Italian Civil Protection volunteers instal a triage tent for COVID-19 patients in front of the emergency room of the University of Padua Hospital. Only patients were allowed to enter the hospital.

Desperately ill patients died alone in hospitals, tended in their final hours by burnt-out health workers.  An avalanche of misinformation undermined care, and non-COVID patients and programmes faced cancelled appointments and treatment delays.

These are some of the factors that undermined patient safety during COVID-19, according to a rapid review by the World Health Organization (WHO), published on Tuesday.

Dr Francesco Venneri, an Italian emergency surgeon who worked in COVID-19 hospital care in Florence, described the stress of treating so many patients at the launch of the review.

“The pandemic was a sort of tsunami in Italy. Being on the front line, what I experienced was the stress on healthcare workers trying to follow all the patients.

“There were so many patients who flowed into the hospital with acute conditions. Many of our emergency departments overflowed, and sometimes to treat acute patients was very difficult,” said Venneri, who advocated for hospitals to conduct simulation exercises to address catastrophes.

He also said health workers were overwhelmed by information about the virus.

“One of the most important pitfalls is the mass of information that they came to us, and some of this information was contradicted immediately, a few minutes or a few hours afterwards. So we were very, very confused and this influenced many medical decisions and many nursing conditions,” said Venneri.

Family members excluded

“We heard many harrowing reports of family members being excluded from physical contact with a loved one who was seriously ill or even dying. Of course, this was all in the interest of trying to control the spread of the infection, but it seemed almost to squeeze out the compassion in care,” said Sir Liam Donaldson, WHO Envoy for patient safety.

Australian patient advocate Stefanie Newell agreed, describing the presence of a patient’s family member or friend as something that should be a “non-negotiable norm” in hospital policy.

She warned against “prioritising infection control over all other risk factors”, stressing that the presence of a family member or patient care partner help to minimise adverse events for patients.

“Exclusion of the personal team member of the patient has led not only to distress but certainly poorer outcomes for people,” said Newell.

“We need to think about the health system including those critical people as part of the clinical team because to exclude them creates a major issue not only for the patient but also for staff because that communication link has gone,” said Newell, who is a founding member of the Australian chapter of the WHO Patients for Patient Safety programme.

Patient safety panel

Misinformation

Baylor College of Medicine’s Dr Hardeep Singh, who was assisted with the review, said that a “big surprise was the amount that misinformation really impacted patient safety”.

“The impact of misinformation has really, really been brought out by the pandemic. We had some of this going on even before the pandemic, but what we noticed was adverse events that were happening because of misinformation, and this was a global phenomenon,” said Singh, who heads health policy quality and informatics at the US-based college.
“This is going to be a problem for decades to come.”

However, Singh also said that a “lot was unknown” about the impact of COVID-19 on patient safety as there was a lack of information about adverse events during COVID-19.

Donaldson also highlighted disruptions to essential childhood immunisation programmes around the world, in part because “the staff involved in those programmes were repurposed to treat and diagnose patients with COVID”.
“The consequence of course was that for all the childhood immunisation programmes, there was an estimated loss of at least a year, particularly in low-income countries.”

Singh added that care disruptions included the postponement of elective surgeries, while “many patients with advanced cancers could not get care for months”.

Neelam Dhingra, WHO unit head of patient safety, said that the review “explored the impacts of the COVID 19 pandemic on patient safety in terms of the risks and avoidable harm, specifically in terms of diagnostic, treatment and care management related issues”.

The review was commissioned by the Federal Office of Public Health Switzerland in preparation for the fifth ministerial summit on patient safety, which will take place in Switzerland in February 2023.

 

 

Image Credits: Credit: Press Information Bureau (PIB), Wikimedia Commons/Amarvudol.

US Secretary of State Anthony Blinken

The bulk of $3 billion in annual aid the US has committed to helping the most vulnerable countries to adapt to the impact of climate change is likely to go to sub-Saharan Africa, said US Secretary of State Anthony Blinken.

Sub-Saharan Africa is home to 17 of the world’s 20 most climate vulnerable countries, which puts it first in line to benefit from the aid package US President Joe Biden announced at the 26th Congress of the Parties (COP26) meeting last year, Blinken said during a visit to South Africa on Monday.

The United Nations recognises Africa as the most vulnerable region in the world to the effects of climate, with droughts and floods “now twice as likely to occur due to climate change”, said Blinken. 

“Not all countries bear equal responsibility for this crisis. The United States has around 4% of the world’s population and we contribute about 11% of global [carbon] emissions, making us the second biggest emitter after China. Sub-Saharan Africa, which accounts for 15% of the world’s population, produces only 3% of emissions,” said Blinken. 

 

 

“Leaders across Africa have made it clear that, while they’re committed to doing their part to reduce climate change, they need greater and more reliable energy access to meet people’s urgent needs and growing needs,” said Blinken.

The US is committed to helping different countries with energy transition “tailored to individual capacities and individual circumstances” and to “supporting the workers and communities who will bear the greatest short-term costs,” he added.

Making a “just energy transition” offers a “once-in-generations opportunity to expand energy access and create opportunities for Africans and for Americans”, said Blinken. 

The US is working with partners to build West Africa’s first hybrid solar-hydro plant which is going to “improve reliability, reduce costs, and cut more than 47,000 tonnes of emissions every year”. 

“That is the equivalent of taking about 10,000 cars off the road. In Kenya, where 90% of the energy comes from renewable sources, US firms have invested $570 billion into off-grid energy markets, creating 40,000 green jobs,” said Blinken.

He added that partnerships to “conserve and restore the continent’s natural ecosystems” was also crucial to reducing Africa’s emissions and preserving its unique biodiversity. 

“That means delivering real incentives for governments and communities to choose conservation over deforestation, not just pledges, because the lasting consequences of losing forests like the one in the Congo Basin, will be devastating and irreversible for local communities as well as for communities around the world.

The Democratic Republic of Congo lost almost 500,000 hectares of rainforest in 2021, the second highest loss in the world after the Amazon in Brazil, according to the World Resources Institute’s Global Forest Review. 

Chinese companies have been linked to large-scale illegal logging in the forests in the DRC.

Surveillance for the Ebola virus disease at the border between the Democratic Republic of Congo and Uganda.

LEIDEN – Pandemic preparedness rests on having a robust surveillance system to identify health threats – something that is still “rudimentary” in many African countries, says Professor Salim Abdool Karim, a South African infectious diseases epidemiologist.

Describing monkeypox as a threat to health security in Africa, Karim said that it was important that health services were able to identify individuals with recent onset of skin lesions and test them for monkeypox to control the infection.

“Ensuring the public knows what the monkeypox lesions look like and having the laboratory infrastructure to do widespread testing is key,” Karim told Health Policy Watch on the sidelines of the EuroScience Open Forum in Leiden in the Netherlands. 

Last month, the World Bank approved a $100 million programme to strengthen the Africa Centres for Disease Control’s (Africa CDC) technical capacity and institutional framework so that it could “intensify support to African countries in preparing for, detecting, and responding to disease outbreaks and public health emergencies”, according to the Africa CDC.

Laboratory testing

Testing for monkeypox is doable in almost all countries in the world as it is based on PCR technology that has been vastly improved during the COVID-19 pandemic, according to Karim. 

“The elements of surveillance [for pandemic preparedness] are well-known and most countries in Africa have [them] but they are rudimentary and we’ve got to build it up. It involves ensuring that healthcare services are aware to look for clinical symptoms and signs and look for patients that might be unusual,” said Karim.

Pandemic preparedness also means having laboratory testing capacity to identify new organisms, and having the data analytic and epidemiological capacity to monitor trends to know when things are changing.

The capacity to do surveillance in animals is also critical to be one step ahead and “not wait for organisms in animals to jump to humans”, cautioned Karim.

Another component of preparedness involves “epidemic intelligence” – knowing what is going on globally as well as on the ground in African countries to produce intelligence reports that feed into policy and into planning. 

Countries also need to ensure that they have health systems capacity to address epidemics, – including enough hospital beds, ventilators, laboratories and adequate health service personnel – and the tools to fight a pandemic, including diagnostics, vaccines and treatments. 

Misinformation

Communicating public health decisions and the science behind them is a fundamental plank in building public confidence and understanding – particularly in the era of disinformation and conspiracy theories on social media. 

“What disinformation does is shift the narrative, and undermine the public’s confidence in the government, in science and transparency,” said Karim, who served on South Africa’s COVID-19 ministerial advisory committee.

At the height of the COVID-19 pandemic, African governments and scientists “were not communicating enough, which created the opportunity for disinformation peddlers to get an upper hand” said Karim. 

“There wasn’t a counter-narrative that provided clear explanations to meet people’s anxieties and concerns,” he added.

Monkeypox is endemic in 10 African countries, but it is spreading in the general population and not, as in Europe and the US, in the men who have sex with men. But the fight to keep the infection rate low could be dealt a blow if stigmatization is not addressed adequately among this group of people, said Karim.

 “We have to avoid stigmatising any group for monkeypox, as it is a disease that affects anyone. In countries where the virus is spreading in the gay community, the acknowledgement of these individuals is key to whether the virus can be controlled or not,” said Karim.

Members of the South African National Defense Force patrol Bree Street Taxi Rank in Central Johannesburg during the country’s COVID-19 lockdown.

COVID-19 lockdowns

The total lockdowns imposed in countries including Kenya, Nigeria and South Africa, might not have been appropriate, said Karim, but there were so many unknowns about COVID-19 at the time. 

“If you turn back the clock to February and March of 2020, we had very little information about the COVID-19 virus.  What we did see, and played out on our television screens every evening, was that developed countries such as Italy and New York City in the US were being overwhelmed, the hospitals were under pressure and people were dying just trying to get a bed, or trying to get a ventilator,” said Karim.  

“That is the image that Africa had to work with at that time. Those countries vastly more resourced than ours were being hugely impacted and no country, no responsible leader can look at that and ignore.”

African countries followed the example set by European cities and China, where lockdown measures helped reduce the number of infections and flow of seriously ill people to hospitals. 

“That is the evidence Africa was faced with at that time and they had to act in good faith,” he said. “If you look at those decisions now ─ with the benefit of hindsight ─ we have a different understanding of the [diverse ways] in which countries in Africa were impacted.

“For instance, South Africa, Uganda and Zambia were struck heavily, especially when the Delta variant came along, resulting in many going to hospitals, and countries experiencing huge clinical burden.

Some countries that imposed strict lockdowns could have avoided such measures, or made them less painful socially and economically if more had been known at the time about virus transmission and severity. 

“When we look at the impacts of the first wave of COVID-19 in many African countries, we could have taken a different route, but that route wasn’t clear at that time. Perhaps that would have meant doing partial lockdowns, identifying cases, implementing stay-at-home orders in sections of the community, restricting movements, getting as many people as possible to work from home, reducing the flow of people and reducing the use of public transport,” conceded Karim. 

 

Image Credits: WHO/Matt Taylor, Flickr: IMF Photo/James Oatway.

Sugary drinks are now taxed in Nigeria to tackle obesity, diabetes, and other NCDs.

Nigeria began imposing a new tax on sugar-sweetened beverages on 1 June, but the aim of using the money raised to help curb the growing rates of obesity, diabetes and other diet-related non-communicable diseases (NCDs) faces a host of challenges including a multibillion-dollar industry.

IBADAN, Nigeria – Working for long hours under a scorching sun, automotive repair worker Alfa Sodeeq gets thirsty often but isn’t content to just drink water. Since he can’t afford to take breaks long enough to find something healthy to drink, he often settles for a cold soda — loaded with sugar.

“A woman sells cold drinks from across my shop. All I need to shout is ‘give me one bottle’ and she will be there with one,” says Sodeeq, who operates a one-man automotive body repair shop. “On the average day, I drink about three large (50cl) bottles of Coke.”

That translates to 36 cubes of sugar daily, or 12 per bottle, which, when added to the late-40s Sodeeq’s three calorie-heavy meals, puts him at risk of obesity and diabetes, according to a Nigerian NGO, the National Action on Sugar Reduction (NASR). But Sodeeq, who weighs about 80kg, says he prefers not to know too much about his diet because “what you don’t know cannot kill you.”

Sodeeq’s dependency on sugary drinks may put him at risk of diabetes and obesity.

Sugary drink tax may generate more revenue than  health benefits

Sugary drink taxes around the world.

With the introduction of a tax on sugar-sweetened beverages under  Nigeria’s 2021 Finance Act, the Nigerian Customs Service on 1 June began implementing a new tax on sugary drinks.

The tax rate of N10 per litre applies to all non-alcoholic, carbonated beverages that contain sugar and are produced domestically — in a country where local manufacturers account for the majority of all soft-drinks production.

WHO has projected that a 20% rise in prices will lead to a comparable 20% reduction in consumption, but that has not turned out to be case always. The actual figures reflect a need for policymakers to adapt to the local context.

Despite the new tax, Sodeeq says he won’t stop drinking soda since it’s so convenient while he’s working. As he sees it, everything in his local market is already priced high — and the little bit more he will have to pay for sodas won’t alter his lifestyle.

“Everything is more costly, not just Coke,” he says. “So why will I stop when I’m making money from my work?”

Nigeria has highest prevalence of diabetes in Africa

Checking blood sugar levels for control of diabetes

Sodeeq’s example shows the challenge that Nigeria faces; the nation’s new sugary drinks tax is intended to discourage people like him from consuming too much sugar in their beverages.

The new tax is in line with the thinking of the World Health Organization (WHO) and some NGOs, along with a variety of major donors and researchers, that recommend addressing some of the health risks of NCDs through higher taxation of sugary drinks, in a bid to lessen their consumption.

Excessive sugar consumption, particularly in beverages, is associated with NCDs such as diabetes, heart disease and obesity, which in turn is an important risk factor in cancer. 

Tackling excessive sugar intake in Nigeria is particularly important considering the country has Africa’s highest prevalence of diabetes with over 12 million Nigerians living with the disease. 

According to the WHO, people who drink one to two cans a day or more of sugar-sweetened beverages regularly have a greater risk (26%) of developing Type 2 diabetes than people who rarely consume such drinks. 

Relative to other countries in Africa, Nigeria has a high burden of NCDs, which account for 24% of total deaths and are projected to be the leading cause of morbidity and mortality by 2030. 

“Sugar taxes are a proven and evidence-informed solution to the prevention and control of NCDs and related risk factors, and their use needs to be stepped up globally,” the NCD Alliance says in a policy brief welcoming the Nigerian move.

Nigerian price surge too small, and muted by inflation

African soda brands.

The Nigerian policy, however, has some drawbacks, the NCD Alliance notes. The new tax will only increase the total price of the average 50cl bottle of soda by 5% or less, it notes, which is far from WHO’s 20% recommendation. A bottle that used to cost N120 will now cost N125.

Even in countries with stiffer price increases, the impacts are mixed.  In Barbados, a 10% tax on sugary drinks led to just 4.3% less consumption, Barbados Health Minister Ian Gooding-Edghill told a World Health Assembly side event in May.

Sugary drink taxes in Mexico, Caribbean, Central and South America

On the other hand, Mexico’s 10% sugary drinks tax is considered a success since it began in 2014. In the first two years, consumption fell by an average of 7%, and more recently by as much as 12%, said Mexico’s Vice Minister of Health Hugo Lopez-Gatell told another recent WHA side event.

In South Africa, a 10% sugary drinks tax since 2018 led to a nearly 40% decline in sugar consumption from the taxed beverages among South Africans, according to a four-year study of 113,000 households published in The Lancet in April 2021. 

But the most successful initiatives also were part of a broader approach, proponents say.

That has included more awareness-raising about unhealthy foods in general, said Lopez-Gatell, noting Mexico recently implemented front-of-package labels about foods high in sugar and salts.

“It’s not confusing labeling, it’s warning,” he said. Further pending measures include limits on the types of unhealthy foods that markets can offer, and a law banning unhealthy foods sold in schools. 

Tax won’t yield dedicated revenues for health services 

Omei Bongos-Ikwue

WHO envisions a secondary aim for these taxes that goes beyond discouraging sugar consumption. It believes they also should provide revenue earmarked for health-related spending.

The UN health agency recommends spending it to improve health care systems and to put in place more effective programmes that encourage healthier diets, increase physical activity, or build capacity for effective tax administration. 

But in Nigeria, the law does not clearly earmark the revenue for health care; advocates say doing that would also engender more popular support for the tax increase. Instead, the money goes to the Finance Ministry’s general coffers. 

“There is a general pool where taxes go in,” NASR spokesperson Omei Bongos-Ikwue told Health Policy Watch. “Depending on the priority needs of the country, tax funds can be allocated. So earmarking the tax for health purposes doesn’t automatically mean that it will happen.

In her remarks at the announcement of the new tax, Zainab Ahmed, Nigeria’s Minister of Finance, Budget and National Planning, said that some of the revenue would be used for health but she didn’t make any commitments. 

“It is also used to raise excise duties and revenues for health-related and other critical expenditures.  This is in line also with the 2022 budget priorities,” the minister said.

Bongos-Ikwue described this as highlighting the need for raising more awareness and advocacy so as to press the government to allocate funds generated for health.

 Tax may be perceived as inflation related 

Prices at the market have risen in Nigeria.

In terms of impacts on consumers, the price increase attributable to the sugar tax also has been muted by the overall increase in the prices of commodities in Nigeria. 

As Sodeeq observed, costs of everything are rising now with inflation, and particularly at the market. 

Beverage distributors like Ige Olutoyin told Health Policy Watch that consumers will not necessarily appreciate that the increased price has anything to do with the drink’s sugar content, or with health.

“When the suppliers said the price is higher now, we simply implemented the price increase and when any buyer asks, we simply tell them that things are now more expensive in the market,” he said.

Further blurring the issue, particularly for middle-aged Nigerians like Sodeeq,  is the fact that taxes on carbonated drinks are not entirely new.

Between 1984 and 2009, the Nigerian government taxed sugar-sweetened beverages, alcoholic drinks and tobacco as luxury items to raise revenue, but the tax on sugar-sweetened beverages was removed in 2009 after such drinks became ubiquitous in the country.  

‘Everything else has gone up’

Bongos-Ikwue says the price of “everything else has gone up” in Nigeria, so people might attribute the cost increase for sugary drinks to inflation.

“This is why I think it is more important to engage with the stakeholders knowing that an additional tax has been placed on the beverages,” she says.

Beverage distributor Olutoyin agrees there is a need for more awareness about the supposed rationale behind the tax. Otherwise, he says, the government may generate more revenues, but the tax will not discourage excessive consumption of sugar-sweetened beverages.

Method of collection also muddies health argument 

He also says the method of collection plays a role in muddying the waters of the health argument. 

The fact that the government will bill the manufacturers directly, rather than taxing the drink at point of sale, Olutoyin says, also means that manufacturers and their distributors can even more easily steer the narrative about the tax to inflation, rather than health, especially if the government is not aggressively raising public awareness.

“I believe the government decided to collect it from the manufacturers because it is much easier to do,” he said. “If they want this to have more effect, it should be collected directly from the customer.” 

At the same time, taxing beverage manufacturers’ production may be the only realistic way to collect the new levy on a good that is later traded and sold by shops and informal markets across the vast nation. “This way, the [government] is able to account for the beverages produced within a period,” said Bongos-Ikwue.

The Herculean task ahead

Some argue that the tax may be counterproductive.

In anticipation of the tax, the Manufacturers Association of Nigeria (MAN) said the tax could be counterproductive and result in a loss of revenue for the government.

According to the report, about NGN81 billion could be collected from the excise duty on carbonated drinks between 2022 and 2025. But the government says it could lose up to NGN197 billion within that period from other taxes paid by drink manufacturers, such as Value Added Tax and Company Income Tax, if consumption of sugary drinks declines.

“The introduction of the excise duty, despite its potential overwhelming negative impact, is rather unfortunate. The revenue aspirations of the government in introducing this excise tax may not be justified in the long run,” said Segun Ajayi-Kadir, MAN’s director-general.

He said the tax could lead to job losses, but Bongos-Ikwue said such claims are unfounded.

In East and southern Africa, other sugary tax initiatives blocked by industry interests 

Industries have pushed back against Africa’s soft drink taxes.

Over the past few years, industry pushback in a number of other African countries, including Kenya, and Uganda, has effectively undermined efforts to introduce  sugary drinks taxation.

Research published in April 2021 by Global Health Action on seven east and southern African countries – Botswana, Kenya, Namibia, Rwanda, Tanzania, Uganda and Zambia – found all have excise taxes on soft drinks, but the tax levels are well below WHO recommendations. None of those taxes target sugar content. 

Only a few African countries impose sugary drink taxes, and these are well below WHO recommendations.

In Uganda, where NCDs account for one-third all deaths, authorities decided in 2018 to gradually reduce the excise tax on non-alcoholic drinks to 10%, down from 13%, as an enticement for Coca-Cola Co. to invest in the country; the company’s CEO in Uganda agreed it was a favorable move.

“The soft drink industry has been influential in framing the taxation debate,” says the authors of the 2021 Uganda case study.

Win-win  approaches – changing industry drink formulas and consumer awareness

There are multiple methods to reduce NCDs.

Not everything has to be a win-lose approach. In the UK, sugary drinks taxes, combined with stepped-up pressure and advocacy on manufacturers, prompted soft-drinks companies to reduce the sugar content in key products by changing formulations. This, along with  changes in consumer purchasing, led to a 30% reduction per capita in the daily volume of sugars sold in soft drinks.

In Nigeria, however, manufacturers are not yet being aggressively encouraged to fully embrace reformulation and, as such, the available options in significantly reducing sugar intake among the population is not being fully explored, Bongos-Ikwue says.

Advocacy was responsible for the progress made so far, she says, but still more advocacy is needed to extend the tax to other priorities. And she says other approaches can help, too, such as health education, front-of-package labeling about how much sugar is in beverages, and school programs.

“It’s a multipronged approach, she says. “Taxes are just one way; there are other different things, including education, on how to reduce NCDs.”

Kerry Cullinan contributed to this story with reporting from southern and eastern Africa.

Image Credits: Heala_SA/Twitter, Alan/Flickr, Global Health Research Program , Tih Ntiabang/Twitter , Thomas Stellmach/Flickr, James Hall/Twitter , Global Food Research Progrma, World Bank Tanzania/Twitter .

Diversity is closely linked to dignity, and if separated, it can become “a checkbox exercise that fails to shift the dominant power dynamics,” according to Garry Aslanyan in his latest edition of “Global Health Matters.

In a dialogue with Marie Ba, director of the Ouagadougou Partnership Coordination Unit based in Dakar, Senegal, and Tom Wein, director at IDinsight, based in Nairobi, Kenya, Aslanyan discusses how although dignity has a universality to it, it can also be regarded as a capability that if lacking, can result in the best intentions achieving rather unintended and even harmful consequences.

“Strengthening one’s own dignity capability should be a daily intention that all of us in global health pursue,” Aslanyan says. “In doing so, we can hopefully foster more respectful engagement in global health, making everyone feel seen and valued.”

Wein focused his part of the podcast on how to define dignity, emphasising the subjective experience of the person with the least power in any interaction. And said that there are three pathways that can help serve as a framework for dignity: representation, agency and equality.

According to Wein:

  • Representation is about people feeling seen by the institutions that they’re interacting with and seeing themselves represented in those institutions.
  • Agency is about having choices and a meaningful chance to consent for the decisions that are being made about their lives.
  • And equality is about the power inequalities being reduced, and even where they cannot be eliminated, people feeling treated as if they were fundamentally equal, even if those power differentials persist.
The Three Pathways of the Dignity Framework
The Three Pathways of the Dignity Framework

He added that capability and purpose are other key ingredients in dignity.

Ba pointed out that in any situation, accountability and good intentions needs to come from both sides.

“I know we talk a lot about shifting powers, decolonizing global health and really putting the focus on the Global North, but I feel like there’s some work that needs to be done from the Global South first,” she said.

Learn more about this episode.
Listen to previous episodes on Health Policy Watch.

Image Credits: Tom Wein.

US Health and Human Services Secretary Xavier Becerra – Monkeypox vaccine ‘sparing’ in the face of a national health emergency

The United States is considering shifting to intradermal injections of Monkeypox vaccine that could potentially stretch one dose of the approved MVA-BN vaccine, available only in limited quantities, into five doses, said US Food and Drug Administration Commissioner Robert Califf on Thursday.

He was speaking at a press briefing minutes after Xavier Becerra, US Secretary of Health and Human Services (HHS)  said he would declare a national health emergency over the monkeypox outbreak, which has now 6,600 confirmed cases in the United States – making it the global hotspot for the virus, followed by Spain and Germany. Some 26,000 cases had been reported worldwide, as of Thursday – not including several thousand suspected cases in central and western Africa, where the disease is endemic, but testing capacity remains poor.

 

“I will be declaring a public health emergency on Monkeypox.  We are prepared to take our response to the next level in addressing this virus,” said Becerra, speaking at a Thursday virtual press briefing in Washington, DC.

The United States currently holds about 1.4 million of the only  FDA-approved approved monkeypox vaccine in a strategic stockpile, which until recently had been intended for use mainly against any future smallpox threat, according to estimates by the global forecasting firm, Airfinity. HHS officials have already released about 1.1 million doses from the stockpile to cope with the emerging outbreak – which WHO declared a global health emergency on 23 July.

While the US has contracts to receive another 13 million doses in 2022, a significant proportion remain in bulk formulation, requiring fill-and-finish. Meanwhile, the only plant manufacturing the raw vaccine formula, produced by Denmark’s Bavarian Nordic, is closed for renovations until late 2022 – meaning that the global supply also is finite – in the face of a rapidly-developing outbreak.

‘Dose-sparing’ at critical inflection point

“Given the continued spread of the virus we are at a critical inflection point, dictating the need for continued solutions,” said Califf. While he said that the US was “working closely with the manufacturer to accelerate the delivery of doses,” another solution could be to “allow health care providers to use an existing 1 dose vial to administer up to 5 separate doses.

“Under the proposed approach, a fifth of the proposed dose would be introduced intradermally,” he said, explaining this is a more “shallow injection” than the typical subcutaneous injection.  But evidence suggests than if administered correctly, it could provide a powerful immune response for Monkeypox.

Intradermal administration is used only for a few vaccines. Here is a graphic description.

“This approach which we’re referring to, as dose sparing, would change the method of administration of Jynneos [the brand name for the MVA-BN vaccine], which is currently administered subcutaneously,” he said.

“Under the proposed approach, one-fifth of the current vaccines dose would be administered intradermally. There are some advantages to intradermal administration including an improved immune response to the vaccine,” he declared.  Although in fact the procedure is relatively rare, it is widely for hepatitis B vaccines in adults as well as the BCG tuberculosis vaccine in infants as well as children.

Califf said that a while a decision had not yet been made whether to move ahead with the dose-sparing strategy, “we are exploring all scientifically feasible options and we believe this could be a promising approach. … We look forward to sharing more information on the dose sparing approach in the days ahead.” 

Dose-sparing previously was recommended by WHO in the case of COVID vaccines, during much of 2021, when there was a global scarcity.

More than 600,000 vaccines already distributed in the United States

Becerra meanwhile said that of the 1.1 million BVA-MN vaccine doses committed by the US from its stockpiles to the health emergency, more than 600,000 doses have already been distributed to health providers around the country.

The US expects to receive another I50,000 finished vaccine doses in September, said Dawn O’Connell, HHS Assistant Secretary for Preparedness and Response, adding that “we expedited those doses that they were previously scheduled to arrive in October. We anticipate continued delivery of additional doses in October, November and December,” she said, referring to vaccines now held in bulk by Bavarian Nordic, which need to undergo fill-and-finish.

As for testing, Becerra said that  “we have the capacity to administer some 80,000 tests a week, and that has continued to rise. … On treatments, we have deployed some 14,000 treatments of TPOXX, [Tecovirimat anti-viral treatment], and we have roughly 1,700,000 doses in our strategic stockpiles.” 

Meanwhile, the Director of the US Centers for Disease Control, Rochelle Walensky, said that the CDC estimates that there are about 1.6 -1.7 million Americans “who are at highest risk right now and that is the population that we have been focused on in terms of vaccination.” That includes groups such as men who have sex with men, as well as people already infected with HIV, and therefore with a potentially weakened immunity overall. 

Image Credits: Global Health , https://mvec.mcri.edu.au/references/intradermal-vaccination/.

africa
Africa recorded the world’s highest gain in life expectancy in the new WHO report.

Africa recorded the world’s highest gain in healthy life expectancy over the past decade. But the lack of sustainable finance for health systems is a major threat to the gains recorded.

Africa recorded the world’s highest growth in healthy life expectancy—or the number of years an individual is in a good state of health—between 2000 and 2019. Healthy life expectancy increased on average 10 years per person, the World Health Organization (WHO) assessment reported.

The Tracking Universal Health Coverage in the WHO African Region 2022 report shows that healthy life expectancy—or the number of years an individual is in a good state of health—increased to 56 years in 2019, compared to 46 in 2000. While still well below the global average of 64, over the same period global healthy life expectancy increased by only five years.  

At a press briefing launching the report Thursday, WHO officials and other invited experts attributed the gains to increased universal health coverage (UHC) on the continent. But sustainable financing remains a major challenge for the 47 sub-Saharan countries that belong to WHO’s Africa Region – with all but seven of the 47 WHO African region countries depending on outside donors for more than 50% of the costs of health services delivery.  

Many WHO Afro countries rely on outside funding for health care costs.

At the same time, increased provision of essential health services, including for reproductive, maternal, newborn and child health were among the factors to which the gains of the past decade could be attributed. Other contributors are progress in the fight against infectious diseases notably rapid scale-up of HIV, tuberculosis, and malaria control measures from 2005. 

“The sharp rise in healthy life expectancy during the past two decades is a testament to the region’s drive for improved health and well-being of the population,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. 

“It means that more people are living healthier, longer lives, with fewer threats of infectious diseases and with better access to care and disease prevention services,” she said. “But the progress must not stall. Unless countries enhance measures against the threat of cancer and other noncommunicable diseases, the health gains could be jeopardized.”  

Most governments in Africa fund less than 50% of their national health budgets 

Progress in healthy life expectancy could also be undermined by the impact of the COVID-19 pandemic unless robust catch-up measures are instituted, WHO and other experts at the briefing warned. Insofar as the report’s data ends at 2019 – the COVID years were not captured by the data presented. 

On average, for instance, African countries reported greater disruptions across essential services compared with other regions, according to a 2021 WHO survey.  

Efforts have been made to restore essential services affected by the pandemic. However, to ensure long-term sustainability, it is crucial for governments to step up self-financing of services – weaning their countries away from heavy reliance on international donors.  

Most governments in Africa fund less than 50% of their national health budgets, the report notes.. Only Algeria, Botswana, Cabo Verde, Eswatini, Gabon, Seychelles and South Africa fund more than 50% of their national health budgets. 

“COVID-19 has shown how investing in health is critical to a country’s security. The better Africa can cope with pandemics and other health threats, the more our people and economies thrive. I urge governments to invest in health and be ready to tackle head on the next pathogen to come bearing down on us,” said Dr Moeti.      

UHC coverage increased in the region an average of 22 points.

According to the report, UHC coverage across the region increased by an average of 22 points on a scale of 0 to 100, rising to 46 in 2019 up from from 24 in 2000, along the lines of a Service Coverage Index (SCI). The scale measures some 14 UHC indicators including those for reproduction, material and child health, infectious diseases, and non-communicable diseases.  Even so, only four countries had a UHC index between 56 and 75, with the highest values in southern and northern African subregions respectively. 

“This progress, though significant, falls short of meeting the SDG 3.8.1 global target of a minimum of 80% coverage of essential health services by 2030,” the report notes.

Inequality across many countries remains a crucial determinant of the level of health service coverage.

Botswana provides good practice 

Moses Keetile, of Botswana’s Ministry of Health and Wellness Botswana

Botswana is one of the African countries making appreciable progress in public funding for healthcare, the report says, with almost 80% of its health spending in 2019 going towards the government’s domestic programs.

Speaking at the briefing, Moses Keetile, of Botswana’s Ministry of Health and Wellness Botswana, told Health Policy Watch the country’s ability to sustain its gains on UHC  largely hinges on ensuring that health ranks high on the priority list of politicians.

“Allocation of national resources is very important,” he said. “To what extent is health given a priority? What is it that we are spending our resources on? Is it on health, physical education, or is it in the military. So it’s very important that we speak to our politicians for that political will and ownership.” 

He also described reliance on external funds as unsustainable for Botswana and other African countries. Countries have to implement innovative ways of creating revenue and funding for health care delivery, he said, stressing that the private sector is also an important partner in advancing UHC. 

“The Botswana UHC experience is still predominantly government but that is not the most ideal situation. It is important to have all the necessary sectors, including the private sector, to be part of it,” he concluded.

The exception, rather than the norm

The overall change in out-of-pocket expenditure between 2000 and 2019.

Botswana remains the exception, rather than the norm, however, the report says.  

Government coverage of catastrophic and out-of-pocket expenditures through health insurance or free health care systems is one of the measures key to improving health coverage. Health expenditure is considered “not catastrophic” when families spend less than 10% of their annual income on it, irrespective of their poverty level. 

Yet over the past 20 years out-of-pocket spending stagnated or increased in 15 countries out of the African Region’s 46 countries, the report finds. And out- of-pocket expenditure increased by more than 90% in at least three countries.

Conversely, a total of 15 countries are faring above the regional average, in terms of combined service coverage and financial risk protection. 

Good performance among that latter group of countries is not entirely income driven, the report says. Rwanda, Malawi and Mozambique are low-income countries among the 15 good performers on that scale of measurement.  Angola, Nigeria, Mauritania, Côte d’Ivoire, Cameroon and Comoros are middle-income countries with low performance in both service coverage and financial risk protection.

Lack of investment in health threatens economic and national security

Professor Muhammad Ali Pate, of the Harvard T. H. Chan School of Public Health

Professor Muhammad Ali Pate,of the Harvard T. H. Chan School of Public Health agreed with Keetile. He noted that public and private investments in health in Africa can also be pitched to policymakers as contributing to economic growth.

“There is scope to harness private capital to invest in laboratories in hospitals. But with a public mission protected, every citizen should be guaranteed basic access to quality health care. The public health function should be publicly financed, and tax financing is a key part of that,” he told Health Policy Watch. 

According to Pate, enhancing the private sector’s role should not, however, absolve African governments from domestically investing in health services, including through robust tax collection.  

“What we have seen with the pandemic is a lack of investment in health that threatens economic and national security,” he said. “Finance ministers and economic planning ministers have a vested interest to ensure the public health outbreaks are contained, and that equipment and the test kits are available and produced locally so they also contribute to economic growth.”

Dr Lindiwe Makubalo, Assistant Director, WHO Regional Office for Africa

Dr Lindiwe Makubalo, assistant director of WHO’s Regional Office for Africa, also highlighted the importance of multi-party partnerships. She noted that the new report provides guidance towards properly building health systems and ensuring health security in Africa.

“We elaborate the different components of what needs to be done. At the end of the day, I think it’s the value of understanding the value of health and health security, and appreciating all of the wider sector approach that is really what is going to be important,” she told Health Policy Watch.

Image Credits: World , WHO Afro.

Breastfeed
Woman breastfeeding her child.

Nearly $575 million in global economic and human capital is lost every year due to insufficient government promotion of, and support for, breastfeeding, according to data from the latest report on  The Cost of Not Breastfeeding. 

The 2022 report, released for World Breastfeeding Week (1 August – 7 August) finds that these losses are the result of increased child and maternal mortality and other healthcare costs, and account for an average 0.7% of a nation’s gross national income. 

However, increasing country-level support for breastfeeding could save not only 515,000 lives each year, it could also save the global economy $1.5 billion each day, according to the report by the Alive and Thrive initiative and Nutrition International. 

This support would be in line with the World Health Organization’s recommendations, which include initiating breastfeeding within the first hour of birth, exclusive breastfeeding for the first six months, and continuing breastfeeding alongside complementary feeding from six months to two years and beyond.

“Breastfeeding is the primary building block of a healthy food system and one of the best ways to give a child the right start in life,” said Joel Spicer, President and CEO, Nutrition International. 

“But women around the world aren’t getting the support, resources, and protection they need to begin breastfeeding soon enough and sustain it for the recommended period. Governments need to make breastfeeding a top public policy priority, and with the Cost of Not Breastfeeding Tool, policymakers can see the real-world benefits of doing just that.”

The revamped report includes tools like a new user-friendly dashboard and data from 180 countries. In addition to mortality rates and healthcare costs, the report offers new calculations for the impact of not breastfeeding on childhood obesity, IQ losses and education. 

Inadequate breastfeeding has negative impacts for children ‘down the line’ 

Investment in breastfeeding can improve health outcomes later in life.

Inadequate rates of exclusive and continued breastfeeding can lead to increased healthcare costs down the line, as well as decreased cognitive ability for children, impacting their education and future income potential. 

The lack of support may have to do with the increased promotion for breast milk substitutes, which were found by WHO to undermine breastfeeding through use of digital ads and other forms of advertisement. 

For families, not breastfeeding also increases the cost of living, as household income is redirected to formula or other breastmilk substitutes. 

The Global Breastfeeding Collective recommends seven policy actions that national governments can implement to support and promote breastfeeding, including enacting paid leave and workplace breastfeeding practices, strengthening the links between health facilities and communities, and implementing the International Code of Marketing of Breastmilk Substitutes.

The Code is meant to stop the “aggressive and inappropriate marketing of breast milk substitutes.”

“Increasing breastfeeding rates through supportive actions and policies can help to save the lives of mothers and children, and protect economies from preventable losses,” said Sandra Remancus, Director, Alive & Thrive.

Image Credits: WHO, UNICEF.

food crisis
Millions of lives are at risk due to an unprecedented food crisis in the greater Horn of Africa.

In light of an unprecedented food crisis in the Horn of Africa, the World Health Organization has launched a $123.7 million funding appeal for urgently needed supplies to treat severe malnutrition and related health conditions. 

Driven by conflict, changes in climate and the COVID-19 pandemic, this largely arid Eastern African region of some 2 million square kilometres spanning the Indian Ocean to the sources of the Nile, traditionally home to pastoralists and subsistence farmers living off of livestock and harvests of rain-fed crops, has become a hunger hotspot with disastrous consequences for the health and lives of its people.

“Hunger is a direct threat to the health and survival of millions of people in the greater Horn of Africa, but it also weakens the body’s defenses and opens the door to disease,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus, in a statement. 

Four consecutive failed rainy seasons have decimated locally grown crops such as maize, wheat and caused abnormally high numbers of livestock deaths, in a crisis considered to be one of the worst climate change-related disasters in over 40 years. 

In addition, Russia’s invasion of Ukraine has disrupted supply chains and sent prices of imported wheat, cooking oil, and other cooking staples soaring, further worsening the crisis.

Prior to war, Russia and Ukraine supplied 40% of Africa’s grain

Children across the Horn of Africa are at risk for acute malnutrition. 

Prior to the war, Russia and Ukraine supplied Africa with more than 40% of the continent’s grain. Somalia alone used to import more than 92% of its wheat from these two countries, but supply lines have since been blocked. 

Now over 80 million people in the 7 countries spanning the region – Djibouti, Ethiopia, Kenya, Somalia, South Sudan, Sudan and Uganda — are estimated to be food insecure, as a result of this food crisis. 

Upwards of 37.5 million people are classified by WHO as being in a Phase 3 food crisis, a stage where people have to sell their possessions in order to feed themselves and their families, and where malnutrition is rife.

Additionally, more than 1.7 million children across parts of Somalia, Ethiopia, and Kenya urgently need treatment for acute malnutrition, according to UNICEF. 

“WHO is looking to the international community to support our work on the ground responding to this dual threat, providing treatment for malnourished people, and defending them against infectious diseases,” Tedros said. 

“Hunger is a direct threat to the health and survival of millions of people in the greater Horn of Africa, but it also weakens the body’s defenses and opens the door to disease,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. 

“WHO is looking to the international community to support our work on the ground responding to this dual threat, providing treatment for malnourished people, and defending them against infectious diseases.”

The funds raised from the appeal will go towards urgent measures to protect lives in the region, including increasing countries’ capacity to detect and respond to disease outbreaks, procuring and ensuring the supply of life-saving medicines and equipment, identifying and filling gaps in health care provisions, and providing treatment to sick and severely malnourished children. 

Situation continues to worsen

With the start of the autumn rainy season expected to be delayed once more, thus delaying the planting of new crops, the food insecurity in the Horn of Africa is expected to continue to grow through the autumn. 

In Somalia alone, about 7.1 million people — almost half the population — will confront crisis-level food insecurity or worse until at least September and 213,000 of them face catastrophic hunger and starvation, according to the Integrated Food Security Classification (IPC), an intergovernmental consortium including UNICEF, the World Food Programme and the UN Food and Agriculture Organization, that tracks and ranks food insecurity hotspots.  

“Ensuring people have enough to eat is central. Ensuring that they have safe water is central. But in situations like these, access to basic health services is also central,” said Dr Michael Ryan, Executive Director of WHO’s Health Emergencies Programme. 

“Services like therapeutic feeding programmes, primary health care, immunization, safe deliveries and mother and child services can be the difference between life and death for those caught up in these awful circumstances.”

 Violence, disease outbreaks, and displacement result from food crisis  

The food crisis has resulted in avoidable death of children and women in childbirth.

The food crisis has also resulted in increased violence, outbreaks of disease, and mass displacement. 

​​There are already reports of avoidable deaths among children and women in childbirth. Gender-based violence is on the rise. There are outbreaks of measles in 6 of the 7 countries, against a background of low vaccination coverage, in addition to the mass displacement of people and relaxation of social distancing norms. 

Countries are also simultaneously fighting cholera and meningitis outbreaks as hygiene conditions have deteriorated, with clean water becoming scarce as people migrate.

The region already has an estimated 4.2 million refugees and asylum seekers, with this number expected to increase as more people are forced to leave their homes in search of food, water, and pasture for their animals. When on the road, communities find it harder to access health care, a service already in short supply following years of underinvestment and conflict.

WHO has already released US$ 16.5 million from its Contingency Fund for Emergencies to ensure people have access to health services, to treat sick children with severe malnutrition and to prevent, detect, and respond to infectious disease outbreaks.

The global health agency has also set up a hub in Nairobi to coordinate delivery of medical supplies and other WHO support to areas of the region in the throes of conflict, humanitarian and climate-related crises.

Image Credits: Mohammed Omer Mukhier/Twitter , WHO/Twitter , HBNonline/Twitter .

Twelve African nations have joined with the United Nations and other international organizations in forming a new alliance that will work to prevent new infant HIV infections and to ensure no child living with HIV is denied treatment by the end of the decade.

Proponents of the new Global Alliance for Ending AIDS in Children by 2030 announced its creation on Tuesday at an International AIDS Conference wrapping up in Montreal, Canada.

The first phase includes Angola, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo, Kenya, Mozambique, Nigeria, South Africa, Tanzania, Uganda, Zambia, and Zimbabwe.

Three UN agencies — UNAIDS, UNICEF and the World Health Organization (WHO) — are behind it along with the Global Network of People Living with HIV (GNP+), the Global Fund to Fight AIDS, Tuberculosis and Malaria and the U.S. President’s Emergency Plan For AIDS Relief (PEPFAR).

At the conference, UNAIDS revealed that progress against HIV slowed down during the COVID-19 pandemic as donors pull back, countries test and treat fewer people and miss key targets.

Countries with the biggest increases in new HIV infections include Philippines, Madagascar, Congo and South Sudan, according to UNAIDS’ annual report, issued just ahead of the opening of the 24th Annual AIDS conference.

Nearly Half of All Children with HIV Lack Life-Saving Treatment

Just 52% of all children living with HIV are receiving treatment that can save their lives, far behind the 76% of all adults that are receiving antiretrovirals. That’s according to data released in the UNAIDS Global AIDS Update 2022.

Because of that the alliance says over the next eight years it will focus on closing the treatment gap and breastfeeding adolescent girls and women living with HIV and optimizing continuity of treatment, and on preventing and detecting new HIV infections among pregnant and breastfeeding adolescent girls and women.

Its other priorities include ensuring there is accessible testing, optimized treatment, and comprehensive care for infants, children, and adolescents exposed to and living with HIV, and that the rights, gender equality, and social and structural barriers that hinder access to services are adequately addressed.

“The wide gap in treatment coverage between children and adults is an outrage. Through this alliance, we will channel that outrage into action,” UNAIDS Executive Director Winnie Byanyima said.

“By bringing together new improved medicines, new political commitment, and the determined activism of communities, we can be the generation who end AIDS in children,” said Byanyima. We can win this, but we can only win together.”

Aids in children prompts call for community leadership

AIDS in Children
A mother from Lesotho, Limpho Nteko, who serves as a spokesperson for the female-led mothers2mothers program (Credit: m2m.org)

A mother from Lesotho, Limpho Nteko, who serves as a spokesperson for the female-led mothers2mothers programme that works to combat HIV pregnancy transmission, told the conference that community leadership is an important factor.

“To succeed, we need a healthy, informed generation of young people who feel free to talk about HIV, and to get the services and support they need to protect themselves and their children from HIV,” said Nteko, who found out she had HIV while pregnant at age 21 with her first child.

WHO’s Director-General Dr Tedros Adhanom Gheberyesus said no child should be born with or grow up with HIV, and no child with HIV should go without treatment.

“The fact that only half of children with HIV receive antiretrovirals is a scandal, and a stain on our collective conscience,” he said. “The Global Alliance to End AIDS in Children is an opportunity to renew our commitment to children and their families to unite, to speak and to act with purpose and in solidarity with all mothers, children and adolescents.”

Image Credits: Emmanuel Museruka/DNDi, m2m.org.