The WHO assisted Zimbabwe to respond to a cholera outbreak in the country. As part of the response, mobile community centres were set up to detect and treat cases.

Deaths during the cholera outbreaks over the past two years have been “unacceptably high”, according to the World Health Organization (WHO).

“We are looking at outbreaks with unacceptably high case fatality ratios (CFR),” said Philippe Barboza, WHO’s cholera lead and head of the Global Task Force on Cholera Control (GTFCC) secretariat.

“Without any type of treatment or case management, the CFR of cholera can be up to 50%. However, with adequate treatment, the CFR should be below 1%. The 1% is not the target, the 1% is the maximum acceptable CFR,” Barbosa told a WHO meeting on cholera this week.

But in recent outbreaks in Malawi, Zambia, Uganda and Sudan, around 3% of those infected have died, according to WHO statistics.

“This is totally unacceptable. And when I say that, I’m not blaming the country. The size of the outbreaks are so big, that they overwhelmed the national capacity,” said Barbosa.

Cholera is a bacterial disease spread largely in contaminated food and water, and can cause severe acute watery diarrhoea.

However, Barboza added that it was also “totally unacceptable” that, in the 21st century people are still dying “because they are drinking water contaminated with faeces”.

Between 2017 and 2020, significant progress was made to reduce cholera but the pandemic reversed these gains. Climate change and conflict are also driving the recent outbreaks.`

Since the start of 2023, there have been almost 850,000 reported cases, with this year alone already recording 140,000 cases.

The WHO declared cholera a Stage Three health emergency, the most serious level, in early 2023 and this remains the case currently, with 23 countries experiencing outbreaks.

“Around 80% of the patients WHO have symptoms of cholera can be treated have either no or very mild signs or mild to moderate dehydration and can be treated with oral rehydration solution alone,” said Kathryn Alberti, WHO technical offer on cholera.

Although the global surveillance of cholera is poor, a GTFCC review shows that many deaths occur in communities rather than in health facilities.

Barboza and other speakers emphasised the importance of involving the community in outbreak response. During a large cholera outbreak in Malawi following a cyclone that caused widespread flooding, the country’s health ministry set up community outreach centres to provide people with oral rehydration. Community engagement was also seen as essential in encouraging people to seek care.

Representatives from civil society organisations wait around in the WHO canteen in Geneva for news from the pandemic agreement negotiations.

A crucial stocktake of the state-of-play of the World Health Organization (WHO) pandemic agreement talks on Friday afternoon (3 May) will determine the way forward for the final five days’ negotiations.

But progress has been slow in the past four days, according to reports – with differing opinions about whether a skeleton agreement can or even should be nailed down in time for the World Health Assembly (WHA) at the end of the month – or whether it should be deferred for another year.

An array of civil society organisations wrote to WHO Director-General Dr Tedros Adhanom Ghebreyessus last week expressing concern that the Bureau co-chairs of the intergovernmental negotiating body (INB) are pushing hard for countries to adopt an agreement that “perpetuates the status quo, entrenching discretionary, voluntary measures and maintaining inequitable access as the norm for addressing PPPR” [pandemic preparedness, prevention and response]. 

Meanwhile, 20 medicines access advocacy groups also issued an open letter over the weekend describing a pandemic instrument that does not deliver equity as a “failure”.

This group – which includes organisations from Brazil, South Africa, Kenya, Mexico and Peru – made various suggestions to make the PABS system more equitable, including that “all users that financially benefit from using the PABS system must be required to make monetary contributions to WHO especially to build resilient health systems in developing countries”.

However, over the past weekend,  AU deputy chairperson Dr Monique Nsanzabaganwa, told a meeting of African health ministers that postponing an agreement may not be in the continent’s interests “because we may postpone forever”. 

In a communique issued after the meeting, Africa called for “an international financing mechanism that is accountable to the Conference of Parties [envisaged to govern the agreement] and enshrining explicit commitments to new, sustainable, and increased funding support from developed countries for country-level PPPR in developing countries, debt relief and debt restructuring mechanisms including debt for PPPR swaps”.

PABS: Equity and bitter experience

The proposed WHO pathogen access and benefit-sharing (PABS) system (Article 12) remains the biggest sticking point, absorbing almost two days of the five-day talks so far, according to an INB report-back to stakeholders. By the end of Thursday, little progress had been made. However,  member states are to come up with a consensus on the text and bring it back to plenary, according to a stakeholder briefing.

While it sounds dry and technical, PABS encapsulates all the inequity and heartache of past pandemics. It is also one place where developing countries have some leverage, given that many outbreaks originate in these countries from zoonotic transfer from animals to people – so they might well have first access to information about responsible pathogens.

In short, the PABS system wants to facilitate the rapid sharing of genetic and biological data of pathogens that could become global threats so that researchers and manufacturers can develop medicines and vaccines to prevent their spread.

Countries that share this information will be compensated with “access to pandemic-related health products, and other benefits, both monetary and non-monetary, arising from such sharing”  according to the proposal from text from INB’s 16 April draft.

Most tangible offer: 20% of the goods

Article 12.3 contains the agreement’s most tangible offering: that 20% of pandemic-related health products are allocated to the WHO for distribution – 10% as a donation and 10% at cost. 

This would ensure that the WHO, not wealthy governments playing to their electorates, could then distribute these products to those in greatest need. So, for example, if this had been the case during the COVID-19 pandemic, the WHO could have ensured that health workers and the world’s most vulnerable got early access to vaccines.

But as Nina Schwalbe of Spark Street Advisers and a key commentator on the process says: “Will 20% be the ceiling or the floor?” That still needs to be decided.

The INB co-chairs have proposed that the mechanics of the PABS system, as well as One Health implementation measures, should be finalised by May 2026 but the basic principles still need to be agreed on.

The INB also discussed surveillance (Article 4), diversified production of pandemic products (Article 10), and are reaching consensus on Cooperation (Article 19) and Financing (Article 20). Working groups have been established on Articles 4, 5, 10, and 11 to fast-track agreements, INB co-chairs told stakeholders this week.

However, as the Pandemic Action Network (PAN) has noted, civil society organisations  “are still relying on snippets from the corridor” and there is “no confirmation yet on whether the Friday stocktake will be opened to relevant stakeholders”.

Image Credits: Nina Schwalbe.

Surgeons in Burkina Faso operate on a patient after undergoing surgical training at the Geneva University Hospitals (HUG) as part of an international collaboration.

In the universe of Geneva’s global health hub, which includes dozens of international NGOs and WHO as the brightest star in the solar system, a parallel universe of locally-grown health and humanitarian collaborations have also developed around the University of Geneva and Geneva University Hospitals.

GENEVA – Ten years ago, two medical professionals from Madagascar met up with Dr Alexandra Calmy, a leading infectious disease expert at the Geneva University Hospitals (HUG in French) at the Geneva Health Forum to tell her about the bane of TB-meningitis that they were confronting in their country among people with HIV or weakened immunity – a disease that has a 40% mortality rate. 

“They told me ‘we are really in trouble in Madagascar with TB-Meningitis – we don’t know what to do and we have no way to diagnose and treat them efficiently,” recalled Calmy.  

That chance meeting proved to be the beginning of a major collaboration between the HUG and a hospital in Madagascar that introduced, firstly, more accurate GeneXpert diagnostics for earlier intervention, and later, two alternative treatment options for TB-meningitis. 

That eventually led to a grant from the European Union’s EDCTP, and a randomized, multi-country trial of the new treatments  in Madagascar as well as three other African countries – Ivory Coast, South Africa and Uganda (INTENSE-TBM), now underway. 

International Geneva’s ‘global health hub’ 

A training session in Mali for health professionals about therapeutic patient education and diabetes co-organized by the Malian Ministry of Health, HUG and the NGO, Santé Diabète

The story is one of dozens of examples of research innovations and health and international development success stories that have emerged out of a unique ecosystem of the University of Geneva and its university hospital affiliate, working in partnership with the city’s many NGOs and international aid organizations, all part of the constellation known as “International Geneva”.  

Others call it the Geneva ‘Global Health Hub’- with the World Health Organization as the center of the solar system –  around which dozens of other planets and satellites revolve.  

The projects stimulated by the University-HUG collaborations, per se, range from new medicine regimes like the one being tested for TB, to new, easy-to-use diagnostic tools for conditions such as cervical cancer, long-neglected in developing regions. 

They also span an enormous range of initiatives to actually introduce innovations into health systems and build the capacity of medical professionals. Examples of the latter include educating nurses to provide diabetes control information and training community health workers in refugee settings.   

In fact, the labyrinth of collaborations, particularly in the health and humanitarian arena, is so extensive and complex that it is difficult to map and describe. At the core are the HUG, the University of Geneva Faculty of Medicine and the University’s Geneva Centre of Humanitarian Studies.  

Around these, are a satellite array of collaborations and partnerships with WHO, ICRC, Médecins Sans Frontières and other, smaller, but influential Swiss-based NGOs, such as Terre des Hommes. The Geneva Health Forum, convening this year on 27-29 May, historically has played a key role as a platform to showcase many of the initiatives and bring stakeholders together.  

And finally, the ‘State’ of Geneva, and its “Service of International Solidarity” stand as the backbone behind all of these efforts – funding directly and indirectly over CHF 40 million in international health and development projects in the name of the “State of Geneva” – a title reflecting the influence it wields. And that is in addition to financial support from the Swiss national government’s department of Development and Cooperation (DDC)

HUG equalization fund ‘kickstarts’ innovative projects

The HUG has funded or partially funded nearly 100 health and humanitarian collaborations across the globe over the past six years.

A report on the HUG’s collaborations cites a total of 97 international health projects, entirely or partly funded by the Hospital, in the most vulnerable countries of sub-Saharan Africa and the world, over the past six years for a total of more than 3 million CHF, says Calmy. Some 43 projects are currently ongoing, with 20 new projects approved in 2023, she adds.  

The HUG finances start-up projects based on a “Fond de Péréquation” capitalized by doctors’ income from private patient visits to the hospital, Calmy notes. (The English translation is “Equalization Fund” – with all that implies). 

The fund enables HUG-affiliated staff to propose and launch innovative projects from the grassroots in their areas of expertise, notes Calmy, providing a unique laboratory for creative collaborations. Proposals can be submitted by any health professional – from doctors and  nurses to psychologists and dieticians.

“We are here to provide the kickstart,” added Calmy who is co-chair of the HUG Commission of Humanitarian Affairs and International Cooperation, that administers the medical facility’s programme – in collaboration with a parallel Commission at the University of Geneva. 

“You want to do cervical cancer detection in Cameroon.  You have to map what is going on there, what is the expertise, who are your contacts.  So we’ll give you the money to kickstart – after that you can go to the Canton, the ICRC, the Confederation for help in obtaining larger grants for research and implementation.”  

A nurse-led project launched in education about chronic diseases is one such example that she cites. A noteworthy feature of the HUG approach is its eclectic sponsorship of a very diverse portfolio, she adds.  

“We are well aware that we are funding diverse projects, there is no line in terms of themes, countries, or types of projects. Anyone in this hospital that has expertise, identified partners, and wants to do a project, can make a proposal,” she said. 

Seeking coherence amidst diversity

Alexandra Calmy, HUG Vice-Dean for Clinical Research and co-chair of the Medical Faculty’s Commisson for Humanitarian Affairs at the HUG-University  Humanitarian Conference “Assises de l’Humanitaire”, 9 October 2023

At the same time, there is growing recognition that more coherence and coordination amongst a wide array of initiatives would be useful – to share lessons learned and ensure maximum impact. 

That plethora of programmes and projects led all of the partners to hold a first-ever stocktaking event in October 2023, to seek a common direction and way forward. 

Called simply the Assises de L’Humanitaire (Humanitarian Conference)” the one-day encounter brought together stakeholders from the HUG and University system, along with the Swiss Confederation, Geneva State, WHO, ICRC and a wide array of other international organizations working with the Geneva-based institutions.

Now, six months later, a report on the findings and recommendations for a way forward is soon to be published. 

“I think the conclusion was that ours is still a good approach. But we wanted to explore new ways of doing things better,” said Blanchet.  

Key themes that emerged as recommendations include an increased focus on facilitating south-south along with north-south collaborations, and in-country partnerships that emphasize the education and training of local actors to ensure sustainability and scale up of projects. 

“But we want to remain a laboratory of ideas,” Calmly said.

‘Assises de l’Humanitaire was the triangle’  

The day was particularly important in terms of helping the University and the HUG share experiences between themselves and better align, said Karl Blanchet, who is the director of the university’s Geneva Centre for Humanitarian Studies. 

“The Assises de l’humanitaire was this triangle of the Geneva Centre, the Faculty of Medicine and the HUG. There were two objectives to all meet and all be aware to make sure that we are aware of what we do in different parts of the world,” he said.

“The next step is to formalize relationships and contribution to these programmes,” he added, noting the wide range of UN and NGO actors, like MSF and ICRC involved in individual projects.

The same network of collaborations underpins many of the events featured in the Geneva Health Forum, co-founded by the HUG, the University of Geneva and its Faculty of Medicine in 2006. 

This year’s GHF takes place 27-29 May, and coincides with the kickoff of the 77th World Health Assembly.  Health and Environment, Migration Health and Equity and Malaria Elimination are the key themes.  But a day-long session on  “International Hospital Collaborations” is also taking place on 29 May. Held in French, it will look even more deeply at some of the topics discussed at the conference last October.   

“The aim of the seminar is to collectively question the way partnerships between hospitals in the global north and global south are designed, and how to promote ethics and sustainable solutions within the frame of these partnerships,” said Bruno Lab, head of Humanitarian and International Cooperation Affairs at the HUG. 

“It’s a dive into the specific domain of long-term technical assistance projects. Through multi-year collaborations, the objectives are set around capacity building, teaching and research.”

Karl Blanchet, head of the University of Geneva’s Centre for Humanitarian Affairs

Many HUG staff also have joint appointments in the University of Geneva’s Medical Faculty, which also hosts an array of international health research initiatives, under the research portfolios of various departments. 

The Centre for Humanitarian Studies, therefore, collaborates with both institutions, and others, in a range of health and humanitarian research and education projects, says Blanchet. 

Examples of the former include a research study on reducing the impact of attacks on healthcare, as well as a five-university initiative on re-imagining the future of global health, he adds

But there are also collaborations in field settings on priorities like teaching doctors how to perform war surgery or a new programme in community health for refugees. 

The latter, targeting long-time refugees in Jordan and Kenya, provides students with a basic education that allows them to gain employment as health workers, as well as to qualify for further university training in their host countries, Blanchet says. 

The end result is better integration into local communities and health systems after decades as refugees.  

“During the COVID pandemic, the first settings that were closed in lockdown were in refugee camps,” Blanchet recalls. “”So we created a course not only to help refugees deal with health issues in their community, but to be able to get jobs.

“It’s the first advanced course on community health accredited by a University Faculty of Medicine, for students and refugees who cannot demonstrate their level of studies.  If they finish the certificate, they can go onto national university,” he said. 

University ‘open to the world’

Blanchet himself has a strong public health background. He came to the centre as an academic from the London School of Tropical Hygiene and Medicine.

He found the pace much faster and topical than the usual university ivory tower.    

“I can’t tell you how amazing this environment is,” he said. “When I arrived at this new post, where we are grappling with some of the most challenging environments, people would tell me, over and over, ‘just tell me what you need.’

That led to initiatives such as a website publishing briefs on the latest scientific knowledge about  COVID in Ukrainian after  the 2022 Russian invasion; as well as the hosting of leading Afghan health experts in the Centre, including the former minister of health, following the Taliban’s takeover of Kabul. 

The centre is likewise involved in an initiative to help medical students in conflict-ridden regions such as Gaza, Iran, Pakistan and Afghanistan to complete their studies in host countries abroad.  And there are now plans now in the works to host an international symposium soon on the rebuilding of Gaza’s health system, he confides.  

“These are all examples of the agility of the teams and the faculty,” he said. “The University of Geneva is so anchored in the news and what is going on – and they want to make sure that they can contribute, not only to research but as a university open to the world.” 

Paula Dupraz-Dubois contributed reporting to this story

Image Credits: Hopitaux Universitaires de Genève, Hopitaux Universitaires de Genève, Geneva University Hospitals , Paula Dupraz-Dubois.

Milking a cow in Texas. H5N1 Avian influenza is spreading among US cattle herds, most probably during the time of milking.

Most H5N1 infections spreading through US dairy cattle and other animal populations are likely going undetected despite stepped up surveillance by the US Department of Agriculture, Michael Osterholm, director of the Centre for Infectious Disease Research and Policy (CIDRAP), told Health Policy Watch on Wednesday.

Osterholm spoke as a growing number of infectious experts were sounding alarm bells about the expanding spread of the deadly virus to mammalian populations – and especially dairy cattle in the United States, where some 36 herds have so far been infected, according to the latest US Centers for Disease Control and Prevention (CDC) update April 30. Sanitation gaps and lax surveillance in industrial dairy operations are facilitating H5N1 transmission, experts now suggest. 

Total number of H5N1 cases in different animals in the US. Infection spread in dairy cattle, the newest ‘terrain’ for the virus, is causing the most concern.

And “most” infections are likely going undetected due to farmer reluctance to have cattle and employees tested for avian flu, warned Osterholm, an internationally-known expert. 

“We need much more extensive follow up, serology studies and close monitoring of mixing vessel animal species, e.g. pigs,” Osterholm stressed in emailed remarks. 

He noted that pig infections, for example, constitute a “mixing vessel animal species” because they can become co-infected with both animal and human forms of avian influenza, increasing the risks of spread to humans of a virus that has a greater than 50% fatality rate.

On the positive side, Osterholm added that it was “very unlikely” pasteurized milk could transmit the infection if pasteurization “is done properly.”

Policymakers have taken their ‘eye off the ball’ of ‘One Health’ principles

“Policymakers have again taken their eyes off the ball in efforts to protect humanity from new pandemics,” stated Dr Nigel Sizer, an Executive Director of the non-profit Preventing Pandemics at the Source (PPATS), as part of a stiff warning  issued Tuesday by half a dozen international experts on the wave of H5N1 infections.

“In this case, it is hard not to point the finger at lax monitoring and regulation of animal agriculture in the United States and elsewhere,” Sizer said.

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

The expanding outbreak takes place as WHO member states are in the throes of finalizing a draft Pandemic Accord agreement, where a commitment to stronger “One Health” measures for preventing spillovers of animal pathogens to humans remains a sticking point for some countries in the Global South. 

But in the case of the USA, a dearth of surveillance is also a hallmark of the rapidly expanding avian flu outbreak in the Global North, other experts also pointed out.  

“The situation with avian influenza across the United States exemplifies the inherent hypocrisy and vested economic interests around Pandemic Prevention, Preparedness, and Response,” said Dr. Christian Walzer, Executive Director of Health at the Wildlife Conservation Society, and a professor at the University of Veterinary Medicine in Vienna, Austria, in the PPATS statement of experts.

“As one hundred ninety-four member states of the World Health Organization (WHO) are negotiating perceived responsibilities and equity around a new Pathogen Access and Benefits-Sharing [PABS] Mechanism – while the Global North is demanding transparent and rapid access to pathogen data from the Global South to develop diagnostics, vaccines, and therapeutics, it seems unwilling to share such information with the world,” Walzer said.

Spread through milking machines

Among dairy cows, H5N1 appears to be transmitting rapidly through their mammary glands via virus contaminated milking machines, Stat News reported on Tuesday. The milking equipment is typically not sanitized between sessions with individual animals, becoming an obvious transmission path to infection by more and more cows from the herd.

Experts such as Jared Taylor, a professor of veterinary pathobiology at Oklahoma State University, noted that the H5N1 infections in cattle herds reported so far have been  limited to lactating dairy cows. And the ones who produce most milk – and therefore spend more time on the milking machines – have the highest disease incidence.

Even more worrisome is the potential presence of the virus in raw milk – which some consumers in the USA as well as in Europe prefer as a more ‘natural’ alternative.

US states where H1N5 has been detected in cattle

There also have been virus remnants found in pasteurised milk. “The role of pasteurization in inactivation of the virus […] is currently being investigated,” states a 23 April assessment by the WHO, issued jointly with the UN Food and Agriculture Organization (FAO) and the World Organisation for Animal Health (WOAH).

Infection with H5N1 from pasteurised milk is, however, “very unlikely, if [the pasteurisation is] done properly,” Osterholm said.

As compared with consumers, farm workers who have everyday contact with cattle are, however, at a far higher risk of infection. And the one case of human infection reported in March, does not reflect the scale of the disease spread to people, experts say because farmers have been reluctant to allow testing of cattle or employees, and such testing remains voluntary. 

That’s why “most” cases likely go undetected, Osterholm told Health Policy Watch.

Avian influenza as symptom of world’s failure to apply ‘One Health’ measures

Virus spillovers to more and more species are a direct effect of the poor animal management practices in the  intensive livestock production conditions that are common throughout the developed world today, said Sizer in the statement on April 30.

“Improved animal husbandry conditions, more rigorous inspection standards, as well as better reporting and sharing of animal health information could reduce the risk of these outbreaks as well as improve the welfare of the animals we consume,” he asserted. “We must question for how much longer consumers will have to worry that the price of a cheap sausage or steak is the risk of another global pandemic.”

One Health principles recognize the interlinkages between ecosystems, animal and human health, and call for enhanced collaboration between sectors to prevent zoonotic spillover into human populations. 

“This outbreak highlights the need for One Health approaches for preventing spillovers and interventions to reduce risk of such threats ‘at source’,” argued Dr. Malik Peiris, Professor of Virology at the School of Public Health at The University of Hong Kong, and a leading H5N1 expert.

Pigs are an important possible intermediary host for avian influenza.

“There is still a widespread philosophy of aiming for maximum profit in meat production, when it should be about optimizing food security, food safety, animal welfare and ecological sustainability,” added Dr. Dirk Pfeiffer, Professor of One Health at City University of Hong Kong, in the same statement, adding: 

 “Global investors who see opportunities in making money out of meat production should be aware that ‘growing cattle, pigs or chickens’ is not the same as making parts for mobile telephones.”

WHO still ranks human health risks as low or low-to moderate

In its 23 April assessment, WHO ranked avian influenza risks to humans as low generally insofar as human-to-human transmission has never been documented, and low-to-moderate for those “with exposure to infected birds or animals or contaminated environments.”

Only one human case connected with the US outbreak has been reported, a cattle worker from Texas.

Since 2003, WHO reported only rare instances of human infections all from close contact with animals. Even so, the mortality was “extraordinarily high,” according to WHO Chief Scientist Jeremy Farrar. He was referring to the 52% mortality rate registered amongst the 889 human cases of H5N1 reported to WHO between 2003 and 1 April 2024.

Jeremy Farrar, WHO Chief Scientist, during a press briefing April 18

“Being one of the few people around the world who have actually treated patients with H5N1 […] this remains I think an enormous concern,” Farrar stressed at an April 18 media briefing in Geneva. From 1996 until 2013, Farrar was Director of the Oxford University Clinical Research Unit in Ho Chi Minh City, where he and a Vietnamese colleague identified the re-emergence of the deadly bird flu, or H5N1, in humans in 2004. 

What worries experts the most is the virus’s expanding host range. Naturally found in wild birds, avian influenza has developed a limited ability to infect other species, including mammals. The recent joint assessment by WHO, FAO and WOAH reports mentions the virus as the probable source of infection in sea mammals, multiple fur animal farms and ferret-to-ferret infections, according to some studies.

The list of infected animals is getting longer: cats, dogs, goat kids or polar bears, already known to suffer from the disease were recently joined by a walrus, as The Guardian reported.

“The great concern, of course, is […] that that virus now evolves and develops the ability to infect humans. And then critically, the ability to go from human-to-human transmission,” Farrar told the media briefing.

Reassurance, but… 

Other WHO officials have still sought to issue a more reassuring note.

Speaking at another WHO press briefing on April 24, Dr. Maria Van Kerkhove, a WHO epidemiologist, asserted that appropriate surveillance systems are working well.

“We are concerned about this particular virus because we know influenza has the potential to cause epidemics that have the potential to cause pandemics,” she said. “And that’s why we have a global system in place to monitor, detect, and to rapidly do risk assessments to look at viruses that could potentially be used in vaccines as we go forward. There’s a lot of work in place right now,” she said.

Since the beginning of 2021, 28 detections of H5N1 in humans have been reported to WHO, with all nine cases reported in Europe or North America being assymptomatic or mild cases, notes the WHO/FAO/WOAH joint assessment. Still the three agencies also recommended tougher monitoring – calling on national authorities to  use “active case finding and serologic methods, as well as work with national agencies to understand the exposure and risk from milk and milk products.”

Osterholm, like other experts doubts that US authorities have the situation under control. What’s needed is, among others, a “much more extensive follow up,” said Osterholm. 

He also advises a close monitoring of pigs, which have “influenza virus receptors for both avian and human influenza viruses.

“If they get coinfected with both viruses simultaneously then viral reassortment can occur and a new human virus emerge, like what happened in 2009 with the new H1N1 [strain] that emerged in swine in Mexico.” 

With editing and reporting contributions by Elaine Ruth Fletcher 

Image Credits: Josh Kelahan, US CDC, CDC/ Courtesy of Cynthia Goldsmith, Flickr: Dutchairplaneshooter.

On the final day of INC-4, delegates held talks until the early hours of the morning trying to find a way forward

The fourth session of the UN intergovernmental negotiating committee (INC) to develop an international legally binding instrument on plastic pollution ended in Ottawa on Tuesday with “an advanced draft text of the instrument and agreement on inter-sessional work ahead”, according to the UN Environment Programme (UNEP).

Delegates engaged in text-based discussion on the revised draft for the first time, but there were major sticking points – especially on limiting plastic production. The European Union (EU) proposed extending the meeting but delegates failed to agree on the proposal, according to the Earth Negotiation Bulletin.

Other issues on the table related to emissions and releases; product design; waste management; problematic and avoidable plastics; financing, and a just transition.

The INC members agreement to hold inter-sessional work – expert meetings between the official INC sessions –  to work on “convergence on key issues” ahead of the next negotiating session, INC5, will take place in Busan, Korea, in November.

The inter-sessional groups will look at financing to achieve the objectives of the instrument and approaches to address  plastic pollution and chemicals of concern in plastic products and product design, focusing on products that can be recycled and reused. 

Long road to agreement

INC5 is supposed to adopt an agreement, but there is still a long road ahead as “meetings to discuss the technical elements of the text diverged on almost all points of discussion, from problematic and avoidable plastics to product design, composition and performance,” according to the Earth Negotiation Bulletin..

“We came to Ottawa to advance the text and with the hope that members would agree on the intersessional work required to make even greater progress ahead of INC-5. We leave Ottawa having achieved both goals and a clear path to landing an ambitious deal in Busan ahead of us,” said Inger Andersen, UNEP executive director.

 “The work, however, is far from over. The plastic pollution crisis continues to engulf the world and we have just a few months left before the end of year deadline agreed upon in 2022. I urge members to show continued commitment and flexibility to achieve maximum ambition.”

However, several NGOs that attending as observers were unhappy with the influence of member states with significant fossil fuel industries. Most plastics are made from oil and gas derivatives.

“Despite hearing people from polluted communities around the world give sensible proposals to curb the lifecycle harms of plastics, fossil fuel and petrochemical interests are still shamelessly blocking progress and focusing on utterly inadequate plastic waste management,” said Julie Teel Simmonds, a senior attorney at the Center for Biological Diversity (CBD).

While Rwanda and Peru, part of the high-ambition coalition, proposed production reductions,  a coalition of fossil fuel–aligned countries, including Russia, China, and Saudi Arabia, objected to treaty measures to address plastic production, according to the CBD. 

Not ‘if ‘but ‘how’

“Canada is committed to reaching a final agreement at INC-5 in the Republic of Korea before year end. We are no longer talking about ‘if’ we can get there, but ‘how.’ Together we can land one of the most significant environmental decisions since the Paris Agreement and the Kunming Montreal Global Biodiversity Framework,” said Steven Guilbeault, Canada’s Minister of Environment and Climate Change, who hosted INC4. 

“We are doing everything we can to raise the international profile of the plastic pollution crisis so that the agreement gets the global attention it deserves to cross the finish line.”

INC chairperson Ambassador Luis Vayas said that “some common ground” had been found and “I firmly believe that we can carry this same spirit forth to Busan to deliver on our mandate.” Delegates accepted Vayas’ proposal for a legal drafting group to ensure legal clarity in the text of the future agreement.

Jyoti Mathur-Filipp, executive secretary of the INC secretariat,  said that “compromise and commitment remains strong at this advanced stage of the negotiations”.

“Members should arrive in Busan ready to deliver on their mandate and agree a final text of the instrument. This is more than a process – it is the fulfilment of your commitment to saving future generations from the global scourge of plastic pollution.”

Image Credits: Kiara Worth/IISD.

A rollout of malaria vaccine in Western African countries with a special focus on immunising children is an important step towards eliminating the disease

Rollout of malaria vaccines are starting in Benin, Sierra Leone and Liberia, and the West African countries plan to deliver more than 800 000 doses of the RTS,S or R21 vaccines, according to WHO.

The new vaccine will be added to their immunisation programmes for children, and are expected to protect over 200,000 children from the life-threatening disease. The RTS.S vaccine can be administered to children as young as five months old.

In another promising development against malaria, a new formulation of a malaria treatment, Coartem, has proven to be safe and efficacious for babies under five kilograms, a previously overlooked group of patients.

Pharmaceutical company Novartis and Medicines for Malaria Venture (MMV), a leading product development partnership, announced that their product has good efficacy and safety and is appropriate for babies in the wake of the successful CALINA study.

The trial data have been submitted for regulatory review, they informed during the Multilateral Initiative on Malaria conference.

“Infants below five kilograms make up a critical neglected group, and developing antimalarials specifically suited to their needs is essential to malaria control efforts,” said Wiweka Kaszubska, MMV vice president.

The new formulation, known as Coartem <5 kg Baby, uses a new ratio and dose of artemether-lumefantrine to account for metabolic differences in babies under 5kg to minimise the risk of overdose and toxicity.

“Infants under five kg can be affected by placental malaria, leading to poor birth outcomes, or contract malaria from the bite of an infected mosquito. The prevalence of the disease in this age and weight group is poorly understood, and it is therefore often misdiagnosed,” according to a company media release.

Current antimalarials have not been developed small babies, who are usually treated with tablets meant for children above 5 kg adjusted by weight – yet, these tiny patients handle drugs differently due to the immaturity of their metabolising organs.

Decreasing the burden

Malaria is a life-threatening infectious disease with an estimated 249 million cases and 608 000 deaths in 2022, according to the World Malaria Report 2023. It is present in 85 countries, with 95% of cases in the African region. Most of the fatalities in the region – four out of five – are children under the age of five.

“With the new, safe and efficacious malaria vaccine, we now have an additional tool to fight this disease. In combination with insecticide-treated nets, effective diagnosis and treatment, and indoor spraying, no child should die from malaria infection,” said Dr Austin Demby, the Minister of Health of Sierra Leone.

The emerging interventions will likely decrease the burden of malaria substantially. In the recent years, (2019-2023), a pilot malaria vaccine programme in Ghana, Kenya and Malawi reached over two million children, showing a significant reduction in malaria illness. It also reached a 13% drop in overall child mortality and a reduction in hospitalisations.

Benin, Liberia and Sierra Leone joined five other African countries that have already implemented the rollout of the newly developed malaria vaccines.

Image Credits: WHO.

African leaders who attended at the high level meeting in Addis Ababa on Saturday.

African leaders want “explicit commitments” to debt relief and debt restructuring mechanisms, including debt swaps to support country-level pandemic prevention, preparedness and response (PPPR) in the pandemic agreement.

This is one of the continent’s demands, made on the eve of the World Health Organization’s (WHO) pandemic agreement talks, following a high-level meeting of African health ministers and diplomats on Saturday.

At the meeting, a key African Union (AU)  leader warned against postponing the adoption of a pandemic agreement, saying it might never be passed.

The pandemic agreement negotiations entered their final two-week phase in Geneva on Monday with 10 May as the deadline for what observers are describing as an “instrument of essentials” – a basic text that will be fleshed out by further talks in the next couple of years, as reported recently by Health Policy Watch.

The first communique from the African leaders’ Saturday meeting was withdrawn a few hours after its release. 

The new statement released on Monday was identical except it removed a reference to the Pandemic Fund in its call for “an international financing mechanism” to support countries’ pandemic-proofing efforts.

It also wants the accelerated “operationalisation of the financing of the African Epidemic Fund”.

Support for PABS

The continent supports a “multilateral pathogen access and benefit sharing system (PABS)” that provides legal certainty to users and providers and ensures improved access to pandemic-related health products and technologies.

The draft agreement proposes a WHO-coordinated PABS system but for the operational details of this contested proposal are to be finalised by May 2026.

Africa also wants “measures to establish regionally-distributed production of pandemic-related health products” and “commitments to organise and resource technical support” on all equity-related provisions. 

Pandemic prevention, preparedness, and response (PPPR) demands relate largely to national and regional responsibilities, with measures such as the enactment of “domestic laws providing for broad exemptions and limitations to intellectual property to address public health emergencies”, and supply chain diversification and logistics streamlining throughout the continent.

Africa also wants the various WHO-coordinated mechanisms in the agreement – such as on research and development and technology transfer – to be operationalised and accountable to the Conference of Parties, a multi-country structure which is set to govern the agreement.

“Africa stands ready to play its part and comments to engage actively in the ongoing negotiations and finalisation of the draft pandemic agreement,” the statement concludes.

AU warns against postponement

“I don’t think postponing an agreement is going to be in our interest because we may postpone forever. I look forward to us consolidating our common position today, consolidating our negotiating positions and ensuring that Africa’s interests are represented in the global pandemic agreement negotiations,” said AU deputy chairperson, Dr Monique Nsanzabaganwa, during the opening of the ministerial meeting.

AU deputy chairperson Dr Monique Nsanzabaganwa warns against delaying the agreement.

She also urged pragmatism when addressing the meeting on Saturday, explaining that several African demands – such as a seat at the G20 – had taken years to achieve.

“In some situations, we don’t have even a choice because we need to continue being pragmatic as we look for all conditions that can allow us some equity and some flexibilities and conducive conditions for us to do what we’ll have to do for ourselves,” she said.

She also warned of the likelihood of another COVID-like pandemic in the not so distant future, adding that it is “crucial that we work together to strengthen our collective preparedness and ensure that Africa’s voice is heard in global health discussions”.

While Africa’s negotiators wanted a win-win situation, in negotiations “there is always give and take”, said Nsanzabaganwa, who hails from Rwanda.

“We have also the duty to continue pressing for multilateralism to work.”

Meanwhile, Zambia’s health minister, Sylvia Masebo, who chairs the Africa CDC board, called on the African negotiators to ensure “equitable access to pandemic-related health products” and “increased access to vaccines, diagnostics and therapeutics, ensuring that no one is left behind”. 

Africa CDC Director-General Dr Jean Kaseya said that unity and a common African position in the negotiations was key.

Food insecurity increased in 2023 due to a combination of conflicts, economic shocks and extreme weather events.

In 2023, nearly 282 million people – 21.5% of the analysed population across 59 countries and territories – faced high levels of acute food insecurity, according to the Global Report on Food Crises (GRFC) 2024.

This is 24 million more people than 2022. The rise was due to the report’s increased coverage of food crisis contexts and a sharp deterioration in food security, especially Gaza and Sudan.

“The Gaza Strip became the most severe food crisis in our reporting history. Conflict and insecurity, along with extreme weather, events and economic shocks, are the key drivers of food insecurity and nutrition crisis,” said Dominique Burgeon, Director of the Food and Agriculture Organization (FAO) Liaison Office in Geneva.

The current situation in the Gaza Strip accounts for 80% of those facing imminent famine, along with South Sudan, Burkina Faso, Somalia and Mali.

For four consecutive years, the proportion of people facing acute food insecurity has remained persistently high at almost 22% of those assessed, significantly exceeding pre-COVID-19 levels.

“This crisis demands an urgent response. Using the data in this report to transform food systems and address the underlying causes of food insecurity and malnutrition will be vital,” said António Guterres, UN Secretary-General.

 

Number of people facing high levels of acute food insecurity in 59 countries and territories in 2023.(GRFC 2024)

The report brings focuses on the enormity of the challenge of achieving the end of hunger by 2030 – a key UN Sustainable Development Goal. Improvements in food security in some countries was outweighed by deteriorating conditions in others.

Over 26 million people are one step away from famine, while  the total population in catastrophe was “more than four times higher than in 2016,” said Burgeon.The report was produced by the Global Network Against Food Crises (GNAFC), a multi-stakeholder initiative that is working to address the food crises.

Protracted hunger

Acute malnutrition worsened in 2023, particularly among people displaced because of conflict and disasters. Children and women are at the forefront of these hunger crises, with over 36 million children under five years of age acutely malnourished across 32 countries, the report showed.

“The report also tells us that 60% of children experiencing acute malnutrition live in the ten countries facing the highest level of acute food insecurity,” said Burgeon of FAO. 


Thirty six countries have consistently featured in the GRFC analyses since 2016, reflecting continuing years of acute hunger, and currently representing 80% of the world’s most hungry. One million people more people face emergency levels of acute food insecurity across 39 countries and territories.

In 2023, more than 705,000 people were at the catastrophe level of food insecurity and at risk of starvation – the highest number in the GRFC’s reporting history and up fourfold since 2016.

 

The share of the analysed population facing high levels of acute food insecurity increased sharply from 14 percent in 2018 to more than 20 percent each year since 2020.


Key drivers: Conflicts and extreme weather 

Conflict remained the primary driver of hunger, affecting 20 countries and forcing 135 million people into acute food insecurity – almost half of the global number. 

Sudan faced the largest deterioration due to conflict, with 8.6 million more people facing high levels of acute food insecurity as compared with 2022.

“Sudan is a major concern for, the nutrition component because primarily of the major caseload, the number of people is staggering and also for the difficulty of reaching these people. In many areas, there is impossible access and or inconsistent access,” said Stefano Fedele, Global Nutrition Cluster Coordinator for UNICEF Geneva.

Extreme weather events were the primary drivers in 18 countries where over 77 million people faced high levels of acute food insecurity, up from 12 countries with 57 million people in 2022.

The impacts of economic shocks affected 21 countries where around 75 million people were facing high levels of acute food insecurity, due to their high dependency on imported food and agricultural inputs, persisting macroeconomic challenges, including currency depreciation, high prices and high debt levels.

 

The drivers of food insecurity are interlinked and mutually reinforcing

Breaking the cycle

Tackling persistent food crises requires urgent long-term national and international investment to transform food systems and boost agricultural and rural development, according to the report.

It also advocates for peace and prevention of conflict to become an integral part of the longer-term food systems transformation. 

Since 2023, needs have outpaced available resources and many humanitarian operations now overstretched, with many being forced to scale-down and further cut support to the most vulnerable.  

“This is truly a global challenge. There are far too many people waking up in the morning not knowing where their next meal will come from, not knowing how to feed their children, and having to make really truly impossible decisions throughout the course of their day to ensure that their most fundamental needs are being met,” said Courtney Blake, Senior Humanitarian Advisor for the US Mission in Geneva.

Image Credits: Unsplash, Global Report on Food Security 2024.

The Africa CDC convened a high-level meeting in Addis Ababa on Saturday to discuss the continent’s position on the draft pandemic agreement.

The World Health Organization’s (WHO) pandemic agreement negotiations begin their final two-week stretch on Monday (28 April) amid a gamble with the process, a show of unity from African member states – and more suggestions for the draft text.

This final intergovernmental negotiating body (INB) meeting will focus on finding “common ground and consensus”, according to a decision taken at the last fractious meeting.

The programme of work sets down 12-hour days, with the first week (29 April-3 May) focusing on finalising the substantive negotiations on the draft text. 

A “stock take” of progress will be held on Friday 3 May, and the second week (6-10 May) will look at outstanding articles, along with the draft resolution for the World Health Assembly at the end of May.

The INB Bureau has also undertaken to provide daily briefing to relevant stakeholders on progress.

‘Take it or leave it’

After the previous session at which member states expressed frustration with one another and the INB Bureau, the INB co-chairs have taken a gamble with the process this time – and member states may not play along.

The multitude of bracketed contested text has been purged from the new draft, and the co-chairs want the meeting to focus on saying “yes”, rather than being bogged down by disagreements.

The meeting will go through the 23-page draft paragraph by paragraph, and member states that don’t agree with the text will be invited to have informal sessions, the co-chairs told a recent stakeholder briefing.

But the draft will be considered as the default text where there is no consensus, which the co-chairs described as a “take it or leave it” approach.

“The Bureau is of the opinion that the text as presented in the proposal for a WHO Pandemic Agreement is consensus ready,” it explained in a briefing document sent to stakeholders on Friday (26 April).

“It was drafted on the basis of our many rounds of negotiations. The co-chairs will open the different articles and will ask the member states if the article is ready for approval. If not, delegations will be invited to explain what their issue with the article is. 

“Where possible the co-chairs will immediately propose a way forward. If the issue at hand is more fundamental, either a small informal meeting between a few member states can be proposed, or – if more member states want to be involved –  a working group session can be proposed.” 

These working groups would be led by a member of the Bureau and the plan would be found them to return to the drafting group with a solution.

At the recent stakeholder briefing, the European Union indicated that not all the text was consensus-based while Bangladesh, a key player in the Group of Equity negotiating bloc, criticised the approach of grabbing  “low-hanging fruit for the sake of consensus”.

Africa asserts unity

Meanwhile, African leaders urged continental unity and pragmatism at a high-level meeting on the pandemic negotiations convened on Saturday by the Africa Centre for Disease Control and Prevention (Africa CDC).

Dr Monique Nsanzabaganwa, Deputy Chairperson of the African Union, urged pragmatism and realism at the meeting, attended by health ministers, diplomats and UN agency officials.

Dr Monique Nsanzabaganwa, Deputy Chairperson of the African Union

“At the time of COVID, multilateralism collapsed completely and then Africa was shut [out of] accessing all the things we needed at the time, the PPE and the vaccines,” she said, adding that the pandemic negotiations were an attempt to revive multilateralism.

“In some situations, we don’t have a choice because we need to continue being pragmatic as we look for all conditions that can allow us some equity and some flexibilities and conducive conditions for us to do what we’ll have to do for ourselves,” she added.

Africa CDC Director General Dr Jean Kaseya told the meeting, which was also briefed by INB co-chair Precious Matsoso, that “what matters most is for the continent to speak with one voice”.

He stressed that Africa’s priorities, as contained in its New Public Order, are “to boost manufacturing capacities, expanded manufacturing capabilities, tech transfer, resilient supply chains, and robust regulatory frameworks”.

Kaseya said member states had three options: to reject the agreement, to accept it, or  to bring “strategic thinking” to the Geneva negotiations, which was “not yes or no”.

Whatever happened, he urged that the continent speak with “one voice” during the “tough” upcoming negotiations.

A communique released after the meeting identified Africa’s three bottom lines, which related to equity, pandemic prevention, preparedness and response (PPPR) and predictable, sustainable governing and financing. 

However, Africa CDC withdrew the communique a few hours later and claimed another would be following shortly . However, no replacement had been sent by late Sunday night, indicating some disagreement between parties about how to express the outcome of the meeting – not exactly an auspicious start for negotiations.

One of Africa’s bottom lines has been in relation to PABS, where continental leaders have insisted that they need to be compensated for sharing information about pathogens. The current  draft agreement proposes that details of a mutually beneficial PABS system – one of the biggest areas of disagreement – will only be finalised by mid-2026.

However, the continent stressed its leaders were ready to engage actively in finalising the agreement.

Ethiopia’s Ambassador to Geneva, Tsegab Kebebew Daka, told a recent event in Geneva that “the differences in the text are not huge”.

“They are mainly differences of ideas and they’re not that many. So we can come to an agreement,” Daka, a key negotiator for the Africa group, told the event at the Geneva Graduate Institute’s Global Health Centre.

While Daka acknowledged that there were still sticking points, he appealed to member states to take a “holistic view on the entire pandemic agreement” rather than dwelling on “specific articles where we have differences” – thereby endorsing the Bureau’s approach.

 

An exhausted looking WGIHR co-chair Ashley Bloomfield reports back on the process

The World Health Organization’s (WHO) working group has failed to meet its deadline of Friday (26 April) for amending the rules governing global disease outbreaks – the International Health Regulations (IHR) – and will reconvene.

This emerged late afternoon on Friday (26 April) at a briefing after the week-long Working Group of Amendments to the IHR (WGIHR), when drawn co-chair Dr Ashley Bloomfield announced that the group would reconvene on 16 and 17 May for a final two days’ negotiation.

“The mood in the room has been outstanding, and we have worked really hard to make amazing progress. We’re not quite cracking the bottles of champagne and sparkling grape juice, but we were getting very close and I have every sense that you are all committed to finishing the job,” said Bloomfield.

WHO Deputy Director General Dr Mike Ryan commended the group, saying he was “very confident” that the IHR would be  “a clearer, better instrument for your efforts, something that we can apply better on your behalf and on behalf of the people that you serve”.

The WGIHR has asked member states to submit written inputs, particularly on the articles that the meeting failed  to reach agreement on or did not discuss, by 6 May and it will reconvene for a further two days after that.

The Articles that still need agreement relate to technology transfer, financing and governance.

However, many of the WGIHR members are also part of the pandemic agreement talks, which start on Monday 29 April under the intergovernmental negotiating body (INB). The programme of work for the INB envisages 12-hour days, so there will be no space for IHR talks until after 10 May.

However, the two processes are closer linked and the definitions adopted by the IHR, including all the phases that led up to the WHP Director General declaring a public health emergency of international concern (PHEIC), will be used in the pandemic agreement.

The World Health Assembly, which is due to ratify the amendments, begins on 27 May, so time is very tight.

The WGIHR will submit an updated proposed text to member states by 10 May.