The World Health Organization will convene an Emergency Committee meeting over the new coronavirus outbreak that began in Wuhan, China, after more than 300 new cases were confirmed since 17 January, including the first cases to hit other Chinese megacities and provinces. On Tuesday, the virus crossed the Pacific, with the first case in the United States confirmed in Washington State.

The Emergency Committee will meet Wednesday, 22 January, to determine whether the outbreak constitutes a “public health emergency of international concern” (PHEIC) under the International Health Regulations, WHO’s Director General Dr Tedros Adhanom Ghebreyesus said on Monday. An official PHEIC designation would ramp up global resources for the outbreak response, including establishing an official international expert group and WHO outbreak focal points in affected countries. Short of declaring such an emergency, the Committee may also provide recommendations for managing the outbreak as new information about the mysterious disease emerges by the hour.

Along with new reports of the disease in Beijing, Shanghai, and Guangdong Province, South Korea on Monday confirmed its first imported case of the pneumonia-like virus, dubbed 2019-nCoV. Taiwan soon followed suit, with the first case confirmed in a woman traveling from Wuhan on Tuesday.

The United States Centers for Disease Control released a statement Tuesday confirming the first case of the novel virus to cross the Pacific. A patient with recent travel history to Wuhan was tested for the disease after developing symptoms after returning to the US on 15 January.

Some nine people so far have died, and the number of total cases in China has exploded from 41 confirmed cases last Friday to 473 confirmed cases, according to a report issued in the evening Beijing time on Wednesday, by the Chinese state-owned news outlet CGTN.

In the latest update of the CGTN report, authorities said that they had confirmed at least 248 new cases in Wuhan and 12 in the surrounding province of Hubei, 5 new cases in Beijing, 14 in Guangdong Province and 1 in Shanghai, Officials are monitoring suspected cases in four other provinces. Tianjin, Guangdong city, and Henan province confirmed their first cases on Tuesday. The fear is of a much larger spread of the infectious agent, as China approaches its busiest travel season of the year during the Spring Festival.

Zhong Nanshan, the Chinese expert who discovered the deadly SARS virus in 2002, told state-run CCTV network on Monday that they had found the first cases of 2019-nCoV in 14 frontline healthcare workers – one of the groups at highest risk of contracting an emerging disease – confirming the presence of human-to-human transmission.

Wuhan authorities are encouraging citizens to wear face masks to protect against potential person-to-person transmission of the new viral disease.

A national working group of experts from the Chinese National Health Commission said in an official statement released Sunday that they believe the outbreak is “controllable,” and larger epidemic is “preventable. However, the statement notes that authorities are still lacking three key pieces of information to control the outbreak; the source of the outbreak, the dynamics of how the disease spreads, and the likelihood of the virus will mutate into a more transmissible or deadlier strain.

Academics say that the sharp uptick in numbers is consistent with a new report by researchers at Imperial College London that estimates the mysterious disease has already caused symptomatic infections in over 1,700 Wuhan residents since it was first reported in the city on 31 December 2019, while even more people may be asymptomatic carriers. The study modelled likely scenarios for infection in the city of 10 million people, based on documented reports of travelers who had become infected with the virus, total volumes of daily travelers visiting or transiting Wuhan, and a presumed virus incubation period of 10 days.

Imai et al. estimate the total number of 2019-nCoV infections

Experts believe that the original source of the infection were animal hosts sold in a Wuhan live animal market, with most of the original 41 cases reported on 13 January traced back to the Huanan Wholesale Seafood Market in Wuhan, which has been closed since January 1st for health related inspections. On Friday, the World Health Organization confirmed that environmental samples from the market had tested positive for 2019-nCoV – although the exact animal host is still unknown.

However, new cases emerging now have reported having no contact with that particular market. A 35-year old Chinese woman from Wuhan was hospitalized for flu-like symptoms after thermal surveillance at Icheon airport in Seoul, South Korea detected her fever. A statement released by the South Korean Ministry of Health and Wellness said the patient has so far reported no visits to live markets nor direct contact with any known cases while in China, although authorities are continuing to investigate her case.

Similar to the South Korean case, Japan and Thailand’s cases have reported no history of traveling specifically to Huanan Wholesale Seafood Market. New patients in Beijing and Shenzhen have likewise reported no contact with the live market. Still, all patients thus far have recently traveled in Wuhan – which experts say can indicate that either the animal source of the disease is found in more than one market, or person-to-person transmission may be a larger factor than initially suspected.

Once a new virus makes the jump from an animal species to people, it can also evolve to become infectious via human transmission, carried by sneezes, coughs, or other sharing of bodily fluids. That was the case in the 2002-2003 SARS outbreak – which caused over 8,000 cases and 774 deaths. So far, the new outbreak appears to be less fatal than SARS, but authorities and academics are concerned that the virus could mutate into a more deadly strain.

As of 22 January, the new pathogen – belonging to the same family of single-strand RNA viruses as the deadly SARS and MERS (Middle East Respiratory Syndrome) viruses – has claimed the lives of nine people with pre-existing health conditions. Some 17 people remain hospitalized in “severe condition” and 3 in “critical condition” according to a statement released by Wuhan authorities on Tuesday.

This story was published 20 January 2020. It was updated 22 January 2020.

Image Credits: Flickr/Nicolò Lazzati, Imai, N et al. 2019. Estimating the potential total number of novel Coronavirus (2019-nCoV) cases in Wuhan City, China.

The failed 2019 UN Climate Conference in Madrid ended in mid-December just about when the massive wildfire destruction of Australia’s bushlands was beginning.

The wildfires that broke shortly afterward took the form of a Gaia-like revenge.  Australia, along with the United States, Japan and Brazil, had been among the countries that had blocked real progress at the UN Conference of Parties (COP25) on a more realistic system of carbon emissions accountancy – that could track and ensure real progress on emissions reductions over the critical coming decade.

And the price exacted was almost immediate –  in terms of ecosystems and wildlife damaged, and ultimately human health and well-being.

Australia’s smoke plumes seen from space, rising from forests and bushlands in the southeast.

The converging problems of global warming, environmental degradation, and public health have been well-reflected in the bushfire destruction, along with a record drought in southern Africa, floods elsewhere, and off-the charts air pollution in Delhi, India, all occuring just as 2019 ended and the new decade of 2020 began. And therefore it is not surprising that climate has been placed at the top of the 2020 agenda by groups as diverse as the World Economic Forum (WEF), as well as the World Health Organization.

The Global Risks 2020 Report, released last week, just ahead the WEF meeting that begins Tuesday in Davos (21-24 January), notes “climate response shortcomings” as well as “biodiversity loss impacts” among the top two out of five categories of risks faced by the world for 2020.  “Creaking health systems” is listed as a sixth.

WHO has also listed the climate and health crisis as among the 13 top threats to global health in the next decade. Among the other threats highlighted by the agency – as well as by a range of experts interviewed by Health Policy Watch about the globala health outlook for 2020, include:

  • Emergence of new diseases at an increasing rate and intensity – as reflected in the Wuhan pneumonia outbreak;
  • Stalled action on medicines price tranparency – watch to see if European countries take a lead this year in adopting stronger measures;
  • Failing medicines markets contributing to the rise of anti-microbial resistance (AMR) – when prices for other vital drugs, particularly antibiotics, dip too low;
  • Non-communicable Diseases (NCDs) and Universal Health Coverage – how the global “syndemic” of obesity, undernutrition and climate change creates barriers to achieving UHC.

Digital health and AI technologies – which hold much promise for improving health, but also create new ethical challenges – were among the other issues cited by experts interviewed by Health Policy Watch. Long-simmering neglected diseases, often pushed to the sidelines of health agendas was another issue noted, as the world prepares to observe on 31 January, the first-ever World NTD Day.

The global shortfall of health workers, as well as gender challenges faced by women who dominate the lowest ranks of healthcare professionals, is another issue that will be highlighted prominently this year, which WHO member states have designated as “The Year of the Nurse and Midwife.”

Climate and Health

The real-world convergence of climate and health agendas has been playing out in the Australia story, which has left some 29 people dead, uncounted numbers of people displaced, and over 1 billion animals killed – driving some species to the brink of extinction. There has been a 30% increase in asthma cases and more children presenting with respiratory infections, Sydney doctors have reported. Scientists, meanwhile, have said that the long-term human health impacts of exposures to the air pollutants “won’t be known for years.”

Bushfire smoke over Sydney Opera House, 29 December 2019

But immediate health impacts were visibly demonstrated to global audiences during the initial, pre-qualifying rounds of the Australia Open, where the Slovenian Dalila Jakupović collapsed on the tennis court choking for air, and other stars also cancelled matches underway. Canadian Liam Brody later tweeted that players’ blood was “boiling” over the decision to continue the games in such hazardous air quality conditions.

Ironically, just four weeks earlier, as the December COP25 climate talks wound up, it was Indians in Delhi who were gasping for breath, and Australia was among the handful of countries to thwart a critical deal on how to count countries’ carbon reductions, in order to meet the pledges of the 2030 Paris Climate Agreement.

Along with Brazil and the United States, the conservative government of Prime Minister Scott Morrison, insisted on using carryover credits from the expiring 1992 Kyoto protocol, a loophole criticized by Costa Rica, New Zealand, France as something that would thwart accurate measurement of real progress, and even described as “cheating” by former French minister Laurence Tubiana, an architect of the 2015 Paris Agreement.

The Australia narrative illustrates the Global Risks Report finding that “climate response shortcomings” are among the top five risks faced in 2020. “Weak international agreements belie rising investor and popular pressure for action, against a multitude of natural catastrophes and indicators of longer-term disruptions,” the report states. “2020 is a critical year for nations to accelerate progress towards major emissions reductions and boosting adaptation actions.”

Smoke from a wildfire near Gosford, New South Wales, Australia turns the sunset an ominous red.

Experts have described Australia’s experience as just a taste of what to expect in the world’s most fire-prone continent from a changing climate. The year 2019 was the hottest year for the country on record, with average temperatures 1.5C° higher. Rising temperatures and lower levels of winter rainfall dried out bush and forest cover, which more readily become fuel for summer fires, occurring with greater frequency in the prolonged heat and drought conditions.

In just three months, Australia’s fires are estimated to have released 350 million metric tons of carbon dioxide, said climate experts quoted by the Sydney Morning Herald, warning that a century or more will be needed to absorb the carbon dioxide released. Drifting smoke from the fires has by now lapped around the world, and turned glaciers in nearby New Zealand brown – darker glaciers accelerate ice melt, in turn threatening the long-term stability of water reserves.

It’s also a record year for drought in Southern Africa with 12 countries affected, including Zimbabwe, Angola, Eswatini, Mozambique, and South Africa. The World Food Programme estimates a record 45 million people in Southern Africa are food insecure, including 5.1 million in Zimbabwe.  That face of climate change may have had even more dire, immediate, human health consequences. But there is no Australia Open playing in Harrare.

Climate & Health Lack Synergies

Within the broader spectrum of government failure, health and climate sectors remain disconnected –  sapping efforts to face a common threat to human health and well-being.

“The climate community lacks both the political leverage, the experience and the institutional mechanisms of the health sector—this expertise is badly needed for climate negotiations, but we don’t really work together,” lamented one senior European negotiator to Health Policy Watch, during the Madrid COP25.

He contrasted the high-profile October Global Fund Replenishment event in Lyon that had raised $US 14 billion to combat just three diseases, HIV/AIDS, TB and malaria, against the Green Climate Fund Replenishment conference that took place in Paris two weeks later. The latter raised less than US$10 billion for four years – and that was far short of the $US 100 billion in near-term climate finance that developed economies had pledged to channel to developing countries at the 2015 Paris Climate Conference.

Flavia Bustreo (left) with former UN Secretary of State John Kerry at COP25

“If you look at the Global Fund Replenishment, Emmanuel Macron, Bill Gates as well as Bono were all there,” lamented the negotiator.  “But who even heard about the Green Climate Fund event? Was there a Gates or a Macron or a celebrity like Bono?  No.”

In fact, behind the rhetoric, there are few formal institutional mechanisms to bring the knowledge, capacity and power of the health sector to bear on climate negotiations or to inform effective climate policies, at either national or global levels, he remarked.

One obvious reflection of that is the fact that year after year, attendees of the COP climate meetings include virtually no health ministers – with the exception of delegations that have been sponsored by WHO from time to time, from groups such as Small Island States, are faced with the virtual disappearance of their nations as a result of climate change.

This year, while climate delegates were huddling in Madrid in December, major health conferences were also going on in Brussels and in Oman, around non-communicable diseases. Meanwhile, WHO Director General Tedros Adhanom Gheyebresus was in Geneva putting the final touches on an organizational restructuring plan. WHO’s Maria Neira, who has won acclaim as the WHO’s lead on climate, health and environment, was pulled back to Geneva by the WHO Director General before the conference ended.

“With the exception of the Gender Action Plan, agreed by the end of the meetings, discussions did not bring to agreements and ended up in a disillusioned domain of unmet expectations,” reported Flavia Bustreo, chair of governance for the Interagency Partnership for Maternal, Newborn and Child Health, one of the few health officials to attend Madrid’s COP25.

She added that: “A low number of debates concerning the link between climate change and health suggests a low prioritization of what is now one of the biggest issues in this ongoing crisis.”

Grassroots Activists Target Finance & Fossil Fuel Producers

Outside the halls of debate, however, youthful protestors have been ramping up their campaigns against governments, fossil fuel producers, as well as their industrial and financial partners. Here too, Australia’s government has been a recent target, and tennis has even played a role.

Late last year, the Australian government approved the long delayed opening of the Carmichael open pit coal mine, the world’s largest, to supply fuel to India – just weeks before the bush fire emergency. The 447 square kilometre project owned by the Indian company Adani, has been hotly criticized by Australian environmentalists as a threat to the Great Barrier Reef.

Then in January, climate activists, including Sweden’s Greta Thunberg, called on the German engineering group Siemens to withdraw from the project; Siemens is to supply rail technology to transport coal from the mine. On Monday (January 13), Siemens rebuffed those calls.

Another prominent target has been Credit Suisse. In mid-December, in fact, the bank announced that it would stop lending for new coal-fired power plants, following on its decision to halt lending for new coal mine development. But the bank remains one of the world’s largest investors in fossil fuel companies with a US $57 billion portfolio, critics say. Swiss climate activists have called upon the bank, as well as its ambassador the billionaire tennis star Roger Federer, calling on them both to step back from fossil fuels.

Swedish climate activist Greta Thunberg at the Lausanne Climate Strike, 17 January 2020

Last Friday, Thunberg joined Swiss activists at a climate protest in Lausanne, at the end of a week where protestors ramped up a @RogerWakeUpNow campaign aimed at Credit Suisse and Federer, who is also competing in the Australian Open.

That followed a landmark Swiss ruling on Monday (13 January), where young activists associated with Lausanne Action Climat  were acquitted by a local court of CHF 21,600 in fines for storming a Credit Suisse office in 2018 with tennis rackets and balls. In an unprecedented decision, the judge declared that the urgency of climate action in the public interest outweighed their violations of the law.

A day later the protestors entered the Swiss offices of UBS, another major investor in fossil fuels, and dropped bags of coal on the floor.

“So far during this decade, we have seen no signs whatsoever that real climate action is coming and that has to change. To the world leaders and those in power I would like to say, that you haven’t seen anything yet, you have not seen the last of us. We can assure you that,” Thunberg told cheering crowds in Lausanne on Friday.

Such scenes may become more common throughout 2020 as youth activism, fueled by public concern over climate grows, while governments and industries try to carry on business as usual with fossil fuels.  As the next stop, Thunberg and other climate activists are heading to the WEF in Davos, to demand that financial leaders halt investments in fossil fuels.

“We don’t want these things done by 2050, 2030 or even 2021. We want this done now – as in right now,” Thunberg said in a Guardian Op-Ed published Monday (20 January) with other youth climate activists.  Since the 2015 Paris Climate Agreement, 33 leading banks have poured some $1.9 trillion into fossil fuels, the op-ed noted, and an International Monetary Fund report estimates that in 2017, the world spent $US 5.7 trillion in fossil fuel subsidies.

Although oil-producing Abu Dhabi rang in 2020 with a Futures Energy Summit devoted to clean energy, in fact investments in renewables in developing countries “plummeted” in 2018, according to a November 2019 MIT Technology Review.  Coal power production in 2018 reached an all-time high according the International Energy Agency. And across southeast Asia as well as parts of Southern Africa and the Middle East new coal power plant development continues apace, much of it driven by Chinese and Japanese investment.

Natural gas is also having a heydey. While less damaging than coal, natural gas development has often been at the expense of even cleaner solar energy sources, critics say. In the sun-drenched Mediterranean region, Turkey celebrated the New Year with the launch of a new natural gas pipeline connection to Russia; Israel launched its second major natural gas platform; and regional tensions heightened over conflicting claims between Turkey and Libya on the one hand, and Greece and Cyprus, on the other, to other potential Mediterranean gas reserves – creating new and dangerous sources of regional political tension.

Predicted future coal production capacity.

What To Watch in 2020

The 2020 Climate Conference in Glasgow on 9-19 November (COP26) will confront all of these financial and political forces head-on. This is when countries will gather to make new political commitments on emissions reductions. The European Union’s landmark agreement to reach net zero emissions by 2050, formally announced on 13 December, represented one important bright spot in the otherwise dim closing hours of the Madrid COP.  Significantly, that commitment was also accompanied by a €100 billion pledge in funding by the European Commission to help the ease the energy transition, particularly among some of the region’s most coal-dependent countries, such as Poland, as part of a European Green Deal Investment Plan that aims to attract €1 trillion in public and private finance over the next decade.

But the last hope for the global community to prevent temperatures from rising above 1.5°C still appears dim – if fossil fuel development across the rest of the world moves forward unabated, and the United States, which has announced that it will withdraw from the 2015 Paris Climate Agreement, follows through on that promise right after the US Presidential elections. Those elections are scheduled for 3 November, just days before the Glasgow COP26 commences.

Whether European leaders can and will wield sufficient muscle to convince the other big drivers of climate change to change course, including both high-income Australia, Japan and the US, as well as emerging economies led by the “BRICS” of Brazil, Russian, China and South Africa, remains an open question. Not only will COP26 be the year’s climax in climate policy-making – it could be the most decisive meeting for decades to come.

Leading up to that, observers can expect to see more youth-driven protests around Europe and elsewhere, and more civil disobedience.  It remains to be seen if this will capture the imagination of the broad public – or exacerbate social confrontations  with other interests, such as public opposition to higher fossil fuel prices. It was, after all, Emmanuel Macron’s earlier moves to raise fuel prices, which triggered the prolonged, and often violent, “Gilet Jaune” (Yellow Vest) protests seen in France over the winter of 2019, as well as civil disturbances in Africa and the Middle East on other occasions.

Also expect to see a series of protracted technical negotiations between countries over the new 2020 commitments to protect the world’s biodversity. Biodiveristy underpins what scientists call critical “ecosystem services” to health, such as food and fresh water supplies, sources of existing and future medicinal plants, as well as certain forms of natural regulation of infectious diseases.

At February meeting of the UN Convention on Biodiversity (CBD) in Kunming, China, technical experts will wrangle over proposed new targets for protecting the world’s seas, open spaces and species, hopefully paving the way for a new global agreement at the 15th CBD Conference of Parties in October. The agreement aims to halt the increasingly rapid decline and extinction of plant and animal species – after the 2010 CBD targets were largely missed.

Biodiversity loss is another topic on the Davos agenda, having been included among the top five risks in the Global Risks 2020 Report. The ways in which biodiversity loss threatens the stability of future food supplies and medicines discoveries, as well as other life support systems, are laid out in a WEF blog by a top official at Zurich Insurance Group – illustrating how an longtime scientific concern is now drawing attention from actors such as the insurance industry.

As for measuring progress on bringing health and climate agendas just a little bit closer together, watch out for where WHO’s top leadership will be in that critical week of November 9-19 – and what ministers of health, as well as rank and file doctors and nurses are saying and doing during Glasgow’s Climate Conference.

[First of two parts]  For Part II see this link

 

This story was published as part of Covering Climate Now, a global collaboration of more than 250 news outlets to strengthen coverage of the climate story, co-founded by The Nation and Columbia Journalism Review.

 

 

Originally published Friday 17 January, 2020.  Updated 20 January 2020

Image Credits: Wikimedia Commons/Rob Russell, Japan Meterological Agency/National Institute of Information & Communication Technology/Pierre Markuse, Wikimedia Commons/Nick-D, Flavia Bustreo , Twitter/@RogerWakeUp, CarbonBrief.org.

The low worldwide prices for antibiotics, combined with the need to carefully ration sale of any powerful new drugs that come to market to preserve their efficacy, continue to dampen industry investment in desperately-needed treatments for new drug-resistant superbugs, according to a sweeping new report by the AMR Industry Alliance, released today.

While civil society advocates have focused significant attention on the high prices of some new drug treatments for non-communicable diseases such as cancer, the AMR Industry Alliance Progress Report, sheds light on market forces playing out at the other end of the spectrum.

In this case, low market prices are thwarting efforts to bring promising new treatments to market, treatments needed to combat so-called “superbugs” – bacteria, viruses and parasites that are increasingly resistant to existing drug treatments.

The findings about investment trends and barriers should be a “wake-up call” for people concerned about rising antimicrobial resistance (AMR) in disease-causing pathogens, said Thomas Cueni, head of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) and Alliance Chair in a press release.

He added, “Discovering new and effective ways to leverage positive preclinical pipeline results and working together to ensure that late-stage antimicrobial drug discovery and development is better supported are vital.”

Pharmaceutical technician in sterile environment working on production of pills at pharmacy factory

The same market forces that are preventing new treatments from reaching the marketplace are also leading to increased shortages in some of the most common antibiotics, which billions around the world take for granted – although an estimated 5.7 million people die every year due to lack of access, the report states.

The massive new report, which tracks successes as well as setbacks in the global fight against superbugs across the range of AMR issues, is the synthesis of a detailed survey among 65 member companies of the AMR Industry Alliance, a group of life science companies dedicated to curbing the growing threat of superbugs.

According to the report, some $US 1.6 billion was invested by the private sector in 2018 in the development of new treatments that could help combat antimicrobial resistance, along with some $US 500 million in public funds. But that probably represents a flat trend, or even a decline over private sector investments in previous years, said industry experts interviewed by Health Policy Watch.

Investors are still funding pre-clinical discoveries of potential antibiotics, as well as new generation diagnostic tests, where there is a healthy pipeline. But little money is going towards funding costlier late stage R&D, such as clinical trials, the report finds.

Smaller biotech companies are especially struggling to secure investments that “will allow them to survive,” says Greg Frank, director of Infectious Disease Policy at the Biotechnology Innovation Organization, a member of the AMR Industry Alliance told Health Policy Watch, in an interview.

He described the chill cast over the industry after the biotech firm Achaogen went bankrupt, shortly after it brought a new antibiotic to market approval. This was followed by the filing of bankruptcy by Melinta, another biotech firm with a drug candidate in late stage development.

“While Melinta continues to operate during its restructuring, this doesn’t send a good signal to the investment community. It says, ‘this is an area that you should never touch’,” said Frank.

Frank explained that once new antibiotics are approved and brought to market, they are usually regulated to only treating the most drug-resistant diseases. While that may prevent resistance to the new drug from developing as quickly, this results in only small amounts of sales. Antibiotics are also expected to be priced lower than new drugs for other diseases such as cancer, so it is difficult for smaller companies to recoup the costs of R&D and manufacturing in the first few years after new antibiotic is approved.

Thus, Frank adds, many smaller firms will bring a product to mid-development, then “shop around” and sell their product to larger firms that have the capital to take on the risk of bringing a new antimicrobial to market.

However, with the exit of several large research-based biopharmaceutical companies such as Novartis, Sanofi, and AstraZeneca from the AMR drug development space in the past two years, smaller companies are no longer able to follow this model to secure investments.

That means that highly promising early-stage discoveries may never reach patients unless investment in later and more costly sages of R&D for these products is ramped up, and new government incentives for antibiotic research are enacted.

Further Downward Trend Predicted – Unless Public Sector Rewards Increase

The industry report predicts that investment in AMR R&D may see a downwards trend in the coming years unless governments enact new incentives to pull large pharmaceutical companies back into the space. Frank says that ultimately, small companies with potential novel compounds that could “treat a public health need” must also be able to incentivize investors and make a sustainable return on investments.

One potential solution, said Frank, is the creation of new types of “market-entry rewards” by the public sector that reward a company with an approved antibiotic that meets a specific criteria with some form of cash benefits or its equivalent.

On example of such a reward would be a more flexible formula for “exclusivity vouchers,” which extend the patented life of a product by a year and have been created in some countries to reward new drug innovations. If these were made transferable, they could be used by a company to protect another, more profitable product in its portfolio or sold – providing added return on investment.

Currently, these vouchers can only be applied to the approved antibiotic, said Frank, but for a medicine that is not very profitable, this creates little incentive to advance research and production:  “I once had a company tell me, ‘it’s great that we have it; now it gives me another 5 years to solely lose money on my medicine.’”

Diagnostics – Bright Spot on AMR Investment Horizon

The threat of drug-resistant superbugs has often focused on the “arms-race” between the development of stronger disease-causing pathogens and new drugs to fight them.

Lab researcher dripping test liquid in petri dish and checking reaction.

But the AMR report also highlights one brighter spot – the increased investment in new diagnostics development, which can play a critical role in reducing drug resistance.

Expanded use of diagnostics can help make sure that the “right tools” are available for the “right patient” at the “right time,” explains Jean-Louis Tissier, vice president of public and government affairs-AMR at the in-vitro diagnostics company bioMérieux, an AMR Industry Alliance member.

For example, it can be difficult to tell if certain diseases are caused by bacteria or viruses based on symptoms alone. Acute respiratory infections, which often present with cold-like symptoms, can be caused by both bacteria or viruses. But prescribing antibiotics for viral illnesses contributes to growing drug resistance without actually treating the patient effectively.

For instance, a simple lab test for the bacterial biomarker pro-calcitonin that takes less than one hour, can tell a physician if the patient has a bacterial infection; it can also help the physician decide for how long the patient might need antibiotic treatment. This test is being widely used in some European countries, such as Germany, he said.

“Today, you see an increase in [drug resistance] because in some countries there is overuse of antibiotics… if you go to the south of Europe or the US you can see an increase in resistance in patients who are over-prescribed with antibiotics,” says Tissier.

With new diagnostic tools becoming available, the next step is to support low- and  middle-income countries to invest further in diagnostic and laboratory capabilities that can use these tools effectively, said Tissier. “Health care facilities are looking at the most efficient systems, and these countries are where we need to demonstrate the economic and medical value of diagnostics solutions. Yes, there is a cost at the laboratory level [to do a diagnostic test], but at the hospital level diagnostics are a key source of savings.”

Going a step further, newer molecular biology diagnostics for conditions such as acute respiratory infections can provide clinicians with even more accurate information about the type of pathogen involved, as well as to which drugs it may respond, leading to faster, more appropriate treatments for patients.

 Addressing Antibiotic Shortages

The same market forces that are preventing new treatments from reaching the marketplace also are also leading to supply-chain shortages for some of the most common and critical antibiotics, which billions around the world take for granted, while millions of other people still lack access, the report finds.

“Continuity of supply of antibiotics is of paramount important and there are many elements needed to ensure this is the case, including supply chains with suppliers that have robust quality and environmental health and safety systems in place,” says Steve Brooks, chair of the manufacturing working group at the AMR Industry Alliance.

“Maintaining robust systems takes management commitment and money, and it’s these costs that may not be fully valued in the current procurement practices when antibiotics are purchased by large/institutional buyers.”

Shortages also are linked to low prices, which have prompted the withdrawal of many manufacturers from antibiotic production, leading to increased concentration in supply chains that can also create bottlenecks when just one manufacturer shuts down or fails to fill an order.

Solutions can involve what some have called the “Netflix” model of longer-term contracts between health systems and drug manufacturers, said Frank. This allows drug suppliers to rationally plan production and therefore supply, without fear of the sudden loss of a customer.

Environmental Concerns, and Other Challenges

On the enviromental front, where the release of antibiotic residues from pharma production facilities can foster development of drug resistant bacteria in sewage effluent, industry members are taking additional steps to control the release of such residues into the environment, the Alliance report says. Members are two years ahead of schedule in establishing a standard framework for limiting manufacturing emissions to “no-effect” concentrations within the next seven years.

“Alliance manufacturers are committed… to auditing their sites and those of their suppliers against the Alliance Common Antibiotic Manufacturing Framework and assessing concentrations of antibiotic residue in waste streams,” explained Brooks.

The framework dictates that for a factory supplying one million antibiotic tablets per year, the concentration of antibiotic in the collected waste water must be less than 1 microgram per litre. Effectively this would mean that residue concentrations released annually into wastewater effluent would not contain enough active ingredient for even one antibiotic tablet, he said.

So far, the findings show that 82% of participating companies’ antibiotics manufacturing facilities meet or partially meet the framework requirements. Those suppliers that don’t meet the standard are required to take action to reduce their antibiotic emissions, or potentially face losing their contracts.

“In the event changes are not not being made in a timely manner, members may look at alternate supply arrangements,” said Brooks.

Industry members have also made efforts to combat falsified and substandard antimicrobials; develop strategies to improve access to medicines in low-income countries; and formalize standards for appropriate use of antibiotics.

Together, the AMR Industry Alliance group of some 91 biotech, diagnostics, generic medicines, and research-based biopharma companies account for approximately one-third of the global antibiotic supply, and nearly half of the antibiotics in pre-clinical development, and half of the diagnostics sector producing AMR-related products.

Additional information about the report can be found at the AMR Industry Alliance.

Image Credits: AMR Industry Alliance.

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

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

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

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

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

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

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

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

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

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

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

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

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

Number of New Ebola Cases Stabilizes

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

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

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

A Red Cross team demonstrates a safe and dignified burial.

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

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

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

Story updated 17 January 2020

Image Credits: Arend Kuester/Flickr, IFRC.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Wholesale seafood and animal market in China.

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

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

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

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

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

Cats awaiting sale in a Chinese live animal market.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Strub-Wourgaft: No.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

 

 

 

Image Credits: DNDi.

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

WHO Executive Board meeting, 2019

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

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

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

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

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

Image Credits: William New.

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

Measles Immunization in DRC’s Kivu region

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

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

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

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

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

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

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

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

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

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

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

 

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

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

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

Wuhan, China

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 

Image Credits: Wikipedia .