HIV medicine dolutegravir.

The World Health Organization (WHO) recently reported drug resistance to the world’s gold-standard antiretroviral medicine, dolutegravir  “exceeding levels observed in clinical trials” – with resistance ranging from 3.9% to 19.6%.

This was potentially very bad news as dolutegravir has been the recommended first- and second-line HIV treatment for all population groups since 2018 – but the WHO told Health Policy Watch this week that the drug resistance was largely related to patients not adhering to treatment properly rather than growing resistance to the medicine.

Dolutegravir is “more effective, easier to take, and has fewer side effects than other drugs currently in use” with “a high genetic barrier to developing drug resistance”, according to the WHO.

It is used in antiretroviral therapy (ART) in combination with tenofovir and lamivudine, and its use has led to “very high levels of viral load suppression at the population level, often in excess of 90% or even 95%”, according to WHO. 

Country reports on resistance

The reports on resistance come from country surveys in Uganda, Ukraine, Malawi and Mozambique, WHO told Health Policy Watch.

In Uganda, Ukraine and Malawi, the levels of resistance to dolutegravir ranged from 3.9% to 8.6% in adults, ranging from those who had never taken ART to those with some exposure to the drugs.

But in Mozambique, the survey involved people experienced with treatment who had transitioned to a dolutegravir-containing regimen while having high HIV viral loads. And in this instance, resistance reached 19.6%. 

“Overwhelmingly, data suggest that non-adherence to treatment is the primary reason for viral non-suppression in people taking dolutegrivar, not drug resistance,” said the WHO spokesperson.

“Levels of HIV drug resistance observed to the integrase inhibitor dolutegravir are much lower than resistance levels observed in populations failing non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based antiretroviral therapy,” added WHO.

NNRTIs refer to a class of ARVs that block an HIV enzyme called reverse transcriptase, which prevents the virus from replicating. Efavirenz, the previous WHO-recommended first-line HIV treatment regimen, was an NNRTI.

“In populations not achieving viral suppression on NNRTI-based ART, we saw levels of resistance from 70-90%. The combination of higher levels of viral load suppression and the much lower levels of acquired drug resistance affirm the global guidelines’ change from NNRTI- to dolutegravir-based treatment,” the WHO added.

The WHO official noted that there was still “much to learn about dolutegravir resistance”, with “very early and limited data” suggesting that “very large proportions of people not achieving viral suppression” on the dolutegravir would do so with “enhanced adherence support”. 

Dolutegravir and TB medication 

Meanwhile, a new clinical trial has found that people newly diagnosed with HIV fared well when given preventative treatment for tuberculosis at the same time as dolutegravir.

These results were released at the recent Conference on Retroviruses and Opportunistic Infections in Denver, Colorado.

“Each year, there are an estimated 670,000 new TB cases among people living with HIV and an estimated 167,000 deaths from TB-related HIV,” according to a media release from the Aurum Institute, one of the research partners in the trial.

The trial – called DOLPHIN-TOO – focused on whether the efficacy of dolutegravir in people living with HIV who had never previously been treated with ARVs was affected by prophylactic TB treatment – either the standard isoniazid (6H) or the newer regimen comprising of a weekly dose of isoniazid and rifapentine for three months referred to as 3HP.

The results showed that, while people in the 3HP group did have lower levels of dolutegravir in their bloodstream than people in the 6H group, they were able to achieve an undetectable level of HIV virus in blood by eight weeks and maintain this for the length of the six-month study. 

Minimal side effects were seen, none were severe, and the majority were resolved with continuation of therapy. 

Previous research released at the Union World Conference on Lung Health in November of 2023, had provided information on the safety and efficacy of the use of 3HP and dolutegravir  together, but without data on the drug levels in the blood.

“This study points to the use of short course TB preventive treatment in people who are newly diagnosed with HIV and are at highest risk of active TB disease,” according to a media release from Aurum.  

Medication-related harm accounts for a half of preventable harm in medical care

As many as one in 20 patients experience avoidable side effects from medication that they use, with this figure rising to 7% in developing countries. 

The causes range from taking the medication at the wrong time, which could result in minor side effects, to taking an  inappropriate drug, which might result in unpredicted harm as serious as yet another disease or even death.

Such errors are not that scarce, concludes Dr Maria Panagioti, senior lecturer in primary care and Health Services Research at the University of Manchester and one of the authors of a new World Health Organization (WHO) systematic review “Global burden of preventable medication-related harm”. 

The global cost associated with administering unsafe care is estimated at $ 40 billion each year, WHO says.

“Without measurement, action to drive improvements are not possible, regardless of context,” said Dr Neelam Dhingra, head of  WHO’s Patient Safety Unit, during a webinar on the new guidance. 

While developing new treatments and better policies is important, much progress in healthcare can be achieved as a result of simply “doing no harm,” she said.

Errors occur, reduction targets are scarce

Only 18% of WHO member countries have a national target for reducing medication-related harm.

Seven years ago, WHO established a Medication Without Harm challenge in which it setting the goal of reducing harm by incorrect medication by half in five years. This was followed by a Global Patient Safety Action Plan, approved by the World Health Assembly in 2019. But much remains to be done.

“Assessing the burden of patient harm and also medication-related harm is a critical part of measuring patient safety,” Dhingra highlighted. “However, this truly remains a challenging agenda still.”

According to the new systematic review, half of all avoidable harm in medical care is related to medication, and a quarter of mediciation’s preventable harm can have severe or even life-threatening consequences.

Medication error is often avoidable. Yet, it is experienced by 5% of all patients.

Many mistakes occur in specific contexts, such as when patients are already taking many different kinds of medication (polypharmacy) that interact with one another, or patients who transition between caretakers, or in situations where high risk drugs are used.

Areas of improvement

The new WHO policy brief proposes key areas for addressing the risks including better communication and engagement of patients and patient organisations. With good public awareness of medication effects, it is easier for patients themselves to identify errors, such as the prescription of the wrong drug by a pharmacist.

Four domains and three key areas outlined in the WHO’s Global Patient Safety Action Plan

Healthcare workers should also receive training on medication harm, the brief notes. Better health worker conditions also reduce the risk of errors from factors such as fatigue and multi-tasking.

Identification of high risk drugs and additional care in their management is also critical. 

There is a “huge burden of preventable harm due to unsafe medication practices and medication errors,” Dhingra noted. ”Action is required at all levels, […] and we need to implement safe systems and practices for medic medications.”

Image Credits: WHO/Quinn Mattingly, WHO, WHO.

Air pollution
Despite significant air quality gains, air pollution remains the 10th leading cause of death in the European Union.

Average concentrations of small and fine particulates (PM2.5 and PM10)  decreased across Europe between 2003-2019 – with the largest reductions in PM10,according to a new study published in Nature on trends over the past two decades. Despite air quality improvements, more than 98 of the European population lives in areas exceeding the WHO recommended annual levels for PM2.5, the pollutant most closely associated with premature mortality, and more than 86.34% for Nitrogen dioxide (NO2), associated with impaired lung development and chronic lung disease.    

The study of trends in 35 European countries was led by the Barcelona Institute for Global Health (ISGlobal).  It estimated daily ambient concentrations of four pollutants, based on machine learning techniques, to assess days exceeding the WHO 2021 guidelines.

In particular, PM10 levels decreased the most over the study period, with annual decreases of 2.72%, followed by NO2 and PM2.5, which declined by 2.45% and 1.72% annually respectively.  Notably, for PM2.5, the pollutant most closely associated with adverse health impacts, the number of ‘unclean air days’ – in excess of WHO guidelines levels of 15 micrograms of pollution per cubic meter (15μg/m3)  declined from nearly 150 days in 2002 to around 90 days in 2019, the study found.

Average daily PM10 concentrations across 35 European showed the biggest declines between 2003-2019.

It is estimated that there were more than 250,000 deaths in the European Union from air pollution-related cardiovascular and respiratory illnesses, as well as cancers, according to the European Environment Agency.

In the wider European region, which includes Scandanavia, Turkey, Russia and independent republics of the former Soviet Union, there were an estimated 569,000 premature deaths in 2019, according to WHO.

While the health impacts of PM2.5 are the most measured, ozone (O3) along with NO2 are responsible for considerable morbidity and mortality related to asthma, and chronic respiratory disease.

 

Declines in “unclean air” days from PM2.5, as per WHO guidelines, alongside population increases (blue line) in the European countries studied, between 2003-2019.

The most significant reductions in PM2.5 and PM10 were observed in central Europe, while for NO2 they were found in mostly urban areas of western Europe.

Southern and eastern Europe remained pollution hotspots with PM2.5 and PM10 levels highest in northern Italy and eastern Europe, while PM10 levels were highest in southern Europe. Similarly, O3 increased by 0.58% in southern Europe, while it decreased or showed a non-significant trend in the rest of the continent. Warmer temperatures and stronger sunlight in summer boost O3 formation through chemical reactions with NO2 and other pollutants.  

High NO2 levels, associated with vehicle emissions, were mainly observed in northern Italy – although also in some areas of western Europe, such as in the south of the United Kingdom, Belgium and the Netherlands, the study found.  

Trends in NO2 levels across 35 European countries, 2003-2019

Key drivers of the reductions

Dr Zhaoyue Chen, lead author of the study, attributed the trend of tightening European Union regulations for the air quality improvements.

“The European Union has implemented various regulations and directives aimed at curbing emissions. For example, the Ambient Air Quality Directive (2008) setting air quality standards and the National Emission reduction Commitments Directive (2016) targeting specific pollutants. And also those efforts made by each local government,” he told Health Policy Watch.

“However, we are still far away from enjoying clean air in Europe. Most Europeans are still breathing unhealthy air,” he added.

“Our study showed 98.10%, 80.15% and 86.34% of the European population live in areas exceeding the WHO recommended annual levels for PM2.5, PM10 and NO2, respectively, while no country met the ozone (O3) annual standard during the peak season from 2003 to 2019.”

In late February, the European Council, which reprents the EU’s political leadership, agreed witht he European Parliament on the final outlines of a new EU Air Quality Directive which would further tighten EU air quality standards reducing permitted pollution levels from the current annual average of 25 μg/m3  to 10μg/m3  for PM2.5 and from 40 µg/m3 to 20 µg/m3 for NO2. However, those standards are still double the WHO recommended guideline limit for each pollutant.

The new EU directive also calls for member states to meet the new standards by 2030 – pushing back on political pressures to delay implementation to 2035.  States could, however, extend the 2030 deadline for compliance under strict conditions, like climate factors, as stipulated in the final agreement.

Anne Stauffer, deputy director of the Health and Environment Alliance (HEAL), called the EU agreement “a major step forward”, despite its shortcomings.

“While regrettably the compromise falls short on fully updating with the scientific recommendations, the package has a huge potential to lessen people’s suffering, prevent disease and achieve economic savings,” Stauffer said.

Said Chen, current EU air quality standards still “need to align more closely with the new WHO guidelines,” referring to the stricter standards recommended by the global health agency.

“I know the EU is still seeking a way to bring EU air quality standards in line with the World Health Organization (WHO) recommendations,” he added. “If that comes true, I believe it would be good news for public health, as it means people will be exposed to less harmful air.”

Image Credits: Mariordo, Nature, 2024 , Nature , Nature .

Women perform 76 percent of unpaid care work.

Women perform an estimated 76% of all unpaid healthcare activities, according to a new WHO report on gender-based discrimination in healthcare. 

Globally, it has been estimated that women spend between two and ten times more time on unpaid health care work than men, amounting to a total of 16.4 billion hours per day.

Further, in their paid work in the health and care sector women face an average pay gap of 24 percent compared to men, after controlling for working time, experience, education, occupational category and institutional sector, according to the report, “Fair share for health and care,” published Wednesday.

A country and gender comparison of time spent in unpaid work among healthcare workers.

The report describes how chronic underinvestment in health systems results in a vicious cycle of unpaid health and care work, lowering women’s paid labour participation and their economic empowerment. 

With stagnation in progress towards universal health coverage (UHC), resulting in 4.5 billion people lacking full coverage of essential health services, women may take on even more unpaid care work as time goes by, the report warned.

“The ‘Fair share’ report highlights how gender-equitable investments in health and care work would reset the value of health and care and drive fairer and more inclusive economies,” said Jim Campbell, WHO’s Director for Health Workforce, in a press release.

“Investments in health and care systems not only accelerate progress on UHC, they redistribute unpaid health and care work,” according to a WHO press release. “When women participate in paid health and care employment, they are economically empowered and health outcomes are better. Health systems need to recognize, value and invest in all forms of health and care work.

“We are calling upon leaders, policy-makers and employers to action investment: it is time for a fair share for health and care,” Campbell empathized.

Image Credits: WHO, WHO.

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

A leading Geneva-based global health organization has decried the lack of tests available for mpox in the Democratic Republic of the Congo (DRC) – where an outbreak declared in 2023 continues unchecked – saying that children are the main victims. 

“The mpox situation in the DRC is deeply alarming and the lack of tests for both mpox and HIV means it’s unclear just how bad the mpox situation is and what the underlying comorbidities are,” said Dr Ayoade Alakija, Chair of the Board at FIND in a press release.

According to FIND, a global non-profit dedicated to accelerating access to diagnostics, only 16% of suspected mpox cases in DRC undergo a PCR test. Among suspected cases that are tested, six out of ten test results are positive, underlining the degree of under-estimation of confirmed mpox cases.

“Testing capacity for mpox and HIV in the DRC is severely limited, meaning that many likely cases of mpox in the country are treated as suspected cases only,” Dr Sergio Carmona, FIND CEO and chief medical officer said.

Left unchecked – virus risks further spread abroad

Alakija compared the current mpox outbreak in the DRC with the situation during the COVID-19 pandemic, when many African countries were left behind in terms of tests and treatments and vaccines.

Left unchecked, the deadly Clade I form of the mpox virus now circulating in the DRC risks spreading further in Africa and beyond, she warned. 

“The people that are being prioritized for tests, treatment and vaccination are not in the outbreak countries in Africa,” she noted, referring to the rollout of measures in high- and middle-income countries over the past two years to counter the much milder, Clade I, form of the mpox virus that exploded in 2022. 

“We can either mobilize resources and fight the deadly mpox outbreak now in the DRC, or we can let the virus continue to spread and fight it when it is imported into other countries,” Alakija  said.

DRC outbreak is the largest ever recorded

According to the US Centers for Disease Control (US CDC) the current DRC mpox outbreak is the largest ever recorded, with cases reported in 22 out of the DRCs 26 provinces. Some 12,569 suspected cases and 581 deaths have been reported since 1 January 2023.  

From the start of 2022 to January 2024, the DRC reported 21,630 suspected MPXV cases and 1,003 deaths. Around 85% of deaths in this period were children under 15 years of age, according to WHO data.  

Epidemic curve shown by month for cases reported to WHO from the African region. Recent cases mostly in DRC.

Potentially ‘distinct’ Clade I strain and new patterns of transmission 

Mpox is a viral infection, which belongs to the same virus family as smallpox. It was traditionally confined to remote, rural areas of central and western Africa, where transmission was sporadic and occurred primarily through human contact with rodents and other small mammals. 

The virus burst onto the global arena in 2022 when WHO declared a global health emergency after the milder, Clade II form of mpox, began to spread through dozens of countries worldwide, infecting thousands of people, mainly through sexual transmission, and particularly men having sex with men. 

The global health emergency was declared over in 2023 following the scale up of diagnostics and vaccination in middle- and high-income countries, aimed at high-risk groups. 

Over the past year, however, global health authorities have expressed rising alarm over the increased circulation of the more deadly Clade 1 of mpox throughout central and east Africa – including through patterns of sexual transmission, including heterosexual transmission, not previously seen. 

In the case of the eastern DRC, female sex workers found to be among the leading groups transmitting the disease, along with transmission through close familial or community contacts, according to a study published Tuesday on the pre-print health sciences platform, MedRxiv. The study looked at transmission patterns in the city of Kamituga, in DRC’s south Kivu province.  

The sustained community-level transmission of mpox now seen in Kamituga “is….  being driven by a distinct Clade I mpox strain, possibly a novel subgroup, as confirmed with qPCR,” the researchers from over a dozen countries found. 

Mpox has similar symptoms as smallpox, including painful blisters and rash, fever, chills and fatigue. In the case of the milder, Clade II form of the virus, most patients recover after a few weeks of supportive care, WHO says.

Image Credits: WHO.

Aitano Valentina (4 years) holds her health booklet after receiving DPT and Polio vaccination in Guatemala City; immunization is key to reducing child mortality.

The number of children who died before their fifth birthday has dropped to 2.9 million in 2022, reaching a historic low, according to the latest estimates of under-5 mortality released today by the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME).  And since 2000, the global under-five mortality rate has declined by more than half.  Under-5 deaths have fallen by half since 1990.

Yet the annual death toll among children, adolescents and youth remains unacceptably high, states the report, published by UNICEF in collaboration with WHO and the World Bank, among others. Of the 4.9 million under-five deaths in 2022, 2.3 million occurred during the first month of life and 2.6 million children died between the ages of 1 and 59 months. There are also broad disparities in rates of child survival by region, with children under-5 facing the greatest risks in sub-Saharan Africa.

Global under-5 mortality trends 1990-2022

A child born in sub-Saharan Africa is on average 18 times more likely to die before turning 5 than one born in the region of Australia and New Zealand, the report found.  The risk of death amongst those younger than 5 in the highest-mortality country is 80 times that of the lowest-mortality country.

Worldwide, children born into the poorest households are twice as likely to die before the age of 5 compared to the wealthiest households, while children living in fragile or conflict-affected settings are almost three times more likely to die before their fifth birthday than children elsewhere.

Under-5 mortality remains highest in sub-Saharan Africa and parts of south Asia

“The new estimates show that strengthening access to high-quality health care, especially around the time of birth, helps to reduce mortality among children under age 5,” said Li Junhua, United Nations Under-Secretary-General for Economic and Social Affairs in a press release issued jointly by WHO, UNICEF and other UN agencies. “While the milestones in the reduction of child mortality are important to track progress, they should also remind us that further efforts and investments are needed to reduce inequities and end preventable deaths among newborns, children and youth worldwide.”

Studies show that child deaths in the highest-risk countries could drop substantially more if a basic package of interventions is delivered in communities at need.  These include: immunization, clean drinking water, hygiene and sanitation, healthy nutrition, and integrated management of childhood illnesses close to home – including for acute respiratory infections, diarrhoea, and malaria.

In Guatemala only 56% of the population has access to safe drinking water services; safe drinking water and good nutrition are critical to early childhood survival along with immunization and effective management of childhood illnesses.

At current rates, 59 countries will miss the SDG under-5 mortality target, and 64 countries will fall short of the newborn mortality goal. That means an estimated 35 million children will die before reaching their fifth birthday by 2030—a death toll that will largely be borne by families in sub-Saharan Africa and Southern Asia or in low- and lower-middle-income countries.

Progress slowed between 2015-2022 although some countries outperformed

Additionally, progress in reducing under-five and neonatal mortality slowed between 2015–2022, during the era of the Sustainable Development Goals (SDGs) in comparison to 2000–2015 – the era of the Millennium Development Goals (MDGs). Economic instability, new and protracted conflicts, the intensifying impact of climate change, and the fallout of COVID-19, pose threats that could lead to stagnation or even reversal of gains, the report warns.

On the brighter side, six low-income countries, and 13 lower-middle income countries outperformed their neighbours – reducing under-5 mortality by two-thirds or more.  Among these, Malawi, Rwanda and DPR Korea, reduced under-5 mortality by 75% since 2000, along with four lower middle-income countries, Cambodia, Mongolia, Sao Tome and Principe, and Uzbekistan.

In addition, the low-income countries of Burundi, Ethiopia and Uganda, as well as and nine lower-middle-income countries – Angola, Bhutan, Bolivia, India, Iran, Morocco, Nicaragua, Senegal and the United Republic of Tanzania – have reduced their under-5 mortality rate by more than two thirds since 2000. This reflects the possibility for greater gains at any income level, the report’s authors stressed.

The report, however, also notes large gaps in data, particularly in sub-Saharan Africa and Southern Asia, where the mortality burden remains particularly high. Data and statistical systems must be improved to better track and monitor child survival and health, including indicators on mortality and health via household surveys, birth and death registration through Health Management Information Systems (HMIS), and Civil Registration and Vital Statistics (CRVS), it underlines.

The United Nations Inter-agency Group for Child Mortality Estimation or UN IGME is led by UNICEF and includes the World Health Organization, the World Bank Group and the Population Division of the United Nations Department of Economic and Social Affairs.

Image Credits: UNICEF 2024 , UNICEF , UNICEF 2024.

COVID-19 screening in Bangkok, Thailand: Financing future pandemic preparedness and response is unclear.

Many practical questions about how the pandemic agreement will be implemented – including how to finance countries’ pandemic prevention, preparedness and response (PPPR) – seem likely to be ceded to the Conference of Parties (COP).

According to the latest pandemic agreement draft, a “Coordinating Financial Mechanism” will support the implementation of the pandemic agreement and the International Health Regulations (IHR) (see Article 20).

“There’s a key debate with Article 20 within the negotiations about whether the coordinating mechanism should be hosted by the Pandemic Fund, the World Health Organization (WHO), or whether a new entity should be created,” Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds, told a Geneva Global Health Hub (G2H2) media briefing on Tuesday.

“There’s seemingly little appetite for a new institution, and there is a strong narrative being promoted for the Pandemic Fund in order to decrease fragmentation,” added Wallace Brown, who is director-designate of new WHO Collaboration Centre for Health Systems and Health Security.

The Pandemic Fund’s Priya Basu has made a strong bid for her entity to become this mechanism, telling Devex this week that a new fund to support PPPR would mean “duplication”.

Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds

But Wallace Brown said that “final decisions about the details of the coordinating mechanism are being offloaded to the Conference of the Parties (COP), which I think is a wise decision given the circumstances”. 

“There are only nine negotiating days left and there are lots of details to work through. But I think it’s only wise if the COP is representative, inclusive, proportional to risk and deliberative, meaning a move away from business as usual.”

In conversation with delegates involved in the Intergovernmental Negotiating Body (INB) thrashing out the pandemic agreement, Wallace Brown said that “what they want to do is make the wording strong enough to show that there’s a commitment to a coordinating mechanism and a commitment to financing those”.

In addition, they were “being somewhat more clear about what types of financing and what types of mechanisms would be housed underneath that, but offshoring those details for 12 months – I’m suggesting 24 months – to try to work out exactly how that is done”. 

Domestic funds?

According to the draft, the financing mechanism would include a pooled fund for PPPR, and may include “contributions received as part of operations of the [Pathogen Access and Benefit-Sharing System], voluntary funds from both states and non-state actors and other contributions to be agreed upon by the Conference of the Parties”.

G2H2 co-chair Nicoletta Dentico

However, G2H2 co-chair Nicoletta Dentico warned that poorer countries were mired in debt and debt cancellation should be a consideration to help these countries.

“Fifty four low-income countries with severe debt problems had to spend more money on debt servicing than on the COVID disease in 2020,” said Dentico, who heads the global health justice program at Society for International Development (SID).

“Contrary to the WHO Framework Convention on Tobacco Control, the [pandemic agreement] text opened for the final negotiations stubbornly ignores the repeated calls for legal safeguards that are indispensable to immunise the treaty implementation and financing from vested corporate interests,” added Dentico.

Mariska Meurs from the Dutch health NGO WEMOS, warned that “domestic funding for pandemic prevention preparedness and response must not undermine other domestic public health priorities”. 

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation”.

“But undermining other domestic public health priorities is exactly what we’ve seen happening under COVID-19. We’ve witnessed the shifts in global and domestic funding and how funding for basic health care has gone down,” warned Meurs.

“The text, as it lies before us now, does not acknowledge or try to remedy this.”

Mariska Meurs from the Dutch health NGO WEMOS

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation,” said Meurs.

Pandemic Fund ‘black box’

Low and middle-income countries are more in favour of the pandemic financing mechanism being housed in the WHO “because they see it as being more representative” than the Pandemic Fund, said Wallace Brown.

But donors “are less keen because they see it as a mechanism that would give them less control of how funds are spent”.

However, for the Pandemic Fund to become the PPPR mechanism would require “radical changes” not “minor tweaks as we’re currently being told”. 

Some of the problems with the fund, are that it only focuses on three elements of PPPR and this “creates vertical silos”, and there is no explicit guidance in the fund’s governance framework on “how equity will be addressed in either the fund process or with reference to prioritise beneficiaries of programmes”, according to Wallace Brown.

In addition, the first round of funding was eight times over-subscribed but the selection process “was not clear”.

“Applications that met the scorecard threshold for funding had to be rejected, and it remains unclear exactly how the governing board made their final decisions,” he added.

Describing his personal view on the way forward as “agnostic”, Wallace Brown said he had been studying the Pandemic Fund for a while and “think it’s a bit of a black box”. 

However, the WHO would need capacity building to become the mechanism 

“They do handle funds, they have the contingency fund for emergencies. They are able to make funding available to people and have processes for that, but they don’t have it at the same scale as a World Bank,” he said.

“Or there could even be a third entity. So at the moment, I’m remaining agnostic. I think there needs to be better analysis, better evidence to decide what works and what doesn’t work” – and these kinds of details “won’t be decided in nine days”.

Image Credits: Prachatai/Flickr.

Lab technician at a pharmaceutical company conducting a test.

The new draft of the pandemic agreement “is a step backwards rather than forwards”, according to Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). 

“It is critical that any agreement takes steps to ensure equity in access to medicines and vaccines in future pandemics, whilst preserving the innovation ecosystem that delivered a vaccine just 326 days after the SARS-CoV2 genome sequence was first sequenced,” said Cueni.

 Article 12 of the current draft proposes that manufacturers pay an annual subscription fee to a yet-to-be-formed World Health Organization (WHO) Pathogen Access and Benefit-Sharing (PABS) System.

In exchange, they would get “rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens”.

The article also proposes that manufacturers provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

‘Uncertainties will cause delays’

But Cueni was dubious: “Stringent requirements for accessing pathogen data would severely impact responses to future pandemics and basic research and development (R&D).

“Conditions, uncertainties, and negotiations surrounding pathogen access will cause delays in the developing medical countermeasures, leading to significant public health consequences, including loss of lives and unnecessary economic pressures. In the COVID-19 pandemic context, even a one-month delay could have meant an extra 400,000 lives lost.”

The pharmaceutical industry has warned that a mandatory financial contribution could dis-incentivise companies from joining the PABS system.

“The pharmaceutical industry is determined to continue to play our part in these final stages – sharing our experience, evidence and expertise to help deliver an agreement that will better protect the world when the next pandemic hits,” Cueni said.

Thomas Cueni, Director General of the IFPMA.

This week, the biopharmaceutical industry published a statement on how companies can work between pandemics – as well as when a pandemic hits – to deliver equitable access to medical countermeasures on the basis of public health risks, needs and demands.”

The statement was signed by a broad range of trade associations aside from the IFPMA, including the Developing Countries Vaccine Manufacturers Network, DCVMN, Europe (EFPIA), the US (PhRMA) and Japan (JPMA), and the Biotechnology Innovation Organization (BIO).

The companies detail the commitments to pre- and during pandemic measures.  These include improving surveillance; research on pathogens of pandemic potential; voluntary licensing and technology transfer based on “mutually agreed terms to improve geographic diversity of manufacturing”; real-time allocation of part of production, and equity-based tiered pricing.

Companies are also engaged in ongoing activities to support health system preparedness, whether by building clinical trial and regulatory capacity and harmonization, health care worker and community health worker trainings, or the continual investment needed to establish and maintain new technologies and platforms.

“With a final draft of a pandemic agreement now published, negotiators should redouble their efforts to find consensus as there is still much work to be done before an agreement can be reached, added Cueni. 

Previously, Cueni warned that “It would be better to have no pandemic treaty than a bad pandemic treaty.”

Image Credits: AMR Industry Alliance, World Health Summit.

The Bureau of the intergovernmental negotiating body session during negotiations in June 2023.

The negotiating text of the pandemic agreement (see below) landed in the inboxes of World Health Organization (WHO) member states last Friday afternoon – 10 days before the penultimate negotiation on 18 March and on the eve of the fourth anniversary of the WHO’s declaration of COVID-19 as a pandemic.

The 31-page draft was also sent to official stakeholders previously excluded, as agreed by the eighth meeting WHO’s intergovernmental negotiating body (INB).

READ: WHO Pandemic Agreement draft – negotiating text

The INB Bureau and staff only had a week to distil a mishmash of often contradictory proposals into the negotiating text, and will brief member states and stakeholders this Friday (15 March) on the revised draft and propose how the final round of negotiations will be structured.

Contested articles contain many caveats, with giveaway phrases such as “where appropriate”, “may” and “voluntary”.

What’s new? Chapter I (Articles 1-3)

Chapter I deals with terminology, aims and guiding principles. According to the note accompanying the latest text, what is new in Chapter I, are “refined textual proposals” as proposed by the INB Bureau in Articles 1, 2, and 3.

The stated objective of the WHO pandemic agreement – no longer referred to as a treaty or accord – “is to prevent, prepare for and respond to pandemics” with “equity as the goal and outcome” and recognising the “common but differentiated responsibilities and respective capabilities” of countries’ health systems.

This chapter also explicitly refers to “the sovereign right of states to adopt, legislate and implement legislation, within their jurisdiction, in accordance with the Charter of the United Nations and the general principles of international law, and their sovereign rights over their biological resources”. 

This is in response to misinformation that the pandemic agreement is a WHO power grab that will enable the global health body to impose, amongst other things, global lockdowns.

Chapter II (Articles 4-20): Site of most disagreement 

The meat of the agreement – and site of most disagreements – lies in this chapter. Its theme is “achieving equity in, for and through pandemic prevention, preparedness and response (PPPR)”.

According to the note accompanying the latest text, Articles 7, 8, 16, 17, and 18 contain refined textual proposals as proposed by the INB Bureau based on INB 8 talks.

Meanwhile, Articles 4,5, 6, 10, 11, 13, 19 and 20 contain refined textual proposals as proposed by the INB vice-chairs and co-facilitators from the work of the drafting subgroups. 

Article 4 addresses countries’ responsibilities in terms of “pandemic prevention and public health surveillance”, with countries committing to “progressively strengthen” these. It outlines  eight key responsibilities for member states to prevent pandemics including providing clean water, sanitation and hygiene; reducing the risks of zoonotic spillover and spillback; laboratory biosafety and managing antimicrobial resistance (AMR).

Article 5 sets out a One Health approach, with assistance to developing countries to prevent zoonotic spillover of diseases from animals to humans. This section has been shortened considerably over previous drafts.

Article 6 addresses health system preparedness and readiness, resilience and recovery – but once again dwells on countries’ responsibilities. Responsibilities related to health system strengthening for PPPR includes “the progressive realisation of universal health coverage”.

Article 7 deals with the responsibility of each country to sustain “an adequate, skilled and trained health and care workforce”. However, it makes a veiled acknowledgement of wealthier countries poaching skilled personnel by including a section where countries agree to “minimise the negative impact of health workforce migration on health systems while respecting the freedom of movement of health professionals”.

Article 8 deals with “preparedness monitoring and functional reviews”. Countries are to report to the WHO every five years on their PPPR.

Activists have pushed for companies that get government research and development (R&D) funding to be compelled to share their findings with countries from the global South and to publish the terms of these agreements with private companies. 

But the strongest that Article 9, which deals with R&D, gets is to state that that countries shall “support the transparent and public sharing of research inputs and outputs” from government-funded R&D pandemic-related products and publish the relevant terms of these.

pandemic
Activists want companies that get government funds for R&D to share their findings.

Article 12: PABS is the biggest bone of contention

The most contested section, Chapter II’s Article 12, addresses pathogen access and benefit-sharing (PABS). The new section contains “structural design elements as proposed by the vice chair and co-facilitators from the work of the drafting sub-group”.

This article was not included in the previous draft at INB 8 but it is virtually the same as the vice-chair’s proposal that was leaked shortly before that meeting.

Article 12 spells out the formation of a “multilateral system for access and benefit sharing for pathogens with pandemic potential: the WHO Pathogen Access and Benefit-Sharing System (PABS system)”. 

Its aim is to “ensure rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens” to facilitate the development of products to control such pathogens.

Countries with access to such pathogens will share biological material “as soon as it is available” to one or more laboratories and/or bio-repositories participating in WHO-coordinated laboratory networks (CLNs)” and its GSD to “one or more PABS sequence databases (SDBs)”.

All users of biological materials and GSD “shall have legal obligations under PABS regarding benefit sharing”.

The WHO shall conclude legally binding standard PABS contracts with manufacturers, taking into account their size, nature and capacities.  

Manufacturers will be expected to pay annual contributions to support the PABS system and relevant capacities in countries. They will also be expected to provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

Manufacturers will also be expected to make voluntary non-monetary contributions “such as capacity-building activities, scientific and research collaborations, non-exclusive licensing agreements, arrangements for transfer of technology and know-how” and implement tiered pricing.

The agreement envisages that a Conference of the Parties (COP) will govern the pandemic agreement (detailed in Article 21), and this will “regularly review the operation, monitor adherence and effectiveness of the PABS system” and “promote and support its effective and sustainable implementation”. 

Article 20: New financial mechanism

Article 13 addresses the establishment of a “global supply chain network” developed and operated by WHO in partnership countries and other stakeholders. This will identify needs during pandemics, aimed at avoiding “competition for resources amongst international procuring entities, including regional organisations and/or mechanisms”.

Article 13 bis is a new addition, dealing with “national procurement- and distribution-related provisions”. It declares that countries “shall publish the terms of its government-funded purchase agreements for pandemic-related products at the earliest reasonable opportunity and in accordance with applicable laws” – but shall “exclude confidentiality provisions that serve to limit such disclosure”. 

Article 14 addresses countries’ regulatory systems strengthening, and Article 15 addresses liability and compensation management.

Article 16, on international collaboration and cooperation, covers support for countries to develop PPPR. Article 17 covers whole-of-government and whole-of-society approaches, and Article 18 addresses communication and public awareness geared to tackling misinformation. Article 19 addresses implementation capacities and support.

Article 20 deals with financing. It proposes the establishment of a “Coordinating Financial Mechanism” to support the implementation of the pandemic agreement and, in a new addition, also the implementation of the International Health Regulations (IHR). 

The mechanism shall include a pooled fund to provide financing to support PPPR, and this  may include “contributions received as part of operations of the PABS System, voluntary funds from both states and non-state actors and other contributions to be agreed upon by the Conference of the Parties”.

Chapter III (Articles 21-37): A Conference of Parties

Chapter III, which deals with institutional arrangements and final provisions, contains “refined textual proposals as proposed by the INB Bureau with respect to Article 21, and as proposed by volunteer delegations regarding the remaining Articles of the Chapter”, according to the INB.

It proposes a Conference of the Parties (COP) to review the implementation of the pandemic agreement every three years, based on the countries’ reports on their pandemic readiness, and take the decisions necessary to promote its effective implementation. However, the COP can also request information from countries.

The first COP will be held within a year of the agreement’s adoption. The WHO secretariat is to provide support for the COP.

The previous draft simply referred to a governing body to review the implementation of the agreement to be run by a secretariat. 

In another clarification to address misinformation, Article 24 states: “Nothing in the WHO pandemic agreement shall be interpreted as providing the Secretariat of the World Health Organization, including the WHO Director-General, any authority to direct, order, alter or otherwise prescribe the domestic laws or policies of any party, or to mandate or otherwise impose any requirements that parties take specific actions, such as ban or accept travellers, impose vaccination mandates or therapeutic or diagnostic measures, or implement lockdowns.”

Reaction: ‘Underwhelming governance’

Nina Schwalbe, CEO of Spark Street Advisors and a keen observer of the negotiations, told Health Policy Watch that “the governance section is truly underwhelming”.  

“While they do call for a Conference of Parties, there is almost no regular reporting let alone any type of monitoring vis a vis states’ compliance with their obligations. It’s not even punted to a future date – it is simply not mentioned,” said Schwalbe

Meanwhile, 58 charities, NGOs, and health experts including the Pandemic Action Network, Oxfam, African Vaccine Alliance, Innovarte, and Public Citizen have called on the US and the European Union to end their “patent hypocrisy” in the pandemic agreement  negotiations.

Pamela Hamamoto (right), lead US negotiator in the pandemic accord and Colin McIff.

While US President Joe Biden and President of the European Commission Ursula von der Leyen “have overseen ‘laudable’ proposals to step around intellectual property rules when they prevent Americans and Europeans from securing access to affordable medicines”, they “have shown a ‘double standard’ by stopping lower-income countries from doing the same thing”, according to the groups.

In an open letter coordinated by the People’s Vaccine Alliance, organisations including Oxfam, the African Alliance, Innovarte, and Public Citizen, the groups urge the EU and US leaders to support measures in the pandemic agreement “to enable lower-income countries to overcome intellectual property barriers, to make public funding of R&D conditional upon sharing pharmaceutical technology and know-how with Global South countries, and embed transparency in global health by publishing all government contracts with companies involved in public health”.

They also want the pandemic agreement to “go beyond current proposals to require a small proportion of vaccines and medicines to be set aside for the Global South, and instead ensure those at the highest risk are prioritised regardless of where they live”.

They also want  “an extension of the pandemic flu mechanism”, which guarantees that countries that share pathogen data will receive benefits in return, including “fair access to medicines produced and financial contributions”. 

‘Untenable double standard’ of US and EU

“President Biden is staking his reputation on his ability to take on Big Pharma’s profiteering. While the President is taking crucial steps to stand up to the industry domestically, his administration still holds open a door for pharma companies to profit at the expense of people’s lives in lower-income countries. He must change course from this untenable double standard,” said Peter Maybarduk, Access to Medicines Director at Public Citizen.

“Millions of people in developing countries died at the height of the COVID emergency without access to the NIH-supported mRNA vaccines that made such a difference in the United States. The world has a rare, fragile chance to do better through the Pandemic Accord. The United States has uncommon power, and therefore responsibility, to help make a strong agreement that protects lives and livelihoods at home and worldwide, with some measure of justice.”

Image Credits: WHO.

The entrance of the Sokoto Noma Hospital (also called Noma Children’s Hospital) in Sokoto, north-west Nigeria. For over two decades, the Nigerian Ministry of Health has run a specialised noma treatment programme at the hospital.

The atmosphere at the Sokoto Noma Hospital, named after the city and state in north-west Nigeria bordering the Republic of Niger, is serene. The buildings are modest structures painted in soft, earthy tones. Several large trees form lush green canopies, providing shade from the afternoon sun.

Huddled under the shade trees, caregivers — mainly mothers — engaged in quiet conversations. Their children were amongst those selected for reconstructive surgery during a two-week campaign of surgical interventions organised in February by Médecins Sans Frontières (MSF) in collaboration with the hospital.

The surgical campaigns, usually held four times a year, have been conducted since 2015, with 1310 surgeries conducted for 918 patients over the past decade.

Milestone moment 

But this year’s event came at a special moment. It was the first campaign since the WHO’s recognition of noma as a neglected tropical disease (NTD)—a category of diseases intrinsically linked with poverty.

Noma, is a deadly disease that begins as common gum sores but develops into ulcerative gingivitis that destroys the soft tissues and bones of the mouth, rapidly progressing to perforate the hard tissues and skin of the face.

It mostly affects children between the ages of two and six years, who are malnourished, live in extreme poverty and suffer from weakened immune systems.

Detected early, its progression can be halted rapidly through basic hygiene and/or antibiotics.  

Untreated, it progresses rapidly and has a 90% mortality rate within the first two weeks of the onset of the disease. This is primarily due to sepsis, severe dehydration or malnutrition.

Despite its aesthetics and functional impact, noma survivors are regarded as the lucky ones.

Sokoto state, Nigeria

A lifeline for noma patients

Mohammadu Usman, 23, a popular figure at the Sokoto Noma Hospital, counts himself amongst the fortunate. At the age of five, he became infected with the disease. While he survived, he grew up with the prominent scars that the disease left on his face — characteristic to noma survivors.

“My parents were desperate to find a treatment that would help me look normal, just like everyone else,” Usman said.

He recalled that he could not eat in public and received disparaging remarks from people who did not know about noma.

In 2017, he and his father embarked on a gruelling 14-hour journey from Maiduguri to the hospital after they heard about the free surgical treatments. Usman’s timing was serendipitous, as he was chosen for surgery around the same time he presented at the hospital.

Mohammadu Usman, a 22-year-old noma survivor, works in the Sokoto Noma Hospital as a car washer and a cleaner. He’s now a secondary school student at a local school and wants to be a doctor. ‘I strive to educate others about noma so they know, for example, that cleaning their mouths daily reduces the risk.’ May 9, 2023.

By the time Usman arrived at the hospital, he had developed trismus, a complication of noma that makes it difficult to open the mouth.

Since his initial surgery in 2017, he has undergone two more operations. The most recent one was performed last year.

“I have been told that I need another surgery,” he said.

But he is pleased with the outcome so far. It has given him a new lease of life. After his surgery, the hospital staff helped him enrol in a public school. To support himself financially, he started working as a hospital cleaner.

“This surgery has completely transformed my life. My parents, too, are happy about the changes,” he said.

MSF’s Surgical Intervention

Ummu Salma, aged 30, travelled from a village in Katsina with her eight-year-old daughter for the surgical intervention. She learned about it from a father whose son received treatment in the hospital.

This February, MSF conducted its 28th intervention at the Sokoto Noma Hospital. Over the course of two weeks, from February 11th to 23rd, MSF’s surgical team of four plastic surgeons, two maxillofacial surgeons, and five anaesthesiologists joined hands with the hospital’s staff to perform reconstructive surgeries for noma survivors.

Prior to the team’s arrival, the hospital staff conducted thorough screenings of noma patients to determine their eligibility for surgery, which is greatly influenced by their nutritional fitness. Twenty-nine patients were eventually selected to undergo surgical treatment.

Growing recognition of Noma nationally and globally 

The programme at Sokoto is the oldest in the country, and it was also the only one available before the launch of a Noma Centre in Abuja, Nigeria’s capital city, in November 2023.

The launch of the Abuja centre reflects the growing awareness about the disease across Nigeria, and more broadly in West Africa, where it is endemic.

Nigeria, with a national noma incidence ranging from 4.1–17.9 per 100,000 is amongst the eight countries with the highest incidence of noma in sub-Saharan Africa. Indeed, the countries in this region form the so-called ‘noma belt.’

The majority of the Nigerian cases are seen in the northern region. In 2018, a survey found that in north-west Nigeria, 3,300 out of every 100,000 children aged newborn to 15 years were affected by noma.

Estimates of global incidence are challenging due to insufficient data collected through standardised methods across the affected regions. The WHO’s global estimate of 140,000 noma cases annually, with a disease prevalence of 770,000 people, remains the most widely referenced. But that data dates from 1998. A 2023 study suggests a global incidence of 30,000–40,000 cases.

Cases are not limited to Africa. From 1950 to 2019, noma patients were reported in 88 countries. However, the number of countries reporting new cases narrowed to 23 across Africa and Asia between 2010 and 2019, with Italy being the only European country affected, according to a 2022  Lancet review. Amongst these, 11 were in West Africa, where Niger recorded the highest incidence in the sub-Saharan region, with an estimated seven to 14 cases per 10,000 children aged newborn to six years.

Exact causes of the disease remain unclear 

Although the disease is associated with extreme food insecurity, poverty, poor health, and unsanitary conditions, the exact causes are unknown.

Noma treatment depends on the disease stage. At early stages, antibiotics, better oral hygiene practices and nutritional support are effective. In advanced cases, wound care, surgical procedures and physiotherapy may become necessary.

With the backing of international NGOs and the WHO, several West African nations have successfully established specialised noma treatment centres. Since 2015, the Lausanne, Switzerland-based Fondation Sentinelles has operated a care centre in Niger and Burkina Faso, treating nearly 2,000 children affected by the disease.

Ethiopia has three major noma care centres. In Nigeria, beyond the collaboration between the Sokoto Noma Hospital and MSF, noma programmes have received support from the Dutch Noma Foundation, the German nonprofit Hilfsaktion Noma, and the Noma Aid Nigeria Initiative (NANI), with the latter two joining forces to establish the country’s second noma centre in Abuja.

Reported global occurrence of noma cases from 1950 until 2019 based on the last reported noma case in each country.

 

Number of reported noma cases and number of reports on noma cases at national and subnational levels in Africa. ADM0: national administrative division. ADM1: upper subnational administrative division.

Sokoto centre remains strategically important  

Despite the creation of the new Abuja noma centre, the Sokoto hospital will remain strategically critical due to its much greater accessibility to patients in the country’s remote northern region, which sees the highest prevalence of the disease.

The centre has also built a reputation for community outreach into the region.

Its success with outreach is associated with the hospital team’s innovative use of storytelling in their awareness-raising activities. This includes a dramatic tale about a fictional boy suffering from noma, designed to break taboos and spark conversations amongst community members.

Supported by the MSF outreach team, the hospital regularly conducts awareness-raising activities within communities in Sokoto, Kebbi and Zamfara states, all in north-west Nigeria, where noma has long been prevalent. They distribute leaflets, make dramatic presentations and educate villagers on noma recognition.

To streamline the referral process, medical staff require referring hospitals to send images of patients through WhatsApp for preliminary assessment.

The social stigma attached to noma leads to isolation, complicating case detection. To counter this, each community appoints a focal person for follow-up on referrals.

Audrey Beckers, an anaesthesiologist from the Netherlands. She had been part of MSF missions to the Republic of Congo and South-Sudan.

Surgical interventions remain critical 

Even with improved surveillance, however, the surgical interventions offered by the hospital remain critical to recovery, in light of the rapid progression of the disease.

The surgery involves creating new facial features for the patients. The surgeons reconstruct damaged noses, lips, cheeks, palates, and eyelids, and perform trismus surgery. Some procedures can last up to six hours.

The trismus release surgery to improve mouth opening poses a formidable challenge, even for the highly skilled surgical team.

“Normally, we pass a laryngoscope through the mouth to deliver general anaesthesia. With trismus, the mouth is no longer an option. So we go through the nose—a far more complicated procedure,” explained Audrey Beckers, a Dutch anaesthesiologist who is on her third MSF mission in Africa.

Given their socio-economic status, none of the noma patients could afford such care if they had to pay out-of-pocket.

“In a public hospital, where treatment is highly subsidised, each stage of the surgery wouldn’t cost less than 300,000 naira [$190]. Private hospitals could charge up to a million naira [$633] per stage. and noma patients [often] require multiple procedures,” said Jacob Legbo, the MSF surgical team leader.

“Knowing that these are poor patients, the opportunity to provide them with free treatment brings immense joy to me and the team.”

Localisation of the surgical intervention

After COVID-19 related travel restrictions disrupted the 2020 surgical intervention, MSF intensified efforts to include more national surgeons.

In the first years, MSF depended primarily on surgical team members who travelled to Sokoto from Europe or elsewhere.

However, by 2018, local Nigerian surgeons were gradually being integrated into the work. The travel restrictions imposed due to the 2020 pandemic, meanwhile, limited the participation of foreign surgeons, resulting in only one intervention held that year.

This accelerated a shift in the organisation’s approach, prioritising the further integration of Nigerian surgeons, post-pandemic. The goal was to foster an exchange of skills and experience with their international counterparts, paving the way for local professionals to eventually spearhead the missions.

Jacob Legbo, a Nigerian surgeon and the MSF surgical team leader for the intervention.

The strategy appears to be working. Currently, the pool of national surgeons and anaesthesiologists has increased to 45. For this outreach, the surgical team was predominantly Nigerian, with only two foreign anaesthesiologists participating.

Reinvigorated national efforts

The new Noma Centre Abuja located in Abuja, the country’s capital.

In 2017, the Nigerian Federal Ministry of Health (FMoH) designated November 20 as National Noma Day.

By 2019, with the backing of the WHO Regional Office for Africa, Nigeria launched its national action plan to control noma. Ten other countries with a high noma burden have also developed and implemented similar national initiatives under the WHO’s guidance.

During the 2023 national noma day celebration, a new 100-bed national noma centre was unveiled in Abuja, within the grounds of the National Hospital, a tertiary hospital in the country’s capital.

This centre is now Nigeria’s second dedicated facility for noma treatment. It was established through a collaboration between the Nigerian NGO, Noma Aid Nigeria Initiative (NANI), and the federal ministry of health, with support from the German non-profit Hilfsaktion Noma.

Funding from the WHO and MSF also enabled the Nigerian Health Ministry to provide specialised noma training to 741 primary healthcare workers from 2021 through the first half of 2022. Additionally, noma is being integrated into the training curriculum for Nigeria’s nursing and midwifery, MSF told Health Policy Watch.

Pathway to global recognition

In 2021, WHO adopted a landmark Resolution on Oral Health at the 74th World Health Assembly. It recommended that “noma should be considered for inclusion in the NTD portfolio as soon as the list is reviewed in 2023.”

In January 2023, the Nigerian government submitted an official request to WHO on behalf of 32 other member states to have noma recognised as an NTD. The request was backed up by a dossier, providing evidence on how noma meets all four criteria for neglected diseases.

The African campaign was supported by a unique constellation of global health forces in Geneva’s global health hub. This included not only WHO but also leading universities, the Hospitaux Universitaires de Geneve, MSF, Fondation Sentinelles and others.

By December 15, WHO officially recognised noma as a neglected tropical disease, increasing the number of NTDs to 21.  It is hoped that the long-awaited move will lead to more research and funding investments in the long-neglected NTD.

Significance of noma’s recognition as an NTD

In Sokoto, hospital staff are optimistic that noma’s inclusion on the WHO NTD list will drive more research, advocacy and funding.

“My joy in the WHO recognition is that noma will get more attention,” said Mulikat Okanlawon, a noma survivor who now works as a hygiene officer at the Sokoto Noma Hospital. Alongside fellow survivor Fidel Strub, Okanlawon co-founded Elysium, the first foundation for noma survivors.

“[W]hat this list does is it makes the disease legitimate in the eyes of donors to fund further research on the disease, and it brings awareness,” said Mark Sherlock, MSF Health Advisor for Nigeria, in an NPR interview.

The organization expects that the recognition of noma will attract more stakeholders at important stages of noma care: early detection, treatment and referral.

Abubakar Abdullahi Bello, chief medical director of Sokoto Noma Hospital. Sokoto. In 2023, the hospital had about 234 acute noma cases.

Despite the presence of a new facility in Abuja, the surgical interventions offered by the noma hospital in Sokoto continue to grow in popularity – due to its successful outreach activities and close proximity to communities where the disease is most prevalent.  Unfortunately, the funding has not kept up with the need for updated infrastructure.

“The [hospital] structure has been here for more than 20 years and there are some departments in the hospital that need to be upgraded, like the outpatient unit,” said Abubakar Bello, the hospital’s chief medical director.

“The state government has made some contributions, but there is still a lot left to be done,” Bello said.

That’s all the more reason why the recent WHO recognition of Noma is so important, he added, “hopefully we will see more organisations offering support in the prevention, treatment, or rehabilitation aspects of the disease.”

Nutritional support also critical 

While MSF and the state cover the cost of meals for patients during their stay at the hospital, Nigeria’s high inflation rate and associated food insecurity threaten the ability of noma survivors to meet their nutritional needs after discharge. This puts survivors at risk of relapse.

Malnutrition is commonly reported among patients admitted to the hospital, making nutritional rehabilitation a crucial part of treatment.

‘If a noma survivor, after being treated for malnutrition and infection, returns to the same living conditions that led to the disease, there’s a chance they could develop noma again.

“We cannot overlook the possibility of a noma relapse, and these are the areas where more research is needed,’ said Mohammed Abdullahi, consultant oral and maxillofacial surgeon at the University of Maiduguri Teaching Hospital, in the north-eastern region of Nigeria.

Acute need for more surveillance and research  

As many stakeholders noted, the WHO’s recognition is merely the beginning for a disease as neglected as noma – where the agency’s most recent data on global prevalence dates back to 1998. In Nigeria, research on noma has primarily been regional, focusing on northern Nigeria, where most cases are seen.

At a major noma scientific conference in Nigeria in November, Peter Ajanson, MSF Nigeria’s deputy medical director, noted an increase in reports of noma cases in other Nigerian states which were previously unaffected. However, due to limited surveillance, the real extent of noma’s impact across Nigeria remains unknown.

Like in other noma-priority countries, international aid and grants have fuelled much of Nigeria’s fight against the disease. However, local researchers like Seidu Bello from the Nigerian International Craniofacial Academy have urged Nigeria’s Federal Ministry of Health to invest more in increasing public awareness, early detection, and the national capacity for diagnosing and treating the disease

“Therefore, we advocate public awareness on the disease risk factors and prevention within the [country’s] sub-regions as well as training of primary health personnel on disease identification, primary care and nearest referral centres,” he wrote in his study on noma’s incidence and prevalence in north-central Nigeria. He argued that this will help ensure timely treatment of those most in need.

Across the hospital, Usman was sweeping off the sand and fallen leaves that had gathered on the outdoor passageway.

He was mindful of the elderly man and young child sitting nearby as he pulled the dirt across the terrazzo floor and into a small pile.

He harbours dreams bigger than his present situation. He hopes he can complete his education, improve his English and someday become a doctor.

Image Credits: Abdulrasheed Hammad , Encyclopædia Britannica, Fabrice Caterini/MSF, Galli, A., et al. The Lancet Infectious Diseases., Nigeria Health Watch, Abdulrasheed Hammad.