Routine testing for tuberculosis in Lima, Peru.

Tuberculosis has long been the neglected stepchild of global health – but new diagnostic tools and treatments, artificial intelligence (AI) and debt swaps to help countries meet their targets have come into play and are making a difference. 

“There is fresh momentum,” says Dr Jamie Tonsing, Senior TB advisor at the Global Fund, in a wide-ranging interview with Health Policy Watch.

“I’ve just come back from a meeting in Manila, where the discussion was all around AI for TB,” she adds.

One of these involves an AI tool that can read chest X-rays and predict whether a person is likely to have TB.

“The chest X-ray goes into the computer and the image is read by software and gives you a threshold above which a person is likely to have TB,” explains Tonsing.

“It’s a screening tool that needs to be followed by a proper molecular test. But this is very exciting because we don’t have radiologists everywhere, and TB is often in the most hard to reach, vulnerable population groups.”

Up to 50% of people with TB do not have the classical symptoms of TB, Tonsing adds.

“So the only way they will be diagnosed early and before they have symptoms is when they do a chest X-ray. And so that’s why we’re very excited by this new advance in technology.”

Jamie Tonsing, Senior TB advisor at the Global Fund,

Those with TB can be started on treatment immediately. Children under the age of five and people living with HIV who don’t have TB but have been exposed to someone with the disease, can be given TB preventive treatment to protect them.

Over three-quarters of international financing for TB comes from Global Fund, which also spends around $150 million per year to new digital tools. These are being used in places like Bangladesh, Paraguay and Indonesia to screen people in remote areas.

Bangladesh, is using digital X-rays with AI and telemedicine to rapidly screen people for TB, while health workers in Paraguay, are using portable X-ray machines and AI technology in prisons screen and diagnose people with TB fast, according to Dr Mohammed Yassi, the Global Fund’s TB advisor.

Cheaper testing for drug-resistance

GeneXpert diagnostics have become the gold standard for TB testing, particularly for drug-resistant TB (DR TB), which is difficult to diagnosis through the traditional sputum smear technologies or chest X-rays.  GeneXpert can rapidly detect rifampicin-resistant TB (a proxy for DR-TB diagnosis) along with drug-susceptible TB.  But the diagnostic machines need electricity and are expensive to operate.

Four years ago, the World Health Organization (WHO) endorsed another rapid molecular test called Truenat, which is also able to detect DR-TB – but is cheaper than GeneXpert and can run on batteries.

The Global Fund and Stop TB Partnership have signed an agreement with Truenat’s manufacturer, Molbio Diagnostics, to provide the machines at a reduced price in all countries that are supported by the two organisations and USAID.

In theory, results from these machines are supposed to be processed in two hours. But in practice, it usually takes clinics a few days to process.

“We need to find the people we are missing. So despite all the good progress, our global detection rate is 77% and we have said we need to get that up to 90%. So all the innovations are important, but what we also really need is point-of-care rapid tests like we have for malaria and HIV,” says Tonsing.

“In the past year, the Global Fund secured a 20% reduction in the price of the most commonly used molecular diagnostic test and a 55% reduction in the price of a key treatment for multidrug-resistant TB,” according to Peter Sands, executive director of the Global Fund.

Better treatment for DR TB

People with DR-TB used to spend 12 to 24 months in hospital, and take lots of pills and injections. But in May 2022, this changed dramatically when the WHO recommended an all-oral six-month regimen known as BPaLM –  a regimen of bedaquiline (B), pretomanid (Pa), linezolid (L) and moxifloxacin (M).

“The shorter duration, lower cost, lower pill burden and high efficacy of this novel regimen should enable much better treatment and treatment outcomes.. while also helping health systems to provide care for more people,” the WHO announced.

But the challenge is to ensure that countries adopt the new guidelines. Drug resistant TB is very high in the central region of Eastern Europe, but the management of TB is still  centralised with people still being admitted to hospital for months in many countries. 

The Global Fund is investing in BPalM, and encouraging countries to adopt the regimen, allow patients to stay at home and train staff and civil society organisations about how it works.

The older drug-resistant TB treatment (above) compared with new BPaL regimen (below).

Innovative financing

COVID has depleted many countries’ budgets, especially in the low-and middle-income countries most likely to be struggling with TB.

“Domestic budgets for TB are often not being increased commensurate with the need,” says Tonsing. “Every year, we get around $5 billion for the global TB response whereas the need is around $13 billion, so that gap is huge.”

Since 2017, the World Bank and the Global Fund have supported many countries by investing with blended finance transactions. For example, a loan buydown in India was tied to increased domestic financing for TB care and prevention. 

Debt2Health is an innovative financing mechanism designed to increase domestic financing in health by converting debt repayments into investments in public health programmes. Under individually negotiated “debt swap” agreements, a creditor nation forgoes repayment of a loan when the beneficiary nation agrees to invest all or part of the freed-up resources in a Global Fund-supported programme.

For example, in April 2021 Germany, Indonesia, and the Global Fund signed an agreement to  increase support to TB in Indonesia by converting €50 million of debt owed by Indonesia to Germany into investments in public health programmes supported by the Global Fund in Indonesia.

Still off track

“We have recovered from COVID-19 and in 2022, a record number of TB cases were identified – 7.3 million out of 10.6 million estimated cases. That’s a big new high and we  think, once we get the 2023 data, it will easily cross over eight million,” says Tonsing.

“So we’re getting back on track after being off track but but I don’t think we will be able to make it to the UN high level meeting, or even the 2030 SDG targets.”

Image Credits: Socios en Salud, Marc Bader/ The Global Fund, Dato Koridze .

A counsellor from MSF talks to a person with drug-resistant TB at the TB hospital in Bydgoszcz, Poland.

Over the last century, Europe – including  Northern, Western, Southern and Central European countries – made remarkable progress in the near elimination of tuberculosis (TB) due to improved socio-economic conditions and advancements in research and development. 

However, a recent surge of TB in Europe, coupled with lack of structural preparedness within many European Union (EU) countries to address it, threatens to undo this hard-earned progress.

Figures released from the WHO Europe region on Thursday also show 7,000 excess TB deaths in Europe during the COVID-19 pandemic and that only 60% of TB patients were cured with first-line medication.

The EU must put this forgotten disease back on its health agenda, and urgently address the testing, prevention, and access to treatment needs for people affected by TB and its drug-resistant forms.  

Poland: A case study

Médecins Sans Frontières (MSF) began working with people with TB in Poland in 2022 in the context of the war in Ukraine, by supporting refugees from Ukraine and trying to ensure the continuity of their TB treatment in close collaboration with the Polish national health programme. 

Having worked with people with TB for more than 30 years in lower- and middle-income countries, we were shocked to note that the standards for testing, treatment and prevention of TB and its drug-resistant forms were outdated in Poland, and lacked an integration of the most up-to-date science – as outlined in the World Health Organization’s (WHO) guidelines – into its national health policy.

People with drug-resistant TB (DR-TB) had to stay in hospital for the entire duration of their treatment, which consisted of old, toxic and less effective regimens lasting at least 18 months and including dozens of daily pills and painful daily injections that are known to cause devastating side effects.

That there was no access to the newer, more effective TB drugs that have been available elsewhere for the past decade, hindered the use of the current WHO-recommended shorter, oral regimens that are adapted for everyone, including children.

The lack of access and registration of child-friendly, water soluble formulations of TB drugs meant that children had to swallow crushed and bitter medicines without appropriate weight-based doses. 

Additionally, people with drug-sensitive TB still have to take 11 pills per day even though the availability of fixed-dose combinations has reduced the pill burden to around 3 pills per day in many of the lower- and middle-income countries where we work to treat TB.

Moving onto the right track

The ongoing national and international efforts by WHO, MSF, and many other organisations in the last two years have led to significant steps in the right direction, with the Polish government now bringing back attention to this forgotten crisis.

In a bid to offer continuity of treatment to Ukrainian refugees affected with TB, the Polish government started to prioritise the management of this disease in 2022 and has made notable progress since then. 

In a notable move, the government launched a pilot project in partnership with MSF and WHO for ambulatory treatment of DR-TB that has resulted in reduction in duration of hospital stay from several months to a few weeks. The government also established a system of reimbursement for hospitals to cover the testing and treatment of TB. 

Poland’s co-chairmanship of the TB United Nations High Level Meeting in 2023 led to the adoption of a political declaration with strong commitments to urgently end the global TB epidemic, and signals a paradigm shift by bringing the disease to the forefront of its health agenda.  

We have to keep at it. While the Polish government has made important moves since 2022, we believe that further actions are further needed if the efforts to address TB are to succeed.

The government must establish a system to actively identify people affected with TB , initiate timely treatment, and effectively control transmission of the disease. Worryingly, an MSF internal analysis revealed that over half of the people affected by TB in 2023 remained undiagnosed and untreated whilst living in Poland for at least two years.

Prices of the newer drugs and regimens must be reduced. The WHO-recommended six-month treatment regimen for DR-TB, consisting of bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM), is still exorbitantly priced at €45,300 in Poland even though it is available at €380 in lower- and middle-income countries through the Global Drug Facility, an international procurement agency. 

All TB drugs should be made available for prevention and individualised treatment, ensuring that people with TB – irrespective of their drug-resistance profile, age and other co-morbidities – have access to appropriate treatment.  

Paediatric TB formulations and fixed-dose combinations of TB drugs for both adult and children, already available in many other countries, must be made accessible in Poland as well.  

The Polish government should urgently establish a National TB programme adopting and implementing the current WHO treatment guidelines. 

EU countries lag behind

TB patient Oleg Chutvatov examines an X-ray of his lungs with a doctor at the TB hospital in Kharkiv, before the Russian invasion of Ukraine disrupted health services in his country.

Regrettably, the challenges we see in eliminating TB are not exclusive to Poland but are common in many EU countries. This affects not only access to services in-country, but also the continuity of care for people with TB crossing borders, especially during emergencies.

EU must put TB back on the agenda as a health priority

The case study of Poland is indicative of a more general lack of preparedness within the EU to combat this deadly infectious disease. Such a lack of preparedness has certainly been highlighted and challenged by the rapidly changing international geopolitical situation, to which the war in Ukraine has contributed, and should serve as a compelling wake-up call for the EU to advance its efforts to deal with TB in the region.

As Poland convenes a TB summit with international stakeholders this week to initiate discussions for re-establishing a national TB programme, we urge all countries in the region to proactively revitalise their TB policies and programs, prioritise people-centered care, and take urgent steps to ensure universal access and affordability of TB tests and newer, all-oral treatment regimens.

We also call on the European Commission and concerned departments, including the Health Emergency Preparedness and Response (HERA), and the European Medicines Agency (EMA) to immediately focus on enhancing access to all the medical tools needed to combat TB across the EU.

Only through our collective efforts can we hope to defeat this ancient, yet curable infection, and prevent unnecessary suffering and deaths.

Krzysztof Herboczek is a medical doctor who has worked for Médecins Sans Frontières since 2006 in various positions in the past, including as a TB doctor, manager and adviser. Since 2023, he has been the medical referent for the MSF TB project in Poland.

Joanna Ladomirska is the Medical Coordinator for MSF in Poland. She is a nurse who has 16 years’ experience in humanitarian work, including in countries in Africa, South America, South East Asia and Europe. She has worked in response to epidemics, natural disasters and conflict as well as HIV and TB, and describes herself as “a mother, an activist, and a doer with a humanitarian heart”.

Image Credits: Aleksander Binek/ WHO, The Global Fund / Evgeny Maloletka.

Glacier
Last year smashed records as the hottest year since 1850, causing the loss of hundreds of gigatonnes of ice coverage and extreme weather across the globe

Heatwaves, floods, wildfires, and droughts unleashed global mayhem in 2023, as the year broke multiple climate records, according to the World Meteorological Organization’s (WMO) State of the Global Climate Report released this week.

It was the hottest year in recorded history, with global average near-surface temperature of 1.45℃ above the pre-industrial baseline.

“Never have we been so close – albeit on a temporary basis at the moment – to the 1.5° C lower limit of the Paris Agreement on climate change,” said WMO Secretary-General Celeste Saulo at a press conference this week.

“Climate change is about much more than temperatures. What we witnessed in 2023, especially with the unprecedented ocean warmth, glacier retreat and Antarctic sea ice loss, is cause for particular concern,” she said.

‘Climate crisis is the defining challenge that humanity faces’

The WMO’s annual report offers a dire snapshot of the world’s climate, sounding a “red alert” for countries to double down on efforts to control global warming. 

For United Nations (UN) Secretary General António Guterres, the earth itself is issuing a “distress call” as 2023 saw record greenhouse gas levels, surface temperatures, ocean heat and acidification, sea level rise, and Antarctic sea ice cover and glacier retreat. 

“The impact of all this is stark, brutal and accelerating with deadly force,” said Guterres in a video message at the launch of the report.

Mean surface temperature anomalies as a result of climate change
Both landmasses and oceans saw record-setting heat

The report confirms 2023 as the hottest year on record, noting that globally, every month from June to December broke records. 

September 2023 was particularly noteworthy, surpassing the previous global record for that month by a wide margin (0.46 to 0.54 °C).

The shift from La Nina to El Nino weather conditions have exacerbated the greenhouse gas effects on warming, and the report also warns of rapidly warming oceans. 

At any given point in 2023, close to a third of the oceans were experiencing a heatwave, by the end of the year, most of the global oceans had experienced heatwave conditions. The most affected was the North Atlantic, with marine temperatures exceeding 3°C above average. 

However, the southern ocean continues to store the largest amount of heat, accounting for around 32% of the global ocean heat content (OHC) content increase since 1958. The Atlantic Ocean accounts for approximately 31% of the global 0–2000 m OHC increase; the Pacific Ocean around 26%.

These intense marine heatwaves harm entire ecosystems and further stress coral reefs. The combination of warming oceans and increased atmospheric carbon dioxide concentrations have further acidified the global ocean. The WMO expects the warming to continue “irreversibly” on a dramatic scale of “hundreds to thousands of years.”

Ice sheets shrink, sea level rise doubles 

Ice sheet coverage graphs
Both Greenland and Antarctic Ice Sheets experienced dramatic losses in ice mass

Heatwaves are not the only phenomenon threatening the planet’s ocean. Global mean sea level reached record highs this year, while the rate of rise in the past ten years has doubled from 2.13 mm/year between 1993 and 2002, to 4.77 mm/year. 

Several factors converge to create this alarming rise: warmer oceans, the switch from La Nina to El Nino, and melting glaciers. 

Both glacier and sea-ice melt accelerated this past year, with Antarctic sea-ice reaching “an absolute record low” not seen since 1979. 

The Greenland Ice Sheet and Antarctic Ice Sheet lost 372 gigatonnes of mass per year from 2016 to 2020, up from 105 gigatonnes/year in 1992-1996.

“Antarctic sea ice was one million square kilometres smaller than the previous record low for the time of year. That’s an area almost 25 times the size of Switzerland,” noted Guterres. 

Beyond the poles, glaciers in western Northern America and Europe suffered the largest loss of ice on record, particularly in the European Alps. The mountain range lost 10% of its remaining volume in just the past two years. 

The toll of extreme weather

Canadian wildfires graph
Canadian wildfires burned through millions of hectacres in the past year alone

Extreme weather including cyclones, rainfall-induced flooding, wildfires, and heatwaves continued to lead to severe socioeconomic impacts. 

Wildfires in Hawaii, Canada and Europe led to loss of life, the destruction of homes and large-scale air pollution. Flooding associated with extreme rainfall from Mediterranean Cyclone Daniel affected Greece, Bulgaria, Türkiye, and Libya. 

“There were particularly devastating consequences for vulnerable populations who suffer disproportionate impacts,” writes WMO Secretary-General Saulo in her forward to the report.

“Extreme climate conditions exacerbated humanitarian crises, with millions experiencing acute food insecurity and hundreds of thousands displaced from their homes.”

Food security, population displacement and impacts on vulnerable populations continue to be of mounting concern in 2023, with weather and climate hazards exacerbating the situation in many parts of the world.

The report calls attention to the fact that the number of people who are acutely food insecure worldwide has more than doubled, from 149 million people before the COVID-19 pandemic to 333 million people in 2023, citing World Food Programme (WFP) numbers.

Climate and extreme weather events are directly tied to the dire food insecurity situation in much of the world; in Southern Africa, for example, Cyclone Freddy submerged extensive agricultural areas and inflicted severe damage on crops in February 2023.

“Across the globe, millions of people, including internally displaced persons, refugees, and migrants, are on the move or have been forced to flee their homes and communities because of disasters exacerbated by climate stresses and shocks,” states the WMO.

The consequences of global inaction

Greenhouse gas emissions
Greenhouse gas emissions continued to climb in 2023 despite growing investment in renewables

“The scientific knowledge about climate change has existed for more than five decades, and yet we missed an entire generation of opportunity,” said Saulo said to media in Geneva. 

She urged the climate change response to be governed by the “welfare of future generations, but not the short-term economic interests.”

The cost of inaction is staggering, the report warns. In the next 75 years, it may reach 1.266 trillion, representing the difference in losses between a business-as-usual scenario and a 1.5° C pathway. Noting that this figure is likely a significant underestimate, the UN weather experts call for immediate climate action.  

The report emphasizes that adaptation finance continues to be “insufficient.” Though adaptation finance reached an all-time high of 63 billion in 2021 and 2022, the global adaptation financing gap is widening, falling well short of the estimated 212 billion per year needed up to 2030 in developing countries alone.

There is, however, reason for hope. Renewable energy generation and capacity surged this past year, driven by solar, wind, and hydropower. 

In 2023, renewable capacity additions increased by almost 50% from 2022, for a total of 510 gigawatts (GW) – the highest rate observed in the past two decades.

“The good news is that we can still keep our planet’s long-term temperature rise below that limit, and avoid the worst of climate chaos,” remarked Guterres. “We know how to do it.” 

“There’s still time to throw out a lifeline to people and planet. But leaders must step up and act – now.”

Image Credits: Melissa Bradley, World Meteorological Organization.

Girls and women protest outside Gambia’s parliament this week in protest against attempts to reintroduce female genital mutilation.

An effort by Gambia’s parliament to reintroduce female genital mutilation (FGM) has been met with widespread condemnation by women’s and human rights organisations.

Gambia’s Members of Parliament voted overwhelmingly this week to refer the Private Member’s Bill that seeks to repeal the Women’s (Amendment) Act of 2015 that banned FGM to parliament’s business committee for further consideration. It may be reintroduced within weeks.

Supporters of the Bill claim that the practice is important for “cultural and religious reasons” in the conservative Muslim-dominated country. 

Only four of the 47 MPs present opposed the decision to entertain the Bill further in Gambia’s parliament, which is made up of 53 male MPs and only five women MPs.

However, Deputy Speaker Seedy SK Njie expressed his support for the current status quo on X, stating that “the FGM law is here to stay. We’re committed to keeping Gambian women and girls safe.”

The Bill was introduced by Almameh Gibba, an MP from the Alliance for the Patriotic Reorientation and Construction (APRC), with the support of Imam Abdoulie Fatty, who advocates for FGM for religious and cultural reasons.

It is being opposed by a number of organisations, including the Network Against Gender-Based Violence and Think Young Women, which is also opposed to child brides.

Despite the banning of FGM nine years ago, almost three-quarters of Gambian women are estimated to have been subjected to the practice, and almost half were cut before their 15th birthday.

“It is very disappointing that, after the long fight Gambian activists put up to advance women’s rights, parliament is preparing to consider this backward move,” said Michèle Eken, senior researcher at Amnesty International’s West and Central Africa office.

“The potential repeal of the FGM ban in The Gambia sends a dangerous message, not just domestically, but internationally,” said Women Leaders Network for Development. (RFLD)

“Other countries grappling with FGM might see this as an opportunity to dismantle their own safeguards, putting millions more girls at risk.

“Proponents of repealing the ban often frame it as an attack on cultural and religious traditions. However, this narrative is misleading. Culture is not static; it evolves with time. Harmful practices, like FGM, have no place in a society that values human rights and equality. The right to health, enshrined in international law, supersedes cultural justifications for practices that cause demonstrable harm,” added RFLD.

Lack of enforcement

Despite the ban on FGM in the three-million strong nation, there has only been one conviction in the past nine years involving three women for cutting babies aged four to 12 months old, according to women’s rights activist Jama Jack. They received fines which were paid by Fatty via a public fundraising campaign, added Jack.

“We must recognise that the practice is rooted in the desire to control our bodies and our sexuality, and any concessions we make today will be applied to other forms of violence we face, because the goalpost will always be shifted,” Jack wrote in a blog this week.

“We have already seen Abdoulie Fatty mention the law prohibiting child marriage, and just as we predicted, they will come for every legislation protecting women and girls.”

FGM involves the partial of total removal of external female genitalia – supposedly to “control” women’s sexuality – and is usually performed on girls under the age of 15.

Around 90% of women in Somalia, Guinea and Djibouti are subjected to FGM, and a range of organisations fear that Gambia’s reversal will encourage others in West Africa.

Over 230 million girls and women alive today have undergone female genital mutilation (FGM), according to a report from the UN children’s agency, UNICEF, released earlier this month. This is a 15% increase since eight years ago.

“The pace of progress to end FGM remains slow, lagging behind population growth, especially in places where FGM is most common, and far off-pace to meet the UN’s Sustainable Development Goal to eliminate the practice. The global pace of decline would need to be 27 times faster to end the practice by 2030,” UNICEF notes.

However, progress to prevent FGM is possible. In the past 30 years, FGM has declined in Kenya from moderate to low prevalence; Sierra Leone has dropped high to moderately high prevalence and Egypt is beginning to decline from a previously near-universal level.

Violation of rights

“In every form in which it is practised, FGM is a violation of girls’ and women’s fundamental human rights, including their rights to health, security and dignity,” according to UNICEF, which estimates that four million girls and women are at risk every year.

“FGM has no health benefits and can lead to serious, long-term complications and even death. Immediate health risks include haemorrhage, shock, infection, HIV transmission, urine retention and severe pain,” said UNICEF, adding that psychological impacts ranged from girls losing trust in her caregivers, anxiety and depression.

“In adulthood, girls subjected to FGM are more likely to suffer infertility or complications during childbirth, including postpartum haemorrhage, stillbirth and early neonatal death.”

Ironically, Gambia’s decision comes in international women’s month and during a global meeting of the UN Commission on the Status of Women. The theme of the 68th meeting of the commission is “Accelerating the achievement of gender equality and the empowerment of all women and girls by addressing poverty and strengthening institutions and financing with a gender perspective”.

Microscopic view of mycobacterium tuberculosis in the lungs.

A Phase 3 trial of a tuberculosis vaccine candidate has been launched in South Africa, according to the Bill & Melinda Gates Medical Research Institute (Gates MRI).

The candidate vaccine – referred to as  M72/AS01E – “could potentially become the first vaccine to help prevent pulmonary TB in adolescents and adults, the most common form of the disease, and the first new TB vaccine in over a century”, according to Gates MRI, which is sponsoring the trial along with funding support from Wellcome Trust and the Bill and Melinda Gates Foundation.

“The launch of this pivotal Phase 3 trial demonstrates our commitment to harnessing the power of medical innovation to fight diseases like TB that are particularly devastating for low- and middle-income countries,” said Dr Emilio Emini, CEO of the Gates MRI. 

“Clinical study of the vaccine will still require years, but our incredible partners in South Africa and elsewhere who have come together for the Phase 3 study share our hope in the vaccine’s potential.”

M72/AS01E was originally designed and clinically evaluated by the biopharma company GSK up to the proof-of-concept phase (Phase 2b). 

In 2020, GSK announced a partnership with the Gates MRI for its further development. GSK continues to provide technical assistance and is supplying the adjuvant component for the Phase 3 trial and will provide the adjuvant post-licensure should the trial be successful. An adjuvant is an ingredient used in some vaccines that can help create a stronger immune response. 

Up to 60 trial sites

“Reaching Phase 3 with an urgently needed TB vaccine candidate is an important moment for South Africans because it demonstrates that there is a strong local and global commitment to fight a disease that remains distressingly common in our communities,” said Dr Lee Fairlie, national principal investigator for the trial in South Africa.

“South Africa also has considerable experience with TB- and vaccine-related clinical trials and a strong track record for protecting patient safety and generating high quality data essential for regulatory approvals.”

At full capacity, the trial will include up to 20,000 participants, including people living with HIV, at up to 60 trial sites in South Africa, Zambia, Malawi, Mozambique, Kenya, Indonesia and Vietnam. 

“After dedicating over 20 years to developing this essential candidate vaccine, we at GSK are delighted that the Phase 3 trial is underway,” said Deborah Waterhouse, CEO of ViiV Healthcare and GSK’s president of global health.

“Developing and ensuring access to global health products is complex but our collaboration with the Gates MRI, Wellcome and the Gates Foundation exemplifies the transformative power of leveraging diverse partners’ expertise to change the trajectory of challenging diseases, like TB, which place a huge burden on communities around the world.”

WHO investment case for screening and prevention

Every dollar invested in TB screening and prevention will translate to $39 in economic and health gain, according to the World Health Organization (WHO) investment case released this week.

The analysis is based on the results of a modelling study developed with the governments of four countries – Brazil, Georgia, Kenya and South Africa. 

“The investment case outlines the health and economic rationale for investing in evidence-based, WHO-recommended interventions on TB screening and prevention that can contribute to advancing universal health coverage,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “Today, we have the knowledge, tools and political commitment that can end this millennia-old disease that remains one of the world’s top infectious killers,” he said. 

TB causes 1.3 million deaths each year and affects millions more, mostly in low-and middle-income countries. Global efforts to combat TB have saved an estimated 75 million lives since the year 2000, according to the WHO.

This year, World Tuberculosis Day on 24 March is being commemorated under the theme ‘Yes! We can end TB!’ conveying a message of hope.

But WHO experts conceded that access to TB drugs remained constrained due to limited investments, speaking at a press conference on Monday. 

Screening and preventive treatment cuts costs

Implementing TB screening along with preventive treatment can substantially reduce TB incidence and mortality, according to the investment report. It argues that these crucial public health investments are essential for addressing the needs of vulnerable populations.

In 2022, WHO reported a significant worldwide recovery in the scale-up of access to TB diagnosis and treatment services, with the highest figure recorded since WHO began global TB monitoring in 1995.

But so far the scale-up of access to TB preventive treatment has been slow. It is also vital to offer TB preventive treatment to those with HIV, household contacts of TB patients, and other high-risk groups.

The global number of people living with HIV and household contacts of people with TB who were provided with TB preventive treatment increased to 3.8 million in 2022 or about 60% of those targeted that year in line with the commitments made at the UN High-Level Meeting of 2018.

Dr Saskia Den Boon, Technical Officer at the WHO’s Global TB Programme.


“Strategies to provide TB preventive treatments are often linked to screening to find and treat people with TB earlier in the course of their disease. And this helped to reduce transmission and improve outcomes. TB screening is a key intervention to find and treat the millions of people not accessing care for TB disease,” Dr Saskia Den Boon, Technical Officer at the WHO’s Global TB Programme.

Lack of vaccines

Vaccines are normally an effective preventive strategy but currently the only available vaccine for TB is the BCG vaccine that is over a century old.

“That’s the BCG, which was only for kids and it is not really effective to provide adults protection against TB,” said Ashna Ashesh, a TB survivor and public health professional and representative of WHO Civil Society Taskforce on TB.

“We’ve seen how fast we can work when we put our money where our mouth is with COVID. We had a vaccine within a year. But that wasn’t because we started from scratch in that one year. We invested in decades of mRNA research that then allowed us to quickly develop the COVID vaccine.”

Dr Tereza Kasaeva, Director of the Global Tuberculosis Programme at the WHO


“It’s absolutely unacceptable that in 21st century with a lot of innovations, we still don’t have new effective TB vaccine,” said Dr Tereza Kasaeva, WHO’s TB director. “This area of the development of new vaccines, it’s very expensive, highly risky area,” she added. 

Kasaeva said that there are more than 16 candidates in the pipeline and newer vaccines could come in the market in the next five years but added that investments are needed.

“And if you look, first of all at the situation with funding of TB research, [it is] less than o$1 billion annually. Overall investments in TB research are absolutely not sufficient,” she said. 

Multidrug-resistant TB 

Multidrug-resistant TB (MDR-TB) remains a public health crisis. While an estimated 410,000 people developed multidrug-resistant or rifampicin-resistant TB in 2022, only about two in five people accessed treatment.

The global targets approved at the 2023 UN High-Level Meeting on TB include: reaching 90% of people in need with TB prevention and care services; using a WHO-recommended rapid test as the first method of diagnosing TB; providing a health and social benefit package to all people with TB; ensuring the availability of at least one new TB vaccine that is safe and effective; and closing funding gaps for TB implementation and research by 2027.

Following the commitments made by Heads of State at the UN High-Level Meeting in 2023 to accelerate progress to end TB, this year’s focus is on tangible action, the world health body said. 

Additional reporting by Kerry Cullinan.

Image Credits: Roche .

A child gets vaccinated against measles during the outbreak in the DRC.

Discussion about disease outbreaks dominated the biannual meeting of the Strategic Advisory Group of Experts on Immunization (SAGE) – which its chairperson described as  “alarming” as the aim of the group is to ensure early vaccination to prevent outbreaks.

“The outbreak-related recommendations is a sign that normalcy is starting to be living with outbreaks,” warned Dr Hanna Nohynek, chair of SAGE, which advises the World Health Organization (WHO) on immunisation.

“My plea to nations is to give us sufficient resources so that we can run our programmes properly and our surveillance systems properly so that we don’t have to deal with outbreaks but we can actually keep up our good vaccine coverage.” 

Mpox: different epidemiology 

There is a “significant” mpox outbreak in the Democratic Republic of Congo (DRC) that involves Clade I of the disease and is predominantly affecting children.

But this outbreak has “a very different epidemiology” from the multi-country outbreak in 2022, which involved the milder Clade II and was mainly spread through sexual transmission, particularly in men having sex with men, said Dr Kate O’Brien, WHO Director of Immunization, Vaccines and Biologicals.

Dr Kate O’Brien, WHO Director of Immunization, Vaccines and Biologicals.

“It’s really important to understand what the source of the mpox exposure is [in DRC], which is presumably related in part to zoonotic transmission, and potentially transmission then in the household or in the community,” she added.

Children in the DRC are being given mpox vaccines (both on- and off-label, depending on which vaccine is involved), and O’Brien urged the country to conduct evaluations of its performance “which we expect to be very high in settings of community transmission”.

“The vast majority of mpox vaccine data is from high income countries and predominantly in communities where there has been sexual transmission,” she noted.

“We have a lack of research, be it clinical research or epidemiological research, in relation to diseases that are most pressing in low income countries and the issue came up in particular in relation to mpox,” said SAGE’s executive secretary, Dr Joachim Hombach, who is also WHO senior health advisor.

“More research needs to be done and, whenever possible local research because the competencies are there it is just that the resources are not, so that more data is generated to allow for more robust policy and for more robust understanding of the disease epidemiology.”

SAGE’s executive secretary, Dr Joachim Hombach.

Measles and misinformation

WHO releases annual measles case and death estimates, and for 2022 there were over nine million cases and 136,000 deaths.

“There are now over 50 countries that have large and disruptive measles outbreaks ongoing during the course of this past calendar year, and that’s about double the number of countries as occurred in 2022,” said O’Brien.

“We warned very much regularly during the course of the [COVD-19] pandemic what the impact would be of the backsliding in immunisation, and we’re seeing that happen now and we do expect that the 2023 numbers will be even worse than the 2022 numbers.”

While there had been an “infodemic” of vaccine-related misinformation during the pandemic, O’Brien stressed that lack of access to vaccines was behind the vast majority of children going unvaccinated. 

“The primary reason for unvaccinated people is really related to the ease of access and the quality of services. But this issue of misinformation, hesitancy and people’s understanding of the value of vaccines is very contributory and in some communities, this is a big contribution to people’s behaviour around vaccines,” she acknowledged.

“The reasons for this misinformation, hesitancy or lack of confidence in vaccines is very, very local so we can’t give global recommendations on exactly what to do,” she added.

However, she urged health authorities to listen to communities, and assure local leaders about the “life-saving nature of vaccines and the safety of vaccines”.

“I want to really emphasise the importance of the process that we have in WHO for pre-qualifying vaccines. Our procedure for pre-qualifying vaccines or issuing an emergency use listing is an assurance to countries that those vaccines are efficacious. They’re safe, and they’re manufactured with quality.”

Polio and Hepatitis E

Dr Hanna Nohynek, chair of SAGE

The wild poliovirus type one is only in circulation in a small geographic area of the border between Afghanistan and Pakistan, but SAGE is concerned about the circulation of vaccine-derived polio type one and type two (VDP2) in a number of African countries.

“Improving routine immunisation coverage is at the heart of getting the eradication goals,” stressed Nohynek.

SAGE is also concerned about Hepatitis E, a liver disease that “can be very severe, especially for pregnant women among whom the case fatality rate can be as high as 25%”, she added. 

“In fragile and conflict-affected and vulnerable settings, it’s really important that pregnant women have access to the vaccine,” said Nohynek.

SAGE has recommended a two-dose schedule, which is off label, instead of a three-dose schedule and additional research on hepatitis E vaccination during pregnancy, in people living with HIV and children under 16.

Image Credits: WHO DRC Office Twitter.


Seven Indian pharmaceutical companies made donations to domestic political parties while they were under investigation for substandard drug production, according to an investigation published in Scroll.

The companies named in the investigation included Hetero Labs and Hetero Healthcare, Torrent Pharma, Zydus Healthcare, Glenmark, Cipla, IPCA Laboratories Limited, and Intas Pharmaceutical. They were under investigation for substandard drugs including the anti-COVID drug, Remdesivir and anti-bacterial and anti-fungal medications.

Overall, some 35 pharmaceutical companies in India contributed nearly Rs 1,000 ($120 million) to political parties competing in the upcoming national elections, which are scheduled in phases through April and May this year.

The donations, originally anonymous, were made through the purchase of “electoral bonds”, system whereby an individual or an institution can fund a political party that was introduced by Prime Minister Narendra Modi’s government in 2017.

India’s Supreme Court recently directed the country’s public sector bank, State Bank of India, to disclose the names of the companies that made donations, and these names have been released by the Election Commission beginning on 14 March.

Punitive actions for failing a drug quality test can range from the suspension of manufacturing to the cancellation of a licence, and the decision lies with the Indian government.

The data released did not, as yet, disclose which political parties were supported, and to what extent. However, with just four weeks to go before the elections, India’s Supreme Court has pressed on for ‘complete disclosure’ of the data in a further order issued 18 March.

The analysis is part of an ongoing series of stories on the electoral bonds by a team of journalists from several independent news organisations including, Newslaundry, Scroll, and The News Minute.

Image Credits: AMR Industry Alliance, Glsun Mall/ Unsplash.

US President Joe Biden on the 20th anniversay of PEPFAR in 2023

Twenty years ago, the sight of women, men and children being carried to hospitals in wheelbarrows as they clung to the fragile threads of life, was heartbreakingly common. 

AIDS was not just a disease. It was a shadow of despair that loomed over our communities, threatening to engulf us in darkness. But then, in a remarkable act of bipartisanship, US President George W Bush and the US Congress introduced the President’s Emergency Plan for AIDS Relief (PEPFAR) and, like the first rays of dawn, it brought hope where there was once only despair.

There was a unanimous call for a five-year reauthorisation of PEPFAR from African Heads of State and government at the African Union Assembly when they met in  February 2023 in Addis-Ababa, Ethiopia. This is a call to action. This crucial extension is not merely a legislative act; it is a covenant with future generations, affirming our shared commitment to ending AIDS by 2030.

The impact of PEPFAR has been nothing short of miraculous. Imagine, 25 million souls given another chance at life, 5.5 million infants cradled in their mothers’ arms, HIV-free, and 20 million individuals now with the medicine that not only sustains their lives but shields others from the virus. 

PEPFAR: 20 years of success

The spectre of AIDS that once snatched infants and young children from this world has been pushed back by a staggering 70%. Villages and cities have witnessed life expectancies surge by over a decade, a testament to the resilience of the human spirit when given a fighting chance.

Through PEPFAR, the very fabric of our societies has been fortified. Our economies, reflected in the GDP per capita, have grown more robust by 2% faster in countries embraced by PEPFAR’s warm reach. 

Seven million children, who might have been orphaned due to AIDS, now find solace and support from their parents. 

Health infrastructure transformed

Our healthcare infrastructure has been transformed with the construction of 70,000 clinics, the establishment of 3,000 laboratories, and the addition of 340,000 dedicated healthcare workers. This strengthened network of care has become our shield and spear, not just against AIDS but against other scourges like COVID-19, Ebola, and more, safeguarding our future from health threats yet unseen.

Amidst our collective stride towards a brighter tomorrow, we find ourselves at a crossroads, confronted by the complex politics surrounding abortion. Let it be clear: in many of our lands, abortion is permitted only under the most stringent of circumstances. 

Our faith-based partners, who have stood valiantly at the forefront of this battle against HIV and AIDS from its inception, would have stepped back if PEPFAR had strayed from its mission to prevent HIV and AIDS. 

Yet, they remain, more committed than ever, a testament to PEPFAR’s unwavering commitment to preserving life. Indeed, 350 African faith leaders have reassured the US Congress, dispelling the misconceptions about PEPFAR’s mission with unequivocal clarity.

PEPFAR mirrors the essence of African values, most notably in our collective resolve to empower and safeguard our adolescent girls and young women.  It embodies the spirit of America’s partnership based on compassion. The DREAMS initiative is more than a program; it is a beacon of hope, offering the education, skills, and support needed to forge paths away from HIV and towards a future filled with promise.

As we look to the horizon, the journey with PEPFAR from emergency response to sustainable progress serves as a shining example of what humanity can achieve when united. 

Yet the road ahead remains long, with millions still in need of treatment and the threat of new infections and deaths looming large. Recent reports forewarn of the catastrophic consequences of halting our march now, with nearly a million more babies at risk of HIV infection and countless lives in the balance by 2030.

As leaders, both in Africa and in the US Congress, grapple with domestic and global challenges, the weight of millions of lives rests in their hands. 

Our heartfelt plea is for a simple, yet profound, continuation of PEPFAR’s mission – a beacon of American leadership, a testament to bipartisan solidarity, and above all, a lifeline for millions. Let us renew our vows, stand united, and march forward together, for the light at the end of the tunnel is within reach, but only if we continue to carry the torch of PEPFAR into the future.

Dr Jean Kaseya is the Director General of Africa Centre for Disease Control and Prevention.

 

 

 

Image Credits: PEPFAR, Africa CDC.

Delhi, India, where toxic smog blocks out the sun.

Bangladesh is the world’s most polluted country and Delhi is the most polluted capital. But India also has the most air quality monitors in South Asia – while some wealthy petro-nations have virtually none.

The air quality global ranking of cities for 2023 has been released by a Swiss firm, IQAir, which has been reporting this annually for over six years now. 

Never before has one country dominated the top spots for the worst air quality to the extent that India does, but the report also exposes massive gaps in monitoring pollution in the global south which stem from a lack of funds, political will or both. Air pollution is linked to over eight million deaths annually, or almost 16 per minute, and is considered a major health risk.

Nine of the top 10 most polluted cities are in India, up from six the previous year. Meanwhile, 42 cities in the top 50 are in India, up from 39; and an astounding 83 cities in the top 100 are Indian (up from 63 and 65 in the previous two years).

Delhi is back to being the most polluted capital of the world, the fifth time in the last six years. Its PM 2.5 level has averaged over 102 micrograms per cubic metre, up 10 units from the previous year. WHO’s safe guideline is just 5 micrograms. 

The report by IQAir summarises PM2.5 air quality data from 7,812 cities spanning 134 countries, regions, and territories. It sourced the data from 30,000 air quality monitoring stations operated by research institutions, governmental bodies, universities and educational facilities, non-profit organizations, private companies, and citizen scientists. 

World Air Quality Report 2023

Report exposes gaps in air quality monitoring

The data, however, cuts two ways. While it shows how dire the crisis is in India, it also exposes major gaps in monitoring. Take South Asia for starters. The world’s top three most polluted nations are all here: Bangladesh, Pakistan, and India in that order. But in Bangladesh, only two places monitor air quality, while Pakistan has 10 sites. India monitors 256 cities . 

“In Southeast Asia as a whole, 74% of the cities in the region are in India. This increase in monitoring shows the Indian government’s awareness of the country’s pollution problem, and the way to begin addressing it is to have a robust monitoring network, which India is actively doing,” a spokesperson from IQAir told Health Policy Watch. 

The lack of monitoring in other regions is stark. In Africa and South America, it raises questions of inequity and funding. The report only has data from 79 places in Africa and 219 in all of Latin America and the Caribbean. In sharp contrast, the United Kingdom alone has 219 monitoring sites, Europe 2,004, and the US has 3,242. 

In West Asia, where some countries have among the highest per capita income and GHG emissions globally, the absence of more widespread monitoring may raise questions of political will or priorities. Iraq for example has only two places with data, Saudi Arabia has three, and the UAE, a federation of seven member states, also only has three.

How the data is collected

Although some countries may have more monitors than reflected in the report, IQAir says it only uses data that meets its threshold. Chad, for instance, was the most polluted country in 2022, but it did not meet their data inclusion standards for the latest report, neither did cities like Hotan in China and Peshawar in Pakistan which are still polluted but are not included in the top 10 most polluted cities this year.

Over the years, the report has come to be extensively quoted – last year it was cited some 4,000 times according to the spokesperson. 

The report endorses a rising trend of the use of a major change in monitoring tech and that is low-cost sensors. In India, for example, the official, regulatory grade while very accurate may cost about 10 times more than the low-cost ones.

Authorities are now rolling these out by the hundreds in some of the heavily polluted regions including in Bihar, home to the world’s #1 most polluted place. Of the roughly 30,000 monitors used for the 2023 World Air Quality Report, most (61%) are low-cost monitors. The margin of error is approximately 10%, a spokesperson said.

World’s worst polluted city, and country

The world’s most polluted city is Begusarai in the east Indian state of Bihar. Its pollution level averaged 118.9 micrograms/cubic meter, 24 times the WHO’s safe limit. The most polluted country is Bangladesh which, at 79.9 micrograms, is more than 15 times higher than the safe limit. The two are hundreds of kilometres apart but air pollution connects them. 

“Due to its geographical location, Begusarai experiences a stream of pollution from various parts of India. This also explains why Bangladesh is the most polluted country in the world. Pollution from northern and southern India is funneled in by winds and affects the entirety of eastern India and Bangladesh. This is known as transboundary pollution.”

The Begusarai-Bangladesh link starkly illustrates the one big hope of tackling air pollution and that is for creating partnerships between governments and authorities. Transboundary pollution or the concept of a common air mass – creating an airshed – across political or administrative boundaries is seen as a cost-effective and most impactful option for reducing pollution. 

Climate change, pollution, and pollen allergies 

Significantly, the report warns that climate change could be exacerbating air pollution. Fossil fuel emissions account for 65% of global CO2 emissions and are also the primary cause of the majority of PM2.5-related deaths, it says, highlighting the interconnected relationship between air quality and climate change.

With extreme heat events becoming more severe and frequent, in many regions, intense pollution events may coincide with extreme heat, where weak winds hinder ground-level ventilation thereby allowing pollutants to accumulate. The frequency of such events is expected to increase. 

Changing climate patterns are also stretching out pollen seasons and making these more intense with increased levels of grass and tree pollen emissions due to changing climate patterns. 

Tackling climate change and air pollution jointly is inevitable for policymakers. The question is, can they deliver quickly enough?

Image Credits: Wikipedia, Sumitmpsd , IQAir.

Gaza’s Al Shifa hospital during WHO visit on Friday 1 March – the hospital had only recently restored medical services.

WHO Director General Dr Tedros Adhanom Ghebreyesus deplored renewed fighting Monday and Tuesday in and around northern Gaza’s Shifa Hospital, the largest medical compound in the besieged enclave, saying that “hospitals should never be battlegrounds.”  He also noted that the hospital, originally the largest and most advanced in Gaza, had only “recently restored minimal health services”.  That was after weeks of fierce Israeli-Hamas combat around the area, including an Israeli raid of the compound in November 2023, followed by a military blockade around northern Gaza that cut off most medical supply routes.

“Any hostilities or militarization of the facility jeopardize health services, access for ambulances, and delivery of life-saving supplies,” Tedros said in a post on X.  “Hospitals must be protected. Ceasefire!”

Israel said Monday that its military had re-entered the hospital compound in the early morning hours of Monday, in pursuit of  Hamas chief of internal security, Faiq Mabhouh, alleged to be hiding in the medical facility. Mabhouh was killed in an encounter with Israeli forces along with 20 other Hamas gunmen in the hospital, Israel said, adding that numerous weapons and envelopes of cash, ready for distribution by Hamas, had also been located on the hospital grounds.

Israel said it had also detained about 200 Palestinians that it suspected of being Hamas operatives. Among those was Al Jazeera journalist Ismail al-Ghoul – who was released about 12 hours later.

Al Jazeera said al-Ghoul was arrested Monday morning along with a number of other journalists “while covering the Israeli occupation forces’ attack on the hospital. ..  targeting of al-Ghoul is part of a series of systematic attacks on Al Jazeera by the occupation authorities” aimed to “deter them from reporting the horrific crimes committed by the occupation forces against innocent civilians in Gaza.”

Following his release Monday evening, al-Ghoul told Al Jazeera that he and other journalists detained were stripped of their clothes and forced to lie on their stomachs for hours, before being taken for interrogation. As he was waiting to be interrogated, an elderly man leaving the hospital requested help, and the journalist was allowed to accompany him out.

Eyewitness reports and TV news footage described aerial bombing of the area surrounding the hospital, as skies filled up with smoke and dozens of injured civilians lay on the ground.  People sheltering on the hospital grounds were reported to be fleeing, while Israeli soldiers continued searches of the hospital buildings Monday afternoon and evening.

In a reply to the WHO Director General, also posted on X, Israel’s ambassador to the UN in Geneva Meirav Eilon Shahar said, “We are also terribly worried @DrTedros, that Hamas once again militarizes hospitals in Gaza…Our request is simple: an immediate end to all Hamas terrorist activities in the hospital.”

IPC report: starvation in northern Gaza imminent

Meanwhile, a report by the Integrated Food Security Classification, also released Monday, warned that famine in Gaza is “imminent” as half of Gaza’s population of 2.2 million people face catastrophic food insecurity.  Around 210,000 people in north Gaza and Gaza City, or 70% of the remaining population, are already in Phase 5 of food insecurity, or a famine status, the agency said.

“The famine threshold for household acute food insecurity has already been far exceeded and, given the latest data showing a steeply increasing trend in cases of acute malnutrition, it is highly likely that the famine threshold for acute malnutrition has also been exceeded.”

The southern governorates of Deir al-Balah, Khan Younis, and Rafah, are classified in IPC Phase 4 (Emergency). “However, in a worst-case scenario, these governorates face a risk of Famine through July 2024,” IPC added.

“The hunger situation in #Gaza is devastating: famine is imminent and it could have grave immediate and long-term health consequences,” said Tedros in another X post later Monday, which was followed by WHO statement, calling for more immediate food relief, as well as the restoration of water and sanitation services.
“There was no reason for this catastrophe to happen. Before October 2023, there was enough food in Gaza to feed the population. Malnutrition was a rare occurrence. Now…over a million people are at risk unless significantly more food is allowed to enter Gaza. The only way to reverse this is through peace.”

 

Image Credits: WHO.