolate it, find every contact.’

“Countries have got to be shifting to a rapid response type of thinking. You can change the shape of this, but it takes a very aggressive and tough programme. In 30 years of doing this business, I have not seen this before,” he said, of the Chinese response.

An expert report outlining key findings and recommendations was being submitted Tuesday to WHO’s Director General Dr. Tedros Adhanom Ghebreyesus, Aylward said.  He described it as a consensus product of the 13 international disease control experts who participated in the mission, from institutions and countries as diverse as Nigeria CDC, the United States Centers for Disease Control, and Germany’s Robert Koch Institute.  Recommendations were made by the experts as individuals, and not on behalf of their institutions, he added.

Main Finding- Tough Chinese Measures Averted Hundreds of Thousands More Infections

While oft-criticized as draconian, Aylward said that the commission found the tough Chinese measures were proving to be effective, and so other countries need to study them and learn their lessons:

“It is the unanimous assessment of the team that they have changed the course of this outbreak. It was a rapidly escalating outbreak.. It has plateaued and is coming downward sooner than expected,” said Aylward.

“Hundreds of thousands of people in China did not get COVID-19 because of the aggressive response… and they also reduced the probability of this going elsewhere.”

He said that the strict quarantine, isolation and contact tracing measures were justified in the name of saving lives, and avoiding the swamping of health systems with seriously ill cases that even developed country health systems often lack capacity to treat.

“You are at war here. Is this a dangerous virus or a serious virus, bottom line is that this virus kills people, it kills older people it kills vulnerable. And young people die too. And they die in industrialized countries.”

“Instead of debating if COVID19 is a pandemic or not, countries need to ask themselves:  ‘Do you have your isolation beds ready for people that will need to be hospitalized? Do you know who your thousand contact tracers are? There are really practical things to be done?

“Countries need to keep in mind: People who get sick remain in hospital from 2-6 weeks so its a long time in hospital/isolation center.

80% of cases are mild, but with regards to more severely ill, there is the “sheer weight of numbers.. that’s really important, you have got to plan, how many beds… etc.

“How many countries are planning hospital beds, ventilators. lab supplies to be able to manage this? “You are going to need beds to isolate people and quarantine really close contacts. You have got to be able to accommodate those people, you have got to have enough ventilators for the serious cases, you have got to be able to transport people, have the lab capacity.”

“People are talking about [whether this is more like] SARS or flu, as soon as we get stuck with the two binary approaches we are not preparing for novel coronavirus.”

Nurse wearing a specialized mask, cap, gown and gloves measures the body temperature of a coronavirus patient in Hubei TCM Hospital. Such gear is vital to protect health workers from infection.

Using Old Fashioned Public Health Tools – And Mobilizing All Government Sectors   

China took a “very pragmatic approach” and decided to aim for the containment of the virus, using this set of traditional public health tools – including finding cases, contact tracing and rapid hospitalization of those who were seriously ill, but also the quarantine of mildly ill cases to stop the transmission chain; and even the isolation of close contacts and suspected cases.

Aylward said that the visiting experts sometimes wondered, “‘Is this real, this extraordinary mobilization to implement fundamental public health principles and approaches in the absence of a vaccine. Can this bring it down? Yes it can.””

“It was a science-driven” effort, agile response but deployed with extraordinary rigour, says Aylward, noting that clear guidelines for managing cases were issued and revised rapidly in line with new developments. Big data was deployed to find cases, and their contacts and to isolate them.

At the same time, the response was not monolithic, he stressed. Uniform guidelines were applied in a “differentiated” manner, across different provinces, depending on the level of infections.

“The fundamentals were always the same but the degree of application was different. There was a  differentiated approach when there were zero cases, sporadic cases or community transmission like they had in Wuhan.”

Aylward said that the differentiation allowed more efficient use of resources so that the national response effort was not exhausted. “A lot of people have said we can’t do this at scale because you will exhaust your response. The Chinese said ‘not if you tailor this properly.’

And at local level “There was a lot of latitude.. big rules were in place but provinces, towns, communities could adapt them to make it work for them, ” he said.

While hospital infection control failures in the first weeks of the coronavirus epidemic led to many health workers becoming ill and even dying, measures are now well in place for managing “clean and dirty channels” of hospital systems, and health workers now appear to be adequately equipped with personal protective gear. These, however, are key challenges that health systems elsewhere now need to prepare to meet.

Another secret to the success of the effort so far, has been the way all government sectors, from transport to agriculture, were mobilized to the public health mission at hand, Aylward said.

“They repurposed the machinery of government – all of government – to fight the virus,” he said, noting that transport services were rerouted not only to skip communities where the infection toll was high, but also ensuring wide spacing between passengers in areas where trains and metros were running normally.

“Food supplies were channeled to ensure that areas under lockdown had adequate provisions. And prepared meals were arranged and served in such as way as to minimize food-borne transmission of the infection, including by seating members of the expert team at separate tables at the China CDC cafeteria.

“We talk about all of government responses, but usually it doesn’t have much meaning,” Aylward said, adding that in the case of the Chinese battle against COVID-19, it did. “Everyone has a role that has been repurposed to fit this machinery.”

Public Support For Aggressive Containment Is Key

Another one key aspect of the China effort was the way in which massive public support was recruited at every level of society.

“They [China] mobilized a phenomenal collective and cooperative action,” said Aylward, saying that the level of commitment exceeded anything that could be simply imposed from above by an authoritarian government.

“It’s never easy to get the kind of passion, commitment and individual sense of duty.

“…We spoke to hundreds of people on planes, trains outside the system, they all shared this responsibility to be part of this.”  Over and over, said Aylward, “we also heard people say, ‘It’s our responsibility to do this for the world.’ ”

Public health officials elsewhere have to think about how to build similar awareness and social solidarity around a critical global public health battle.

“To accept quarantine, to accept rapid isolation there are going to be challenges for people to accept that. And are we ready to quarantine and isolate that number of people?  There are mindset issues. But we have got to overcome them,” said Aylward.

Face mask use across  the Middle East increases as new cases appear linked to travel in Iran. (Photo Credit: Farsnews/Sajad Toloui)

Access China Expertise & Launch “Manhattan Project” For Coronavirus Research 

Aylward also said that Chinese expertise could now be critical in helping other countries fight the virus, and he urged other public health systems to access Chinese experts.

“They have done this at scale. They are really good at it. They are ready to help,” he said.

He noted that rich and poor countries alike need help in preparing for the virus.  Rich countries may have hospital beds, but lack appropriate isolation facilities.  They may have respiratory units, but those may be inadequate to meet the scope of the new virus. And they also need to be identified and mobilized for any area where clusters of illness occur.

At the same time, poor countries lack capacity for treating severe cases, and that also needs to be addressed, he said.

“I also worry that when this gets into lower capacity health facilities, they don’t have ventilators, they don’t have the capacity to keep people alive.”

Ultimately, said Aylward, health authorities need to ask tough questions now, such as:  “Are we ready to manage these people?”

“This is not flu, it is a more SARS-like pathology.  Are we ready to manage that.. to go after the transmission of this thing. Don’t accept the inevitability that you cannot control this virus.”

Research can help to provide longer-term solutions, he added, although there too, a massive response will be needed. “You want a Manhattan Project on your top vaccine candidates and top therapeutics,” he said, for a disease that currently has no effective drug remedies or cures.

“Rapid diagnostics are urgently needed as are seroimmunity studies to see if a much wider population may be silently exposed and developing some protection to the virus, as are household studies to better understand the mechanisms of transmisison. “In terms of research, use the time well,”he advised. “Research saves lives.”

Watch the entire press conference here:

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

 

Image Credits: Dipartimento Protezione Civile, China News Service, FarsNews/Sajad Toloui.

Health checks at the “Guglielmo Marconi” airport in Bologna, Italy

With spiraling outbreaks of COVID-19 in 3 countries, Iran, Italy, and Korea, WHO officials warned Monday of growing risks that the epidemic could become a full-fledged pandemic – although Dr Tedros Adhanom Ghebreyesus stepped back from the brink, telling a press briefing on Monday: “Does this virus have pandemic potential? Absolutely it has. Are we there yet? Not yet.”

“We have hope, courage and confidence that this virus can be contained,” he added, speaking at a daily press briefing. “We are not witnessing the uncontained global spread of the virus with significant deaths.”

In a visit to Geneva, UN Secretary General Antonio Guterres called on UN member states to “do everything they can to contain the disease” warning that if even a few countries fail, the epidemic will veer “out of control, with dramatic consequences to global health and global economy.”

According the latest official Chinese data, the trend showing a decline in new cases in China continued on Monday, with only 423 fresh reports of infection over the past 24 hours, leaving a total of 77,269 cases, and 2,596 deaths. Abroad, however, the story was of a percolating  crisis with 2,281 cases and 32 deaths reported as of Monday afternoon.

Italy, Iran and Korea – New Virus Test Grounds

In Italy, one of the newest epicenters, some 230 cases and six deaths were reported as of Monday afternoon. That was as compared to 16 cases on Friday according to the Ministry of Health.

Some 11 towns – 10 in the Lombardy region just south east of Milan, Italy’s financial nerve center, were under a strict quarantine. Schools were shut, train service suspended, and police barricaded main roads around the communities where at least 163 people were infected. The Ministry of Health on Sunday expanded strict measures region to Italy’s Veneto region too.

Austria temporarily suspended train service from Italy on Sunday, and announced that the country was reconsidering the reintroduction of border controls. But Switzerland and other neighboring European Union countries left their borders open. European Union Health and Food Safety Commissioner Stella Kyriakides told reporters Monday that the WHO had not recommended imposing travel restrictions across the EU’s open “Schengen” “zone . The European Centers for Disease Control meanwhile announced  that a group of European experts were being sent to Italy to assist in the response and further develop recommendations for coordinated action.

Said Kyriakides, “We all need to take this situation very seriously, but without giving in to panic, even more importantly, to disinformation.”

Iranian officials, meanwhile, were still scrambling to determine the chains of transmission behind the cases in the country, even as the outbreak spilled over into neighbors. At least 10 countries tightened border controls and enacted travel restrictions in response to the Iranian outbreak, where at least 61 cases and 12 deaths have now been reported, according to WHO’s Eastern Mediterannean Regional Office. The outbreak has left Iran with the highest death toll from the virus of any country outside of China.

Commuter in Iran wears face mask as COVID-19 cases climb (Photo Credit: Farsnews)

Many of the 10 countries that had imposed travel restrictions  tightened border controls after confirming their own cases of COVID-19, linked not to travel in China, but to travel in Iran. Just Monday morning, Oman also suspended flights to and from Iran indefinitely after the country’s first two COVID-19 cases were confirmed in two Omani women who had recently returned from Iran.

Meanwhile the South Korean government raised the level of the response to “red” – the highest possible level – as cases quadrupled from 204 infections Friday to 833 confirmed cases and 7 deaths as of 8:00AM CET Monday, according to the Korean Center for Disease Control.

Among the new Korean cases confirmed over the weekend, 18 people had just returned from an eight-day religious pilgrimage to Israel on 16 February. That left Israel scrambling to identify local contacts of the pilgrims for followup, while also turning back all but 11 of 188 passengers on board another Korean airliner that landed in Tel Aviv on Sunday, due to infection fears. The return of the Korean passenger plane triggered diplomatic protests from Korea.

In Korea’s Daegu, where an explosion of cases was linked to the Shincheonji Church, Korean authorities have obtained an entire list of the church’s membership for follow-up, and to encourage members to self-quarantine.

Mixed Messages on Outbreak Containment Measures

WHO and other UN officials, however, continued to project mixed messages about what containment measures countries should follow – praising tough Chinese steps as effective, on the one hand, but also discouraging other countries from taking similar measures.

The praise came at a press briefing in Beijing. There, a group of WHO-convened international experts led by WHO’s Bruce Aylward, who had been on a weeklong mission, expressed support for the country’s unprecedented containment efforts.

Those measures effectively put Wuhan, the city of 11 million people at the epicentre of the outbreak, under quarantine, as  mass events and meetings were canceled, commercial and entertainment centres were closed, and the movement of millions more across the country was restricted.

Even in Tianjin and Shanghai, far from the epicentre, some apartment complexes are under virtual lockdown, with only one family member allowed to leave the complex per day to buy food, local sources have told Health Policy Watch. 

Aylward highlighted that new cases had dropped so low in China that a Chinese researcher had trouble enrolling new patients into a clinical study for remdesivir, the only antiviral that “may have real efficacy” against the new virus.

The WHO team’s assessment has been that the measures taken in China averted the more rapid spread of the disease elsewhere. Guterres echoed those remarks in his Geneva briefing today, telling reporters that the world owes a debt of thanks to the Chinese:

“My message to all of those in China, who are deprived of a many aspects of a normal life, is a message of gratitude because it is the sacrifices of those who are deprived of those positive aspects of life, so as to avoid the propagation of the disease, who are rendering a service to humanity,” Guterres said, speaking in French.

He added, “All countries must do everything to be prepared, and all countries must do everything – respecting naturally the principle of non-discrimination, without stigmatization and respecting human rights – do everything they can to contain the disease.”

“This disease is still possible to be contained but if some fail, if some do not do everything that is needed, this can still become out of control, with dramatic consequences to global health and global economy.”

However, an hour earlier at a WHO press briefing, Emergencies head Mike Ryan was more ambivalent about the degree to which other affected countries, such as Italy and Iran, should imitate China’s tough measures – which have included the mass cancellation of public events, as well as the strict curtailment of entertainment, business and commercial activities, even in lesser affected cities, such as Shanghai.

“The natural transmission dynamics if you look at most cases, including in China are in family clusters,” said Ryan. “That has been driving the epidemic. Then there are very then particular circumstances… We need to understand the exact dynamics of what has been happening in Iran. Clearly there have been gatherings for religious festivals, people coming and moving on afterwards.

“We are reaching out to all affected countries to ensure that they have the necessary technical  assistance.  But I caution everybody, please don’t extrapolate from one individual country experience, each country is different.”

As for the outbreak in northern Italy, Ryan expressed strong opposition to travel restrictions, saying. “The European Union and Switzerland and other countries have been working together to maintain their open borders and to manage this risk collectively.”

He added, “There is no zero risk. This is about good risk management. It’s about good communication between states.  It’s about management and early detection of cases and their appropriate isolation and treatment.  It’s not about shutting borders; it’s about coherent coordinated public health actions of of a number of member states that share borders to manage the public health consequences.”

Iranian officials are still scrambling to determine the chains of transmission behind the cases in the country, even as the outbreak spilled over into neighboring countries. At least 10 countries have enacted travel restrictions for people transiting through Iran, reaching 61 cases and 2 deaths according to data from WHO’s Eastern Mediterannean Regional Office.

The 10 countries with travel restrictions on Iran include Turkey, Georgia, Jordan, Saudi Arabia, Lebanon, Iraq, Egypt, Kuwait, Bahrain, the United Arab Emirates, Afghanistan, and Pakistan. Many of the same countries tightened border controls after confirming their own cases of COVID-19, linked not to travel in China, but to travel in Iran. Oman became the latest country, suspending flights to and from Iran indefinitely after the country’s first COVID-19 cases were confirmed in two Omani women recently returned from Iran.

Trucks pile up at Bazargan, Iran border crossing, closed by Turkey since early Monday morning due to coronavirus fears.

Donors Dramatically Step Up Funding Support

With the virus accelerating on European shores, the EU today announced a €232 million package for the coronavirus emergency, one-third of the US $675 million requested by the WHO to fund the global response.

France, Germany, and Sweden have also contributed funding to the global response efforts. Germany today announced a €3 million infusion for the response today, following on Sweden’s commitment of SEK 40 million (€3.8 million) earlier Monday.

In terms of the EU commitment:

  • €114 million will support the World Health Organization (WHO), in particular the global preparedness and response global plan. This money would boost public health emergency preparedness and response work in countries with weak health systems and limited resilience. Part of this funding is subject to the agreement of the EU budgetary authorities.
  • €15 million would be allocated directly to African institutions, including to the Institut Pasteur in Dakar, Senegal to support strengthened capacity for undertaking rapid diagnosis and epidemiological surveillance.
  • €100 million will support development of new health products and tools, including up to €90 million in funds to public-private partnerships with the pharmaceutical industry and €10 million directly spent for research on disease epidemiology, diagnostics, therapeutics and clinical management of containment and prevention.
  • €3 million will be allocated to the EU Civil Protection Mechanism for repatriation flights of EU citizens from Wuhan, China.

Guterres, at the WHO briefing called on countries worldwide to step up to the bat regarding WHO’s appeals for funding to confront the outbreak.

“If there is something stupid one can do in today’s world it is to not fully fund WHO appeals,” he said. “My appeal to all donors is to make sure that WHO appeals in relation to this virus, but also to other commitments around the world are fully funded.”

Image Credits: Dipartimento Protezione Civile, Farsnews.com, Twitter: @IrnaEnglish.

Pilgrims visit the Holy City of Qom in Iran. (Photo Credit: Pierre Le Bigot)

Containing an explosion of COVID-19 cases in Korea and Iran have become top priorities for global health officials battling to prevent the epidemic from growing into a worldwide pandemic. While new lab-confirmed cases in China on Friday numbered 896, more than double the day before, that was still part of an generally downward trend as compared to the two weeks before. But expanding clusters of cases in prisons, including one in the eastern Chinese province of Shandong, elevated concerns about Chinese hotspots outside of Wuhan, the epicentre of the outbreak.

Early Friday evening, meanwhile, Italian health officials announced a cluster of 8 new cases in the northern Italy town of Codogno, five among medical staff at the local hospital, where 3 infected patients who had contracted the virus, were already being treated. The new reports brought Italy’s total of confirmed cases to 16.

The Italian, Korean and the Iranian cases illustrate how seemingly random events involving just a few individuals can drive much larger outbreaks of the highly contagious virus. In South Korea, just one woman has infected dozens of other fellow members of her church in the city of Daegu.

In the case of Iran, a mysterious series of geographically dispersed clusters led to reports of some 18 infections as of Friday, four deaths in the pilgrimage city of Qom, and onwards transmission of the virus by two infected travelers who were identified upon arriving in Canada and Lebanon.

“The window of opportunity may be closing,” said Dr Tedros Adhanom Ghebreyesus in a press briefing on Friday. “Although the total number of cases outside China remains relatively small, we are concerned about the number of cases with no clear epidemiological link, such as travel history to China or contact with a confirmed case.”

Origins of Iran’s COVID-19 Cases Unclear 

While most of the cases outside of China have until now been linked to travel to the epicenter of the outbreak or known contacts of confirmed cases, the transmission patterns in Iran are so far unclear. Reports of cases in Lebanon and Canada, linked to recent travel from Iran, but not to China, were later confirmed by health officials in both countries.

An Iranian Ministry of Health official told CNN news that it was “possible” more cases existed in cities across the country, and speculated that the virus was possibly imported by Chinese workers living in Qom, an important center of Shiite Muslim pilgrimage. China has continued to do business with the Islamic Republic in defiance of US sanctions. However, a Ministry of Health official told Iranian News Agency IRNA on Thursday that two patients who had died of COVID-19 in Qom had not reported any contact with foreigners or Chinese nationals, and their families had not yet been subjected to quarantine.

“We’re getting information [from Iran], but we need to engage with them more,” said Tedros. “These dots or trends are very concerning and we’re working with the government to fully understand the transmission dynamics.”

Meanwhile, cases in South Korea shot up by 100 new cases in the past 24 hours to a total of 204 confirmed cases, making South Korea the country with the highest number of cases outside China. According to the Korean Centers for Disease Control, at least 129 of those cases are members of the Shincheonji church, a Christian organization considered cult-like by many mainstream churches. Most cases related to the church have been clustered in Daegu, although cases in church members have also been reported in Seoul and Gwangju.

Sweeping Closure of Commercial Activities & Public Events In Italy’s Lombardy Region 

In response to outbreak in northern Italy, Minister of Health Roberto Speranza announced a sweeping series of measures in Codogno and about ten other surrounding towns, including: suspension of all public events, commercial activities, schools and day care centers, municipal works, public transport services, and recreation services.

The total number of people infected in the Lombardy region now stands at 14, said the minister and other health officials at a press conference Friday.  The officials’ descriptions of the infection chain illustrates how very casual contacts played a role in the expanding outbreak. The first person to be infected was a 38-year-old man who had become ill after meeting a friend recently returned from China.  He then infected his wife, and a running group acquaintance. They were all hospitalized. Three older friends of the runner, who all frequented the same bar, were then infected, followed by the five health workers at the local hospital, who were treating the initally infected patients, and several others.  There are reportedly two other COVID-19 cases in Italy’s Veneto region.

Despite the fast-changing path of the virus, WHO’s Director General said he still believed that the outbreak could potentially be contained, if countries step up preparedness measures.

“The window of opportunity is still there but [it] is narrowing, and that is why we call on the international community to act, including the financing, and that is not what we see.”” said Dr. Tedros.

China Changes Reporting Protocol Again Amid New Spread In Prisons

As of 5:30pm CET, there were 896 new cases of the virus in China according to official Chinese data, higher than the increase of 404 cases recorded yesterday, but much lower than the 2,000-3,000 new cases reported almost daily in the previous week. Total cases in China were 75,571, while abroad the total number of cases exceeded 1,225 in 27 countries, late Friday afternoon, as Israel also reported its first coronavirus case – in a passenger returning from the Diamond Princess cruise ship.  That latest count did not include the late breaking reports of infections in Italy.

The significant decline in new confirmed Chinese cases may indicate that authorities there are finally getting the infection more under control.  But it is also partly due to another change in the way China reports numbers. After adding over 14,000 clinically diagnosed cases to the number of confirmed cases in Hubei province on Wednesday last week, authorities have reverted back to only including lab diagnosed cases in the count, WHO officials said today at the press briefing. They said that the zig zag was due to the fact that with less pressure on health systems, most suspected cases were now being rapidly lab confirmed.

In a place with the lab capacity to test every suspected case for the virus, the “recommended approach” is to classify lab-confirmed cases as confirmed, and other cases as “suspected,” explained Tedros. “We’re glad China has gone back to this approach, we think it will bring more clarity.”

In response to concerns about the confusing changes in reporting measures, WHO’s director of epidemic and pandemic diseases Sylvie Briand stressed, “As long as we understand the situation, it helps us. Surveillance or monitoring disease is about taking the best possible decision and collecting numbers for action, not numbers for numbers… Beyond the numbers what’s important is trends.”

“Understanding the definition” rather than where the numbers are reported is the basis for decisions, she added. “At the end of the day, as long as the decision behind the numbers is a good decision, that is what matters most.”

WHO Director General Expresses “Concern” Over Increase of Cases In Shandong Province – Reference to Prison Hotspot   

WHO’s Tedros also said that WHO was “concerned about an  increase in the number of cases in Shandong province.” According to a local news station Qilu Evening News, 200 of the 202 new cases reported in Shandong Thursday night occurred in Rencheng prison. Some 207 cases have been reported in total from the prison, including 7 prison guards and 200 prisoners.

The reports were confirmed by state owned news agency Xinhua on Friday, which reported that the index case was a prison guard who was diagnosed on 12 February. However, proper infection prevention control measures were not taken until much later, leading to a dramatic overnight rise in confirmed cases in the prison. The debacle led to the national government launching a formal investigation into the handling of the outbreak, which resulted in the replacement of the director of the Provincial Justice Department and sacking of a number of prison officials, including the director of Rencheng prison, according to Xinhua.

But the South China Morning Post reported that there have been a number of other prisons in China where outbreaks are flourishing in confined and closed conditions. These include a Wuhan Woman’s Prison, which has reported some 230 cases, and smaller clusters in Shayang Hanjin prison in Hubei province and Shilifen Prison in Zhejiang province.

Reports about the contagious virus’ spread in prisons mirror the growing concern around transmission of the virus in so-called “re-education” centres in Xinjiang province, where China has reportedly detained 1-1.5 million ethnic Muslim Uyghurs in overcrowded facilities with limited access to medical care, contact with friends and family, according to a report by the UN’s Office of the High Commissioner for Human Rights (OHCHR).

So far, WHO has not made any public comment on the potential transmission of the virus in the camps, which have been criticized by the OHCHR as “amounting to detention centres” due to their “coercive nature.”

Updated Saturday 22 February 

Image Credits: Flickr: Pierre Le Bigot.

Cover of current edition of Korea Biomedical Review

A sharp decline in new COVID-19 cases was reported by China on Thursday, providing a glimmer of hope about the potential to still contain the epidemic – but only if the steady increase being seen in new cases abroad can now be brought under control.

As of 3 p.m. Central European Time (CET), official Chinese data recorded just 404 new cases of the novel coronavirus over the past 24 hours – for a total of 74,680 confirmed infections. That was in comparison to daily increases of 2,000-3,000 new cases seen over the past two weeks.

However, elsewhere in the world, 68 new cases were reported, for a total of 1,085 reported infections in 26 countries, as of 3 p.m. CET, with yet other cases reported later in the evening.  Most of the international increase was occurring in South Korea where the number of cases had more than doubled from 51 to 104 overnight.

Along with that, there were 8 reported deaths outside of Japan, including two elderly people in Iran, where 3 more coronavirus cases were also confirmed and six were under investigation – in a country that had previously not reported any infections whatsoever.

Two deaths also were reported among the 634 infected passengers of the Diamond Princess Cruise ship that was under a forced quarantine in Japan’s Yokohama harbor until just yesterday, when Japanese authorities began the slow release of the ship’s passengers and crew, which had originally numbered over 3600 people.

In South Korea, a press release by Centers for Disease Control officials said that many of the new Korean cases appeared to be centered around the Shincheonji Church of Jesus, a church with cult-like associations in the city of Daegu. A 61-year old church member had reportedly developed symptoms but refused to be tested, and subsequently infected at least 37 other church members, in what authorities described as a “superspreader” event.  Related to that, there were two clusters of infections within hospitals as well.

Already on Wednesday, the South Korean Ministry of Health and Welfare had put into place a new series of stringent infection control measures nationwide, including screening and limits on  gatherings in schools, leisure venues, and other public places. The Ministry also launched the distribution of hundreds of thousands of masks; stepped up COVID-19 testing in hospitals; issued travel warnings against visit to China’s high-burden COVID-19 provinces; and mandated screening of all inbound travellers, including installation of a self-diagnosis and locational app on their cell phones. Even stricter measures were imposed on Thursday in Daegu, where many public venues were closed and stores and streets remained empty.

COVID-19 cases worldwide, by official China health site as of 3 p.m CET 20 February.

Iranian Deaths May Be Followed By More Cases

The deaths of two elderly Iranians, in the city of Qom, were the first cases to be reported in Iran, making it the third country grappling with the virus spread in WHO’s Eastern Mediterranean Region, outside of Egypt and the United Arab Emirates. Later Thursday Iranian authorities reported, and WHO confirmed, 3 more COVID-19 cases in Qom.  Another six suspected cases in Qom, Tehran and the northern city of Babol were being tested and quarantined, Iranian News Agency IRNA, reported Thursday, for a total of 11.

Iranian authorities did not provide information as to the origins of the various infection clusters, with significant geographic spread. There were some suggestions, however, that the infections may have originated among religious pilgrims arriving to the Shiite holy city from Pakistan or other neighboring countries. IRNA, said that all religious schools in Qom had been closed to head off wider infection spread. Some 60 Iranian students were also evacuated from Wuhan earlier this month, but they were quarantined upon their return to Iran and had not displayed any health problems, authorities said.

Iran had continued to maintain business ties with Chinese companies willing to defy US sanctions. And unlike Saudi Arabia, an important Sunni Muslim pilgrimage destination, the Islamic Republic has not imposed restrictions on travel to our from China, although its national airline reportedly suspended flights several weeks ago, with the exception of humanitarian aid.

WHO Expresses Confidence in South Korean Response; Avoids Japan Criticism 

Speaking at a WHO press briefing on Thursday, WHO’s Director General Dr Tedros Adhanom Ghebreyesus expressed confidence in South Korea’s ability to manage the expanding outbreak there, saying “I think the number of cases are really management and I hope that South Korea will do everything to contain this outbreak at this early stage.”

Added WHO’s Oliver Morgan: “The number of cases in South Korea suggests that they are from several distinct clusters which the Ministry is following quite closely. Although the numbers are quite high, they are mostly linked to known chains, and Korean authorities are following up vigorously on all cases.”

WHO officials, however, sidestepped questions regarding Japan’s handling of the quarantine on the Diamond Princess, which has come under increasing fire as reports of poor disease control conditions aboard the ship seeped out with the gradual release of the 3,700 passengers and crew that had been put under lockdown.  The Diamond Princess COVID-19 cases constitute more than one-half of those reported abroad.

WHO’s Assistant Director General for Emergencies, Jaouad Mahjour, defended the Japanese objectives in the multi-week quarantine which saw infections aboard the ship spiral.

“The objective was to contain it on the ship, and not to prevent infection on the mainland,” he said, “They were heavily following the contacts to detect any case, and if they were detected they were taken it to the hospital for treatment.

“They were practicing drastic measures of quarantine and isolation of the cases to avoid close contacts and transmission… Now they are moving to the second stage,” he said, referring to the gradual release of passengers who have been found to be infection free, along with evacuation of those with mild cases to quarantine locations on land or in their home countries.

WHO Objective “Still Containment” – Repeats Call for More Emergency Funds 

Meaanwhile, Dr Tedros confirmed that members of the United States Centers for Disease Control as well as the US National Institutes of Health were part of the international expert team assembled by WHO and now working alongside Chinese counterparts to support control of the epidemic, as well as means of improving containment, clinical care and cure rates.

He said the team also included experts from national disease control centers or institutes in Singapore, Japan, South Korea, Russia, Germany’s Robert Koch Institute and Nigeria’s Centres for Disease Control.  “Global coordination is key in fighting a dangerous enemy,” said Dr Tedros.

He meanwhile emphasized that donors still have not responded to the WHO call for some $US 675 million to fight the epidemic, which threatens to spill over into a pandemic, saying that money is needed now for “simple public health solutions” that could begin “hammering the outbreak now” while a longer-term quest for a vaccine is pursued.

“Our objective is still containment,” said Dr. Tedros, speaking at the press briefing.  “We believe as WHO there is still a chance to contain this outbreak if we use the window of opportunity that we have now. We need to strike the balance, to finance the simple public health solutions now, but prepare for any eventuality by investing in a vaccine.”

Regarding the most immediate therapeutic solutions, WHO’s Clinical Management Lead, Janet Diaz, said that the results of clinical trials should be completed within three weeks on the two most promising COVID-19 treatments, including Gilead Sciences nvestigational drug remdesivir, as well as a popular HIV combination drug, lopanivir/ritonavir.  The lack of any effective antiviral treatment has plagued clinicians’ efforts to treat the most serious 20% of COVID-19 infections. These cases typically require lengthy hospitilization and often sophisticated mechanical ventilation procedures, with the most critical infections lead to multi-organ failure and death in 2% of cases, risks that increase along with age.

 

 

 

Image Credits: Koreanbiomed.come , Dingxiangyuan, HP Watch .

[WHO Africa Regional Office]

In a strong move for the African state, the Ethiopian Parliament has passed landmark excise tax legislation on tobacco with the express aim of curbing smoking in the country – resulting in some of the strongest taxes on tobacco products on the continent. As a result of the legislation, Ethiopia has now introduced a mixed-excise tax system on cigarettes in line with the recommendations of the World Health Organization (WHO). This involves a 30% tax rate of the cost of producing cigarettes, in addition to a specific excise rate of eight Ethiopian Birr (ETB) (USD$ 0.25) on each individual packet. 

The passing of the legislation demonstrates the commitment of the Government of Ethiopia to addressing one of the leading causes of non-communicable diseases such cancer, cardiovascular diseases and chronic obstructive lung disease.  A considerable number of Ethiopians are at risk: the most recent Global Adult Tobacco Survey estimates the number of smokers in Ethiopia to be around 2.5 million people.

“Cancer and other non-communicable diseases are on the rise in Africa,” said Dr Boureima Hama Sambo, WHO Representative for Ethiopia. “This ground-breaking new law will significantly reduce cigarette smoking among Ethiopians and save lives. It is a powerful example of how the government, civil society and WHO can work together to enact meaningful change.”

WHO has estimated that the tax increase would reduce the rate of cigarette smoking among adults by as much as 10%, and reduce the number of deaths attributable to smoking by around 91,000 people.  The increased tax on cigarettes will also increase cigarette tax revenues by as much as 81%, meaning an additional (ETB) 925 million (US$28.7 million) that can be spent on public health or education programmes.

Prior to the approval of this bill, cigarettes in Ethiopia were among the cheapest in the world, even in comparison to other African countries.  The share of total tax on the retail price of cigarettes was also very low in Ethiopia, averaging 33% in recent estimates, compared to the global average of 61%.  WHO estimated that this legislation will increase the tax share of the average retail price of cigarettes to around 54%.

Smoking poses serious health and economic challenges for Ethiopia.  The annual economic costs of smoking in Ethiopia are estimated to be around 1391 million Ethiopian Birr, or US$43.6 million, according to the most recent edition of the Tobacco Atlas.  Buying tobacco also denies families the resources they need to rise out of poverty. A smoker in Ethiopia would have to spend 11.70% of their average income (measured by per capita GDP) to purchase 10 of the most popular brand of cigarettes to smoke daily each year.

Passing this legislation was the result of coordinated advocacy by WHO that involved engaging civil society groups, the media, medical and professional associations, and government partners.  When the bill was first proposed to the Ethiopian Parliament in 2019, the specific additional rate on each packet of cigarettes was just five Ethiopian Birr (US$ 0.16), far below WHO’s recommended rate.  Sustained efforts by WHO and partner organisations during the public hearings that followed the initial adoption of the tax adjustment led to the final legislation reflecting WHO’s recommendations more fully.

WHO has also been working in partnership with the Ethiopian Ministry of Finance since the adoption for the Framework Convention on Tobacco Control in January 2014.  Following the high-level multi-country meeting on tobacco tax policies and tobacco control in Africa, which took place in Geneva in November 2019, a technical workshop on tobacco tax modelling was organised with representatives from Ethiopia.  WHO helped formulate tobacco tax policy options, conducted independent analysis of tobacco consumption and taxation patterns in Ethiopia, and later also helped to increase the capacity of tax experts in the Ministry of Finance through training, workshops and study tours.

 

Image Credits: WHO AFRO.

Ports of entry in the Democratic Republic of the Congo are now using temperature screening systems, created for detecting Ebola to screen travelers for COVID-19.

Experts were closely watching the development of Japan’s COVID-19 outbreak for signs of whether the virus might escape further out of control, moving closer to the tipping point of a pandemic – the worldwide spread of a new disease.

Meanwhile, a new study in The Lancet  found that in Africa, Egypt, Algeria and South Africa are at highest risk of new coronavirus cases. However, these countries also have the most prepared health systems and therefore  less vulnerable.

Countries at moderate risk, include Africa’s most populous nation, Nigeria, as well as Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya. Significantly, they are also less prepared and more vulnerable, and require further support to help them detect and handle imported cases of novel coronavirus disease 2019 (COVID-19).

Algeria, Ethiopia, South Africa, and Nigeria were also among 13 top priority at-risk countries identified by the World Health Organization (WHO), based on their direct links and volume of travel to China. The first case of COVID-19 in Africa was confirmed in Egypt last Friday, on 14 February 2020.

China is Africa’s leading commercial partner with over 200,000 Chinese workers in Africa, and high volumes of travel, through which the novel coronavirus could reach the continent.

Global distribution of COVID-19 cases, as recorded by Chinese national authorities 19 February at 3 p.m. CET.

In Asia, Japan Most Immediate Focus; Korea and Singapore Close Behind

Currently, however, Japan and Singapore remained the most immediate hotspots of concern, with 84 cases each of the novel coronavirus, the most outside of China itself. China had recorded 74,284 cases as of late Wednesday afternoon Central European Time, 1,756 more than the day before, while deaths now reached 2009. Globally, there were 1,017 confirmed cases, a worrisome rise of 220 more over the day before.

Japan has faced a gradual influx of cases brought about by considerable tourism and employment related travel to and from China. But it has also been forced to grapple with the cases of the 621 infected people identified aboard the Diamond Princess cruise ship that was under a strict quarantine in Yokahama harbour until Wednesday, when the first 600 passengers who had been given a clean bill of health, were finally allowed to disembark.  Others of the original 3700 passengers and crew remained aboard because their COVID-19 tests had been positive, though not serious enough for hospitalization. A number of countries, including Canada, Australia and Korea have announced mass evacuations of their stranded citizens, following on the US evacuation of 300 nationals earlier this week.

Rather than containing infection, the quarantined ship may have proved to be an incubator for the spread of the virus, many experts now fear.  A prominent Japanese specialist, Kentaro Iwata, who boarded the ship on Tuesday slammed the infection control measures on board the ship as “completely inadquate.”  In a video posted on You Tube, but later removed, Iwata was quoted describing the ship environment “chaotic” with no distinction between infected and uninfected zones, and no infection control officials in charge, National Public Radio reported.

Former FDA commissioner Scott Gottlieb told CNBC that Japan seems to be “on the cusp of a large outbreak,” while Syra Madad, another public health expert, was quoted, saying “We’re really closing in on the tipping of this being declared a pandemic.”

Meanwhile Korea, which had 51 reported cases as of Wednesday afternoon, the third highest outside of China, announced a host of stringent infection control measures, for schools, businesses and public places following a meeting of top health officials, which was presided by the prime minister.

Those include: mass distribution of masks; as well as stepped up COVID-19 testing in hospitals. It has issued travel warnings against visiting China’s high-burden COVID-19 provinces, and instituted a mandated screening of all inbound travellers, including installation of a self-diagnosis and locational app on their cell phones.

Chinese employees returning from China following the Lunar New Year, will be required to spend two weeks in self-isolation, prior to returning to work as will a group of Koreans evacuated from the Diamond Princess, the announcement by the Korean Ministry of Health and Welfare also noted.

In Cambodia, meanwhile, Cambodian health officials, supported by WHO and the US Centres for Disease Control (CDC), were now scrambling to put in place a series of measures to contain transmission risks, after another cruise ship, the Westerdam, was allowed to dock in Sihanoukville last week and release its 1,455 passengers and 802 crew with far less scrutiny than the Diamond Princess.  However, shortly after disembarking, one 83 year old passenger was found to be infected with the virus upon her arrival in Malaysia.

In a press release late Wednesday evening, WHO said that in response to the confirmed case, the Cambodian Ministry of Health had convened an emergency working group, which decided to undertake COVID-19 laboratory screens for all former passengers still in Cambodia, and “health screening” of passengers still in Phnom Penh or Sihanoukville.   WHO also called on all of the 1455 former cruise passengers, who have now scattered widely, to practice “self-monitoring” and report any possible symptoms to their local health authority along with their travel history.

The WHO announcement reflected a wave of growing concern among global public health experts about the way in which the Westerdam’s passengers disembarked and scattered so quickly, without a rigorous screening for the virus, measures diametrically opposed to the tactics used on the quarantined Diamond Princess, however controversial.

“WHO’s strategy is still to contain the outbreak in China and try to make sure there is no sustained transmisison in other countries,” Eyal Leshem, head of the Center for Travel and Tropical Medicine at Sheba Medical Center in Israel, and a former medical epidemiologist with US CDC, told Health Policy Watch.  “The strategy mandates contact tracing and quarantine of contacts. Based on traditional public health principles, contact tracing and isolation, if you take 1400 people that have been potentially exposed, and you discharge them without creating a full quarantine, you potentially spread this disease to everywhere they go.”

African preparedness still creates huge risks for continent

In terms of Africa, another major at-risk region, only one case has so far been confirmed in Egypt.  However, weak health systems, combined with the sheer volumes of traffic between the continent and China, leave the continent extremely vulnerable should the virus make a beachhead, the Lancet study notes.

According to the China Africa Research Initiative (CARI), there were 202,689 Chinese workers in Africa by end of 2017, concentrated primarily in Angola, Algeria, Nigeria, Ethiopia and Zambia. Most of the Chinese investments in Africa go to Nigeria and Angola, according to Brooklings.

The Lancet study estimated the risk of African countries importing a COVID-19 case from China using data on the volume of air travel from infected Chinese provinces to Africa and the proportion of COVID-19 cases in the Chinese provinces as of 11 February 2020. Hubei province was not included, given the travel ban introduced by Chinese authorities on travel to and from the province on 23 January.

Maps showing (left) importation risk by country, (top right) country capacity to respond to risk, and (bottom right) Infectious Disease Vulnerability Index

The study notes that some measures to prevent the importation of COVID-19 cases from China, and contain transmission when and if infected people arrive, have already been implemented in many African countries.

However, more technical and operational expertise is required to carry out a full suite of measures that would be  required, including: heightened surveillance, rapid identification of suspected cases, patient transfer and isolation, rapid diagnosis, contact tracing, and follow-up of potential contacts.

“African countries have recently strengthened their preparedness to manage importations of COVID-19 cases, including airport surveillance, temperature screening at ports of entry, recommendations to avoid travel to China, and improved health information provided to health professionals and the general public. However, some countries remain ill-equipped,” said study author Dr Vittoria Colizza, of Inserm, Sorbonne Université, France in a press release.

But, “while almost three-quarters of all African countries have an influenza pandemic preparedness plan, most are outdated and considered inadequate to deal with a global pandemic. In addition, despite efforts to improve diagnostic capacity from WHO, some countries do not have the resources to test for the virus rapidly, meaning that tests would need to be done in other countries,” she added, noting:

“It is essential to train, equip, and strengthen the diagnostic capacities of hospital laboratories close to infectious disease and emergency departments to reduce the time to deliver results, manage confirmed cases and contacts more rapidly, and preserve strict infection control measures. Equally, increasing the number of available beds and supplies in resource-limited countries is crucial in preparation for possible local transmission following importation.”

More Countries Screen but Few Limit Travel Outright

As a result of the risks, pressure has been mounting in some African states to enact stricter limitations on travel to China, as well as on arrivals coming from the Asian nation.

While some countries have indeed issued travel advisories, and some major African airlines have suspended flights to mainland China, most countries have left the doors open.

On Jan. 31, Nigeria – Africa’s most populous nation, sent a powerful signal when Alhaji Lai Mohammed, the Minister for Information and Culture told journalists that Nigeria would not impose travel restrictions.

“We know it’s difficult to ban people from travelling,” Mohammed was quoted in The Guardian, a local Nigerian Daily as saying. “Another thing is that this is not stigmatise people who come from there.”

Despite the inherent risks, open doors policies have been generally supported by Dr Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director General, who has spoken out repeatedly against travel restrictions, both to the media as well as at the outset of the WHO Executive Board meeting in Geneva in early February, saying “there is no reason for measures that unnecessarily interfere with travel or trade.”

His advice clearly echoed among African health policymakers as well, among them Chikwe Ihekweazu, director general of Nigeria’s Centre for Disease Control, who tweeted, “I completely agree with the decision of the #Nigerian Govt. not to ban travel to China. As @DrTedros said, travel restrictions cause more harm than good by hindering info-sharing for public heatlh action, medical supply chains etc & have no obvious benefit.”

Observers have said that with such intertwined economic ties, most African countries simply cannot afford to be more restrictive about travel, regardless of the diverse public health and ethical issues involved.

“What is going on in China clearly shows that it is beyond a health issue. It is an economic threat to china and the world, it’s a security threat to China and the world, and it’s a social threat to China and the world,” said John Nkengasong,  director of the African Centre for Disease Control and Prevention in Addis Ababa, in an African Union news briefing in late January.

Instead of closing borders and limiting travel, countries have focused on ramping up early detection and screening measures at ports of entry, said Michael Yao, head of emergencies for the WHO Africa region, in a press briefing last week.

“What we are emphasizing to all countries is that at least they have early detection because we know how fragile the health system in the African continent is. and these systems are already overwhelmed by many ongoing disease outbreaks,” he said.

It is “critical” for cases to be detected early to “prevent spread within communities” which can trigger an influx of cases that would “easily overwhelm the treatment capacity,” added Yao. Severe cases of the new disease must be treated in intensive care units with respiratory equipment, facilities which are extremely limited in African clinics and hospitals.

 

Image Credits: Twitter: @MoetiTshidi, Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study.

Boys play on a beach in Kiribati, an island nation threatened by rising sea levels.

Ecological degradation, climate change, and exploitative marketing practices are the greatest emerging threats to children’s health, says a new report from a WHO-UNICEF-Lancet Commission on the future of child health.

Despite dramatic improvements in survival, education and nutrition for children over the past five decades, the report, titled A Future for the World’s Children?, found that today’s youth face an “uncertain future.”

“Progress [in child and adolescent health] has stalled, and is set to reverse,” said former prime minister of New Zealand and Co-chair of the Commission, Helen Clark, in a press release.

“It has been estimated that around 250 million children under five years old in low- and middle-income countries are at risk of not reaching their developmental potential, based on proxy measures of stunting and poverty. But of even greater concern, every child worldwide now faces existential threats from climate change and commercial pressures.”

The report finds that economic inequalities persist in countries across the board, affecting the ability of indigenous and marginalized children to thrive. Commercial practices push heavily processed foods, sugary drinks, alcohol and tobacco at youth, contributing to a “double burden” of over and undernutrition. And climate disruption is creating “extreme risks” to children from rising sea levels, extreme weather events, water and food insecurity, heat stress, infectious diseases, and large-scale migration.

According to the report, children are particularly vulnerable because they often lack a voice in policy and health governance, relying instead on parents, governments, and local and global leaders to act in their best interest. Yet a global movement led by youth climate activists such as Sweden’s Greta Thunberg and India’s Licypriya Kangujam has caught the attention of leaders around the world – and allowed children to insert a voice in policymaking. However, global frameworks for promoting and monitoring progress in such matters and in child health are still insufficient.

The Commission compared measures in child education, survival, nutrition, and health across 180 countries to rank countries by “child flourishing”- a concept that aims to represent a holistic view of child health. The report also measured sustainability by using a proxy for greenhouse gas emissions, and equity along with income gaps in order to measure future threats to child health.

Based on the child flourishing index, children in high-income countries such as Norway, South Korea, and the Netherlands had the best chance of surviving and thriving, while children in Sub-Saharan Africa and the Sahel faced the worst odds. However, high-income countries also represented the bulk of the world’s emitters, contributing disproportionately to future threats for children’s health. When ranked by CO2 emissions, Norway fell to 156, South Korea to 166, and the Netherlands to 160. The United States, Australia, and Saudi Arabia represented the highest emitters by volume.

“We all know from the science that the carbon budget is giving us at most ten years before we exceed 1.5 degrees of warming and that was a target agreed by all countries at the Paris Agreement five years ago. We’re way off track, emissions are going up and the future for children we can see all around us already,” Anthony Costello, professor of Global Health and Sustainability at the University College London and lead co-author of the study, said at a press briefing.

Most urgently, the report finds that countries ranked lowest for child flourishing are contributing the least directly to the existential threat caused by climate change, but will likely be most susceptible to the impending ecological damage.

“While some of the poorest countries have among the lowest CO2 emissions, many are exposed to the harshest impacts of a rapidly changing climate,” said Awa Coll-Seck, health minister of Senegal and co-chair of the Commission. “More than 2 billion people live in countries where development is hampered by humanitarian crises, conflicts, and natural disasters, problems increasingly linked with climate change.”

A handful of small countries, however, seem to be on track for both child flourishing and sustainability – Albania, Armenia, Grenada, Jordan, Moldova, Sri Lanka, Tunisia, Uruguay, and Viet Nam all ranked within the top 70 for child flourishing, and are on track to beat their CO2 emission per capita targets by 2030.

“This report shows that the world’s decision makers are, too often, failing today’s children and youth: failing to protect their health, failing to protect their rights, and failing to protect their planet,” Dr Tedros Adhanom Ghebreyesus, director-general of the World Health Organization said.

“This must be a wakeup call for countries to invest in child health and development, ensure their voices are heard, protect their rights, and build a future that is fit for children.”

Harmful Advertising Pushing Products Towards Children

Children are also vulnerable to increasing commercial marketing of highly processed junk food, sugary beverages, and alcohol and tobacco, the report stated.

According to the findings, children are “frequently” targets of advertisements for addictive and unhealthy foods – which can contribute to childhood obesity and poor nutrition. The report cited a review of 23 studies in Latin America that found advertising exposure was associated with a preference for and purchase of unhealthy and low-nutritional value foods by families and children who were overweight or obese.

Additionally, children are often exposed to advertising for products for adult use, such as alcohol, tobacco, and e-cigarettes. E-cigarette advertising is of specific concern to high-income countries such as the United States, where youth exposure to television e-cigarette advertisements increased by 256% between 2011 to 2013. There is even evidence of inequities in exposure to harmful marketing – one study cited by the report found that African-American and Hispanic youth in Los Angeles were exposed to twice as many alcohol advertisements per day as non-Hispanic white youth.

Advertisers are increasingly targeting children through social media marketing via smartphones and computers.

Another unknown threat is “the trend in social media advertising and algorithm targeting,” said Costello, who added he was “rather horrified” to learn that many search engines and social media websites operate by selling consumer data, including data generated by children’s profiles, according to a report released by the Norwegian Consumer Council in 2019.

“This is totally unregulated, unlike TV and the other forms of media. And we know that self-regulation doesn’t work.”

Solutions for the Future: Opportunities to Protect Child Health  

The report concludes with a series of recommendations for the global community to mitigate the threats to child health, including:

  1. Stopping CO2emissions with the utmost urgency, to ensure children have a future on this planet;
  2. Placing children and adolescents at the centre of efforts to achieve sustainable development;
  3. Promoting new policies and multisectoral action towards child health and rights;
  4. Incorporating children’s voices into policy decisions;
  5. Tighten national regulation of harmful commercial marketing, supported by a new Optional Protocol to the UN Convention on the Rights of the Child.

“Children are already advocating for the need for a shift in the governance structure and that they should be playing a greater role in driving the agenda,” said Jennifer Requejo, senior technical officer for the Partnership for Maternal, Newborn & Child Health.

“The opportunity is great. The evidence is available. The tools are at hand…It will take courage and commitment to deliver,” added Richard Horton, editor-in-chief of The Lancet family of journals. “It is the supreme test of our generation.”

Image Credits: WHO, A future for the world’s children? A WHO-UNICEF-Lancet Commission.

Checking temperatures at a Chinese supermarket in Wuhan in late January. Measures since have tightened even further.

Amidst reports of an even tougher crackdown in China, including door to door visits by Wuhan public health authorities to identify people infected with the novel COVID-19 coronavirus and place them in mass quarantine facilities, WHO’s Emergencies Head Mike Ryan defended the tough government measures at a press briefing on Tuesday.

“Door to door surveillance, going around and doing active surveillance, this is a very good public health measure,” Ryan said. “Right now, the strategic and the tactical approach in China is the correct one.”

He noted that a slow reduction in the number of cases in China had created space for public health authorities to take more active measures in the Wuhan, Hubei epicentre of the epidemic, as well as in other cities such as Beijing, where new rules require residents returning to the city to isolate themselves for 14 days.

“While they are getting the success in putting out one fire, they don’t want the first to start somewhere else,” he said. “Now, you can argue whether those measures are excessive or restrictive on people, but there is an awful lot at stake here in terms of public health, and in terms of not only the public health of China, but all of the peple in the world.”

As of 5 p.m. Tuesday Central European Time, China was reporting a total of 72,532 cases in China, and 1872 deaths, 1,888 more than the day before. Abroad, there were 897 cases and 3 deaths reported across 25 countries. Of the more than 200 new cases outside of China, 99 of them were concentrated on the Princess Diamond cruise ship moored in Japan’s Yokohama harbour, where a total of 542 of the ship’s original 3,600 passengers and crew have tested positive for the virus.

House To House Surveillance in Wuhan, China

In Wuhan, authorities tightened their grip even further on residents that have been under lockdown already for several weeks, seeking to round up and quarantine anyone with the infection, including people with mild cases.

The Wuhan Health Commission announced a system of “closed management” of all apartment blocks and neighborhoods in the city of 11 million people, with 24/7 surveillance, and even stricter controls on those allowed to exit than had been in place previously.

Chutian Daily, a Wuhan newspaper was cited saying that 10 new quarantine centres with 11,400 beds were being set up across the city for people showing mild symptoms of infection, identified through house to house surveillance. Anyone suspected of having the virus would face mandatory testing.

Outside of Wuhan, other communities in Hubei province were also being sealed off. placed under around-the-clock “closed-off” management, in effect putting them under lockdowns.  The actions came as a prominent Wuhan doctor, Liu Zhiming, had reportedly died from the virus on Tuesday at the age of 51.

While COVID-19 can be very mild for younger people, deaths such as that of Zhiming, illustrate the way that the virus can hit much harder at older people, even when they are presumably in good health.

“Clearly there has been an apparent drop in the fatality rate,” said Ryan, pointing to results from a newly published paper by China CDC reviewing some 44,672 cases in China.  The findings indicate a case fatality rate of about 2%, somewhat lower than the 3% fatality rate of the very first patients who fell ill in Wuhan in January.  About 80% of those infected have only mild symptoms and quickly recover, the paper also found, although others become severely ill.

“We need to be careful that sometimes this is projected as a mild disease,” Ryan said. “That is true, but there is a significant number of people, 20 percent of people, who get this are severely or critically ill.”

Notably, average hospitalization time for the severely ill has been about 20 days. “If you have lots and lots of people in hospital for a very long time, requiring intensive care, it requires takes a huge effort from the health system,” Ryan observed. “We must remember that there is an at-risk group which is 40-79 years and older, and they can have a very severe course of disease, and we must be aware of that, if the disease is imported to a third country….”

Strengthening Weaker Health Systems

To that end, WHO has continued its efforts to bolster the preparedness of weaker health systems for the potential arrival of the virus, said WHO Director General Dr Tedros Adhanom Ghebreyesus, also speaking at the press briefing. “By the end of this week, some 40 African countries and 29 countries in the Americas will have the ability to detect COVID-19,” he said.

“Many of these countries have been sending samples to other countries for testing, waiting several days for results. Now they can do it themselves, within 24 to 48 hours.

“DRC is leveraging the capacity they have built to test for Ebola to test for COVID 19,” he said, noting it as a “great example” of how health system strengthening generates knock-on benefits. “Namibia, Timor Leste and Nigeria are running workshops and workshops with the media.”

A number of Asian and African countries have also stepped up their monitoring at ports of entry, including Bangladesh, Cambodia, Ethiopia, Pakistan, and South Sudan, Dr Tedros added.

And WHO has recently released new guidance related to management of ill travellers at international points of entry as well as interim guidance on planning and preparing for mass gatherings, in the context of the COVID-19 emergency.

Ryan confirmed that WHO was also in the process of shuttling supplies to test for the virus to DPR Korea, as well as meeting with North Korean officials in Geneva’s mission on risks the country might face due to its close ties with China. So far no cases have been reported in the country, however, he added.

China API Shortages May Boost Indian Drug Prices

Meanwhile pharma observers were nervously eying the crisis in terms of potential interruptions it might create in the Chinese supply of active principle ingredients (APIs), to the global drug market.

Reportedly, Chinese firms supply some 80-90% of the world’s APIs for basic drugs such as antibiotics, which undergo final manufacture as patented or generic drugs elsewhere.

While India’s pharma industry may be able to ramp up capacity to cover some of the shortfalls, India also procures almost 70% of its APIs from China, including for many generic drug formulations which help keep the world’s drug prices low.

Many suppliers had stocked up on API’s ahead of the Chinese Lunar New Year, so the shortages may not be felt immediately.

However, Daara Patel, secretary general of the Indian Drug Manufacturers Association, which represents over 900 of the country’s drug producers,  told Reuters that he could project supply disruptions beginning in April, if the crisis continues.   He said that antibiotics would likely be among the hardest hit as India is a major global generics producer.

Other international pharma companies are also watching the situation with concern.

However,  Thomas Cueni, head of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), which represents most of the large patent drug producers said that currently the epidemic was not expected to create the same level of  interruptions in the patent drug market.

“Generic companies operate on tight margins, with often with procurement based on the lowest price, this does put pressure on companies for treatments such as antibiotics,” Cueni said.

“As a rule, the innovative pharmaceutical industry have tried and tested business continuity plans with alternative suppliers.…At this moment, the novel coronavirus outbreak isn’t causing problems for innovative medicines supply.

“The companies are continuously monitoring and proactively handling the situation as it’s developing and do not expect any long-term impact on the availability of medicines and vaccines, unless disruption due to the novel coronavirus outbreak is sustained over the next several months.  That being said, we (IFPMA and its innovative pharma member companies) are far from complacent and are monitoring the coronavirus situation in China closely.

“R&D biopharmaceutical companies are working to prevent and mitigate potential shortages through close coordination with national regulatory authorities and other global stakeholders, including the World Health Organization.”

 

Image Credits: Wikimedia Commons: Painjet.

Rush hour traffic in Ho Chi Minh City, one of the cities supported by Bloomberg Philanthropy’s Global Road Safety Partnership

Bloomberg Philanthropies announced a six-year US $240 million commitment to prevent road traffic injuries in low- and middle-income countries on Tuesday, just a day ahead of the Global Ministerial Conference on Road Safety in Stockholm, Sweden. The new commitment aims to fund efforts to prevent 22 million injuries and save 600,000 lives from road traffic accidents.

“The price we are paying for our mobility is unacceptable. We need to do much more to save lives on our roads. This new investment is excellent news that comes at a critical time when world leaders convene to decide on achieving a 50% reduction in road traffic deaths by 2030,” said Etienne Krug, director of the Department of Social Determinants of Health at the World Health Organization in a press release.

The announcement comes just a day before 1700 delegates – including over 80 country delegations led by Ministers of Transport and Health – plan to meet in Stockholm for a two-day forum co-sponsored by WHO on road traffic safety. The attendees will set global priorities for road traffic safety for the next decade and review lessons learned from the Global Plan for the Decade of Action for Road Safety 2011–2020.

Road traffic injuries are the number one killer of people ages 5-29. More than 1.35 million people die and up to 50 million are seriously injured in road traffic crashes each year. Some 15 countries account for 60% of all road traffic deaths globally.

“We should keep in mind that these deaths and injuries are completely preventable. After more than a decade of working with our international and in-country partners, we know which policies and interventions are saving lives,” said Kelly Henning, director of Public Health at Bloomberg Philanthropies.

The investment will help support implementation and enforcement of a package of “best-practice” interventions in up to 30 cities and 15 countries most impacted by the global road safety crisis:

  • Help governments regulate vehicle safety standards and raise consumer awareness to demand safer cars that meet the UN safety recommendations;
  • Reduce deaths on high-mortality roads such as interstate highways, through reduced speed limits, wider use of helmets and seatbelts, and reducing speeding and drunk driving;
  • Improve and enhance the collection of road crash data to more accurately capture fatalities and injuries, monitor the impact of policies, and prioritize interventions;
  • Launch the “Awards for Outstanding Excellence in Road Safety” to highlight countries and cities that have made progress in road traffic safety.

The new commitment builds on 12 years of previous investments by the foundation, which have resulted in at least 10 countries changing laws or policies to improve road safety.

Image Credits: Flickr/ M M.