A nurse prepares a trial participant for various tests as part of a trial of drug-resistant TB drugs.

The World Health Organization (WHO) this week recommended three new regimens for multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) tuberculosis (TB) that are far shorter than the current regimens and can be taken orally.

The new regimens can cure patients in six to nine months rather than the usual 18 months and dispense with the painful injections that people with DR TB have had to endure as part of their treatment.

Almost half a million people contract MDR-TB/RR-TB every year, and many die from it – in part because it is hard for them to adhere to treatment.

“The use of new and repurposed medicines like bedaquiline, pretomanid, linezolid, and delamanid and the shift away from older injectable-based regimens has led to incremental improvements in the treatment success rate for people with MDR/RR-TB,” according to the WHO.

“Globally in 2022, in MDR/RR-TB patients who started treatment in 2021, the treatment success rate was 63%, reflecting a steady improvement from 50% in 2012 .”

Bedaquiline and delamanid are the first new TB drugs in 50 years.

Tested on wide range of patients

The WHO recommendations are based on results from the BEAT-TB clinical trial conducted in South Africa and the endTB trial conducted in seven countries between 2017 and 2023 by Médecins Sans Frontières’ (MSF), Partners In Health (PIH) and Interactive Research and Development (IRD), and funded by Unitaid.

Trial participants included children, adolescents, pregnant and breastfeeding women. 

“Clinicians can now offer these advances to nearly all patients, thereby increasing chances of cure while reducing exposure to treatment toxicity and reducing the spread of drug-resistant forms of TB in the community”, says Professor Carole Mitnick, PID Director of Research for the endTB project, co-Principal Investigator of the study, and Professor of Global Health and Social Medicine at Harvard Medical School. 

“With treatment complexity, duration, and toxicity reduced – and options increased – prospects for eliminating the gap between need (approximately 500,000 patients/year) and percentage treated (no more than 35%/year) are vastly improved,” she added.

Drug cost barrier

“WHO’s recommendations are a major step forward for the health of millions of patients affected by this form of the disease, which is particularly difficult to treat,” said Dr Lorenzo Guglielmetti, MSF’s director of the endTB project and co-principal investigator of the clinical trial.

“MSF carried out the endTB clinical trial – along with another TB trial called TB PRACTECAL – because the pharmaceutical industry failed to do so. Both trials have found better treatments for people with TB and influenced WHO recommendations and guidelines,” said MSF in a media statement released on Thursday.

“After several decades of therapeutic status quo – and for the second time in two years, along with TB PRACTECAL – new treatments evaluated by independent actors, including NGOs, have been rapidly incorporated by WHO into its recommendations for combating the scourge of MDR-TB,” added Guglielmetti. 

“It’s important to remember that the pharmaceutical industry, despite significant public financing, has only brought new drugs to market. They have not informed the use of these drugs in regimens. It has been left to NGOs to conduct controlled trials to inform practical use of, and innovations with, novel products.”

However, the success of the new guidelines rests on a reduction in the price of delamanid, which MSF described as “excessively high”. 

Japanese pharmaceutical corporation Otsuka produces delamanid through an exclusive licence with Viatris.

“We call on Otsuka and Viatris to stop blocking price-lowering generics from entering the market and to immediately share delamanid with every company interested in making more affordable quality-assured generic versions of this lifesaving TB drug,” said Christophe Perrin, TB advocacy pharmacist at MSF’s Access Campaign. 

“Otsuka and Viatris must also urgently drop their prices for delamanid so that many more people with DR-TB can access this lifesaving drug as part of shorter, all-oral regimens.”

Image Credits: TB Alliance.

Access to the internet offers educational opportunities, but excessive social media use can harm children.

As evidence mounts of the health harms of excessive social media use on children, governments and academics are mulling how to regulate and contain these harms – notably anxiety, depression and low self-esteem.

US Surgeon General Dr Vivek Murthy recently appealed to his country’s Congress to compel social media sites to carry warning labels about the potential negative effects on the mental health of teens and children. This approach is akin to that used in many countries to warn of the harms of tobacco products and alcohol.

A study of over 6,500 US teens adjusted for baseline mental health status found that those who spent more than three hours a day on social media faced double the risk of experiencing poor mental health outcomes including symptoms of depression and anxiety.

Excessive time online also cuts children off from friends and family, makes them less likely to exercise and increases their exposure to online marketing of unhealthy goods such as alcohol, cigarettes and gambling – as well as sexual predators.

But there are also educational advantages to online access, which complicates regulation. In addition, many parts of the world are still grappling with how to extend internet access to their citizens.

Approximately one billion children and young people under the age of 26 have access to the internet at home – approximately one-third of this age group and skewed in favour of high-income countries and households, according to UNICEF.

UNICEF: Children and young people with access to the internet at home

Public health approach

A viewpoint published in last week’s Lancet appeals for “a public health approach” to protect children from digital harms. 

“To build healthy digital environments for children now and future generations, we recommend a precautionary approach to governance that prioritises children’s health and wellbeing, recognises their desire to enjoy the benefits of the digital world, and allows children to have a role in shaping their digital futures,” urge the authors, Louise Holly, Prof Sandro Demaio and Prof Ilona Kickbusch.

“New algorithmic features are emerging at a rapid pace to capture children’s attention and increase platform use. Legislation is failing to keep up with these developments and children remain unprotected,” they note.

The authors suggest three broad areas for intervention: delaying the age at which children  use digital media and devices; health warnings on device packaging, digital apps, and websites and health promotion campaigns to raise awareness of the benefits of delaying digital technology use among young children. 

To achieve these, they suggest six strategies.

The first involves using the built-in technical features of smartphones and apps limit users’ time. 

“Regulations could require such time-limiting features to be strengthened to protect children and could also be set as a default on all devices, games, and apps so the onus is on users to reduce, rather than set or increase time limits,” they suggest.

The second involves increasing the cost of products such as games, apps and smartphones by taxation.

The introduction of “device-free spaces similar to smoke-free spaces” is their third suggestion.

The fourth strategy involves “comprehensive digital education”. In addition, UNESCO recommends that schools limit the amount of learning done on individual devices.

Fifth, they recommend changing the “norms around children using smartphones”, referring to how the French town of Seine-Port has banned the use of smartphones in public places after this was agreed via a referendum. 

Finally, they recommend creating offline alternatives for children such as  green spaces and sports facilities. Here they refer to Iceland’s “whole-of-society approach that includes increasing opportunities for children to engage in organised leisure activities” to reduce drug use.

Impact on girls

The US Surgeon General has also published an advisory on the impact of social media on young people highlighting its pernicious influence on girls.

“Social media may also perpetuate body dissatisfaction, disordered eating behaviors, social comparison, and low self-esteem, especially among adolescent girls,” it notes.

“One-third or more of girls aged 11-15 say they feel ‘addicted’ to certain social media platforms and over half of teenagers report that it would be hard to give up social media. “When asked about the impact of social media on their body image, 46% of adolescents aged 13-17 said social media makes them feel worse,” according to the advisory. 

“Additionally, 64% of adolescents are ‘often’ or ‘sometimes’ exposed to hate-based content through social media. Studies have also shown a relationship between social media use and poor sleep quality, reduced sleep duration, sleep difficulties, and depression among youth.”

Image Credits: UNICEF.

Prof Jean-Jacques Muyembe (left) and Africa CDC director general Jean Kaseya (right)

The Africa Centres for Disease Control and Prevention (Africa CDC) is in talks with Bavarian Nordic, the only global producer of an mpox vaccine, about technology transfer to enable African manufacturers to make the vaccine on the continent.

“I want to recognise and thank Bavarian Nordic for accepting to do the tech transfer in Africa, for Africa to manufacture the vaccine,” Africa CDC Director General Dr Jean Kaseya told a media briefing on Tuesday.

Kaseya added that Africa CDC aimed to have 10 million doses available by the end of 2025, and Bavarian Nordic “tell me the doses we are talking about are not a dream”. 

However, he acknowledged that this was a longer-term solution to the mpox outbreak affecting 12 African countries.

More immediately, the continent expects donations from wealthier countries during what Kaseya dubbed as the “emergency humanitarian era”. He thanked the European Union (EU) for assistance in procuring 215,000 vaccines.

In the past week, there has been an increase of 1,405 cases on the continent bringing the official total to 18,910 although Kaseya cautioned that surveillance was not optimal in some countries.

The biggest increase was in the Democratic Republic of Congo (DRC), the epicentre of the outbreak, which now has 17,794 cases (an increase of 1,030). 

However, armed conflict in eastern DRC is hampering efforts to curb the outbreak, and Kaseya thanked Angola’s president for his efforts to broker peace between the DRC and Rwanda, which has supported the M23 rebels in the DRC.

Cases in Burundi jumped from 265 to 572, while the Central African Republic also recorded more cases (up from 206 to 263) as did Nigeria, (from 24 to 39).

No new cases were recorded in Cameroon, Congo, Kenya, Rwanda, Uganda, South Africa, Côte d’Ivoire or Liberia.

There have been 541 recorded deaths.

Single incident management team

For the first time, the Africa CDC, the World Health Organization and UNICEF have united to form a single African incident management team to address the outbreak, which was declared a public health emergency of international concern (PHEIC) last week.

Professor Jean-Jacques Muyembe, general director of the Democratic Republic of the Congo Institut National pour la Recherche Biomedicale (INRB), told the Africa CDC briefing that better communication about the causes of mpox was necessary to prevent its spread.

Children to be warned against touching dead animals or eating jungle meat, he advised Almost 70% of mpox cases in the DRC involve children under the age of 16.

In addition, communities had to be educated about human-to-human transmission via bodily fluid, using all the lessons from  Ebola, HIV and COVID-19 including condom use and good hygiene. Mpox clade 2 has been spread primarily via sexual contact between men.

Muyembe also reported on a recent trial of an antiviral medicine, tecovirimat, to treat mpox. The trial was “discouraging” as tecovirimat failed to reduce the duration of mpox lesions in children and adults with clade I mpox in the DRC, he reported.

A small study with an increased dose of tecovirimat was currently underway.

However there was a 1.7% mortality rate in the trial – significantly lower than the mpox mortality of 3.6% in the DRC.

This mortality rate applied to all subjects regardless of whether they received tecovirimat or a placebo, indicating that “hospitalization and high-quality supportive care” improved outcomes regardless of treatment, according to a report from the US National Institutes of Health, which sponsored the trial.

More domestic resources

Over the weekend, South African President Ramaphosa – the African Union (AU) Champion on Pandemic Prevention, Preparedness, and Response (PPPR) – called on member states to devote more domestic resources to mpox.

Ramaphosa also urged the international community “to mobilise stockpiles of vaccines and other medical countermeasures for deployment in Africa” via Africa CDC.

“This is also an opportunity to call on the international community to finalise a fair and equitable pandemic agreement—a duty that must be pursued with urgency and a spirit of equity,” added Ramaphosa.

Deforestation drives vector-borne diseases
Oropouche virus, which causes similar symptoms to dengue, is now spreading in countries beyond Brazil’s heavily forested Amazon region. Cases have increased ten-fold since last year, prompting the CDC and PAHO to issue warnings.

A little known, but potentially lethal virus is spreading throughout Latin America and the Caribbean, prompting the US Centers for Disease Control (CDC) and other health agencies to issue warnings for travelers and clinicians.

Oropouche virus, an arbovirus like dengue, Zika, and chikungunya, is spread through certain midge or mosquito bites. Oropouche symptoms are similar to these other arboviruses with fever, rashes, muscle aches, and headaches common. Symptoms typically last 5 to 7 days, but more recently, the virus has been linked to severe fetal outcomes, including congenital abnormalities and death. 

While the virus was first detected in 1955 in the Caribbean nation of Trinidad and Tobago, the Americas saw few cases each year – and those that were reported were mostly concentrated in the  Amazon or other rainforests.  

Oropouche-carrying midge
Biting midges along with certain mosquitoes, are the primary vector for the disease.

Now, however, Oropouche cases have jumped dramatically. The Pan-American Health Organization (PAHO) has reported 8,078 confirmed cases since January – almost a ten-fold increase since last year – with Brazil’s endemic Amazon regions contributing most to the case count. Other countries, like Cuba and Bolivia, are reporting cases for the very first time.

Despite ongoing research, much about Oropouche virus remains unknown, including the factors behind this year’s unusually severe outbreak, which prompted The Lancet to label it a “mysterious threat.” Historically, no Oropouche-attributed deaths have occurred since the virus was discovered, yet this year has already seen the deaths of two otherwise healthy Brazilian women. 

PAHO notes that “although the disease has historically been described as mild, the geographic spread in transmission and the detection of more severe cases underscore the need for increased surveillance and characterization of possible more severe manifestations.”

Vertical transmission reported, travel-associated cases

Graph of Oropouche cases 2024
Brazil accounts for the majority of Oropouche virus cases, yet several countries are now seeing first-time transmission.

 

Brazil was the first country to report instances of vertical transmission – when a disease passes from mother to fetus – earlier this summer. The latest epidemiological alert notes four cases of infant microcephaly, and four suspected fetal deaths. 

The CDC has thus urged pregnant women to reconsider nonessential travel to Cuba and if unavoidable to strictly follow the CDC’s prevention recommendations, which include using insect repellent, and window and door screens. These recommendations also work to prevent dengue, which has so far caused over 10 million cases in the Americas, including the US territory of Puerto Rico. 

The CDC’s alert comes as a response to several travel-associated cases in the US and Europe, mostly from individuals returning from Cuba and Brazil. No local transmission has been reported in the US or Europe.  

Climate change, deforestation, mutations, possible culprits

Oropouche mosquito monitoring
PAHO staff explain mosquito sampling methodology to better understand the distribution of disease-carrying species.

The CDC report came just a few days prior to World Mosquito Day, in which the World Health Organization has called for member states to intensify their awareness of the dangers posed by mosquito-borne diseases. 

Climate change, deforestation, and unplanned urbanization are facilitating Oropouche’s march through Latin America and the Caribbean, PAHO noted in its analysis. As in many cases, these trends help facilitate the leap of vector-borne diseases that were previously prevalent mostly in remote rural areas to cities.

“Oropouche virus has infected people living in regions far from forested areas, thus indicating that an urban cycle can exist as well,” wrote the Lancet editorial team. The authors also speculate that genetic mutations could help explain the rapid increase in cases. Yet the virus’s spread follows a pattern similar to dengue, zika, and chikungunya – the mosquito-borne diseases that have smashed records this year. 

Like many neglected tropical diseases, the actual number of Oropouche cases may be much higher, said PAHO in a recent statement. 

And with Oropouche presenting symptoms similar to other arboviruses, PAHO is urging member states to strengthen epidemiological surveillance and laboratory diagnosis, particularly to identify fatal and severe cases and possible cases of vertical transmission. The organization also urges countries to “expand prevention campaigns and strengthen entomological surveillance and vector control actions to reduce mosquito and gnat populations.”

Image Credits: Earth.org, PAHO , PAHO/WHO.

Registered nurses Fatmata Bamorie Turay (left) and Elizabeth Tumoe, at the Princess Christian Maternity Hospital, in Freetown, Sierra Leone. Some ealthy countries are actively recruiting nurses from LMICs.

The International Council of Nurses (ICN) has called on the World Health Organization (WHO) to consider a “time-limited moratorium of active recruitment of nurses” from countries on the WHO Health Workforce Support and Safeguard List.

This follows a “dramatic surge” in the recruitment of nurses from low- and middle-income countries (LMICs) by wealthy countries, according to the ICN.

The Safeguard List identifies 55 countries that face the most pressing health workforce challenges related to achieving universal health coverage (UHC). Health workers shortages are one of the primary causes of countries’ inability to achieve UHC.

The ICN made this proposal in a recent report to the World Health Organization (WHO) on the implementation of the WHO Global Code of Practice on the International Recruitment of Health Personnel.

It attributed the “dramatic surge in international nurse migration and recruitment” in large part to “attempts by some high-income countries to address their vast nursing shortages by actively recruiting from LMICs and easing the entry or professional recognition of internationally educated nurses (IENs)”.

The proportion of overseas-trained nurses employed in the Organisation for Economic Co-operation and Development (OECD) – made up of 38 developed countries – jumped from 5% in 2011 to nearly 9% in 2021.

The UK, USA, Canada, Australia, Germany and certain Gulf states are driving this recruitment 

UK takes nurses from ‘red list’ countries

In the UK, for example,  over 24,000 new international nurses were registered from September 2021 to September 2022, the highest in recorded history.

Some 19% of new overseas nurses in the UK between 2021-2023 came from countries facing “severe health workforce deficits”, according to the WHO Health Workforce Support and Safeguard List.

Over six months in 2022,  over 20% of new international nurses (more than 2,200) came from just two “red list” countries: Nigeria and Ghana. 

“Although active recruitment from these countries to the National Health Service (NHS) is prohibited in the UK, nurses can be first hired by for-profit recruitment firms to work in the private sector and later apply directly to the NHS as passive recruits,” according to the ICN.

International recruiters are also directly advertising to recruit scarce health care staff from low- and lower-middle-income countries in Africa, Asia, and the Caribbean, in breach of the code. 

The US reported that over 17,000 nurses applied for visas in 2022, a 44% increase from the previous year.

“Countries that have not been traditionally active in international nurse recruitment are also showing increased demand for overseas-trained nurses, including Finland as well as Scotland, where the government announced an allocation of £4.5 million to support active international recruitment of nurses as part of the overall plan for pandemic recovery and renewal,” notes the ICN.

Low-income countries face huge nurse shortages

Tonga and Fiji reported losing 20% to 30% of their nurses, primarily to Australia and New Zealand, at the 2024 World Health Assembly (WHA).

In Fiji, 800 nurses in resigned in 2022, over a fifth of the nursing population. At present, the country has 2,003 remaining nurses and around 1,650 nursing vacancies. Many hospitals have less than 40% of their established Registered Nurse positions 

Nursing representatives from Jamaica also reported at the WHA that around 20% of the country’s nurses have applied for certificates of current professional status, indicating that they are preparing to work abroad.

Over 1,700 registered nurses in Zimbabwe resigned in 2021, and some 900 left the country in 2022, with many moving to the UK. 

The Ghana Registered Nurses and Midwives Association recently reported that around 500 nurses are leaving that country every month, particularly experienced, specialist nurses.

The Philippines has a current shortage of 190,000 healthcare workers and is expected to face a shortage of 250,000 nurses by 2030 

Nurses’ right to migrate

“The ICN recognises and supports the right of individual nurses to migrate and pursue professional achievement through career mobility and to better the circumstances in which they live and work,” according to the report.

However, it is “gravely concerned” about the “large-scale nurse migration from the world’s most vulnerable countries, in large part driven by active nurse recruitment by a small number of high-income countries, including the United Kingdom, United States, Canada, Australia, and Germany, as well as certain Gulf States”. 

It “condemns the targeted recruitment of nurses from countries or areas within countries that are experiencing a chronic shortage of nurses and/or a temporary health crisis in which nurses are needed”.

“These trends are depleting already fragile health systems, preventing LMICs from rebuilding and responding to health challenges post-pandemic, and widening the significant gap in healthcare access and quality between high-income and low-income countries. 

“This situation jeopardises the global achievement of the UN Sustainable Development Goals, including universal health coverage, by 2030.”

Mitigating migration

Some wealthier countries are increasingly their own nurse training. In the UK, for example, the NHS Long Term Workforce Plan aims to educate over 60,000 nurses in England by 2029, a 54% increase from 2022/23.

Australia is developing its National Nursing Workforce Strategy to improve sustainability and self-sufficiency, while Germany’s 2024 Nursing Studies Strengthening Act aims to attract nursing students with monthly salaries to ease the workforce shortage.

The Filipino Department of Health has recently allocated funds to provide nurses with health insurance, housing, and other benefits in an attempt to stem the tide of nurse migration.

However, several LMICs are experiencing nursing shortages and are unable to provide employment or other measures to retain their nurses due to insufficient funding and other structural factors,

In Lesotho, in southern Africa, for example, almost a third of professional nurses and midwives are unemployed because of a lack of funding.

“LMICs require support to develop and strengthen their health and care workforce and systems so that they can meet their population’s needs,” the ICN stresses.

Aside from unemployment, nurses in LMICs often face poor working conditions, low compensation and safety issues.

“We have seen increased evidence of labour unrest and/or strike action in developing and lower-income countries in the past three years, including Uganda, Ghana, Fiji, and Tonga. 

“This must be recognized as symptomatic of the underlying issues feeding nurse migration and clearly demonstrates the need for efforts to strengthen LMIC health systems rather than deplete them by draining their workforce.”

Image Credits: World Bank/Flickr.

Indian doctors on strike nationally in protest against the rape and murder of a colleague while on duty.

Indian doctors held a 24-hour national strike over the weekend to protest the rape and murder of a young female doctor in a hospital in Kolkata, demanding better protection for health workers.

Around one million health workers were estimated to have supported the strike. Some junior doctors remain on strike, saying that they will not return to work until the authorities meet their safety demands.

The bloodied body of 31-year-old Dr Moumita Debnath was found in a seminar room in RG Kar Medical College and Hospital on 9 August. 

An inquest report confirmed sexual assault, and her family wrote in a court petition that they believed she had been gang raped. She had been on duty at the time of her murder.

Following protests by junior doctors and medical residents after the discovery of Debnath’s body, the Indian Medical Association (IMA) called for a 24-hour “nationwide withdrawal of services” and the suspension of all non-essential procedures over the weekend.

“We ask for the understanding and support of the nation in this struggle for justice for its doctors and daughters,” said IMA president  RV Asokan said in a statement ahead of the strike.

In a letter to India’s Prime Minister, Narendra Modi, the IMA called for a Central Act outlawing violence and damage to property at health facilities and for the security at health facilities to be as tight as airports.

“The 36-hour duty shift that the victim was in and the lack of safe spaces to rest… warrant a thorough overhaul of the working and living conditions of the resident doctors,” added the IMA in the letter.

According to the IMA, 60% of doctors and 85% of nurses in the country are female. An IMA study found that 75% of doctors have faced abuse, usually verbal, while at work, according to The Times of India.

the weekend protests took the form of marches, demonstrations and a 3km human chain of health workers in Kolkata, near the site of the attack. 

Despite its impact on patients, the action has had substantial public support. Supporters of the two biggest soccer clubs in West Bengal, the state where the attack took place, united in a march on Sunday evening to demand justice for Debnath and protection for doctors.

This Thursday, women in the state of West Bengal have called a “Reclaim the Night” march beginning at midnight, according to The Hindustan Times. The protest will coincide with the official start of India’s Independence Day.

The proliferation of untreated sewage and waste in wartime Gaza has led to the re-emergence of poliovirus.

The World Health Organization and UNICEF have appealed for ‘humanitarian pauses’ in the grinding Israel-Hamas war in the Gaza Strip in August and September to facilitate a massive polio booster campaign – as three suspected polio cases were being investigated by a Jordanian laboratory.

The appeal came as the entire region see-saws between the possibility of a regional war between Iran, the Lebanese Hizbullah and Israel, and an Israeli-Hamas ceasefire in Gaza. 

Israeli and Hamas negotiators are meeting in Doha today in a last ditch effort mediated by the United States, Egypt and Qatar, to find acceptable terms for a ceasefire that could help avert a wider war and lead to the release of some or all of the 116 Israeli hostages now held by the Islamic Hamas for over 10 months. 

But irregardless of that outcome, humanitarian pauses of at least seven days are needed to enable the mass administration of oral polio vaccine boosters to some 640,000 Gaza children, WHO and UNICEF said, in a joint statement on Friday. 

“WHO and UNICEF request all parties to the conflict to implement humanitarian pauses in the Gaza Strip for seven days to allow for two rounds of vaccination campaigns to take place. These pauses in fighting would allow children and families to safely reach health facilities and community outreach workers to get to children who cannot access health facilities for polio vaccination. Without the humanitarian pauses, the delivery of the campaign will not be possible.” 

Three children suspected of polio paralysis

Vaccine-derived poliovirus, which can spread through faeces and infect under-immunized children thus exposed, was detected in July 2024 in sewage samples in Khan Younis, in southern Gaza, as well as in Deir al-Balah, further north. More worrisome, three children presenting polio-related symptoms of suspected acute flaccid paralysis (AFP), were recently reported in the Gaza Strip, WHO revealed:

“Their stool samples have been sent for testing to the Jordan National Polio Laboratory.”

Over 1.6 million doses of the novel oral polio vaccine, nOPV2, which is used to stop vaccine derived poliovirus transmission (cVDPV2) in under-immunized populations, is due to be delivered to the Gaza Strip via Israel’s Ben Gurion Airport, WHO further revealed. 

Vaccine deliveries via Israel’s international airport

“The deliveries of the vaccines and the cold chain equipment are expected to transit through Ben Gurion Airport before arriving in the Gaza Strip by the end of August,” WHO and UNICEF stated, stressing that, “it is essential that the transport of the vaccines and cold chain is facilitated at every step of the journey to ensure their timely reception, clearance and ultimately delivery in time for the campaign.” 

“At least 95% vaccination coverage during each round of the campaign is needed to prevent the spread of polio and reduce the risk of its re-emergence, given the severely disrupted health, water and sanitation systems in the Gaza Strip,” the joint statement further said. 

“Other requirements for successful campaign delivery include sufficient cash, fuel and functional telecommunication networks to reach communities with information about the campaign,” it added. Currently, Israel and Hamas forces continue to battle across various parts of the 365 square kilometer enclave on the Mediterranean sea sandwiched between the Egyptian border and pre-1967 Israel.     

Polio is a sign of broader infectious disease crisis

The Gaza Strip has been polio-free for the last 25 years, WHO noted, with vaccine rates of 95% or more.  Israel withdrew from the enclave in 2005; two years later, Hamas seized power from the Palestinian Authority, which was violently ejected from Gaza. Israel re-occupied Gaza shortly after the Hamas invasion of Israeli communities along the enclave perimeter on the early morning of 7 October 2023, which led to the deaths of some 1200 men, women and children – as well as the capture of another 240 Israelis and foreign residents. 

Israel has been waging a bitter battle against the Islamic group ever since, cutting off access to Gaza from Egypt, but it has not succeeded in crushing the organization entirely.  Some 40,000 Gazans have since died during the fighting, while tens of thousands more people are wounded.  Amidst a sanitation catastrophe including the destruction of drinking water and waste management facilities, infectious diseases have run rampant in the enclave – exacerbated by heat, hunger and malnutrition. 

Polio’s re-emergence, “which the humanitarian community has warned about for the last ten months, represents yet another threat to the children in the Gaza Strip and neighbouring countries.  A ceasefire is the only way to ensure public health security in the Gaza Strip and the region,” said WHO and UNICEF.   

Image Credits: @WHOoPT.

Vials of the Bavarian Nordic mpox vaccine are now in ample supply, officials say. But deployment is another story.

Bavarian Nordic has no plans to sell or manufacture its vaccines directly to African countries, the company’s Vice President of Investor Relations told Health Policy Watch, saying that donations from rich countries will likely be the main source of supplies.  

WHO’s announcement of a global mpox health emergency may have sent a wake-up call to the world regarding the ‘perfect storm’ of mpox virus transmission brewing in the Democratic Republic of Congo (DRC) and a dozen other neighboring countries in central and southern Africa. 

And contrary to the situation in 2022-23 there is now ample production capacity to supply Africa with some two  million mpox doses by the end of this year, and another eight million doses by end 2025, Bavarian Nordic’s CEO Paul Chaplin, told Bloomberg News on Wednesday.   “What we are missing are the orders,” Chaplin said. 

Even so, the high costs of the vaccine, estimated at $100 a dose, as well as the huge challenges of deploying jabs in conflict-ridden DRC, the country at the epicenter of the crisis, create formidable challenges to actually matching supply with need – and getting jabs into arms, observers say. 

‘Vaccines to Africa will come from donations’  

Vaccines
A United States delivery of 655,200 COVID-19 vaccines to Ethiopia in 2021. Donations to Africa were too little, too late.

While Africa CDC officials talked about their aims to deploy millions of mpox vaccine doses, to counter the continental health emergency, declared on Tuesday, near-term procurement is likely to be far more limited, if it relies on third party donations – as was the case with COVID vaccines. 

And that seems to be the scenario unfolding so far.

Shortly after the WHO global health emergency was announced Wednesday, the United States offered to donate 50,000 doses of the BVN vaccine from its stockpiles, while the European Union announced a donation of  175,000 doses, to be combined with a pledge of 40,000 by Bavarian Nordic itself.   

“We have capacity ready to help. We have donated doses that Gavi [the Global Vaccine Alliance] has not yet used,” said another top Bavarian Nordic official, Rolf Sass Sørensen, in an email to Health Policy Watch.

But he dismissed a query as to whether the pharma firm might consider selling vaccines directly to the African nations at concessionary prices:

“It’s very unlikely that any African country will ever be responsible for buying vaccines,” said Sørensen, who is vice president of investor relations. “Vaccines to Africa will come from donations from organizations and countries. Pricing structure is always related to contract volumes and long term commitments,” he added.

Sørensen also ruled local African production of the Bavarian Nordic vaccine as technologically unfeasible. 

“We talk to producers around the world. We are not aware of any producers that can produce with our technology. So your scenario doesn’t seem realistic at all,” he said.

Ten times more vaccines are needed 

Mpox lesions – transmission can be through family and household contacts when lesions appear all over the body.

Donation offers made so far remain woefully inadequate to meet the needs, said Professor Piero Olliaro, a researcher at Oxford who studies mpox in the Central African Republic (CAR) as well as Europe.  

“It is disturbing that people will feel satisfied and portrayed as if they have provided a solutions, if they donated 100,000 doses,” he said. “You need enough doses so you can be guided by the needs and not the availability.” 

But with vaccine costs at around $100 per dose for the two jab series, deploying a more meaningful quantity – on the order of one or two million doses to at-risk people and communities in the 13 African countries where the outbreak is now spreading, would cost $100- $200 million to donors.

“Its taxpayers who will foot the bill,” Olliaro said, noting that the dilemma points, once more, to the need to shift more manufacturing to Africa.

DRC’s perfect storm of disease conditions 

DRC residents of eastern Congo have suffered years of displacement by violent militia groups – exacerbating hunger, poverty and disease.

Long before any vaccine deployment, WHO and its partners first need to come up with a strategy for mounting an effective immunization campaign – and engage political leadership in the Democratic Republic of Congo and its neighbours.   

The challenges to deployment are formidable – due both to the lack of knowledge about transmission as the conflict setting of the DRC, which is the epicenter for the most deadly variants that are circulating, Clades 1a and Clades 1b.  

“Vaccine is one thing,” said Olliaro.   “But it is not the ultimate answer. We know how difficult it is to vaccinate people and get acceptance to more vaccines, particularly in countries like the DRC that have been exposed to Ebola. 

“To deliver vaccines, you need to know who you are going to vaccinate. That should be made based on what you know about transmission and not upon how many doses are available,” he said. 

Clades 1a and Clades 1b now pose the real threat

Whereas the 2022-2023 global mpox emergency involved a milder form of mpox, transmitted mainly among men who have sex with men, the two variants circulating most widely in central Africa now include the more deadly Clade 1a and a novel Clade 1b, with a combined case fatality rate around 3%, according to the latest data from the Africa Centers for Disease Control.

Left untreated at the source, the potential for worldwide spread is growing, as the first Clade 1 case was reported outside of Africa, by Sweden’s public health agency, the BBC reported on Thursday.

Mpox in Africa – 2024

“Mpox is almost the archetype of these complex outbreaks that have not been dealt with properly and have the potential for spreading, creating more problems locally and nationally. But they are complex because of the context in which they occur. We need a much more systematic approach.” 

The eastern DRC Kivu region where the Clade 1b variant of the virus has emerged and is now spreading through community as well as heterosexual contact, has been wracked by a violent conflict with the M-23 militia forces – operating from and along the Rwanda border. 

This has led to the forced migration of tens of thousands of people within the region and across borders, exacerbating virus transmission due to malnutrition, unprotected sex and immune deficiencies from other untreated conditions like HIV/AIDS, Olliaro said.

Along with that, illegal mining operations deep in the Congo’s rainforest, add to the misery and exploitation of local communities, engaging women and child labourers in conditions where they are chronically exposed to heavy metal contamination.   

In that perfect storm of social conditions that exists in the DRC, as well as neighbouring countries such as CAR, malnutrition and immunodeficiencies from other untreated conditions like HIV – make people even more vulnerable to the virus.

“Any outbreak happening in that area has the potential for being very difficult to control,” said Olliaro. 

More deadly Clade 1a variant seeing longer transmission chains

Geographic distribution of reported mpox cases, the Democratic Republic of the Congo, 1 January to 26 May 2024 (7,851 cases). Since then infections rates have accelerated even more.

Meanwhile, the Equateur region of western DRC is  seeing longer transmission chains of the traditional and even more deadly, Clade 1a variant, which can be transmitted by close household contact, contact with infected items like linens, as well as sexual contact. 

Researchers are perplexed as to why Clade 1a transmission, which typically occurred from close contact with infected animals or bush meat but burned out rather quickly, now seems to be more persistent. 

“The classical Clade 1a that has been causing a big wave in the northwestern parts of DRC, Equateur province, is showing high morbidity and mortality in parts of that province well above 10%,” said Olliaro. 

“But the chains of transmission also seem to be much longer, the spread, and how far it can travel. This is also where you see more kids being infected. 

“As for how the infection is transmitted.  We don’t know enough about this. And that’s another foundation of a vaccine campaign,” he said, of the rapidly spreading variants of the orthopoxvirus, which belongs to the same family as smallpox.

Image Credits: CEPI , US State Department, Tessa Davis/Twitter , UNHCR, Africa CDC , WHO .

mpox

The World Health Organization has declared an international public health emergency for mpox, its highest level of alarm, as the virus experiences a resurgence across Africa less than two years after ending the previous emergency.

The declaration comes as the case total in Africa this year has already surpassed the total from 2023. Over 2,500 cases and 56 deaths were reported across the African Union last week alone. Since January, 17,541 mpox cases have been reported across 13 AU states, according to the latest Africa CDC epidemic intelligence report published August 9.

“Today, the Emergency Committee met and advised me that, in its view, the situation constitutes a public health emergency of international concern,” WHO Director-General Dr Tedros Adhanom Ghebreyesus said at a briefing on Wednesday. “I have accepted that advice.” 

The Democratic Republic of Congo (DRC) is at the heart of the outbreak, accounting for more than 96% of both cases and deaths. A new variant of the virus, Clade 1b, has spread from the DRC to countries that have never reported mpox cases before, including Burundi, Kenya, Rwanda, and Uganda.

In the DRC, where mpox was first detected in 1970 and remains endemic, 60% of cases involve children under 15 years old, Africa CDC reports.

The WHO announcement follows a similar declaration by Africa CDC on Tuesday, when it declared its first-ever continental emergency of international concern since the agency’s founding in 2016.

“We declare today this public health emergency of continental security to mobilize our institutions, our collective will, and our resources to act swiftly and decisively,” said Africa CDC Director-General John Kaseya.

Both emergency declarations were based largely on evidence that the primary mode of circulation for the current mpox outbreak is person-to-person transmission, primarily through sexual networks. This differs from the historical pattern of zoonotic transmission from animals to humans.

“The potential for further spread within Africa and beyond is very worrying,” Tedros said. “It’s clear that a coordinated international response is essential to stop these outbreaks and save lives.”

Vaccines missing from outbreak frontlines

The African Union has approved $10.4 million to support Africa CDC’s crisis response efforts. The funding will target securing vaccines, improving epidemic surveillance, and assisting in overall preparedness and response efforts. The WHO has also released an additional $1.45 million from its emergency fund to support the African response.

Despite these actions, continental response systems remain underprepared and under-resourced. Africa needs an estimated 10 million vaccine doses but currently has only 200,000 available. Deployment of these vaccines has also been problematic. While the DRC received 50,000 doses donated by the United States, they have yet to be put to use. Meanwhile, doctors on the frontlines of the outbreak report that no vaccines are available at all.

“We have to be very strategic in who we use the limited number of vaccines,” said Professor Salim Abdool Karim, head of the Africa CDC Emergency Consultative Group convened to assess the need for an emergency declaration. “Healthcare workers have been one of the groups that have to be addressed.”

Vaccine stockpiles exist in several countries outside Africa. The United States purchased 500,000 doses last year, and an undisclosed European country also made several orders. Other countries such as Japan and Canada also have stockpiles of the vaccine.

The WHO is working with international partners to coordinate what it calls “vaccine donations.” However, the willingness of countries to share their stockpiles remains unclear. The Globe and Mail reported this week that officials from Canada’s Ministry of Health said they have no plans to share their national stockpile with the frontline countries in the African outbreak.

Africa CDC said in Tuesday’s press briefing that a plan to secure the necessary doses is in place. “We have a clear plan to secure more than 10 million doses in Africa, starting with 3 million doses in 2024,” Kaseya added, without specifying the source or timeline for these vaccines.

This potential declaration comes just over a year after WHO ended the previous global health emergency for mpox in May 2023. The earlier crisis, declared in July 2022, stemmed from a worldwide outbreak mainly affecting men who have sex with men. About 90,000 cases and 140 deaths were reported across 111 countries during that emergency.

Mpox has been endemic in parts of Africa for decades, with the first human case detected in the DRC in 1970. The current outbreak underscores the ongoing challenges in controlling the virus in its endemic regions and the need for a coordinated global response to prevent its spread.

The World Health Organization has convened 10 International Health Regulations Emergency Committees to date, addressing global health concerns such as COVID-19, Ebola, H1N1, MERS-CoV, and Zika virus.

This is a developing story. 

Participants gather to share their mental health struggles and offer support at a Friendship Bench meeting in Zanzibar, part of a nonprofit initiative to improve well-being across the continent.

Africa has the highest rate of suicide in the world, and the lowest per capita spending on mental health – with critical shortages, in particular, of community health workers and facilities that could help prevent many mental health conditions from becoming even more severe. 

Two recent high-profile suicides in Tanzania have cast a stark spotlight on the nation’s growing mental health crisis, reflecting a broader struggle across the African continent.

On the evening of May 16, 2024, Archbishop Joseph Bundala of the Methodist Church in Tanzania was found dead inside his church building in Dodoma Region. Eyewitnesses reported that the respected religious leader had taken his own life by hanging, shocking the community and leaving many grappling with unanswered questions.

Just days later, on May 21, another tragedy unfolded as Rogassion Masawe, a 25-year-old Roman Catholic seminarian, was discovered hanged in his room at the seminary. Local media reports suggest that Masawe’s death may have been triggered by his failure to advance to the next stage of priestly formation, which involved taking his first religious vows.

These incidents have brought Tanzania’s mental health challenges into sharp focus. Tito Kusaga, Archbishop Bundala’s brother, expressed disbelief that overwhelming debts could have driven the bishop to such a drastic decision. The fact that Bundala did not seek help underscores a common issue faced by many struggling with emotional distress in the region.

Africa’s mental health crisis

The African continent has the highest suicide rate in the world, according to WHO.

The twin tragedies in Tanzania are not isolated incidents but part of a larger crisis gripping the African continent. Africa has the highest suicide rate in the world, according to the World Health Organization (WHO), driven predominantly by depression and anxiety. Someone dies by suicide approximately every 40 seconds, resulting in roughly 700,000 deaths per year globally.

Globally, someone dies by suicide every 40 seconds, totalling about 700,000 deaths annually. In Africa, the rate is 11 per 100,000 people, compared to the global average of nine. African men are at particular risk, with 18 suicides per 100,000 — significantly higher than the global male average of 12.2. Experts believe these statistics could well be an undercount given the lack of data.

Approximately 29 million people in Africa suffer from depression. The 2023 World Happiness Report found that 17 of the 24 least happy countries are in Africa. Yet mental health programs remain severely underfunded.

In 2020, Africa spent less than $1 per capita on mental health, while Europe spent $46.49. This stark underinvestment is directly correlated with higher suicide rates and poorer mental health outcomes across the continent.

Africa averages just one mental health worker per 100,000 people, compared to the global average of nine. The continent faces critical shortages of psychiatrists, hospital beds, and most important of all – community outpatient facilities.

Few Africans receive needed treatment as a result. The annual rate of mental health outpatient visits in Africa is 14 per 100,000 people, far below the global rate of 1,051.

Tanzania mirrors continental crisis

A stressed patient stands in deep thought in the wards of Mirembe National Mental Health Hospital. Perched on the rolling hills outside the capital, Dodoma, it is the only mental health facility in the country.

The state of Tanzania’s mental health workforce mirrors the continent’s challenges. The country has 1.31 mental health workers per 100,000 people, including 38 psychiatrists, 495 mental health nurses, 17 psychologists, and 29 social workers for its 65.5 million population.

Community-based mental health services are limited in Tanzania. Despite policies to integrate mental health into primary healthcare, resources remain scarce, especially for children and adolescents.

Neighboring Uganda faces a similar situation, with 2.57 mental health workers per 100,000 people, including just 42 psychiatrists . Kenya fares slightly better with 15.32 workers per 100,000, including 115 psychiatrists and 6,493 psychologists. However, Kenya still struggles to meet growing mental health service demands.

Chained to beds  

Perched on rolling hills on the outskirts of the country’s capital, Mirembe National Mental Health Hospital in Dodoma struggles with overcrowding and limited resources. Patients’ recovery and discharge times average six weeks, but many face relapses due to long distances, financial problems, and the side effects of antipsychotic medications.

It is Tanzania’s only mental health hospital for its population of over 65 million, offering just 600 beds in the capital and 300 more in satellite buildings.

With a lack of preventive services at community level, patients suffering from mental health issues often wind up in prison for either petty or serious crimes, where they face practices reminiscent of a bygone era. At Isanga Correctional Facility, a unit for a unit for convicted criminals with mental health issues, aggressive patients are sometimes chained to metal beds, their anguished cries echoing through urine-scented corridors, according to eyewitness accounts.

Dosanto Mlaponi, head of forensic psychiatry at Isanga, defends these measures as necessary to prevent violence. Yet the facility’s challenges extend beyond its walls.

Aziz Kessy, a 27-year-old speaking under a pseudonym, exemplifies a common post-discharge struggle. Suffering from psychosis, Kessy heard voices urging him to kill himself, prompting his father, a grape farmer, to seek professional help.

After initial treatment stabilized him, Kessy was discharged. He soon relapsed after refusing to take his prescribed medications.

“It’s very difficult to track discharged patients and ensure they stick to prescribed medications,” Mlaponi told Health Policy Watch.

Abandoned patients

Tanzania has only one mental health hospital for its population of over 65 million.

Beyond patient care, Mirembe Hospital faces another troubling issue:  some fully recovered patients remain on its grounds due to a lack of family support. Hospital guidelines require patients to be discharged into a relative’s care.

“Each patient costs between $6-8 per day,” said Dr Paul Lawala, the hospital’s director. “It’s troubling when families disappear after treatment, leaving patients in limbo.”

Extensive research maps a strong correlation between suicide and socioeconomic crises, including unemployment, failed relationships, and domestic abuse, compounding the dangers for abandoned patients.

“It’s as if some people don’t want to be associated with those who had mental health issues, even after they’ve recovered,”  Lawala explained. “We must continue to provide accommodation and food, increasing our costs and impacting our ability to care for others.”

Experts emphasize the dire need for innovative solutions. Over 70% of Tanzania’s population resides in rural areas with limited access to health services. Primary health facilities are ill-equipped to handle psychological problems, as many staff lack diagnostic expertise and medication is scarce.

Dr Praxeda Swai, a senior psychiatrist at Muhimbili National Hospital, agrees. She told Health Policy Watch that the country  is facing “a serious mental health crisis that requires a [more] holistic approach to address it.”

Desperate need for solutions at primary healthcare level

The need for innovative solutions is particularly dire at the primary healthcare level. The Health Ministry is investigating options and seeking funding for a feasibility study on using mobile phones to connect patients with health workers, potentially enhancing communication and reducing relapses.

One approach under consideration is harnessing mobile technology for mental health counseling.

A recent study, “Using Mobile Phones in Improving Mental Health Services Delivery in Tanzania: A Feasibility Study,” explores how technology can bridge the gap between mental health patients and health workers.

“An ICT/mobile phone-driven platform can significantly reduce the need for patients to physically visit hospitals, saving time and money,” says lead researcher Perpetua Mwambingu of the University of Dodoma.

Patients could receive medical advice, information on medication side effects, and reminders for appointments and medication refills via their phones. Health workers could monitor symptoms and provide therapeutic interventions remotely.

This continuous communication could also lead to earlier diagnosis and treatment, potentially reducing hospital stays.

Causes and solutions

Dr Michelle Chapa, the founder and CEO of a Dar es Salaam-based  Foundation that innovative mental health programs, attributes the rise in suicides to clinical depression, exacerbated by poverty, unemployment, and cultural stigma.

“Poverty and unemployment are major contributors to the mental health crisis in Tanzania,” she told Health Policy Watch. “Unemployment can lead to a loss of identity, purpose, and self-worth, which are significant contributors to depression and anxiety or poor mental health.”

Chapa explained that constant financial instability, lack of access to basic needs, and uncertainty about the future trigger chronic stress, often manifesting as anxiety and depression.

“Poverty can lead to unemployment, which results in food insecurity and increases the likelihood of substance abuse,” she noted. “Inadequate nutrition directly impacts brain function and development, increasing vulnerability to mental health disorders.”

Traditional beliefs may hinder individuals from seeking professional help, Chapa added. Men, for instance, are expected to be stoic and self-reliant, and are thus less likely to seek help for mental health issues, perceived as weak or unmanly.

“Exposure to violence also can lead to long-term psychological trauma, including PTSD, depression, and anxiety,” Chapa said. “Violence disrupts community cohesion and family structures, leading to social isolation and a lack of support systems, which are crucial for mental well-being.”

Mental health services are not well-integrated

Chapa described Tanzania’s mental health services as “often not well integrated with general healthcare, resulting in fragmented care and missed opportunities for early intervention.”

“This issue is particularly pronounced in rural and remote areas, where access to mental health services is more limited,” she added.

Chapa emphasized the need for increased funding to build and renovate mental health facilities, integration of mental health services into primary healthcare, and robust training programs for mental health professionals.

She also called for public awareness campaigns to reduce stigma and encourage individuals to seek help. Chapa stressed that suicide should be decriminalized.

New directions and long-term strategies 

Experts told Health Policy Watch that long-term strategies to build a robust mental health support system in Tanzania are multifaceted. These include policy reform to prioritize mental health, workforce development to increase the number of mental health professionals, and infrastructure expansion to improve facilities and services.

Community-based care initiatives and education campaigns are also crucial, the experts noted. They emphasized the need for increased research and innovation, as well as stronger collaborations and partnerships across sectors.

To guide these efforts effectively, improved data collection and policy advocacy are necessary. These strategies aim to address the diverse mental health needs of Tanzania’s population and improve overall mental health outcomes.

‘Grandmothers’ as mental health workers 

The Friendship Bench (FB) project, an innovative mental health initiative founded in neighbouring Zimbabwe, bridges the treatment gap with a unique approach. Developed over two decades, the FB uses problem-solving therapy delivered by trained lay health workers, focusing on individuals suffering from anxiety and depression.

The project employs ‘grandmothers’ as community volunteers, who counsel patients through six structured 45-minute sessions on wooden benches within clinic grounds.

“Since 2006, we have trained over 600 grandmothers who have provided free therapy to more than 30,000 people in over 70 communities,” said Dr Dixon Chibanda, who leads the project.

The FB model has expanded beyond Zimbabwe to Malawi, Zanzibar, and even New York City, demonstrating how mental health interventions from low-income countries can be adapted globally. Several ongoing studies, including the Youth Friendship Bench and FB Plus, continue to expand the project’s impact.

In Africa, the initiatives are supported by private philanthropies and donors. Government officials express interest in mainstreaming these approaches but cite financial constraints as a persistent challenge.

A series of local initiatives are pushing to make a difference in the mental health of people in Zanzibar. Zanzibar Mental Health Shamba (ZAMHS), established in 2014 by UK mental health nurses, has been pivotal in enhancing services on the island. ZAMHS has provided consistent support for mental health care in Zanzibar’s rural areas, including medication delivery.

“Here in Zanzibar, the need for mental health interventions is pressing, especially for our young people who are grappling with drug abuse and mental distress,” said Amina Hassan, a coordinator at the Friendship Bench of Zanzibar. “The Ministry of Health has been incredibly supportive of our initiative, recognizing the importance of addressing these issues head-on.”

Hassan explained that the mental health policy and legislation introduced in 1999 have led to significant enhancements in mental health activities over the past decade. “Despite our extremely low resources, we’ve seen progress, but it’s a constant struggle,” she added.