US officials hand over the mpox vaccines to Nigerian health officials

Nigeria, accounting for just 1% of Africa’s confirmed mpox cases, has become the first African country to receive a vaccine shipment outside a clinical trial. 

This week, Nigeria received 10,000 doses of Jynneos, a vaccine manufactured by Bavarian Nordic and donated by the United States government.

“We are pleased to receive this modest initial donation of the mpox vaccine which is safe and efficacious,” Nigeria’s Minister of Health, Muhammad Ali Pate said. “We will continue to strengthen surveillance and be vigilant to prevent and control mpox.”

Leading up to the vaccine delivery, Dr Jean Kaseya, Director-General of the Africa CDC, confirmed that Nigeria was one of the two African countries to have issued regulatory approval for the vaccine’s introduction. 

Nigeria’s preparedness, marked by a robust vaccination plan, ensured its place at the forefront of receiving these doses.

According to Africa CDC’s latest epidemic intelligence report, nearly 21,000 suspected and fewer than 3,400 confirmed mpox cases have been reported across Africa this year. 

While the Democratic Republic of Congo (DRC) accounts for 95% of suspected and 90% of confirmed cases, Nigeria has only confirmed 40 cases and no deaths — a mere 1% of the continent’s total confirmed cases. 

Despite this relatively low number, Nigerian public health officials have raised the alert level and strengthened outbreak preparedness.

‘Very, very busy’

Dr Jide Idris, head of Nigeria’s frontline agency for disease prevention and control, the Nigeria Centre for Disease Control (NCDC), has had action-packed days since mpox was declared a public health emergency of international concern (PHEIC) – for the second time in two years.

The day after the announcement, Idris was too busy for interviews, his schedule crowded with preparations and briefings. 

The atmosphere at the NCDC’s head office was intense, mirroring the urgency felt across the country as teams worked tirelessly to monitor and coordinate response to multiple outbreaks. 

Meanwhile, requests for guidance on Nigeria’s mpox preparedness poured in. Between briefings for the health minister, press briefings and meetings with health commissioners from Nigeria’s 36 states, he found a few moments to speak to Health Policy Watch.

“It is very busy, very busy,” he said. “We do not have Clade 1b in Nigeria. All cases are Clade 2,” Idris said. 

Clade 1b is the new strain that is spreading fast in the DRC and neighbouring countries.

Idris outlined Nigeria’s three-pronged mpox response strategy: enhancing surveillance at ports of entry, boosting laboratory capacity for testing and genomic surveillance, and providing medical countermeasures (MCM) commodities.

Although mpox is currently classified as a PHEIC, the NCDC’s latest situation report for Nigeria shows a stable outlook: no surprises in case counts, no fatalities, and a consistent pattern in states reporting cases. 

There has been no change in cases since 18 August 18, when the cumulative case count for 2024 stood at 40 across 19 states. Only five states reported more than two confirmed cases: Bayelsa (5), Akwa Ibom, Enugu, and Cross River (4 each), and Benue (3).

Bayelsa, which reported the third highest number of confirmed cases (45) during the 2022 outbreak and ranked second the previous year, has consistently been among the top three states for mpox cases in Nigeria over the past eight years, except in 2020.

So far in 2024, children under the age of 10 years account for 35% of confirmed cases, followed by adults aged 31 to 40 years, who make up 20%.

“Before 2024, most of the confirmed cases were in young adults aged 10-40 years, with males being predominantly affected. In 2024, however, over 33% of confirmed cases are in children aged 0-10 years,” Idris told Health Policy Watch.

Beyond Nigeria and beyond vaccines

According to the official announcement, the 10,000 vaccine doses will be administered in a two-dose schedule to 5,000 individuals most at risk of mpox, including close contacts of confirmed cases and frontline healthcare workers. 

The vaccination exercise will primarily target the five states with recorded cases, with provisions for reactive vaccination in other states as needed.

With DRC not getting the first mpox shipment despite its central status in the outbreak, attention is on the global health players’ ability to let priority guide allocation and delivery of doses. 

Gavi CEO Sania Nishtar revealed that, aside from donations from the US government and the vaccine manufacturer, DRC can also access 65,000 doses of mpox vaccine from Gavi immediately after it makes a request to Gavi. 

However, Nishtar noted that the current supply of mpox vaccines will not be enough to reach everyone in Nigeria, the DRC or elsewhere that needs the shots hence the need to also bring attention to other areas, especially in the short term.

“The first response should be to boost areas such as surveillance, data collection, case management and community engagement: these important foundations are critical for helping us to understand and ultimately contain the outbreak,” Nishtar told Health Policy Watch.

Idris agrees. When asked what he thinks has uniquely positioned Nigeria to fully contain the spread of mpox without having to consider travel restrictions, he did not mention vaccine donations or any medical countermeasures. 

Instead, he acknowledged Nigeria’s vast experience in responding to multiple outbreaks including more fatal ones, and the “surge capacity” it has acquired already – capacity for coordinated response mechanisms, genomic sequencing and molecular diagnosis.

This is why Nigeria is one of the very few African countries reporting cases that do not have a wide gap between suspected and confirmed cases.

Image Credits: WHO.

A UNICEF staff member checks a polio vaccination shipment for Gaza’s vaccine campaign. The proliferation of untreated sewage and waste in wartime Gaza has led to the re-emergence of poliovirus.

BREAKING:  A massive polio vaccine campaign targeting some 640,000 Gaza children is now set to begin on Sunday, 1 September, with agreement by Israel for a three-day humanitarian pause in fighting, a senior WHO official said on Thursday. A second round of the campaign for the two dose vaccine is planned three weeks later. 

“We have had discussions with Israeli authorities and we have agreed to humanitarian pauses…for three days,” said WHO’s Dr. Rik Peeperkorn, speaking to reporters at a briefing at UN Headquarters in New York City.  “I am not going to say this is the ideal way forward. But this is a workable way forward…we have to stop [polio] transmission in Gaza and outside Gaza.”

“Of course, all parties will have stick to this. We have to make sure that everyday we can do this campaign in this humanitarian pause…it is an ambitious target of 90%, but the teams here are ready for it, we are ready to go,” said Peeperkorn.
He was referring to the nearly 11-months of Israeli-Hamas fighting that began 7 October with a bloody Hamas incursion into two dozen Israeli communities near the Gaza enclave in which 1200 people, mostly civilians, were killed and 240 people taken hostage. Following that, Israel launched a devastating invasion of Gaza in which some 40,000 Palestinians have died.
Against the backdrop of continued fighting, some 1.2 million polio vaccine doses reached the Gaza Strip on Sunday via Israel’s Kerem Shalom crossing, after arriving at Tel Aviv’s Ben Gurion airport the week before.
Inside Gaza, some 2,700 medical staff have been trained and poised for deployment at 400 vaccination points to ensure doses can be delivered to all eligible recipients in two stages, Palestinian health officials said.
Trucks carrying special refrigeration equipment for vaccine storage and transportation were also brought into the Gaza Strip by the United Nations Children’s Fund (UNICEF) last Friday. 

Distribution complicated by evacuation orders

UN agencies have pressed ahead with a planned polio vaccination campaign against the background of a rash of new Israeli military evacuation orders imposed on displaced Palestinians sheltering in designated “safe zones”.

Tens of thousands of Palestinians have been ordered move once again from parts of the central Gaza city of Deir al Balah as well as sections of Khan Younis in the south. The areas were among those previously designated by the Israeli army as humanitarian zones for the more than 1.2 million Gazans who have been internally displaced during the grinding war between Israel and the Palestinian Hamas.

“Mass evacuation orders are the latest in a long list of unbearable threats to UN and humanitarian personnel,” Under-Secretary-General Gilles Michaud said in a statement on Tuesday. 

“The timing could hardly be worse,” he added, referring to the polio vaccination programme that was about to start. 

Poliovirus was first detected in Gaza in late June by the Global Polio Laboratory Network. The virus was confirmed in six sewage samples from Khan Younis and Deir al Balah, cities in the south and centre of the 365 square kilometer Gaza Strip. 

In mid-August, three suspected polio cases in children were identified, Health Policy Watch reported, followed by the confirmation of one case in a 10-month old infant last week. As nine out of 10 polio cases are generally asymptomatic, the spread of the virus is likely far wider than reported cases. 

In response, WHO, UNICEF and UN Relief and Works Agency for Palestine Refugees (UNRWA) organised a vaccination campaign targeting over 640,000 children.  

Delaying the vaccinations would have serious consequences, Dr Hamid Jafari, the director of the WHO’s polio eradication programme in the Eastern Mediterranean warned on 23 August.

“The risk of this virus spreading into Israel, into the West Bank and into surrounding countries like Lebanon, Syria, Egypt and Jordan is high. So we need to act fast.”

Humanitarian pauses

To reach the intended vaccination target and gain better population immunity, WHO and other UN agencies had appealed for at least two humanitarian pauses of seven days to deliver the vaccine doses.

The pause in the grinding 11 month Israel-Hamas war is necessary to ensure a cold chain of the vaccines, as well as to guarantee the safety of patients reaching healthcare points and the right timing of the second dose, officials have stressed.

The operation in a conflict zone will be complex, and its outcomes will depend on the conditions on the ground, Sam Rose, Senior Deputy Field Director for UNRWA in Gaza stressed in a statement Monday. 

UN agencies and partners “stand ready to vaccinate children, but need a humanitarian pause. We and the rest of the system involved will do our absolute utmost to deliver the campaign,” Rose said, “because without it, the conditions will be much worse sadly.”

Overcrowding

Polio is a highly infectious viral disease largely affecting children younger than five years of age. It spreads between humans by a fecal-oral route or, in the minority of cases, through contaminated water or food.

One in 200 infections causes permanent paralysis and, in 2-10% of the paralysed, death. While there is no known cure for polio, the disease was mostly eradicated in the World Health Assembly-initiated Global Polio Eradication Initiative starting 1988. 

In some cases, the weakened virus present in the oral polio vaccine (OPV) can mutate and spread in communities not fully vaccinated against polio, especially in poor hygienic conditions or in overcrowded areas. The longer it is allowed to circulate, the higher the chance for further mutations, creating concerns about a large-scale outbreak.

Updated 29 August, 2024.  Elaine Ruth Fletcher contributed to reporting on this story. 

Image Credits: UNICEF.

Dr Faustine Ndugulile (centre) flanked by outgoing WHO Africa

Tanzania’s Dr Faustine Ndugulile has been nominated as the next Regional Director for the World Health Organization (WHO) African Region, defeating more experienced WHO insiders in a closely contested race.

Ndugulile secured 25 of the 46 votes at the WHO Africa regional conference in the Republic of Congo, defeating Dr Ibrahima Socé Fall (proposed by Senegal), Dr Richard Mihigo (proposed by Rwanda) and Dr Boureima Hama Sambo (proposed by Niger). 

Socé Fall has a high-profile position at WHO headquarters in Geneva and Mihigo has held global positions in the vaccine alliance, Gavi, and WHO.

Ndugulile, a former deputy health minister and ICT minister in his country, has represented the Kigamboni constituency in Dar Es Salaam as a Member of Parliament since 2010 and chairs the country’s parliamentary health committee.

He is also vice-chair of the global Inter-parliamentary Union’s advisory group on health. 

Aside from a medical degree, 55-year-old Ndugulile has a Masters degree in public health and a law degree. 

While representing Tanzania at the Pan African Parliament from 2015 to 2018, he chaired the Inter-Parliamentary Union (IPU) Advisory Group on Maternal, Child Health, Newborn, and HIV/AIDS from 2015 to 2017. 

In his CV, Ndugulile lists his notable achievements, including “championing the passage of the Universal Health Insurance Bill in 2023, advocating for the implementation of an integrated and coordinated community health worker program and successfully advocating for the ratification of the African Medicine Agency (AMA) convention”.

Describing himself as a “technocrat, politician and policy maker”, Ndugulile has promised to I “prioritize strengthening of WHO country offices to ensure timely, relevant, optimal and effective support to the member states”.

His nomination will be submitted to the WHO Executive Board meeting in January 2025, and he is expected to take office in February 2025 for a five-year term.

Ndugulile will succeed Botswana’s Dr Matshidiso Moeti, who has served two five-year terms at the helm.

“Dr Ndugulile has earned the confidence and trust of the Member States of the region to be elected the next regional director for WHO Africa. This is a great privilege, and a very great responsibility,” said WHO Director General Dr Tedros Adhanom Ghebreyesus. 

“I and the entire WHO family in Africa and around the world will support you every step of the way.”

Tedros also thanked Moeti “for the example she has set, and the legacy she has left”.

Moeti congratulated Ndugulile, describing the position as “extremely fulfilling”. 

“Despite the many challenges, I know you will take the baton and go on to accelerate the gains already made, putting the health and well-being of the people of Africa at the centre,” said Moeti.

The 50 cities evaluated in the City Heartbeat Index.

Hong Kong and London topped the list of 50 cities ranked for their efforts to prevent and address cardiovascular diseases – while Kathmandu and Cairo languished at the bottom.

The City Heartbeat Index is a first-of-its-kind initiative of the World Heart Federation (WHF), a Geneva-based non-profit that works on cardiovascular disease (CVD) prevention.

CVD is one of the top causes of death worldwide, according to the World Health Organization (WHO).

Preventing them could significantly improve public health and quality of life for the population living in a city.

The index evaluated cities using 44 indicators including social determinants of health such as poverty, environmental factors such as air quality, and health risks like hypertension, access to health services and health policies.

It used data from city government websites, health departments and published literature, along with interviews with local experts to validate findings and fill information gaps.

“This is the first attempt of this kind, and more importantly that it is going to enthuse the governments or the non-governmental organizations or the local bodies to be trying to do better,” said Dr Jagat Narula, president-elect of the WHF. “We are talking about the heartbeat index here, but it is actually going to give you a much broader vision and much better chances of working towards policies.”

While there were a few exceptions, cities in Asia and Africa performed the worst. Even high-income cities such as Riyadh and Kuwait City ranked poorly.

Hong Kong and London topped the list of the City Heartbeat Index.

“I am extremely proud of the work we have done to make London a healthier place to live. We have made real progress improving health outcomes by taking old polluting cars off our roads and bringing cleaner air to millions more Londoners, enabling more walking and cycling and promoting healthier food advertising on our transport network,” said London mayor Sadiq Khan.

The burden of CVD is driving action

Of the 10 highest scoring cities on the Index, four (Berlin, Toronto, Helsinki and New York City) are in countries with high burden of CVD.

Access to universal healthcare has also helped cities’ ranking.

“It is the factors of what is the will, how much is the advocacy, how the policy has resulted in all those things, whether there is a universal care. Or the National Health schemes, for example, in London and Madrid and other places where the healthcare is available to all,” Narula told Health Policy Watch.

Some cities in middle-income countries like Sao Paulo in Brazil and Bogota in Colombia have also done well, said Narula, emphasizing that resources are not a constraint when there is will.

Critical data is still missing

However, critical data is missing to evaluate cities. Few cities have data on food security (42%), cholesterol (22%) or transfat consumption (14%) – key risk factors for CVD.

This data would provide the first step in understanding the scale and scope of how key risk factors are affecting populations.

Only Jakarta and Singapore had data available for all 12 sub-indicators included in the Index, demonstrating intent to understand and address the factors affecting cardiovascular health.

Percentage of cities for which data are available on key factors impacting CVD risk

Cities prioritise some risk factors over others

Based on the average scores across the key CVD risk factors, cities most often prioritise diabetes (78.9), tobacco use (66.5), hypertension (63.0) and obesity (62.9).

High scores on these indicators are due to the presence of city-level data.

Other key risk factors, including levels of consumption of vegetables (45.8) and trans fats (53.9), and levels of physical activity (60.4) and cholesterol (31.8), have lower scores, which may indicate fewer city-level efforts to monitor and address these health concerns.

“The City Heartbeat Index shows that the many efforts by cities – where over half of the world’s population resides – on heart health are visible and increasingly important,” said Dr Vasilisa Sazonov at Novartis who sponsored the index.

“There are opportunities to improve data collection at the city level including prioritising CVD risk factors that have typically been overlooked such as high cholesterol,” said Sazonov.

Worsening climate impacts like heat were not a part of the report this year but Narula said that the indicators will evolve.

Image Credits: City Heartbeat Index Report.

Children are vulnerable to mpox due to contact with infected animals and poor immune systems.

The government of Japan is preparing to send donations of mpox vaccines to the Democratic Republic of Congo (DRC), the epicentre of the global outbreak, according to the Africa Centre for Disease Control and Prevention (Africa CDC).

The Japan-based KM Biologics makes LC16, the only mpox vaccine currently licensed for children. This is essential for Africa up to 60% of cases in the DRC and 43% in neighbouring Burundi are children under 10.

Most of the children infected in the eastern DRC are malnourished, which means that their immune systems are weak and susceptible to mpox infection.

Vaccine donations are also underway from the European Union (215,000 doses), the US (15,000) and Gavi (5,000), and the first vaccines expected to land on the continent next week, Africa CDC Director-General Dr Jean Kaseya told a media briefing on Tuesday. 

Bavarian Nordic’s Jynneos (also called MVA-BN), is the other vaccine expected. This is not yet licensed for use in children but the company said it had recently submitted clinical data to the European Medicines Agency “to potentially support the use of the mpox vaccine in adolescents (12–17-year-olds)”. 

This follows a clinical study involving over 300 adolescents completed with the US National Institute of Allergy and Infectious Diseases (NIAID).

“Furthermore, through a collaboration with the Coalition for Epidemic Preparedness Innovations (CEPI), the company will shortly initiate a clinical trial to assess the immunogenicity and safety of MVA-BN in children from 2-12 years of age, aiming to further extend the indication of the vaccine into younger populations,” the company added.

Bavarian Nordic confirmed that it was working on tech transfer to enable African manufacturers to make the vaccine, which Kaseya told the briefing would involve the end process of “fit and finish”.

The African Union has made $10 million available to address the outbreak, and this is being used to prepare countries to receive and distribute the vaccines and improve surveillance, said Kaseya.

Gabon reports first case

Meanwhile, Gabon is the latest country to report an mpox case as cases continue to rise on the continent – up almost 2000 to 22,863 cases since last week.

However, Kaseya said that the Africa CDC was concerned that this was an undercount given weaknesses in surveillance, with some countries only able to test around 18% of suspected cases.

To address this, Africa CDC is deploying 72 epidemiologists to the outbreak hotspots to enhance surveillance and data quality.

Kaseya also confirmed that the Africa CDC had met close to 200 partners to galvanise support for mpox response, and had been assured via a foreign ministers’ forum that Western countries would not impose a travel ban on people from outbreak areas.

Kaseya also said that Gavi and UNICEF had been given the go-ahead from the World Health Organization (WHO) to procure vaccines for the continent even though the outcome of the WHO’s emergency use listing (EUL) of the two mpox vaccines was only expected in mid-September.

The EUL procedure fast-tracks unlicensed medical products in public health emergencies. As the vaccines are already licensed in the US and European Union so the EUL is likely to be issued.

The WHO has been criticised for being too slow to evaluate potential mpox vaccines already approved by the US and Europe, thus leaving Africa dependent on donated vaccines.

“Currently, we are putting all African countries’ efforts in one basket. This is why we say we are finalizing the response plan, and we have a meeting in September where countries will also pledge funding [for the outbreak],” said Kaseya.

Image Credits: Tessa Davis/Twitter .

Dr Tedros addressing the WHO Africa regional meeting on Monday.

The World Health Organization (WHO) will decide on whether to issue an emergency use listing (EUL) for an mpox vaccine within three weeks after its manufacturer supplied the global body with all the required information last Friday, Director-General Dr Tedros Adhanom Ghebreyesus told the opening of the WHO Africa regional conference on Monday.

The WHO has been criticised for being too slow to evaluate potential mpox vaccines already approved by the US and Europe, thus leaving Africa dependent on donated vaccines.

Africa’s biggest vaccine procurers, Gavi and UNICEF, are unable to buy vaccines without either EUL or full WHO approval.

The EUL procedure fast-tracks unlicensed medical products in public health emergencies, and Bavarian Nordic’s Jynneos (also called MVA) and Emergent BioSolutions’s ACAM2000 vaccines have both been recommended for consideration by independent health experts. 

Continent needs $135 million for mpox

Tedros added that it will take around $135 million to bring the current mpox outbreaks in Africa under control, requiring “a complex, comprehensive and coordinated international response”. 

The WHO also published a Global Strategic Preparedness and Response Plan for mpox on Monday setting out steps to address the outbreak. 

“So far this year, more than 18,000 suspected cases of mpox, with 615 deaths have been reported in the Democratic Republic of Congo alone, already exceeding last year’s total, which was itself a record,” Tedros told the meeting, which is being held over five days in the Republic of Congo (Brazzaville).

“Of particular concern is the rapid spread of a new strain of the virus that causes mpox called clade 1b in the countries. In the past month, more than 220 cases of clade 1b have also been confirmed in four countries neighbouring DRC, which had not reported mpox before, Burundi, Kenya, Rwanda and Uganda.”

Tedros also commended the WHO Africa region for improvements in primary healthcare across the continent, as well as a 50% increase in funding for the WHO provided by member states.

“District Health Systems have been strengthened. Access to essential medicines is improving. The capacity of the health workforce is increasing, and community health communities are functioning effectively,” said Tedros.

Conference praises outgoing director

Dr Matshidiso Moeti, outgoing WHO Africa regional director

Botswana’s Dr Matshidiso Moeti, the outgoing WHO Africa regional director, told the conference that “economic difficulties, which include debt servicing, growing wealth inequalities and conflicts, are slowing down investment in priority health programmes”.

Poorer African countries are experiencing “deteriorating conditions below 2019, pre-pandemic levels”, making it “even more difficult to achieve the sustainable development goals health targets”.

“As a region, we must unite and encourage the rest of the world to join forces against the major threats of the 21st century, especially climate change, the next pandemic and non-communicable diseases,” Moeti urged.

“These threats, demand, international collaboration. They require government leadership and the public and private sectors to work together with fairness.”

Moeti added that the WHO country teams are “working on the frontline to help reinforce measures to spread to to curb the spread of mpox”, and in partnership with the African Union, “we continue to advocate for the necessary diagnostic therapeutic tools and vaccines”.

Moeti also raised the emigration of African health workers, and called for the implementation of the Africa Health Workforce Investment charter which was luanched in May.

“In Uganda, the immigration of doctors increased by 16% in three years, while in Zimbabwe, during the same period, over one in five doctors has left the country in May,” Moeti noted.

Moeti, who was appointed in 2015 and served two terms so is not available for re-election. She has overseen WHO’s operations through trying circumstances, including Ebola outbreaks and the COVID-19 pandemic.

“Never before has healthy life expectancy been so high in the African region. Never before have fewer young children died each year, or fewer women died of maternal causes. Never before have we responded to emergencies in so short a time. Never before have malaria vaccines been introduced into routine child immunization schedules in Africa, and this after centuries of waiting,” said Moeti, who described her term as the “highest honour of my life”.

Dr Matshidiso Moeti, the outgoing regional director, who served the continent for 10 years during some of its toughest challenges, gets a standing ovation at the WHO Africa regional conference.

Tedros described Moeti as “one of the most formidable health professionals I have ever had the privilege to call my colleague”.

“She is not afraid to tell you exactly what she thinks, but she does it because she cares. She cares deeply about the people of our continent and the people of the regional and country offices. She believes that the people of Africa deserve nothing but her best, and that’s what she has given for the past 10 years,” said Tedros.

“Under the leadership of Dr Moeti, WHO Africa region has been leading a transformation agenda to ensure that the organisation is accountable, effective, and driven by results,” said Botswanan health minister Dr Edwin Dikoloti.

“In this regard, we are pleased that many countries have now undertaken reforms to improve health financing and the delivery of quality essential health services.” 

Hotly contested leadership race

On Tuesday, the conference will elect a new regional director with five males candidates contesting for the position. 

Senegalese Dr Ibrahima Socé Fall, proposed by his home country, is currently the WHO director of Global Neglected Tropical Diseases (NTD). 

Dr N’da Konan Michel Yao, proposed by his home country of Côte d’Ivoire, has been WHO Director of Strategic Health Operations since August 2020, where he coordinates the body’s response to health, natural and humanitarian disasters.

Dr Richard Mihigo, proposed by Rwanda, is currently senior director of programmatic and strategic engagement with the African Union and Africa CDC. 

Dr Boureima Hama Sambo, proposed by Niger, is WHO’s Representative to the Democratic Republic of the Congo as Head of Mission. 

Dr Faustine Engelbert Ndugulile, proposed by Tanzania, was that country’s Minister for Communication and Information Technology between December 2020 and September 2021 and has also served as a deputy minister of health.

 

Air pollution remote sensor India
Remote sensing equipment and camera capturing real-world emissions data of vehicles as they drive by. The data is then matched with the transport department’s database using the registration number clicked by the camera.

New Delhi’s decades-old regime to control vehicular pollution, including a heavy reliance by commercial vehicles on compressed natural gas (CNG) fuel, has been challenged by a new study by the International Council on Clean Transportation (ICCT). 

The report upends the narrative the that CNG is a ‘clean’ fuel, pointing to its high level of health-damaging emissions of nitrogen oxide (NOx), which can damage children’s lung development and contribute to a range of chronic lung diseases.

The report is based on innovative remote sensing technology that monitored actual traffic flows. Its results challenge two critical policy interventions: the mandate for buses and taxis to use CNG, as well as a Pollution Under Control Certificate (PUCC) surveillance system.

Electric bus in India
ICCT calls for replacing CNG with zero-emission vehicles.

The PUCC requires every fossil-fuel powered vehicle to undergo regular emissions checks, with car owners facing fine if they do not have an up-to-date certificate. 

However, the ICCT report highlights how the PUCC inspections fail to capture emissions of the two biggest polluters – NOx and Particulate (PM2.5) – as well as failing to reflect the level of real-time emissions on city roads.

Its authors point out that both automobile tech and air pollution monitoring have become a lot more sophisticated and the PUCC tech has not kept up. 

Vehicle emissions, according to some estimates, contribute as much as 38% to Delhi’s pollution. 

Famous for exposing ‘dieselgate’

The ICCT is famous for exposing Volkswagen for falsifying real-time data on NOx vehicle diesel emissions in its reporting  to the US Environmental Protection Agency in 2015. The scandal, widely known as ‘Dieselgate’, led to a global reconsideration of diesel engines and their health impacts, in terms of excessive particulate emissions as well as NOx.

It conducted this India study on CNG vehicles with the support of the local transport and police departments in Delhi and Gurugram, on its southern border. The two cities are among the 20 most polluted globally. 

“For the first time in India, we have collected significant emissions data from motor vehicles on the road and it is crucial to remember that what impacts our air quality is not the laboratory emissions but the pollutants released by these vehicles when they are in operation. Therefore, it’s time to reimagine our emissions testing regime and aggressively push for the adoption of zero-emission vehicles,” said Amit Bhatt, India managing director of ICCT.

Dehli air pollution sources graph
Why road transport emissions are important to tackle air pollution in Delhi.

CNG is not a ‘clean’ fuel

According to the study, CNG vehicles emitted very high levels of nitrogen dioxide and other oxide of nitrogen  (NOx) emissions, challenging the narrative that CNG is a ‘clean’ alternative fuel.

NOx causes shortness of breath, irritation in the eyes, nose and throat in acute exposures. But there’s also substantial evidence of excess rates of asthma and impeded lung development amongst children growing up along busy highways where NOx emissions are high. Chronic NOx exposure can lead to the development of a range of lung diseases in the long term. For example, some light goods vehicles, commonly seen ferrying vegetables and other supplies in the city, emit up to 14.2 times their lab limits, and taxis are four times. 

“This shows that while the CNG transition has helped cut toxic particulate emissions from diesel vehicles during the early years, NOx emissions from on-road CNG vehicles without adequate controls can be high. This builds a case for the next big transition to electrification to make tailpipe emissions not cleaner but zero,” said Anumita Roychowdhury, executive director of the Centre for Science and Environment, one of India’s foremost air pollution experts.

The report found that tougher engine standards have helped reduce NOx emissions. The latest Indian standard, Bharat Stage 6 (BS6), which is comparable to a Euro 6 engine, shows a reduction in real-world NOx emissions from private cars of 81% and buses by nearly 95% as compared to Bharat Stage 4 (comparable to a Euro 4). Of the over 110,000 vehicles sampled by the ICCT study, 55.5% are BS 4, and 33.5% are of BS 6. (See figure below.)

 

Proportion of fleet at Bharat Stage 1 to Bharat Stage 6 , in ICCT study.

Commercial vehicles pollute more than private cars

One clear trend the study identifies  is that commercial vehicle emissions are higher than private vehicles. 

In the BS6 four-wheeler category, light goods vehicles (LGV) had five times higher NOx emissions, seven times higher carbon monoxide emissions, and five times higher hydrocarbon emissions than private cars.

Meanwhile, in comparison to taxis, light goods vehicles had double the NOx emissions, six times higher carbon monoxide emissions, and four times higher hydrocarbon emissions.

However, commercial taxis were consistently far more polluting than private cars within the passenger car segment, indicating poor maintenance. There were also multiple instances where three-wheelers, mostly running on CNG, had higher emissions than passenger cars.

Innovative remote sensing technology 

ICCT used a remote sensing technology to measure the emissions of vehicles on roads as they drove past the sensors. At each of the 20-odd sites, machines about the size of large microwave ovens were placed on either side of a road lane. It took a split second to capture the emissions data. Simultaneously, a camera snapped a picture of the vehicle and licence plate. The emission data was matched with the registered vehicles database. Over 110,000 vehicles were monitored across four months in early 2023.

Remote sensing equipment and camera capturing real-world emissions data of vehicles as they drive by. The data is then matched with the transport department’s database using the registration number clicked by the camera.

Now, the ICCT is calling for the remote sensing system to be implemented as a regular monitoring system. It points out how air pollution has shut down schools in Delhi and Gurugram and how harmful it is to human health and the local economy.

Current vehicle pollution-check system unreliable 

While the ICCT says the system can complement the over two-decade-old PUCC system, it could render the PUCC obsolete. The latter does not measure on-road emissions; it only measures when the vehicle is parked. 

The PUCC monitors CO and HC but not particulate matter or NOx, which are major contributors to pollution in this region. 

There also are concerns that the PUCC data can be manipulated, especially in states where it’s recorded manually. The low failure rates, the report says, suggest a need to reconsider the reliability and authenticity of the tests. All of this suggests a broken system.

ICCT’s presentation on the real-time sensing points out gaps in the current vehicle pollution control regime.

Swagata Dey, an air quality policy specialist at the Centre for the Study of Science, Technology and Policy (CSTEP), has spent years studying the PUCC system.

She says this is “not effective in controlling real-world emissions. So, in this case, the remote sensing technique is welcome, but we also have to find a way to scale up the process… Further, we have to ensure that results from such methods are acceptable in the court of law.  Without this [legal recognition of the remote sensing technology], vehicles cannot be asked to comply with this test for obtaining PUCC certification.”

The policy stage, however, has been long set for the wider adoption of a more accurate pollution monitoring regime. India’s Supreme Court, the National Green Tribunal, India’s top dedicated environment court and federal pollution control agency, have all called for implementation of more accurate vehicle surveillance for some years. 

ICCT’s table shows how the remote sensing tech compares with India’s emissions compliance test, the PUCC.

Kolkata authorities have been using remote sensing since 2009, the study’s authors point out, even initiating action against vehicle owners based on readings. 

Globally, the system has been used extensively in places like London, Paris, and Hong Kong. 

What the ICCT report offers is new scientific evidence to overhaul or even replace the PUCC regime. It also challenges the notion that CNG can serve as an alternative, clean fuel to diesel and petrol.

For about two decades both concepts have been the bedrock of policy action to reduce vehicular pollution, a significant contributor to India’s air pollution crisis.  Debunking these misconceptions, can jump-start the dialogue about truly sustainable solutions. 

Image Credits: ICCT, Chetan Bhattacharji/HPW.

How did vaccines, once hailed as essential tools for global peace, security and international cooperation, become something that some now fear could kill them?

This is the focus of the latest episode of the Global Health Matters podcast, hosted by Garry Aslnyan. In an interview with author Peter Hotez, the discussion delves into how misinformation and politics, particularly in the United States, have led to a deadly distrust of vaccines.

Hotez and his colleague, Maria Elena Bottazzi, were nominated for the Nobel Peace Prize for “their work to develop and distribute a low-cost COVID-19 vaccine to people of the world without patent limitation.” Hotez is a vaccine scientist, biochemist and paediatrician from Texas. He also wrote several vaccine-related books, including “The Deadly Rise of Anti-Science.”

Aslnyan said vaccines are “one of the most powerful biotechnologies ever invented. It has not only had an effect on life expectancy, as we know, but also, it’s a vital tool for peace, global security and international cooperation.” Yet — and this is the topic of the “Dialogues” podcast — when COVID-19 hit, the situation rapidly changed. By the summer of 2021, there were calls to be defiant against vaccines, Hotez told Aslnyan.

“What happened was that under the banner of health freedom, medical freedom, elected leaders from a political party were telling people, we’re railing against vaccine mandates pushing against the idea of vaccine mandates, but they took it a step further,” Hotez said. “They not only tried to discredit vaccine mandates, but they tried to discredit the effectiveness and safety of the COVID vaccines themselves, and by crossing that line, they basically convinced hundreds of thousands of Americans, millions of Americans, predominantly in conservative parts of the United States, Texas, Oklahoma, Arkansas where I am, not to take a COVID vaccine during the Delta wave.

“So, they were unvaccinated. The results were, again, predicted and predictable,” he continued. “My estimate is 40,000 people in my state of Texas needlessly died because they refused a COVID vaccine.”

From Scientist to Public Enemy

In his book, Hotez describes how he received “dark emails or tweets on a Sunday that ominously warn of patriots hunting me down.” He said, “I never imagined a segment of society turning against me or my scientific colleagues. It is still almost unbelievable how many Americans now view us as enemies.”

He noted that this phenomenon has spread beyond the United States, reaching Africa, Latin America, and Europe. The concern now is that it could also take root in low- and middle-income countries.

“This is a full-on negative global force. I worry now that it’s not stopping at COVID-19; it’s spilling over into childhood immunisations,” Hotez told Aslnyan.

Hotez said that he called out the far right for contributing to the unnecessary deaths of 200,000 Americans for political reasons, “it’s not misinformation or the infodemic as though it’s just some random junk on the internet; it’s organised, strategic, deliberate, well-financed, politically motivated and it’s killing people.”

This misinformation about vaccines has entered a new phase. Instead of acknowledging that people died because they didn’t get vaccinated, some now claim that the vaccine itself caused deaths. There is also the theory that scientists created the COVID-19 virus through gain-of-function research. Hotez emphasised that both of these ideas are baseless.

However, he said the public health community also had to take responsibility for where it failed, which was around communication about the vaccines.

“I could do a whole hour podcast with you on the ways in which we could have communicated better,” Hotez told Aslnyan, “but that, in my view, accounts for 10 to 20% of the problem at most because what was really going on were bad actors weaponising all of this.”

And, as he concludes with an excerpt from his book, “This will only get worse.”

Listen to the Global Health Matters podcast on Health Policy Watch.

Visit the podcast website.

Image Credits: TDR Global Health Matters Podcast.

monkeypox
Patient in a clinical trial of Tpoxx, an antiviral treatment for the mpox virus, in the Democratic Republic of Congo.

With the number of new mpox cases continuing to rise, and many more potentially undetected, African countries affected by the latest outbreak are racing to mobilize funds and urgently deploy medical countermeasures, including vaccines.

But as the current epidemic unfolds, there is an undeniable feeling of déjà vu. Global efforts are falling short of what is needed to mount an urgent, well-coordinated response to curtail the crisis.

The world learned several lessons from COVID-19. But barring some areas of incremental progress, these lessons have yet to be translated into concrete actions.

Below we look at the global response to the latest mpox outbreak to date, zooming in on three specific dimensions that pose the key challenges. These include:  the dynamics of the emergency declarations issued by WHO and African Centres for Disease Control and Prevention (Africa CDC); the incremental progress of surge financing; and the slow and fragmented start to procurement and delivery of medical countermeasures.

Emergency declaration – empowered regional decision-making, but continuing issues with WHO’s ‘binary’ approach 

African Union states reporting mpox cases as of 20 August 2024; Africa CDC has taken a leading role in outbreak response.

On August 13, the Africa Centers for Disease Control and Prevention (Africa CDC) officially declared the ongoing mpox outbreak a Public Health Emergency of Continental Security (PHECS). This was the first time a regional institution had made such a declaration, marking a significant milestone in the empowerment of African institutions to lead and coordinate responses to public health threats.

The World Health Organization’s (WHO) declaration of a public health emergency of international concern (PHEIC) followed the next day. The decision, meant as a signal to donors to step up resources to curtail an outbreak, was made earlier than in previous outbreaks. In comparison, during the 2022 mpox outbreak, the declaration came after approximately 16,000 cases were reported across 75 countries. In contrast, the 2024 declaration was made before the virus had spread beyond Africa, signaling a more proactive approach.

While the regional and global declarations were aligned in this case, questions remain about what happens if decisions do not sync up.

This underlines the ongoing need to improve the WHO “trigger” mechanism for a PHEIC.  It needs to shift from a binary approach [global declaration vs. no declaration at all] to a tiered system reflecting the severity of a pathogenic outbreak, along an ‘epidemic scale‘ like hurricane or earthquake scales, which can serve as a more nuanced trigger for different types of responses.

Surge financing: incremental progress but not yet fully operational  

Mpox vaccine needs versus donations and deliveries to date.

The need for adequate surge or at-risk financing is arguably one of the most salient lessons from COVID-19. G7 and G20 leaders have recognized its importance and several funds and initiatives, including various Development Finance Institutions and the Africa Epidemics Fund, have signaled support, yet there is still little, if no, money flowing.

Gavi’s $500 million First Response Fund that makes resources immediately available for outbreak response is an exception. The Fund was approved by its board in June 2024, so Gavi could theoretically start drawing on these resources. However, these funds can only be used for vaccines, not other medical countermeasures, and regulatory barriers are creating hurdles. The mechanism can only procure vaccines that have received WHO emergency use listing, even though two available mpox vaccines (MVA-BN and LC16m8) have already been approved by several well-resourced regulatory authorities.

In the short term, Gavi and other global health initiatives should revise procurement policies to recognize approvals from WHO-Listed Authorities—a new framework established by WHO to identify mature regulatory bodies operating at an advanced level of performance.

Surge financing should also be deployed to contract for manufacturing capacity. Specifically, Denmark’s Bavarian Nordic and Japan’s KM Biologics that produce the two mpox vaccines recommended by WHO could use third party facilities to ramp up production.

The current outbreak underscores the need for donors to continue to work towards a more coordinated and coherent surge financing facility covering a range of health products and uses (this could entail building upon existing mechanisms rather than creating new ones).

Vaccine procurement: slow and fragmented response so far

Mpox vaccine donations to date.

We already have safe, efficacious vaccines to prevent mpox. But at roughly $100 a shot for Bavarian Nordic’s two-dose regimen (MVA-BN), the vaccine that has been the most widely used in Europe and the Americas, mpox vaccines are expensive for Africa. The immediate priority should be getting as many of the 10 million vaccine doses needed, as estimated by the Africa CDC, procured and delivered to affected countries at the epicenter of the outbreak.

Donated doses can help fill immediate gaps. The DRC whose regulator recently granted emergency use for two vaccines now expects to receive some 315,000 donated MVA-BN doses from the European Union and the United States – with doses from the United States reportedly due to arrive early as next week. Additional announcements are trickling in – with a reported 3.5 million donation by Japan of its one-dose LC-16 vaccine, produced by KM Biologics and approved for use in children, as a significant step forward.

Now is the time for other countries holding mpox vaccine stockpiles to step up, and share supply with the most affected countries – so as to curtail further spread.

But dose donations will require extremely close coordination to manage the myriad legal, regulatory, logistical barriers involved. In leading this effort, Africa CDC should partner with Gavi, The Vaccine Alliance, drawing on its experiences coordinating COVID vaccine donations.

Last week, Bavarian Nordic indicated it has capacity to manufacture 10 million doses by the end of 2025, including up to 2 million doses by end 2024. Activating pooled procurement mechanisms, backed by financing from donors alongside African regional entities and countries, to coordinate purchasing should be a critical component of the global effort.

Bavarian Nordic has also reportedly entered into an agreement to transfer vaccine manufacturing technology to selected African manufacturers, according to Africa CDC Director Jean Kaseya, speaking at a press briefing just this week. While this would be an important move, announcements around diversifying manufacturing via technology transfer agreements will not produce the doses needed in time to curtail the current outbreak.

Delivery of countermeasures challenged by conflict, logistics and health systems issues

Mpox vaccine options and characteristics.

Delivery of medical countermeasures was another shortcoming of the COVID response. Specifics of the current outbreak pose particular challenges for delivery: transmission mechanisms and target populations differ from previous mpox outbreaks; there is ongoing conflict in the most affected areas, such as eastern DRC; and vaccines must either delivered in multiple doses [MVA-BN] or in the case of the the Japanese-made LC16 vaccine, using an intradermal method of administration that a lot of vaccinators are not familiar with.

Global health institutions, including Gavi, UNICEF, and WHO, also need to work closely with other partners, including humanitarian organizations and multilateral development banks, like the World Bank, to leverage their financing to support delivery and related response needs.

Major R&D needs

Scientist runs a test on the mpox virus as part of a Nigerian-United Kingdom research collaboration.

Finally, there are additional R&D needs. Usage of Bavarian Nordic’s MVA-BN vaccine is currently limited to adults, underscoring the urgency to broaden usage to children and adolescents, who are disproportionately affected by the current outbreak. In addition to vaccines, R&D is needed for rapid, point-of-care diagnostics and treatments.

While these immediate priorities should be top-of-mind, longer-term efforts can help down the line. Gavi’s new Vaccine Investment Strategy, approved by its board in June 2024, includes plans to set up a global stockpile.

World leaders must respond to the calls for strong coordination and immediate access to medical countermeasures. If not, the evaluations and after-action reviews of the international response to this latest mpox outbreak will read as the same story of inequitable access that characterized the COVID-19 pandemic.

Janeen Madan Keller is a Policy Fellow and Deputy Director of the Global Health Policy program, Center for Global Development.

Javier Guzman is a Senior Policy Fellow and Director of the Global Health Policy program, Center for Global Development.

Image Credits: CDC, Africa CDC , Center for Global Development , CGD , Center for Global Development, Center for Global Development .

Sudan cholera
A new cholera outbreak is threatening the millions of internally-displaced Sudanese. Over 600 cases have been reported in the past week.

United Nations officials are expressing concern that a new cholera outbreak in conflict-ridden Sudan, declared 10 days ago, could widen dramatically in the wake of increased rainfall and flooding. Some 658 cases of cholera have been reported since 12 August, with 28 deaths, the World Health Organization (WHO) revealed in its latest situation report, published Friday. 

The last outbreak of cholera in May saw more than 11,300 cases and at least 300 deaths.

Twelve of Sudan’s 18 states are struggling to simultaneously contain outbreaks of three or more diseases. The worsening humanitarian situation, fueled by 16 months of fighting between the Sudanese Armed Forces and the insurgent Rapid Support Forces (RSF), crippling humanitarian aid deliveries, have left embattled health workers coping with outbreaks of measles, malaria, and dengue, along with the deadly diarroheal disease.  

Now, with heavy rains deluging the country, cholera cases have “surged,” said UN High Commissioner for Refugees (UNHCR) Representative in Sudan Kristine Hambrouck at a press briefing in Geneva on Friday.

“Risks are compounded by the continuing conflict and dire humanitarian conditions, including overcrowding in camps and gathering sites for refugees and Sudanese displaced by the war, as well as limited medical supplies and health workers. This is in addition to overstretched health, water and sanitation and hygiene infrastructure – all of which have been heavily impacted by the war,” she said.

Since the start of the devastating civil war in April 2023, the violence between the RSF (RSF) and the Sudanese Armed Forces have displaced over 10.2 million people internally – and forced another 2.1 million people into neighboring countries – creating the largest refugee crises in the world along with widespread hunger as well as widening pockets of outright famine in the western Darfour region. 

With large scale displacement, violence, and attacks on humanitarian aid, Sudan’s health system has quickly deteriorated. The WHO reports that over two-thirds of the country’s healthcare centers are not operational, and the ones still functioning are “at risk of closure due to shortages of medical staff, supplies, safe water, and electricity.” Furthermore, targeted attacks on hospitals, like June’s siege on the western Sudanese city of El Fashir, and its only maternity hospital, have left only 2% of the population with adequate healthcare.

“A new wave” of cholera roars through eastern provinces after heavy rains

Cholera oral vaccine Sudan
Already WHO has used over 50,000 oral cholera vaccine doses, and hopes to vaccinate more children in the coming weeks.

Just a few months into the fighting, in June 2023, cholera broke out in a dozen Sudanese states. Since then, these states have reported more than 11,000 cases and 316 deaths. At the country level, cases peaked over the winter of 2023.  But the country’s eastern Red Sea state, at the epicenter of the outbreak, continued to see new cases. 

Just south of the capital state of Khartoum, the Sudan Federal Ministry of Health officially declared a new outbreak in Al Jazirah in the Kassala state earlier this month, raising concerns for outbreaks in an area where aid workers are repeatedly denied access. 

“Of particular concern is the spread of the disease in areas hosting refugees, mainly in Kassala, Gedaref and Jazirah states. In addition to hosting refugees from other countries, these states are also sheltering thousands of displaced Sudanese who have sought safety from ongoing hostilities,” said UNCHR in a statement.

In Kassala’s refugee camps, “people live on top of each other, they are hugely overcrowded,” said Hambrouck. “The water systems that were in place do not have the capacity to respond, it really needs massive investments.”

Yet the risk of cholera is not constrained to within Sudan’s borders. In the neighboring countries of Chad and South Sudan, UNCHR has reported an elevated risk of cholera outbreaks in refugee sites amid the onset of the rainy season. 

Sudan cholera and measles outbreak
Twelve of Sudan’s 18 states are experiencing multiple disease outbreaks, including cholera.

“We are also concerned for the health and protection of Sudanese refugees who fled the country,” said Hambrouk. “Our teams have reported an increase in malaria cases…amid alarming rates of malnutrition, and cases of measles, acute respiratory infections, acute watery diarrhea, and the risk of outbreaks of cholera.”

WHO scaling up cholera immunization campaign – but malaria and measles also threaten

Despite these challenges, an initial vaccination campaign  in Kassala state successfully protected more than 50,000 people from cholera, with hundreds of thousands more doses on the way. 

“The vaccination campaign already started and we used the 51,000 doses that were already in the country,” said Dr Shible Sahbani, WHO Representative in Sudan. Speaking from Port Sudan, he confirmed that the inoculation campaign concluded in Kassala state on Thursday. “We were aiming to reach the 97 per cent of the target population,” he said, adding that the UN health agency has also secured the approval to procure an additional 455,000 doses of cholera vaccine – “good news in the middle of this horrible crisis.”

Sudan WHO representative cholera
Dr Shible Sahbani, WHO Representative in Sudan speaking from Port Sudan, discusses a new cholera vaccination campaign.

Malaria continues to be a leading infectious cause of morbidity and mortality in Sudan. In the past decade, malaria cases increased by more than 40%, most likely due to frequent flooding, population movement, and the emergence of a new, and more invasive mosquito vector, anopheles stephensi. The WHO reports that between November 2023 and July 2024, over 1.67 million cases have been reported from 15 states. 

This comes just two years after the WHO congratulated Sudan on its steps in vector control – efforts that have now been derailed by the civil war. 

The WHO situation report also highlights a concerning numbers of measles cases – nearly 5,000 of a disease that is vaccine-preventable since late 2023. Low immunization rates and hard-to-access areas in places like Darfur and Kordofan states means that the risk of measles remains high, prompting the WHO and its partners to gear up for a large-scale campaign in the coming months.

Yet concerns over funding and humanitarian access may hamper the global health agency and its partners to implement a campaign at that scale. Of the $ 1.5 billion required by UNHCR and other partners for the Regional Refugee Response Plan (RRRP) to provide assistance in countries bordering Sudan, just 22% has been received. The inter-agency response inside Sudan is only 37% funded.

Even with funding, an “immediate ceasefire” and unimpeded and safe humanitarian access is needed to ensure aid can reach those who need it, said UNICEF spokesperson James Elder at the Geneva press briefing. Recent US-mediated peace talk efforts fell through after both warring parties failed to show up for talks last week in Geneva.

Image Credits: WHO, WHO, WHO, WHO.