Exposure to infected poultry is among the main sources of avian flu infections

As more avian flu cases are detected across the Asia-Pacific region, the Food and Agriculture Organization (FAO) is calling for “regional efforts to combat a rise” of the disease. Over the past year, highly pathogenic avian influenza clades, especially H5N1, have gained ground globally, infecting an increasing number of species, including poultry, dairy cows, and domestic animals.

As of July 31, one single avian flu variant of H5N1 had infected 172 dairy herds and 13 farm workers in the United States  and continues to spread further, raising questions about the country’s ability to curb the transmissions. 

In the Asia-Pacific region, there have been 13 human H5N1 avian flu cases since late 2023, six of which were reported in Cambodia this year. The newly-reported cases point to a trend of more human infections from the virus.  And in the Asian-Pacific, at least one other avian flu variant is circulating along with the H5N1 type, clade 2.3.4.4b, prevalent in the US.  

“All these cases involved direct contact with poultry or wild birds, and so far, no human-to-human transmission has been observed,” confirmed Filip Claes, FAO’s Asia-Pacific Regional Laboratory Coordinator in an email response to Health Policy Watch.

“The primary threat is that HPAI continues to circulate in poultry causing economic losses. Additionally, it provides an opportunity [for the virus] to continuously adapt, and spill over to additional species, including humans,” he added.

He called for building diagnostics capacity and more data sharing, along with strengthening farming biosecurity and biosafety measures.

Avian influenza has even reached the arctic and Antarctic regions, infecting scavenger species, marine mammals, carnivorous domestic pets, and mammals farmed for fur, and dairy cattle. Since last year, there have been human cases in Australia, India, the US, Mexico, Vietnam, China, and Cambodia. 

Of the 886 human infections reported from 2003 to May 2024, more than half were fatal.

Alhough the World Health Organization continues to assess H5N1-related risks to the public as low (and low-to-moderate for farm workers), the emergence of new, more easily transmissible strains “increases the pandemic threat,” warned Kachen Wongsathapornchai, Regional Manager of FAO Emergency Centre for Transboundary Animal Diseases earlier this week. Calling the recent bird flu surge “deeply concerning” the FAO official appealed for “immediate action.”

Insufficient outbreak response

Avian flu H5N1 situation update as of 31 July 2024 – all reports since outbreak began in March.

“Strengthening and integrating surveillance systems is crucial,” Claes said, enumerating measures South-East Asian countries should implement to fight the outbreaks. “Countries should invest in advanced diagnostic infrastructure and training for laboratory personnel,” as well as enhance international and inter-agency collaboration, prepare biosecurity protocols for farms and consider vaccination campaigns.

In the US, where the virus has infected an expanding circle of dairy cattle herds since first reports emerged in March, the country response is insufficient, US experts have long maintained.

There is, for instance, too little data and research that would ensure better understanding of the virus and the ways in which it transmits – not only through the mammary glands during milking, as was previously thought, new research seems to suggest.

Farmers reluctant to have herds and workers tested

Modes of infection with avian flu from poultry – a likely transmission path for some of the human cases

There is not enough testing infrastructure either. And farmers and their employees are reluctant to get themselves or their cattle tested, posing yet another problem in the US where there is no legal framework for mandatory animal tests.  

Similarly, for farm workers, testing and even wearing personal protective equipment is neither compulsory nor popular due to a general mistrust towards the official agencies, fear of lost revenue or, in the case of the workers, lack of a healthcare insurance.

Meanwhile, lax sanitation procedures in large dairy operations are big enablers of virus transmission, allowing cow-to-cow transmission when milking machines are not cleaned between every individual animal.

“Much more extensive follow up, serology studies and close monitoring of ‘mixing vessel animal species’, for instance pigs,” which can more easily incubate and transmit viruses to humans is needed, said Michael Osterholm, director of the University of Minnesota-based Centre for Infectious Disease Research and Policy (CIDRAP), in earlier comments to Health Policy Watch.

Overall, a more coherent plan of response is urgently needed in the Americas as well as Asia, Claes emphasized. In creating a plan, communication about the risk “with all stakeholders, from national governments to grassroots levels, is crucial to develop awareness and community engagement in tackling and controlling avian influenza.” 

Image Credits: Pickpik, USDA, CDC.

Dr Hans Kluge is working on access to cheaper medicines in Europe.

The World Health Organization’s (WHO) vast European region – 53 countries, including the entire European Union, Russia and even Israel – is often excluded from cheaper medicine deals because of member states’ high- and middle-income status.

But one of the flagship programmes of WHO regional director Dr Hans Kluge is the Novel Medicines Platform (NMP), aimed at enabling access to innovative new medicines such as gene therapy for cancer, that are effective but extremely expensive.

Norway was the inspiration for the NMP, Kluge told Health Policy Watch in a recent wide-ranging interview.

Before Kluge was elected regional director in 2021, he visited Norway, one of the richest countries in the region, and discovered that it was anxious about the financial sustainability of its universal health coverage if it were to open the door to these effective but costly medicines.

“Because they have universal health coverage, this means if they allow one medicine on the market, they’re obliged to give it to everyone. And they were concerned about these innovative cancer and diabetes medicines,” said Kluge.

Norway had started an initiative for cheaper novel medicines, and this was transformed into the NSP,  a multi-stakeholder collaboration that has country, pharmaceutical and patient representatives.

“Recently, [3-4 July] for the first time in two years, we had a physical meeting of the NSP where we convened all 53 member states, big pharma, patients and the insurers,” said Kluge.

The upshot of the meeting was the establishment of four time-limited working groups focused on transparency, solidarity, sustainability, and novel antimicrobials, which will conclude their work by December 2025. 

Joint procurement for non-EU countries?

For the first time, countries outside the European Union (EU) may have access to joint procurement for novel medicines, particularly the smaller countries in the region with little buying clout with pharmaceutical companies, said Kluge.

Describing the NSP as a “policy lab”, Kluge hopes it will open the door to access to cheaper medicines in the region – not just novel medicines.

The WHO has also resolved to second a representative to the EU’s Health Emergencies Preparedness and Response Agency (HERA) to assist non-EU members to get better access to medicines.

“We have been telling the EU that they will never be safe without the Western Balkans, countries such as Georgia, Ukraine and Moldova. We have said, ‘Guys, if you are procuring mpox vaccines, H5N1, don’t forget your neighbours’,” said Kluge, who hails from Belgium. 

He points to a recent EU meeting chaired by Germany on the price of multi-drug-resistant tuberculosis drugs, currently costing $15,000 a year.

“I would like to give some a positive example because I’m a born optimist,” added Kluge. “In Poland, through their parliament, they got concessional prices and also registered them for the Ukrainian refugees. So if there’s political will and determination, it is possible.”

Hepatitis medicines are also cheaper because of advocacy, while Sweden is spearheading an initiative on antimicrobial resistance (AMR),  he added.

The ‘magic bullet’ of primary healthcare

Kluge is also urging all member states to move from expensive hospital-based care to integrated primary health care (PHC), including health education.

“I used to say there is no magic bullet, but I have changed my mind. The magic bullet is called primary health care. We need to strengthen primary health care and make it multidisciplinary.”

PHC, involving “task shifting” to nurses and more digital solutions, can help to address “medical deserts” – found everywhere from Ukraine to rural France.

“Cardiovascular disease is the biggest killer in our region, but two-thirds of people with hypertension don’t know they have it. And only a minority of those who know are adherent to treatment,” says Kluge. “This is basic case management that should be decentralised to primary level.”

He adds that Europe controlled mpox by “empowering trusted messengers in the community”. 

However, the lack of agency of such civil society messengers in certain member states concerns Kluge – such as the criminalisation of LGBTQ groups and civil society organisations that can reach “key populations” most vulnerable to HIV.

“In the EU, and in whole or region, we have to hold the fort, even on basic issues like sexuality education in school. There is a call for family values, but the data shows an increase in infertility because of unsafe abortion; because of the rise in sexual infection related to no condom use. All of a sudden, the European region is not doing well on condom use.”

Ukraine and Russia

Both Ukraine and Russia are in Kluge’s region.

“We have about 300 people in Ukraine double the number of people we had before the war,” says Kluge. “They work on what we call three Rs: response, recovery and healthcare reform.”

This ranges from providing trauma kits at the frontline to assisting with mobile services and modernising Ukraine’s healthcare with the focus on PHC.

“Thanks to the cooperation of civil society, Ukraine has one of the best HIV responses in the region,” Kluge notes.

While the WHO still has a country office in Moscow and continues to provide Russia with technical support, the regional committee decided to move the regional office on NCDs from Russia to Copenhagen. 

Concern for LGBTQ communities, attacks on healthcare

“I am concerned about what are called the key populations, LGBT communities,” Kluge says. “We need to stand strong for those people.  I worked for two years in the former [Russian] gulags with  Medecins sans Frontieres in TB control so I know the situation quite well. 

“What happens with HIV patients in Donbas [the Ukraine territory under Russian control] is a bit of a black hole. The international community needs to ensure these people get access to treatment. I strongly believe dialogue is very important.”

Kluge also condemns the attacks on healthcare – “be it in Ukraine or in Gaza, the second war in my region”. 

“This is a major concern. People get used to this. But each time, we should scream heaven and earth. You cannot attack a doctor. We already have a lack of doctor and nurses.  It is completely unacceptable to kill them.”

Kluge, who is the only candidate staning for regional director in the WHO Europe elections, is expected to be re-elected unopposed at the regional conference in October.

The Global Pandemic Preparedness Summit in Brazil was addressed by arounf 80 experts over two days.

As climate change drives disease outbreaks, the world remains ill-prepared for another pandemic – lacking in collaborative surveillance, diagnostic tools and finance, speakers told the Global Pandemic Preparedness Summit (GPPS) in Brazil.

The two-day summit, attended by a global who’s who of pandemic experts, aimed to “reinvigorate the momentum for pandemic preparedness and response” – but it also offered a sober assessment of global shortcomings.

“Over half of pathogens are being amplified by climate change. With the global circulation of pathogens, there is a larger risk for transmission across different continents,” warned Professor Tulio de Oliveira, the South Africa-based scientist who is a key driver of Africa’s pathogen genome surveillance.

One of Prof Tulio de Oliveira’s slides.

Ethiopia is experiencing its biggest dengue outbreak, while Burkina Faso is also dealing with dengue after a four-year break. There’s a new strain of Chikungunya and a new lineage of cholera in Cameroon, he noted.

The increased interaction between animals, humans and the environment – in part caused by the destruction of environments and migration – has increased the mobility of pathogens, De Oliveira told the summit, hosted by Brazil’s Ministry of Health of Brazil, the Coalition for Epidemic Preparedness Innovations (CEPI), and the Oswaldo Cruz Foundation (Fiocruz).

The WHO is responding to 42 graded emergencies, 15 of which are Grade Three emergencies requiring international assistance, said Dr Mike Ryan, the WHO’s Executive Director of Health Emergencies.

“We’re tracking today a further 168 ongoing health emergencies around the world being managed at a national level, and … responding to cholera in 30 countries, mpox, avian influenza, H5N1, dengue and yellow fever, as well as multiple health emergencies related to war and natural disasters.”

“It’s our very connectedness that exposes us. We are the most connected human population in history. We live in mainly densely populated urban areas where we work, move, gather and socialise intensely.”

Prof Tulio de Oliveira, Director of the Centre for Epidemic Response and Innovation in South Africa.

Diagnostic gaps

According to the non-profit organisation FIND, of 21 pathogens with outbreak potential, SARS-CoV-2 is the only pathogen for which there is adequate diagnostic readiness.

FIND launched its Pathogen Diagnostic Readiness Index (PDxRI), a comprehensive tool for evaluating diagnostic preparedness at the summit. 

“Fast, equitably distributed diagnostics are essential to spot & stem an emerging pandemic. FIND have a partnership-driven, five-year roadmap for diagnostic readiness to achieve the 100 Days Mission. But this requires $100 million in seed funding,” said FIND’s Dr Marta Fernandez Suarez.

The 100 Days mission refers to the need to develop vaccines, tests and treatments within 100 days of an outbreak, and enable access to those who need them most to prevent pandemics.

“Infectious diseases can pop up quickly and we need to make sure we are ready to respond quickly and equitably,” said CEPI CEO Dr Richard Hatchett.

“If a new coronavirus were to emerge, there is the potential we could respond in 100 days. But if a new disease were from the Paramyxovirus or Orthopoxvirus family, we’d likely not be ready yet. Importantly, we are moving in the right direction – but to reach the 100 Days Mission we need to advance capabilities with medical countermeasures and globalise access to these technologies. ”

Access gaps

Anban Pillay, South Africa’s Deputy Director-General of Health, noted that his country had been charged a higher price for COVID-19 vaccines than Europe.

“There are huge problems with the conduct of the pharmaceutical industry when it came to access to vaccines,” said Pillay. “They didn’t provide access. They raised the prices. They decided not to give certain countries stock, even though we were paying higher prices than Europe.

“So we need a different global system about where we access vaccines and other countermeasures, a system that’s equitable, that is linked to need.”

“But access supposes that you have something to access,” noted Dr Mona Nemer, the Canadian government’s Chief Scientific Advisor and Chair of the 100 Days Mission Steering Group.

“And clearly, when it comes to diagnostics and therapeutics, and I dare say to vaccines, for the for the all the different viral families that we now have in front of us, we have a long way to go.”

Financial gaps

The Pandemic Fund’s Priya Basu said that the World Bank had been able to mobilize $2 billion in seed capital from 28 contributors to start the fund and seen “tremendous demand, and good quality projects”. 

During the first round of funding last year, projects “really focused on coordination and collaboration across different arms of government – health, finance, agriculture, animal husbandry, livestock, environment, all coming together”

But demand has far outstripped available finances, with the Fund having raised $850 million but received high quality proposals worth $7 billion.

“One of our biggest challenges is really to raise more money to maintain that momentum, because soon we’ll see a lot of disappointed countries if they don’t receive the money. And so that’s why we’ve just launched our investment case, our short term resource mobilization effort, last week,” said Basu.

Political progress at INB

Ambassador Tovar da Silva Nunes

Post-COVID, much of the world’s focus has been on politicians at the World Health Organization (WHO) negotiating a pandemic agreement. 

Brazil’s Ambassador Tovar da Silva Nunes, who is a vice-chairperson of the WHO’s International Negotiating Board (INB), told the summit he was confident that an agreement would be reached before the next World Health Assembly.

Da Silva Nunes and Ambassador Anne-Claire Amprou will be chairing a sub-committee on pathogen access and benefit sharing (PABS), the biggest sticking point in the talks.

“If we are able to solve what we call article 12, the doors are open for us to conclude the agreement in good time,” Nunes told delegates.

He added that there was no longer much disagreement on clauses relating to One Health.

“There was a perception that a One Health approach that is not a complete approach was wrong and it was not leading to equity,” he explained, adding that lack access to clean water, for example, was a factor in the spread of certain diseases.

“Vector-borne diseases are clearly related to [access to water]. So it has to be complete. This is overcome. We have decided to incorporate one health. It’s a major step for global community health, provided that it is done in a very balanced way.”

Ryan noted that the finer details of PABS might take time, but without a broad international “it will be very hard to achieve what this conference is setting out to achieve”.

Global South solidarity

“Global partnerships are key to the 100 Days Mission’s success,” said Brazil’s Minister of Health, Dr Nísia Trindade Lima. 

“Post-COVID, we’ve learned that equitable R&D, investment and access are crucial for public health. We cannot work only within our countries; we must think beyond borders. It’s time for science, technology, and innovation to unite for robust public health policies. We must work together in global health so that it becomes a reality.”

Summitt attendees from the Global South signed the Rio de Janeiro Declaration, which calls for greater collaboration between partners within the Global North and Global South to overcome disparities in access to health tools and countermeasures in low- and middle-income countries. 

The Declaration also urges global health partners to prioritise research and equitable access policies to focus on end-to-end R&D and support the establishment of the Alliance for Regional and Local Production, Innovation and Access, as discussed within Brazil’s G20 Presidency framework.

“It’s time to think and design a different world with a new mindset to build global health systems and strengthen global pandemic preparedness and response, with coordination between the Global South and North,” Professor Mario Moreira, President of Fiocruz, which initiated the declaration.

Around a quarter of young women have experienced abuse in an intimate relationship by the age of 20.

By the time they turn 20 years old, nearly a quarter (24%) of adolescent girls who have been in a relationship will have experienced physical or sexual violence from their intimate partner, according to a report from the World Health Organization (WHO) published Monday found.

Even though the prevalence of violence among teenagers largely parallels that of women overall, minors are more affected because of their economic dependence and the devastating effect it has on their health and life prospects.

“Intimate partner violence is starting alarmingly early for millions of young women around the world,” said Dr Pascale Allotey, Director of WHO’s Sexual and Reproductive Health and Research Department in a press release.

She highlighted the “profound and lasting harms” such experiences have and called for more health focus on prevention and targeted support for girls.

Using  WHO’s Global database on prevalence of violence against women, the report analyzes data over the last two decades from 161 countries on violence against adolescent girls aged 15-19 years old.

The analysis focuses on sexual and physical violence; psychological violence was excluded due to a lack of commonly agreed on comparison measures.

Long-lasting consequences of partner violence 

Health, educational achievement, future relationships, and the lifelong prospects of young people overall are all affected by intimate partner violence. 

Such violence also has direct effects on physical and mental health, heightening the risk of depression and anxiety disorders, but also injuries, unplanned pregnancies, and sexually transmitted infections.

According to the WHO, 42% of women aged 15-49 who experienced intimate partner violence report an injury as its consequence. 

Intimate partner violence also raises the risk of a miscarriage (16% more likely) or a pre-term birth (41% more likely). Victims were also nearly three times as likely to be infected with a sexually transmitted disease, in comparison to other girls and young women.

Power imbalances drive partner violence

The prevalence of intimate partner violence varies depending on region: from as little as 3% of teenage girls experiencing it in Georgia to as much as 49% in Papua New Guinea.

There are considerable regional differences in the prevalence of intimate partner violence, ranging from 47% in Oceania and 40% in Sub-Saharan Africa to 10% and 11% in Central Europe and Central Asia respectively.

It is generally more common in lower-income countries where women have less power than male partners.

A lower proportion of girls enrolled in secondary school, weaker legal property ownership and inheritance rights, and child marriage all conspire to foster conditions of economic dependency and social isolation that increase the risks of abuse in intimate relationships, the research found.

The keys to improving the situation are “ensuring secondary education for all girls, securing gender-equal property rights and ending harmful practices such as child marriage, which are often underpinned by the same inequitable gender norms that perpetuate violence against women and girls,” said the report’s author, Dr Lynnmarie Sardinha.

Education, legal, and economic empowerment

Currently, no country is on track to achieve the target of eliminating violence against women and girls by 2030, as countries pledged to do under Target 5.2.1 of the 2030 Sustainable Development Goals.

The study highlights the urgent need to strengthen early prevention measures and support services made especially for adolescents. Actions to advance women’s and girls’ agency and rights are another important measure.

Effective interventions can include school programmes that educate all students on healthy relationships and violence prevention, but also more general legal protections and economic empowerment.

Image Credits: USAID, WHO.

A Palestinian girl on bus from Gaza to Israel’s Ramon airfield for airlift to the UAE

Updated: The World Health Organization confirmed Tuesday evening that it had evacuated 85 severely ill and wounded Gazans to the United Arab Emirates for advanced treatment via Israel’s Ramon airfield. 

The complex operation occurred as tensions escalated in the region following the deaths of 12 children in a Golan Heights Druze community –  apparently from a missile fired by the Lebanese Shi’ite Hizbullah. 

The carefully planned evacuation had originally been scheduled to take place on Monday, WHO confirmed. Israel’s Prime Minister Benjamin Netanyahu reportedly had delayed the plan after a missile hit on the soccer field of Majdal Shams, a mountain tourist town near the Lebanese border, early Saturday evening, killing a dozen children aged 10-16. Hizbullah denied responsibility for the attack, but western experts and intelligence sources said that evidence points to a rocket from Lebanon. 

Tuesday’s evacuation of some 35 children and 50 adults, along with 63 family members and care-givers, finally took place under a shroud of secrecy, and on a day when tensions between Israel and Hizbullah soared to new heights as Hizbullah fired over 50 more missiles into northern Israel, killing one more person.

In the early evening, Israel’s response for the Majdal Shams attack finally came in the form of a retaliatory strike on a Beirut apartment building, targeting a senior Hizbullah military commander in an area near the milita’s headquarters, and causing dozens of casualties, according to Lebanese reports. 

Hizbullah has been fighting alongside Gaza’s Hamas ever since the deadly 7 October attacks that triggered the current war.  The Druze, meanwhile, are members of an ancient religious minority whose communities dot the border regions of pre-1967 Israel and the Golan Heights, not to mention Lebanon and Syria – implicating them in the wider Israeli-Arab conflict on multiple fronts.

Majdal Shams, in the Golan Heights, is considered occupied Syrian territory by the United Nations, but it was annexed by Israel in 1981, becoming a popular Israeli tourist destination with rich natural resources and archeological history. Since the eruption of the Syrian civil war over a decade ago, an increasing number of Golan Druze, who already had Israeli residency, have also taken on citizenship. 

‘We hope this paves the way for evacuation corridors via all possible routes’

Sick and injured Palestinians board a bus leaving Gaza for an airlift  to medical treatment in the UAE via Israel’s Ramon airfield.

Reports of a plan to begin airlifting hundreds of seriously ill and wounded children out of Gaza to the UAE via Israel’s Ramon airfield in the Negev desert first surfaced in media reports last week, despite WHO’s efforts to keep the mission under tight wraps. 

The airlift scheme came against a background of mounting international criticism of Israel’s seizure of the Rafah border crossing between Gaza and Egypt in early May. That effectively sealed off the only available route for medical evacuees, as well as for Gazans who could afford the hefty visa fees to escape the war. 

“The patients had cancer, injuries, blood diseases, congenital conditions, neurological conditions, cardiac and liver and renal disease,” said WHO’s Director General Dr Tedros Adhanom Ghebreyesus in an X post, Tuesday evening.

“We hope this paves the way for the establishment of evacuation corridors via all possible routes,” he added.

The WHO team organized and managed the transfer of patients from over half a dozen areas in Gaza to Israel’s Kerem Shalom crossing under “extremely challenging conditions” the organization said, including active conflict in various parts of Gaza. After the original mission was postponed Sunday, some injured and ill patients had to be held at a Médecins Sans Frontières (MSF) field hospital site, pending Tuesday’s final evacuation.

Speaking at a UN press briefing in Geneva on Tuesday, WHO spokesperson Christian Lindmeier said that some 10,000 people, in all, were in need of medical evacuation – as continued waves of conflict-related displacement, malnutrition and interruptions in medical services continue to haunt Gaza’s 2 million Palestinian residents.  

Since October 2023, around 5000 people have been evacuated for treatment outside Gaza during the grinding nine months of war, with over 80% receiving care in Egypt, Qatar and the UAE.

Many Gazans new rounds of displacement as WHO dispatches 1 million polio vaccines

Administering oral polio vaccine – Gaza’s vaccination rates have dropped sharply.

Lindmeier also echoed recent calls by regional health ministers for a cease fire and an ‘enabling environment’ so that a massive polio vaccination campaign could safely take place in the coming days and weeks.

“Otherwise, the vaccines would be sitting as many other trucks are across the border, either on the Rafah side or at the other checkpoints either inside…or outside Gaza,” Lindmeier said.

WHO last Friday said that it was dispatching 1 million polio vaccines to Gaza after evidence of vaccine derived polio virus was found in local sewage sources. 

No actual cases of polio, which can lead to paralysis and even death, have been reported so far in Gaza. But since the beginning of the war on 7 October, 2023, polio immunization rates have dropped by about 10%, WHO and other global health authorities have observed. And that increases the risk that under-vaccinated Gaza children and adults, who are also suffering from a lack of clean water access and widespread malnourishment, could fall ill. 

“Having vaccine-derived polio virus in the sewage very likely means that it’s out there somewhere in people,” Lindmeier said. “So the risk of (it)… spreading further is there and it would be a setback definitely (for global efforts).”

This is not the first time, either, that polio has circulated in sewage in the densely-populated region. In 2022, Israel conducted its own emergency polio vaccination campaign amongst under-vaccinated groups after a 4-year old Jerusalem child fell ill while six others were diagnosed with asymptomatic cases, and the virus was identified in sewage samples, as well. 

Mounting water, sewage and sanitation crisis 

Explosion of a vital water reservoir in Rafah has prompted outrage internationally and within Israel.

Along with that, there is a mounting water, sewage and sanitation crisis in Gaza – exacerbated by the recent Israeli army explosion of a large water reservoir in Rafah. 

Also speaking at the Tuesday UN briefing, James Elder, a spokesperson for the United Nations Children’s Fund (UNICEF), denounced the blowing up of the Rafah water facility last week at Tel  Sultan – calling it an act of  “blatant disregard” for children’s rights. 

The range of water availability in Gaza is currently 2-9 litres per person per day, he pointed out – whereas the humanitarian minimum standard is 15 liters – and that is notwithstanding the sweltering temperatures Gazans are currently facing at the peak of summer – with daytime temperatures averaging highs of 36°.

Israel’s military has not commented publicly on the incident. But military police are  reportedly probing the incident as a suspected violation of international law, which may have also been sanctioned by a local commander, Israeli media reported. 

The incident provoked expressions of outrage within Israel, as well as internationally, after a soldier who participated in the demolition of the reservoir, known as Canada well, posted a video on Instagram, and later on X, celebrating the explosion with a caption stating it was “in honor of the Sabbath” – the Jewish day of rest.   

The reservoir and solar-powered water treatment facility, was developed by Canada’s International Development Agency in the 1990s and supplies a large proportion of the city’s water needs.

Some 20,000 Palestinians remain in the Rafah area, including in the Tel Sultan area, which had not been subject to forced evacuation.  Around 1.4 million displaced Palestinians had been sheltering there before Israelis forces moved into the southern border city in May.

“Somehow people are holding on, but of course we are now in that deathly cycle whereby children are very malnourished, there is immense heat, there is lack of water, there’s a horrendous lack of sanitation and that’s the cycle,” Elder observed. “On top of that, of course, there is a very, very active conflict.”

Image Credits: X/@Dr Tedros, WHO, Global Polio Eradication Initiative, X/Times of Israel.

South Africa’s Dudu Dlamini (left) explains that her HIV, diabetes and hypertension are all treated at different health facilities. The Global Fund’s Vindi Singh looks on.

As the disease burden in developing countries shifts from infectious to non-communicable diseases (NCDs), governments and patient advocates are grappling with how to re-engineer healthcare systems to address both.

The extraordinary global focus on HIV has resulted in a siloed network of HIV clinics to treat the virus – but there is growing acknowledgement that countries’ HIV gains will be lost if they don’t get NCDs under control.

“People living with HIV are disproportionately affected with NCDs. It is estimated that one in three people living with HIV have either hypertension or other NCDs,” says Professor Kaushik Ramaiya, General Secretary of the Tanzania NCD Alliance and a member of the NCD Alliance Board.

“People living with HIV (PLHIV) have an increased incidence for more than 20 non-AIDS defining cancers, while women living with HIV are up to six times more likely to develop cervical cancer,” he told an event organised by the NCD Alliance at the International AIDS Conference in Munich last week.

There are almost 40 million people with HIV, mostly in developing countries, and many are succumbing prematurely to heart disease, diabetes, strokes and other NCDs. This is often because HIV programmes are so focused on their patients’ HIV that they don’t diagnose and treat these other conditions early enough.

‘I could take ARVS well and die of high blood’

South African Dudu Dlamini lives with HIV, hypertension and diabetes. As a sex worker and the advocacy officer for Sex Workers Education and Advocacy Taskforce (SWEAT), Dlamini knows what marginalisation means.

“We are criminalised,” Dlamini told the meeting. “It is not easy for me to identify as a sex worker. Our doctors don’t know about us. For my HIV, I am treated in one place. For my high blood, another place and for my blood sugar, somewhere else.”

Having three different treatment sites costs time and transport money, and sex workers default on medication “because we are not able to keep all the appointments”, says Dlamini.

“My vision is for sex workers to be helped for all the conditions at the same time; a place where we can identify freely as sex workers and get treated –  for STIs, and all other conditions – in one place. I need one folder with all my medical history and background because I might be taking antiretrovirals well but tomorrow I die from high blood.”

Her experience echoes that of several other people living with HIV and NCDs, as captured by the NCD Alliance in a collection of testimonies that makes the case for integrated care.

Global commitment to integration made back in 2021

NCD Alliance CEO Katie Dain.

At the 2021 United Nations High-Level Meeting on HIV and AIDS, global leaders committed to ensuring that “90% of people living with and affected by HIV have access to people-centred and context-specific, integrated services for HIV and other diseases, including NCDs and mental health by 2025”, NCD Alliance CEO Katie Dain told the meeting.

“This, in many ways, is one of the real frontiers of the global HIV response, recognising that people living with HIV are living longer thanks to advancements in antiretroviral antiretroviral therapy,” she added.

Ntombifuthi Ginindza, from Eswatini Ministry of Health in southern Africa, knowledges the urgency of “integrating NCD treatment into HIV setting”.

Eswatini has an estimated HIV prevalence rate of 25% in people aged 15 to 49, one of the highest rates in the world. 

It has made remarkable progress, achieving a 72% decline in HIV infections and a 55% decline in AIDS-related deaths since 2010. But its premature mortality for NCDs in moving in the opposite direction, growing from 27% in 2015 to 35% currently.

“We are integrating NCDs into HIV setting. In the spirit of client-centredness, we’re working on an integrated chronic disease framework, which is mainly focusing on integration at primary level facilities,” said Ginindza.

“We are trying to sustain the gains that we have made on HIV. There is a lot that we have achieved through HIV, so we want to leverage the resources that we have in place for HIV as we are transitioning HIV clinics to chronic disease clinics.”

Four different models of integration

PATH Kenya’s Nicolas Odiyo and WHO’s Dr Prebo Barango

Dr Nicholas Odiyo, Senior Technical Advisor for PATH Kenya, says his non-profit healthcare group has implemented various different models for HIV and NCD integration in Kenya, India, the Democratic Republic of the Congo (DRC) and Vietnam. 

One model involves screening for certain NCDs at HIV clinics, based on the patients’ assessed risk factors, particularly hypertension, diabetes and cervical cancer, said Odiyo.

The second involves community-based screening, mainly run by community health promoters with blood pressure machines and glucometers to test for hypertension and diabetes.

The third model is integrating “continuous screening for hypertension and diabetes” into HIV programmes, while the final model involves comprehensive care for all, with NCD and HIV screening for the entire population in universal healthcare.

Blood sugar levels can easily be checked with a glucometer

Some donors are on board

HIV donors are also increasingly accepting that they need to incorporate NCD care to safeguard people living with HIV.

The US President’s Emergency Plan for AIDS Relief (PEPFAR) supports the integration of hypertension in five countries that are doing well with HIV, Botswana, Eswatini, Lesotho, Namibia and Rwanda, said PEPFAR ensior advisor Ritu Pati.

“PEPFAR’s HIV hypertension integration initiative was launched in response to  Ambassador [John Nkengasong’s] keen interest to address the very high rates of uncontrolled blood pressure amongst people living with HIV (PLHIV,” said Pati.

The five countries have received supplementary funding of $5 million for a year to improve  hypertension control in PLHIV, although this funding cannot be used to buy anti-hypertensive medication. 

“Close to 30% of men and women in sub-Saharan Africa over the age of 30 have hypertension, and at the same time, only a small proportion of them have controlled blood pressure. So the idea is, is that if we can proactively address hypertension in the populations that we serve, we can then reduce the incidence of cardiovascular events and thereby reduce mortality.

‘It’s become increasingly clear that we need to address hypertension amongst PLHIV to improve their health outcomes and preserve the gains of our PEPFAR programs.”

Pati adds that the integrated service delivery model has many benefits:  “It reduces the number of clinic appointments for PLHIV, promotes early diagnosis and treatment of co-morbidities, minimises service duplication, which really may lead to cost savings, and allows [healthcare] providers to have a comprehensive view of their patients history and offer them patient-centred care.”

Better still, PEPFAR has evidence that the integration of HIV services with primary health care “can actually improve HIV clinical outcomes such as continuity of treatment and viral load suppression”.

The Global Fund includes “integrated people-centred health services” in its strategy for 2023-2028, said Vindi Singh, the fund’s senior disease advisor on HIV treatment

HIV funding in some countries incorporates cervical cancer and hypertension services, Singh noted. Kenya and South Africa have also included HIV and NCD integration in their national strategic plans for HIV.

Stigma and competition

STOPAids CEO Mike Podmore.

But as Ramaiya notes, the stigma associated with HIV means that is far easier for people living with HIV to accept NCD integration than HIV clinics than it is to integrate HIV services into non-HIV clinics.

“You need a policy cohesion that starts from the Ministry of Health and local government, because HIV is a vertical program and TB is a vertical program. So when you are trying to integrate an NCD programme within HIV, you need to have a cross communications with those other programs.”

STOPAids CEO Mike Podmore concluded the event by noting that “with a projected 71% of people living with HIV having at least one NCD by 2035”, the focus on “trailblazing quality integration is necessary and compelling”. 

But Podmore warned that “it is essential that we do not allow HIV and other health issues like NCDs to be in competition to each other in a zero-sum game of flatlined resources”.

“We need to champion quality integration and synergies across health issues that build greater equality across diseases. 

‘It is also essential that the global health community restructures and recalibrates itself to ensure that inequalities of the COVID pandemic response cannot be repeated again, and that there is much stronger coordination of external actors at country level, led by country stakeholders.”

Image Credits: Dischem.

Lab technician at Afrigen, the Cape Town-based firm hosting the WHO co-sponsored Vaccine Technology Transfer Hub.

The Argentina-based biotech firm,  Sinergium Biotech, has agreed to share know-how on the production of an mRNA vaccine for Avian influenza (H5N1) with WHO’s  Tecnology Transfer Hub so that an affordable vaccine could rapidly be produced for developing countries, WHO said Monday.

The agreement marks the first time that a vaccine developer has actually volunteered know-how to the hub, which was founded by WHO in 2021 together with the Medicines Patent Pool, and is hosted by the South African firm Afrigen, based in Cape Town.

Sinergium “has developed candidate H5N1 vaccines and aims to establish proof-of-concept in preclinical models. Once the preclinical data package is concluded, the technology, materials, and expertise will be shared with other manufacturing partners, aiding the acceleration of the development of H5N1 vaccine candidates, and bolstering pandemic preparedness efforts.” said WHO in a statement.

“This initiative exemplifies why WHO established the mRNA Technology Transfer Programme – to foster greater research, development and production in low- and middle-income countries, so that when the next pandemic arrives, the world will be better prepared to mount a more effective and more equitable response,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General.

H5N1 is first vaccine target for the hub since COVID-19

Colorized transmission electron micrograph of Avian influenza A H5N1 viruses (seen in gold) grown in MDCK cells (seen in green).

Following it’s launch, the Afrigen mRNA Technology Transfer Programme focused mostly on testing and developing an mRNA COVID-19 vaccine candidate.  Progress, however, was slow because the major mRNA vaccine manufacturers, Moderna and Pfizer, refused to share their know-how on the WHO-sponsored platform – opting to sign licencing agreements to manufacture COVID vaccines under their brand identities with other manufacturers elsewhere in Africa.

So the agreement by Sinergium to share its IP and partner directly with the WHO co-hosted hub is a breakthrough for the global health agency – which has long sought a role in the emerging mRNA vaccine market –  to reduce costs and make vaccines more accessible in low- and middle-income countries.

The new agreement signed with a Latin-American based firm also takes a small, but meaningful, step towards the ‘regionalization’ of vaccine markets, WHO officials said on Monday.

“This announcement underscores the importance of not only geographically diversifying the innovation and production of health technologies including and recognizing the capacities in Latin American and the Caribbean, but also the importance of early planning for access and the sharing of knowledge and technologies during the research and development processes,” said Dr Jarbas Barbosa, Director of the Pan American Health Organization (PAHO), WHO’s Regional Office for the Americas.

Dr Alejandro Gil, Chief Executive Officer of Sinergium, credited PAHO’s “strong support it offers to regional manufacturers in the Americas” with playing an instrumental role in the deal.

“Sinergium’s enhanced capacity and readiness to apply our expertise to H5N1 will play a vital role in this effort towards global pandemic preparedness. …We are excited to tackle this public health challenge and our R&D team will continue to work closely with the Programme Partners.”

Along with the base at Afrigen, WHO’s mRNA technology transfer hub programme includes Institut Pasteur in Senegal – and is planned to eventually includes manufacturers in over a dozen other low- and middle-income countries around the world.

Moderna also advancing a candidate vaccine with US government help

172 dairy herds in 13 states have so far been affected by the spread of avian flu in dairy cattle since the outbreak was reported in late March.

 

Moderna is reportedly at a more advanced stage in the process of developing and mRNA vaccine for the virus, which is spreading rapidly amongst dairy cattle herds in the United States.  In early July, the US government awarded the Cambridge-based firm $176 million to advance development of “an mRNA-based pandemic influenza vaccine.”

“We have successfully taken lessons learned during the COVID-19 pandemic and used them to better prepare for future public health crises. As part of that, we continue to develop new vaccines and other tools to help address influenza and bolster our pandemic response capabilities,” said HHS Secretary Xavier Becerra, at the time of the announcement.

While WHO has so far assured that the risks to humans of avian flu remain low, as long as human-to-human transmission is not occurring, the ever-widening transmission of the deadly virus amongst different animal species increases the risks that it may one day soon mutate in a way that it can more easily infect, and be transmitted, amongst humans.

And in the absence of effective vaccines, which are also widely available, that could unleash yet another pandemic on the world.

Image Credits: Afrigen, CDC/ Courtesy of Cynthia Goldsmith, CDC.

Mathias Ofoke during his routine blood sugar test at the Ezza Ofu Health Centre, Ebonyi State, Nigeria.

Fifteen-year-old Mathias Ofoke is one of four children in his family born with type 1 diabetes. Whenever his symptoms worsened, he was taken to the nearest primary healthcare (PHC) center where he was repeatedly treated for malaria. 

It wasn’t until February, when a non-governmental organization (NGO), Abby Cares Foundation, organized a clinical outreach at Ezza Ofu Health Centre that Ofoke’s condition was properly diagnosed. 

His blood sugar result of 543 mg/dL alarmed everyone when it was displayed on the glucometer screen. But the understaffed PHC facility at Ezza Ofu could not admit him as they were not properly equipped to care for him.

The NGO facilitated his admission to a secondary health facility and began sourcing insulin for his treatment.

“We frequently see cases of hypertension, diabetes, and cancer but we are not able to manage them, so we refer,” says Elizabeth Nwovu, the officer-in-charge at Ezza Ofu Health Centre. She is a community health extension worker (CHEW) who trained to be a matron.

IDF Diabetes Atlas

An estimated 27% of deaths in Nigeria are linked to diabetes, cancer, cardiovascular and chronic respiratory diseases. These four major non-communicable diseases (NCDs) are the leading causes of mortality globally, with the majority of deaths occurring in low- and middle-income countries (LMICs). 

Diabetes, characterized by elevated blood glucose levels, affects 537 million adults (20-79 years) worldwide. This number is expected to rise by 46% in 2045. 

As urbanization increases, diets change and populations age, Nigeria has also seen a surge in adults living with diabetes, from 209,400 in 2000 to 3.6 million in 2021—only South Africa had a higher prevalence in 2021. 

Diabetes is responsible for about 4.5% of deaths in people under 60 years old in Nigeria, with common complications including hyperglycemic emergencies, diabetic foot ulcers, chronic kidney disease and stroke.

PHCs prioritized in NCD management 

A national survey on NCDs conducted between 1990 and 1992 revealed that less than a quarter of the estimated 1.05 million Nigerians living with diabetes were aware of their condition. Following this survey, the Nigerian government attempted to integrate NCDs into PHC facilities, but these efforts met with minimal success.

Efforts to tackle NCDs in Nigeria were reignited in 2021 following the Brazzaville Declaration on NCDs and the subsequent political declaration at the 66th United Nations General Assembly on the Prevention and Control of NCDs. These declarations set the precedent for the WHO Global NCD Action Plan 2013-2020, which has now been extended to 2030.

Over the years, Nigeria has built on these regional and global strategies to develop several national policies for NCD prevention and control. Notable among these are the National Multi-Sectoral Action Plan for the Prevention and Control of NCDs and the National Guideline for the Prevention, Control, and Management of Diabetes Mellitus in Nigeria.

The scope of the national guideline for diabetes management was developed using the Population, Intervention, Professions, Outcomes, and Healthcare setting (PIPOH) checklist. 

The interventions outlined in the guideline emphasize the importance of integrating community health workers, such as CHEWs, and scaling-up screening, diagnosis and treatment in PHC facilities.

Task-shifting to community health workers

According to the national diabetes guideline, a key indicator of progress is the successful delegation of certain aspects of diabetes care to lower-level health professionals, such as CHEWs and lay health workers.

Similarly, the national multi-sectoral action plan, which informed sections of the diabetes guideline, recommends expansion of the Task-Shifting and Task-Sharing Policy for Essential Health Care Services to include NCD management among its priority areas. Currently, this policy focuses on maternal and child health, and communicable diseases (HIV/AIDS, malaria, and tuberculosis).

In line with this recommendation, during the technical session of the 64th National Council on Health (NCH) in November 2023, the Ministry of Health and Social Welfare announced plans for a National Task-Shifting and Task-Sharing (NTSTS) policy focused on the prevention and control of NCDs.

Elizabeth Nwovu, a community health extension worker (CHEW) and the officer-in-charge at Ezza Ofu Health Centre, Ebonyi State, Nigeria.

“This policy, if adopted, will complement the existing Task-Shifting and Task-Sharing Policy for Essential Health Care Services,” said Dr Anyaike Chukwuma, Director of Public Health, during the event.

The NTSTS policy aims to address the rising burden of NCDs in Nigeria by decentralizing preventive, diagnostic, treatment, and rehabilitative services to PHC facilities.

“By implementing this policy, the country hopes to adopt a patient-centered approach, accelerate progress towards NCD prevention and control, achieve universal health coverage, and work towards the Sustainable Development Goals,” Chukwuma added.

PHCs are ready but support is inadequate

“PHCs are not adequately supplied with medications,” said Nneka Nwankwo, founder of Abby Cares Foundation. She has over 20 years’ experience in public health and social services.

Her NGO sources Ofoke’s daily insulin injection from a tertiary hospital in the city center. Nigeria’s annual diabetes-related health expenditure per person is estimated at $499.7, which falls below the African regional average. If current trends continue, the prevalence of diabetes in the country is predicted to increase by up to 120% by 2045.

In his study on improving primary health care services for NCDs in Nigeria, Whenayon Ajisegiri found that some government stakeholders’ skepticism about the qualifications of community health workers, who constitute the majority of the PHC workforce, has been used to justify the limited supply of NCD drugs at PHCs. Ironically, NCD drugs are contained in the list of essential medicine and should be available at PHC facilities.

“When PHC facilities repeatedly fail to provide patients’ medications, it leads to frustration. And when you lose patients’ trust in the initial stages, it is difficult to regain,” said Nwankwo.

Patient flow for NCD service delivery at the PHC level, with enablers and barriers along the pathway.

A survey of 30 PHCs in Abuja, Nigeria’s capital city, reported a readiness to integrate diabetes care in terms of available paper-based health management information systems, equipment, and personnel. However, the poor availability of diabetes medications makes it impossible to harness this opportunity.

“If we can get access to testing kits and the drugs, it will improve our ability to manage patients with diabetes,” said Nwaovu.

The survey recommended a subsidized drug-revolving fund mechanism to maintain drug inventory, drawing from programs like the Hypertension Treatment in Nigeria (HTN) Program and the Academic Model Providing Access To Healthcare (AMPATH) program in Kenya.

Community health workers play an integral role

The slow progress in integrating diabetes and other NCDs into PHCs is also linked to the omission of community health workers from NCD policies.

The critical shortage and uneven distribution of skilled health workers, particularly physicians and nurses, have necessitated the deployment of community health workers to support essential health services delivery.

Prior to the introduction of the NTSTS, existing policies like the National Standing Orders, which guides the training and practice of community health workers, restricted their role to only screening and referral. Ajisegiri noted that frequent referrals to higher health facilities—secondary and tertiary—could undermine public trust in the services provided at PHCs.

Formalization of task-sharing 

Given the Nigerian government’s prioritization of PHCs to tackle NCDs, experts have advocated for capacity building, while formalizing task-sharing and task-shifting policies for NCDs among community health workers.

In a survey of 30 PHCs in Abuja, Nigeria’s capital city, only 37% reported having at least one staff member trained in diabetes diagnosis and management within the past two years. With the NTSTS for NCDs set to be adopted, Nigeria appears to be on track to address this issue. 

This task-sharing and task-shifting model has already been successfully implemented in maternal and child care, as well as in the management of infectious diseases.

While this approach is expected to help the government maximize the available health workforce for NCD management, it is crucial to allocate sufficient resources to PHC to enhance infrastructure, ensure consistent medicine supplies, and bridge the significant skill gap among community health workers. Additionally, refining the practice scope in the National Standing Orders is essential to prevent interprofessional role conflict.

Funding and political will are paramount

The national multi-sectoral action plan acknowledged the problem of medication access and called for action towards ensuring a reliable supply of essential medicines for treating diabetes and other major NCDs.

It recommended expanding the Basic Minimum Package of Health Services, funded by the Basic Healthcare Provision Fund (BHCPF), to cover comprehensive care and treatment of NCDs. The BHCPF serves as a catalytic funding source to enhance access to primary health care, particularly for poor and vulnerable groups. 

This expansion aims to reduce out-of-pocket expenses for treatment. However, funding for the BHCPF has been inconsistent. 

Nwankwo recalled that Ofoke’s father was reluctant to bring his other children living with diabetes for treatment due to the costs. Despite her offer to subsidize the insulin injections by 50%, her efforts to persuade him were unsuccessful. 

“Even with your help, I can’t afford it,” she remembered him saying. Eventually, he brought one more child for screening.

Nneka Nwankwo, founder of Abby Cares Foundation in her office in Abakiliki, Ebonyi State, Nigeria

Only half of the initial 55.1 billion naira allocated to the BHCPF in 2018 was released and by 2021, the budget had decreased to 35 billion naira. Between 2019 and 2022, it is estimated that 89 billion naira was allocated through the BHCPF, with only 7,250 out of the 35,514 Primary Healthcare Centres in the country receiving these funds.

This scenario is all too familiar for Nwankwo. “At Ezza Ofu Health Centre, the quota for the health insurance scheme is around 300 people, but it’s just a drop in the pond,” she said. During her organization’s first outreach at the PHC, over 1,000 people showed up seeking medical care. “Creating policies is not enough if they are not backed with the right resources,” she added.

Pius Ukpai contributed to this reporting from Ebonyi State, Nigeria.

Image Credits: Chimdiebube Ikechukwu, IDF Diabetes Atlas, Whenayon Ajisegiri.

An extract from the online campaign to ‘Kick Big Soda out of sport’.

Leading global health organisations have called for Coca-Cola to be removed as a major sponsor of the Olympic Games and an end to sponsorship by “Big Soda” of all other sporting events.

Sixty organisations and over 35,000 people have signed an online petition as part of the “Kick Big Soda Out of Sport “campaign, ahead of the opening of the Olympic Games in Paris on Friday (26 July).

“Sugary drinks harm people and our planet. By accepting billions from Coca-Cola to sponsor the Olympic Games, the International Olympic Committee (IOC) implicitly endorses a world where health and environmental harms are ‘sports-washed’ away, undermining commitments to use sport to create a better world,” according to the petition.

It adds that sugary drinks are a major contributor to rising rates of obesity, Type 2 diabetes and heart disease and that Coca-Cola targets children with its marketing.

The petition also says that Coca Cola is damaging the environment with “plastic pollution, carbon emissions and water depletion”.

“With continued Coca-Cola sponsorship, how does the IOC intend to meet its commitment to WHO to promote a healthy society through sport, to advance Sustainable Development Goal 3 (“Good health and well-being”) and prevent non communicable diseases (NCDs)?” it asks.

It urges the IOC to “prioritize the health and well-being of people and our planet over Big Soda’s corporate interests” by terminating Coca-Cola’s Olympic sponsorship, and committing to not accepting future sponsorship from corporations that harm public health and the environment.

“Serving as a major sponsor of the Olympics allows companies to blanket venues and events with their logos, reaching an audience of over 3 billion watching at home,” said Trish Cotter, global lead of the food policy program at Vital Strategies. 

“Alongside growing opposition to soda’s involvement in sport, athletes themselves are beginning to speak up about which companies should be permitted to sponsor sporting events. For example, at Euro 2020 Cristiano Ronaldo made a strong statement when he pointedly removed two bottles of Coca-Cola that were placed in front of him at a news conference.”

‘Contradicts IOC’s mission’

“The link between sugary beverages and chronic and largely preventable diseases such as diabetes, cancer and heart disease is well established,” said Dr. Barry Popkin, W. R. Kenan Jr. Distinguished Professor of nutrition at the University of North Carolina at Chapel Hill Gillings School of Global Public Health. 

“Allowing Coca-Cola to continue as a key sponsor of the Olympic Games directly contradicts the IOC’s mission and undermines the efforts and achievements of Olympic athletes.

“The most insidious actions of the beverage industry, however, are their marketing strategies, which disproportionately target children and adolescents. These tactics perpetuate unhealthy consumption patterns, setting young people up for lifetimes of poor dietary habits and health risks.”

“This campaign is bringing much-needed attention to the ways sugary drink companies use sport to add to their bottom line,” said Nzama Mbalati, Chief Executive Officer of HEALA, a civil society coalition in South Africa advocating for a more just food system.

“This petition underscores the need for the IOC to prioritise the health of people and the sustainability of our planet over commercial interests,” said Alejandro Calvillo, Director of El Poder del Consumidor, a consumer rights nonprofit in Mexico. 

“By distancing itself from Big Soda, the IOC has an unprecedented opportunity to uphold its reputation as a beacon of integrity, excellence and social responsibility.”

“Kick Big Soda Out of Sport” is the beginning of a movement to remove all sugary beverage sponsorship from sport. The campaign is led by concerned global health organizations and advocates and highlights the harmful effects of sugary drinks on our health and the planet.

Lezzita Mphundi, a health worker in rural Malawi, HPV vaccine demand has rebounded – stockouts are now the problem.

After experiencing the distress of caring for a loved one with advanced cervical cancer, Edna Maloya vowed to take proactive measures to ensure that her family and friends would be protected. 

“I was my cousin’s caregiver. I can’t take chances with cervical cancer,” says Maloya, who lives in Blantyre, Malawi’s second largest city.

She happily supported the Ministry of Health’s (MoH) human papillomavirus (HPV) school vaccination campaign aimed at girls aged nine to 14, consenting to her 13-year-old daughter receiving the HPV vaccine.

But some of the other parents in her daughter’s class had reservations and chose not to have their daughters vaccinated -–even though they could have done so either during the school vaccination campaigns or in community health facilities. 

Maloya is firm in her views: “This is my only child. If we have an opportunity to prevent illnesses, let’s utilise it. I’m certain that those who are hesitating now will someday wish they had let their daughters have this vaccine.” 

Malawi’s HPV vaccination rates – rebounding from Pandemic era turmoil 

HPV vaccination rates plummeted during the COVID pandemic, but now have rebounded sharply.

When Malawi first introduced the HPV vaccination in 2019, the uptake was dramatic with 85% of the first group of eligible girls, nine-year-olds, getting their first dose.  

Then the COVID-19 pandemic hit, followed by Cyclone Freddy, which left more than half a million people displaced – and following that, outbreaks of polio and cholera. 

HPV coverage rates plummeted sharply to just 13% in 2021 and 2022, according to WHO’s immunization dashboard that tracks HPV vaccine uptake around the world.  

Rates are finally rebounding with  a dose of the vaccine reaching 68% of eligible nine-year-old girls in 2023.  And according to the new WHO guideline, approved in 2022, one dose is sufficient to provide lifelong protection. 

The rebounding vaccination rate is good news for Malawi, which has the world’s highest incidence and mortality rates of cervical cancer. The disease is also the leading cause of cancer deaths amongst women in the country, according to the national Cervical Cancer Strategic plan 2022-2026. About 4,000 women are diagnosed every year, while nearly 3,000 women annually die from the disease, according to WHO data. 

In 2023, the WHO African region’s HPV vaccination rate was second highest in the world 

HPV vaccination rates in Africa have rebounded in 2023 and are on an upward swing. 0

Throughout Africa, a positive trend can be observed in the 2023 HPV vaccine data, just released by the World Health Organization (WHO). 

After a slight dip in vaccination rates during the pandemic year of 2021, rates rebounded quickly reaching 40% of eligible girls.  

That places WHO’s Africa region as second only to the Americas, which had a 68% uptake, in vaccine roll-out last year. It slightly exceeds the WHO’s European Region, whose 53 member states extending from the United Kingdom to Central Asia and Russia registered a 39% rate for HPV jabs. 

These three regions remain far ahead of the others including: South-East Asia, with a 16% uptake; the Western Pacific, including China, Japan and Australia (11%); and the Eastern Mediterranean Region, extending from Tunisia to Afghanistan, which had a woeful 1% rate of HPV vaccination in 2023. 

WHO’s Africa Region has the best first-dose coverage of HPV vaccine than any other region in the world – except the Americas.

Simultaneous vaccine campaigns confused parents

Malawi’s Ministry of Health first introduced the HPV vaccine in 2019 through campaign mode focusing on schools. 

In 2021,the vaccine was incorporated into the country’s Extended Programme on Immunisation (EPI) schedule. This meant that girls can now get the vaccine in school during campaign days, which occur quarterly, or in community health facilities. 

However in 2021 and 2022, the COVID-19 pandemic led to school closures. It was followed by Cyclone Freddy, and in its wake, outbreaks of polio and cholera. These led to multiple new vaccine campaigns for older children and adults occurring at overlapping moments, something that confused and put off many parents.

“The parents literally accused us of tricking them into giving COVID-19 vaccine to their girls…. We don’t force them to receive the vaccine if they don’t want,” said Florence Nasava, a senior Disease Control Surveillance Assistant (DCSA) for the Zingwangwa Health Centre in Blantyre. 

Nasava adds that local health workers redoubled their efforts with community volunteers, traditional and religious leaders to help in demystifying the vaccine myths – and explain the difference between the HPV vaccines, COVID jabs and others to parents.

“Since its [HPV’s] introduction, Malawi has grappled with multiple and unforeseen crises such as the COVID-19 pandemic and Cyclone Freddy – which left more than half a million people displaced, and outbreaks of polio and cholera,” noted a spokesperson from Gavi, the Vaccine Alliance, which is providing the vaccines to Malawi and 38 other low-income countries worldwide.    

Stockouts are now the major problem 

A young girl receives a single dose of HPV vaccine at Lisawo primary school in Chiradzulu Malawi in 2020, just before COVID sent vaccine rates plummeting.
Florence Nasava, of Zingwangwa Health Centre vaccinates a young girl against HPV in 2024.

Nasava also perceives that demand has now rebounded, reflecting the new 2023 data. Overall, the local health centre typically sees two to three girls a day for the HPV vaccinations, she says, adding that “many more girls get vaccinated during mass school campaigns, where an average of 300 to 400 girls are vaccinated per day.” 

In rural areas, appreciation for the vaccine is also spreading  – in light of the large cervical cancer burden that exists.  

“This vaccine is a life saver for our girls’ generation. I was motivated to have my two daughters vaccinated against the disease since this is an incurable disease,” Zione Limitedi told Health Policy Watch.  She is a DCSA in Gwilima village in Malawi’s southern region.

“I know of a woman from my village who died of cervical cancer…. It’s difficult to manage in a poverty stricken rural area, so the vaccine is our only hope to protect the future,” adds Limitedi.

Lezzita Mphundi, a DCSA based in Chikwawa, a rural area about an hour’s drive from Blantyre, says parents seem to be most comfortable having their girls receive the vaccine with their classmates during school campaigns rather than going alone to the outreach clinics or at a facility.

“Many parents consented to having their girls vaccinated. I vaccinated over 200 girls before supplies ran out,” she said of a recent campaign day. That reflects a new problem. Now that demand is high, stockouts are a growing problem. 

LMICs have the highest rates of cervical cancer deaths

Dr Atupele Kapito Tembo – Malawi was an early adopter of the HPV vaccine.

The WHO says nearly 94% of the cervical cancer deaths in 2022 occurred in low- and middle-income countries (LMICs), where the burden of cervical cancer is greatest, due to limited access to routine screening tools and treatment services for the disease at early stage. These are almost universally available in developed countries. 

That’s what makes HPV vaccination, which sharply reduces risks of developing cervical cancer from the most common cause, human papillomavirus, all the more important in Malawi and other African countries.

Rwanda was the first African country to implement the HPV vaccination program successfully in 2011, followed by Zambia in 2013, then South Africa in 2014, which even managed to maintain an 80% vaccination rate through the pandemic years.  In November 2023, Togo became the latest country to introduce the HPV vaccine, following Nigeria, in October. 

All in all,  27 African countries have incorporated the HPV vaccine into their routine immunization programmes, with a primary focus on girls aged 9-14.  

Malawi was also an early adopter, launching an HPV vaccination pilot program for adolescent girls in Rumphi, a district of northern Malawi, and Zomba, in the country’s eastern region. That scored an early success, achieving 80% coverage, said  Dr Atupele Kapito-Tembo, epidemiologist and public health specialist at Kamuzu University of Health Sciences (KUHes).  

“This demonstrated the country’s capacity and ability to cover the targeted population,” she observed.

As for the sharp decline seen during the pandemic years, she said, “In my view and experience, Malawi needs more engagement with stakeholders since girls and their caregivers may not be fully aware of their HPV vaccine eligibility and benefits.

“They might have heard about the vaccine or cervical cancer, but made no initiative to get screened or have their daughters vaccinated because they haven’t been exposed to enough information.”

“There’s a need for more sensitisation to restore confidence in vaccines,” she urges.

Cancer also takes time to manifest and therefore it can be difficult to appreciate the impacts of the vaccine right away, Tembo observes.

“If we compare with high income countries, they introduced this vaccine in the 1990s and the impact is seen now. For us it may take a decade or two from 2017/2018 [when vaccination began] to see the impact.”

MOH aims to reach 90% coverage goal 

HPV vaccine

In 2020, the World Health Assembly approved a global strategy to eliminate cervical cancer by 2030, setting out the so-called ‘90-70-90’ targets. Those aim to have 90% of girls worldwide fully vaccinated with HPV vaccine by age 15; 70% of women are screened with a high-performance test by age 35; and 90% of women identified with cervical cancer receiving treatment.  

Last March, governments, donors and other partners pledged some $600 million at the first-ever global forum on cervical cancer in Cartagena de Indias, Colombia – putting those  goals closer than ever within reach.

In Malawi’s Ministry of Health, EPI Programme Manager Dr Mike Chisema says the ministry aims to reach the 90 percent vaccination coverage target by 2030, perceiving it as a key lever in the country’s cervical cancer elimination strategy. 

Additionally, if cervical cancer deaths can be reduced, that can also help reduce HIV-related deaths insofar as there are significant co-morbidities, he points out. 

At the same time, vaccines need to be deployed alongside screening and treatment for women, he notes saying: “we have to control for other factors such as HIV prevalence and [other] risk factors for developing cervical cancer.”

Important to sustain demand despite occasional stockouts

Chisema says that vaccine stock outs observed recently, especially in rural Malawi, are largely due to district internal logistical challenges and not necessarily due to inadequate vaccines at central level.

He said that it remains critical, however, for girls to continue coming forward – so that valuable supplies of the vaccine do not expire. 

In recognition of this, Chisema says that the Ministry of Health has come up with several initiatives including expansion of the age eligibility for the vaccine from 9-14 years old, enabling multi-cohort vaccination and more attention to stockouts in the “last mile”. 

The Ministry is also gearing up for a major multi-age campaign in 2025 or earlier working with both primary and secondary school teachers to identify eligible children. Although the results will be reaped decades later, Malawi sees that as a long-term investment in women’s health. 

“We just need to continuously review our health system and strengthen it accordingly, evaluating what works for us or not,” Chisema says.

Image Credits: Nadia Marini/ MSF , Josephine Chinele , WHO, Josephine Chinele.