Midwife vaccinates a man during a COVID-19 vaccine campaign in Madagascar.

A third shot of the Pfizer mRNA COVID-19 vaccine boosted vaccine effectiveness against infection, which had been diminished five to six months after the second vaccine dose, according to a study of over 12,000 healthcare workers released this week by Nature.

The study was conducted in Israel by Sheba Medical Center and involved 12,413 health workers (HCWs). It was released on the heels of an earlier report by a separate research team at Ben-Gurion University who reported in Science of the Total Environment that, based on wastewater sampling, they predict a resurgence of the Delta variant and reports in the US media that the Centers for Disease Controls and Prevention is anticipating a COVID-19 surge in the winter.

South Africa also appears to have entered a fifth COVID wave, reporting a sustained rise in infections in recent weeks. Only 31% of the South African population is fully vaccinated, according to Our World in Data – and nearly all of those only with two doses.

The report is the first to present real-world data on vaccine effectiveness, safety and immunogenicity within a large cohort of HCWs in a large tertiary center. However, conducting the study among HCWs means that it does not represent the general population.

Immunogenicity of third Pfizer vaccine

The Sheba team assessed immunogenicity, vaccine effectiveness and safety of the third Pfizer dose in a prospective cohort study of healthcare workers, which it has been tracking since the onset of the country’s vaccination campaign in December 2020.

The study found that anti-RBD immunoglobulin G (IgG) levels were increased 1.7-fold after a third dose compared with following the second dose; avidity increased from 61% to 96% – a 6.1-fold increase in neutralization tithers; and that there were 1.1 breakthrough cases per 10,000 days in the three-dose cohort versus 5.8 per 10,000 days in the two-dose cohort.

No serious adverse effects were reported in either case.

Specifically, in the first arm of the study, researchers assessed serological tests of samples from vaccinated HCWs at three different points and compared them: after they received the second dose, before receiving the third dose and after receiving the third dose.

Of 4,526 HCWs who were eligible for this part of the study, 1,047 serum samples from pre- and post-third dose time posts were evaluated. A 31-fold increase in IgG and neutralizing antibodies was observed after the third vaccine dose compared to after receiving the second dose and a 41-fold increase after the third vaccine dose compared to immediately before – five to six months after the second vaccine.

There was also a minor but significant increase in T cell activation, the study showed.

Secondly, the team compared antibody levels of breakthrough cases following the third vaccine dose compared to matched, non-infected controls.

“To investigate any added effect of the third vaccine dose on humoral response, we compared IgG and neutralizing antibodies at their peak levels following the second vaccine dose to that of the third dose,” they wrote in their paper.

“IgG and neutralizing antibody results were available for 3,477 and 664 HCWs, respectively, after the second vaccine dose and for 1,232 and 692 HCWs after their third vaccine dose. A linear mixed model was used to examine the differences in immunogenicity across age, sex and number of comorbidities, comparing post-second dose IgG levels and neutralizing antibody titers. The estimated geometric mean titer (GMT) for IgG following the second dose, in binding antibody units (BAUs), was 1,586 (95% CI, 1,458–1,709), and for IgG following the third dose, it was 2,745. Thus, a 1.7-fold increase in IgG levels occurred after the third dose in comparison to after the second dose.

“Neutralizing antibody levels after the second and third vaccine doses were 646 and 3,948, respectively. The neutralizing titer after the third dose was thus 6.1-fold greater than that of the second dose,” they concluded.

Finally, in a third arm, Sheba compared COVID-19 infections among HCWs with two vaccines given at least five months previous compared to those who received three doses. There was data available for 12,290 individuals who had not been previously infected and were eligible for a third shot. In total, 407 HCWs tested positive for COVID-19 via a PCR test: 368 in the two-dose cohort and 39 in the three-dose cohort.

“After adjustment for gender, age and time (weekly period), estimated vaccine effectiveness against PCR-confirmed infection regardless of symptoms of the third dose relative to two doses was 85.6%,” the team wrote.

The safety arm, in which adverse events among those vaccinated with the third dose were assessed via electronic questionnaire resulted in no difference from a second shot.

The study was conducted when the Delta variant was dominant in Israel, and the researchers highlighted that the results could change with other variants of concern. Nonetheless, they said, “our immunogenicity data can be of great importance once vaccine penetration and correlates of protection levels are determined.”

Image Credits: Samy Rakotoniaina/MSH, ABC7 News.

Pro-abortion protests have erupted in the US.

The global anti-abortion movement will get a boost if the US supreme court dismantles the 1973 landmark court case, Roe v Wade, that legalised abortion – but bans are ineffective in stopping abortions, succeeding only in making them unsafer.

“Any regression in protection of the right to abortion would not only stand to damage the global perception of the United States; it would also set a terrible example that other governments and anti-rights groups could seize upon around the world in a bid to deny the rights of women, girls and other people who can become pregnant,” said Agnès Callamard, Amnesty International’s Secretary-General.

Callamard added that even predominantly Catholic countries like Argentina, Ireland, Mexico and Colombia had decriminalised and legalised abortion, but there “are grim signs that the US is out of step with the progress that the rest of the world is making in protecting sexual and reproductive rights”.

Colombia legalised abortion until 24 weeks of pregnancy in February, Mexico’s supreme court decriminalised abortion last year, while Argentina legalised abortion in 2020, and Ireland in 2019. There are signs that Chile and Brazil might also open access to abortion. 

However, Catholic Poland restricted access to abortion in 2020. And if Roe v Wade is overturned, US women and girls in states that do restrict abortion will be in a similar position as women in most countries in Africa, the Middle East, Latin America and South-East Asia.

World Population Review

Nearly half of all pregnancies, totalling 121 million each year, are unintended, according to the State of World Population 2022 report, released last month by UNFPA, the United Nations sexual and reproductive health agency.

Over 60% of unintended pregnancies end in abortion and an estimated 45% of all abortions are unsafe, accounting for five to 13% of all maternal deaths recorded, according to the report. 

A 2020 Lancet study found that unintended pregnancies in high-income countries were 34 pregnancies per 1000 women, 66 pregnancies per 1000 women in middle-income countries and 93 pregnancies per 1000 women in low-income countries.

Yet attempts to ease restrictions on abortion – even when a pregnancy threatens the health of a woman or girl or it was the result of rape – face fierce opposition in poorer countries, often with the support of the same US rightwing Christian evangelical and Catholic groups that have mobilised against Roe v Wade.

These anti-abortion organisations are also often against contraception, comprehensive sexuality education for children and LGBTQ rights.

Malawi in sub-Saharan Africa, is an example. It has a high maternal mortality rate, and an estimated 6-18% of these deaths are the result of unsafe abortions. But when Members of Parliament tried to introduce a Bill to expand access to abortion in 2020, US-based Catholics sponsored campaigns to stop this.

US global funding under threat?

 The US is a major global funder of sexual and reproductive health (SRH) services – but the Helms Amendment has prohibited any US foreign aid for abortion since 1973. 

But US support for SRH tends to yoyo widely, depending on which party is in power.

In 1984, Republican US President Ronald Reagan introduced what has become known as the global gag rule, which outlawed US funding to any non-governmental organisations that provide abortions, information, counselling, referrals or advocacy.

While every US Democratic Administration has rescinded the gag law when coming into power, the huge policy swings have badly affected sexual and reproductive services in countries that are dependent on foreign aid as they are unable to maintain consistent services. 

The anti-abortion movement was massively boosted during the Trump Administration, with key posts going to officials that opposed abortion – and this momentum also propelled the Trump appointment of anti-abortion supreme court judges who are due to strike down Roe v Wade.

The Trump administration’s anti-abortion stance was a point of commonality with Russian arch-conservatives.

In October 2020, two weeks before the US election where it was ousted, the Trump Administration mobilised 34 of the world’s most conservative countries to support the Geneva Consensus Declaration.This declares that “there is no international right to abortion, nor any international obligation on the part of states to finance or facilitate abortion”.

Egypt, Uganda, Brazil, Hungary and Indonesia co-sponsored the declaration, which was also signed by Russia, Belarus, ​​Democratic Republic of Congo, Iraq, Libya, Pakistan, South Sudan and Sudan.

While Trump’s defeat has taken the wind out of the Declaration, it has provided a rallying platform for anti-abortion countries – supported by a host of conservative largely US-based Christian organisations.

The arch-conservative Catholic organisation, Ordo Iuris, based in Poland appears to have taken over co-ordinating the Declaration and activities seem to have dried up since Russia’s war in Ukraine.

However, the removal of abortion rights in one of the biggest democracies in the world is already galvanising right-wing groups opposed to abortion who are poised to enjoy their biggest victory in decades.

Image Credits: Gayatri Malhotra / Unsplash.

Dr Tedros visited Kyiv in Ukraine over the weekend.

Russia’s war on Ukraine and its impact on healthcare in the region is the focus of a special session of the World Health Organization (WHO) Europe on Tuesday, as the latest figures show over 200 verified attacks on health facilities.

Ukraine, backed by 38 other member countries including Germany and the UK, requested the session to discuss the attacks on health facilities, the disruption of healthcare including routine vaccinations, the impact of the war on healthcare in the region strained by refugees, and the danger of radiation and chemical events.

Also on the table at the session is a resolution to sanction Russia, a member of WHO Europe, for its attack on Ukraine. This is may result in the relocation of the WHO’s European Office for the Prevention and Control of Noncommunicable Diseases from Moscow, which has been requested by the Ukraine health ministry.

Over the past three days, WHO Director-General, Dr Tedros Adhanom Ghebreyesus and WHO head of health emergencies, Dr Mike Ryan, have been in Ukraine, where they handed over 20 all-terrain ambulances, generators and blood refrigerators to the country’s Deputy Health Minister, Iryna Mykychak. 

Addressing a media briefing on Sunday weekend, Ryan described “intentional attacks on healthcare facilities” as war crime, adding that he trusted that the United Nations and the International Criminal Court was investigating all transgressions.

 

Tedros also met with other senior government leaders to assess the current health needs in Ukraine and visited health facilities damaged during the war.

“WHO is committed to supporting people in Ukraine in accessing much-needed health services. The donation of 20 ambulances will bring lifesaving care as Ukraine’s health services have been significantly stretched and access to health care remains a challenge for many people,” said Dr Jarno Habicht, Head of the WHO Country Office in Ukraine. 

“One of the health workers we spoke to remembered how during the days of constant shelling in their city, ambulances continued to operate even during curfew to ensure people received the care they needed. We are inspired by the bravery of Ukrainian health workers and hope this donation will contribute to their work.”

“Due to the severe disruption to the Ukrainian health system, including routine immunization activities, there are serious concerns about possible infectious disease outbreaks, including measles outbreaks,” the WHO said in its latest situational report on the crisis.

G7 leaders also resolved over the weekend to impose further sanctions on Russia, including phasing out or banning the import of Russian oil. The US also announced further measures against Russian oligarchs and Russia’s gas company.

Meanwhile, Canadian Prime Minister Justin Trudeau visited to Ukraine on Sunday and met with President Volodymyr Zelenskyy, while US First Lady Jill Biden visited mothers and children to express her solidarity on Mother’s Day.

The Ukrainian war unexpectedly disrupted Monday’s meeting of the World Intellectual Property Organization (WIPO), due to discuss the impact of COVID-19 on various sectors. Numerous delegates walked out of the meeting after Russia claimed it was acting against genocide in Ukraine.

Earlier, Russia had started the meeting by condemning “Nazi activity”, prompting condemnation from Australia, Japan, the US, European and Baltic states –  and an appeal from China for all countries to respect each other’s sovereignty and avoid conflict.

 

 

 

 

 

 

Image Credits: WHO.

Data sharing in the time of COVID-19: What works & what we need

Preparing for future pandemics requires us to reuse and share data quickly in order to repurpose that information for improved diagnostics and treatments, proposed data experts and scientists at a high-level discussion at the Geneva Health Forum Wednesday afternoon.

“It’s the value of what’s in data that can be reused, repurposed, to create new knowledge to provide insights into guidelines, and even lead towards better and improved treatments,” said Rob Terry, TDR, the Special Programme for Research and Training in Tropical Diseases.

The panel, ‘Data sharing in the time of COVID-19: What works and what we need’, focused on raising awareness of the lack of sharing of de-identified individual level data from COVID-19 clinical studies to sharing and identifying strategies for sharing data during the pandemic.  

All panelists noted that with sharing data globally, privacy and confidentiality still remains a concern, with many pointing to a need for data protection alongside data sharing.

“There’s a strong need to rationalize data protection laws and then contextualize them and make sure they’re not working against the public that they’re meant to be protecting,” said Naomi Waithira, Mahidol Oxford Research Unit Data Sharing Working Group, COVID-19 Clinical Research Coalition.

Three E’s of data sharing 

Rob Terry
TDR, the Special Programme for Research and Training in Tropical Diseases

In an effort to maximize the benefits of reusing data, Terry brought up the three E’s of data sharing: efficient, ethical, and equitable.

“We must be equitable about sharing – when data is shared, it must not disadvantage those who are sharing the data,” Terry said.

He points to how researchers from low- and middle-income countries often find themselves exploited and exported for the benefit of others.

Data sharing also needs to be fair, so that it’s findable, accessible, and able to be used with other data sets. 

While there are hurdles to overcome with data sharing, shifting to a culture where data sharing is the norm is key, said Terry. 

“There are a lot of issues with data sharing, and they tend to be political, ethnical, technical, legal, and social. And we have solutions for many of those.”

“We need to create a culture where sharing is the norm. The benefits we’re gaining are so much better when the data is available and available for reuse rather than locked away in a drawer or in these days, a hard drive.”

‘Blanket’ privacy laws do more harm for data reuse 

Naomi Waithira
Mahidol Oxford Research Unit
Data Sharing Working Group, COVID-19 Clinical Research Coalition

However, while data privacy laws exist worldwide, to enable data sharing for scientific research, there needs to be more than just “blanket privacy regulation’, but rather regulation that addresses the actual risks of disclosure within its details,” Waithira proposed. 

In the past, there has been the General Data Protection Regulation (GDPR) in the European Union, the Protection of Personal Information Act in South Africa, the Personal Information Protection Law in China, and others that aim to ensure responsible data collection. 

 With data anonymization and de-identification from these laws used as ways to address confidentiality, this reduces the scientific usefulness of the data that could be used for datasets in the future. 

“When anonymizing data, you remove parameters which could potentially identify the person, but the complexity of data reuse [needs this information] because we actually do not know what in the future these datasets could be used for.” 

“We need to understand the data protection rules. What exactly is meant by the GDPR, what does it cover, what doesn’t it cover?” added Nathalie Strub-Wourgaft, of COVID-19 Response & Pandemic Preparedness, Drugs for Neglected Diseases initiative (DNDi). 

Waithira brings up a need to engage with the public so they fully understand their needs and what is actually considered risks with data sharing. 

“We need to have more engagement with the public to understand their concerns and what they perceive as risks over data sharing and reuse, and then use that data to rationalize data protection laws,” she said.  

Harmonizing and pooling data during times of peace 

Nathalie Strub-Wourgaft
COVID-19 Response & Pandemic Preparedness, Drugs for Neglected Diseases initiative

Others addressed how data must be pooled and harmonized across the board in order to quickly combat future pandemics and the spread of  infectious diseases. 

“We need to have information quickly to make sense of the data as quickly as we can,” said Strub-Wourgaft.

Pooling data together, stated Strub-Wourgaft, allows for secondary research to take place, which is especially important for neglected tropical diseases (NTDs).

NTDs typically have little research, few guidelines and little data to work with. 

Using sleeping sickness as an example, DNDi’s consideration of data from diverse studies together allowed regulators to define a certain drug for treatment of sleeping sickness as a benchmark, she said. This also paved the way for other treatments to be developed and to further understand the severity of the illness.

“How do you make sense of clinical severity symptoms in relation to white blood count? You cannot do that without having more coherence by looking at all the data, putting them together and making a robust analysis,” she pointed out.  

Pooling data also provides researchers with more robust indicators about specific sub-population responses, as well as defining factors like: safety signals to consider in  treatment and baseline characteristics to predict severity progression of an illness, as has been the  case with COVID-19. 

Philippe Guérin
Infectious Diseases Data Observatory

Had this harmonization occurred before, we would have prevented many missed opportunities on the potential therapeutics of certain drugs, added Philippe Guerin of the Infectious Diseases Data Observatory.  

The infectious Diseases Data Observation (IDDO) is a platform managed by University of Oxford which is providing researchers with a quality-assured means of sharing data with other experts exploring the same disease or treatment – it’s the kind of platform that Guerin and other panelists say should be expanded now in preparation for the next pandemic – to enable more robust studies of treatments more rapidly. 

“We can’t organize things in times of crisis,”  Guerin said. “Things have to be organized and set up in times of peace. Without this organization in place, we will eventually fail again as we did for Ebola, as we did for COVID. We will fail again to have an environment where we can share and amalgamate data of value for a pandemic like COVID.” 

Existing data repositories such as IDDO were previously recommended as a way to support data sharing effectively, ethically, and equitably. (See related Health Policy Watch story)

Image Credits: Internet Archive Book Image/Flickr, GHF.

The South Sudan Minster of Health, Elizabeth Chuei, is receiving the COVID-19 vaccine at Juba Teaching Hospital.

Now that COVAX has enough stock of COVID-19 vaccines, its focus is on vaccination uptake – including encouraging countries to combine campaigns against measles and polio with COVID-19, and even helping with “campaign-style” vaccination drives.

This emerged at a media briefing on vaccine delivery called by the Access to COVID-19 Tools (ACT) Accelerator, of which COVAX is the central pillar, on Thursday.

Ted Chaiban, head of COVID Vaccine Country Readiness at the COVID-19 Vaccine Delivery Partnership, said that COVID-19 vaccination drives provided an opportunity to strengthen “pre-existing health challenges”, particularly cold chain delivery, health management information systems and training health workers. 

“Integrating COVID-19 vaccination into primary healthcare activities such as measles, polio, and the distribution of malaria bed nets has become important,” said Chaiban.

In January, 34 countries had vaccinated less than 10% of their populations, but this was down to 18 – and 15 of these were in conflict areas.

“In everything we do, what’s important is to put countries’ governments and partners at the centre,” added Chaiban.

“The next three to four months are key as countries use campaign-style strategies to accelerate COVID-19 vaccination while also addressing some of these other health priorities they are grappling with.”

Ted Chaiban, Global Lead Coordinator for COVID Vaccine Country Readiness and Delivery, COVID-19 Vaccine Delivery Partnership

COVAX’s vaccine delivery partners, Gavi and UNICEF, helped Burkina Faso with funds to run a rapid vaccination campaign as there was a risk that 100,000 of its Pfizer doses would expire.

“As we speak, there is a campaign on the way in DR Congo to use several hundreds of thousands of doses of vaccine that expire between May and July,” said Chaiban.

However, Gavi CEO Seth Berkley said that the waste of vaccines was well below 10%. 

The demand for vaccines from COVAX in the second and third quarters of the year is around 380 million doses. But last December alone, UNICEF delivered more than 350 million doses on COVAX’s behalf. 

“Both delivery shipments and demand are slowing down, specifically from quarter one to two,” said Eva Kadilli, director of UNICEF’s supply division.

“While there is ample supply of vaccines to satisfy country needs, massive work has also been done to support the overall infrastructure to enable the uptake of vaccines and really turn them to vaccination as we speak,” said Kadilli.

This includes the delivery of over 1.3 billion syringes – both to address COVID-19 surges and to ensure that routine immunisation doesn’t suffer. 

Rosemary Mburu

Rosemary Mburu, Executive Director of WACI Health and Co-Lead of the ACT-A’s civil society platform, said that vaccine hesitancy and a general distrust of science needed to be addressed.

“Even as supply picked up, we still have pockets of hesitancy and really low confidence in science itself,” said Mburu, adding that Omicron had lowered people’s risk perception.

“During the peak, there was a lot of diversion of human resources from different programmes to come in support COVID-19 response, and now with fewer cases, those health care professionals have returned to their usual line of duty, so you find that we don’t necessarily even have enough vaccinators, for example,” she added.

Berkeley stressed that COVAX did not ship any doses unless countries wanted them – and “we try to give countries their first choice of vaccine, and if that is not available, then obviously offering a second choice as well”. 

However, Gavi skirted questions about whether it would buy Johnson and Johnson (J&J) vaccines produced by South African generic company Aspen, following weeks of appeals from the Africa Centre for Disease Control. Aspen is likely to close its J&J production facility as it has yet to receive any orders for its vaccines despite 

Berkley simply said there was “more demand for mRNA vaccines”. However, he added that COVAX was “committed to making all vaccines available that are in the portfolio that meet WHO quality standards and recommendations”.

“The challenge we have is that some companies are going to try to particularly push their vaccines,” he added.

Previously, a Gavi spokesperson told Health Policy Watch  that “COVAX is committed to diversifying global supply, including through the development of regional manufacturing sites, especially in Africa.

“In the case of Aspen, the current overall demand situation means we are currently not in a position to buy large quantities of vaccines. However, we are in discussion to see if a collaboration would be feasible as part of expanding regional supply.”

Image Credits: UNICEF.

Geneva Health Forum panel tackles “the effects of pollution on health: Current risk and possible solutions” on May 5, 2022.
Geneva Health Forum panel tackles “the effects of pollution on health: Current risk and possible solutions” on May 5, 2022.

Pollution is responsible for the premature deaths of approximately 9 million people each year; more than the number of deaths attributable to war and terrorism, malaria, AIDS, tuberculosis, drugs, alcohol or even smoking.

Chemical pollution severely undercounted in premature deaths from pollution

That’s also the equivalent of one in six premature deaths worldwide, pointed out Rachael Kupka, of the Global Alliance on Health and Pollution (GAHP) at a panel on the effects of pollution on health on Thursday, the final day of the Geneva Health Forum.

That estimate, originally published in 2017 by the Lancet Commission on Pollution and Health, is likely even higher now, insofar as an updated Lancet report is expected to be published on May 18, she noted.

While the conference this year has focused heavily on a emerging knowledge about the complex relationship between climate change, biodiversity loss, and pandemic risks – the panel on the GHF’s closing day, drove home the point that pollution of the air, waterways and soils is a fundamental driver of all of these trends. And despite half a century of environmental action, health risks from pollution remain as acute as ever.

Types of pollution

Types of pollution

Lead poisoning – one in three children worldwide have elevated blood lead levels

Lead pollution in the Amazons

While there are many sources of pollution – from traditional ones such as biomass burning and water contamination to ‘modern’ sources like vehicles, one important risk that still needs more attention is lead pollution, Kupka and other panelists pointed out.

Despite the worldwide phase out in leaded gasoline, environmental lead remains pervasive, causing some 900,000 deaths a year, according to the 2017 Lancet report.

“We have not eradicated lead poisoning,” stressed Kupka , citing a recent report by UNICEF and Pure Earth that showed one in three children have elevated lead levels of at least 5 micrograms per decilitre of blood – the level at which the World Health Organization recommends intervention. That’s 800 million children and 90% of them live in low-and-middle-income countries, often least equipped to handle the health impacts.

“Lead poisoning causes irreversible neurological damage,” Kupka said.

It also caused up to a 2% drain on LMIC’s Gross Domestic Product (GDP) from loss of productivity, and accounts for 7% of healthcare costs in middle incomes countries.

According to Kupka, primary sources of lead exposure today are not always the expected ones.

They include spices, cookware and lead acid car and truck batteries – as well as areas tainted by oil extraction and other industries.

She explained that in some countries, especially in South Asia, Eastern Europe, the Middle East and North Africa, lead salts are added to spices like turmeric and paprika to make them more colourful.

“Due to climate change, sometimes the turmeric roots become a dull yellow. People use turmeric for colouring – they want to make their rice and other foods colourful – so they are adulterating the spice,” Kupka said.

In countries ranging from Mexico, Turkey and Morocco some artisans still glaze their ceramic cookware with lead glazes.

And in most of the developing world, lead acid batteries are not properly disposed of, but rather dropped into landfills; lead and sulphuric acid seep into the soil contaminating the earth and underground fresh water supplies.

The effects of lead poisoning can be seen in the Peruvian Amazon, where oil extraction started mainly in indigenous areas in the 1960s, according to Cristina O’Callaghan.
The effects of lead poisoning can be seen in the Peruvian Amazon, where oil extraction started mainly in indigenous areas in the 1960s, according to Cristina O’Callaghan.

The effects are acute and chronic

Extractive industries, such as oil, are another source of lead poisoning, including for communities living around mining sites, where the gradual contamination of land and waterways may receive little notice or attention.

The Peruvian Amazon is one example, said another panelist, Cristina O’Callaghan of the Universitat Oberta de Catalunya and Barcelona Institute for Global Health.  Oil extraction began there in the 1960s. In recent years, she lead research efforts looking at the health effects of exposure on the area’s indigenous residents to lead, present in the crude oil spills that dot the areas forests and waterways – also contaminating local wildlife.

A 2021 study of some 1047 people in 39 indigenous communities of the northern Peruvian Amazon found that 49% of children and 60% of adults had blood lead levels (BLLs) above the WHO Guideline of 5 micrograms per decilitre of blood. The study, published in Environment International, found mean blood levels in some areas as high as 8.1 µg/dL among children under the age of 12, and 8.8 µg/dL among older participants.

Mean blood lead levels (BLL) in the study population was higher than 5 μg/dL
49% of children and 60% of adults had BLL above this threshold

“There are several routes of exposure: skin absorption and inhalation, but also ingestion,” O’Callaghan said, citing another study that observed that 50% of hunted biomass in the area had been affected by oil pollution. Displaying images of animals with faces covered in oil, she described how animals often seek out oil slicks to lick up the salts that their bodies require – but in this case are toxic lead salts.

“It turned out consumption of wild game was also a factor,” she said. “From the animals, it was getting into humans.”

Health effects are both acute and long-term. One cross-sectional study published in 2016 by BMC that looked at communities living around oil fields in the Ecuadorian and Peruvian Amazon, as well as the Nigeria’s contaminated Delta region, catalogued health effects as ranging from respiratory, eye and skin symptoms, headache, nausea, dizziness and fatigue, to neurological and psychological disorders; reduction of lung function, genotoxicity and alterations in hormonal status.

“It is very important to have valid data on environmental exposures and conditions of life of understudied populations,” she continued. At the same time, since there is already overwhelming data about the health effects of lead, even at very low levels of exposure, “we should not wait. We do not need these complex studies to act.”

Air pollution in Mashhad, Iran

More than six million people die each year from air pollution

Pollution is the largest cause of death globally.

Even more pervasive than lead, is air pollution from ambient air and household air pollution sources – which accounts for some 7 million deaths annually, according to the World Health Organization’s latest report.

“It is estimated that 99% of the entire world’s population breathes air with unhealthy levels of fine particulate matter (PM2.5) and nitrogen dioxide (NO2)that threatens their health,” said Liz Arnanz Daugan of the NCD Alliance.

Daugan said that air pollution ranks up with unhealthy diets, physical inactivity and tobacco use as a leading but modifiable cause of noncommunicable disease.

While many people associate air pollution with respiratory diseases and lung cancer, air pollution at low levels of chronic exposures also is responsible for a significant proportion of deaths globally from heart disease, hypertension and cancers as well as having impacts on almost every other organ of the body somehow.

People are exposed to higher levels of air pollutants in Asia, Africa and the Middle East in their homes and on the streets – and they may also be exposed to higher levels of dust and chemical air pollutants in workplaces, particularly informal workplaces where enforcement of occupational health rules is poor or non-existent.

The case of Madagascar

Health impacts of pollution in Madagascar

Madagascar is a country whose air quality is considered “moderately unsafe,” according to WHO standards. Some 28,280 people died as a result of air pollution in the country in 2016, according to Tatiana Eddie Razafindravao, chargé d’affaires of the country’s UN Mission to Geneva and the UN, who also spoke during the GHF session.

Considering all forms of air, water and chemical pollution together, some 31% of all premature deaths in Madagascar are due to pollution, shared Razafindravao during the session, citing data from 2016. “That’s a loss of 3.3 million healthy life years in 2016 through exposure to pollution.”

The air pollution in Madagascar is a result mainly of emissions from vehicles, bushfires, brick making, use of fossil fuels, charcoal consumption and waste that is incinerated in urban spaces.

A few years ago, with the support of GAHP, the country decided to take action.

In 2018, it ratified a “Health and Pollution Action Plan” and established a pollution control taskforce. The Health and Environmental ministries started evaluating their pollution policies and made a national plan for health security and air pollution control.

“But we are not without challenges,” said Razafindravao, noting that the country lacks technical and financial support to move as quickly as it wants to against pollution. It is also sometimes difficult to convince the public to adopt new behaviours that are conducive to preserving the environment and protecting their health, she said.

“We are working on developing a 10-year roadmap for pollution management in collaboration with GAHP,” Razafindravao explained.

She said Madagascar also hoped to establish an independent institute for pollution and chemical management that will bring together state entities, academicians, the private sectors, NGOs and international organizations around solving the crisis.

But she added that national and international legal frameworks are also important – because those in turn compel more investments and enforcement.

Practical steps

Daugan called on countries to adopt, and more strictly enforce, tougher emission standards for key pollutants.  Those should include air quality standards that correspond to WHO guideline levels for PM2.5 and NO2.

More sustainable urban planning, particularly in cleaner transport systems can also make physical activity more feasible – for a double “co-benefit” to health.

Other measures include the removal of fossil fuel subsidies that amount to hundreds of billions of dollars a year in G-20 countries alone – and wreak trillions of dollars in health damage, she said.

Removal of such subsidies also would clear the way for redirecting more development investments toward health-promoting renewable energy; cleaner public transport, walking and cycling; and improved housing with access to clean energy sources.

“We must make addressing pollution a national and international priority,” Kupka concluded.

Image Credits: ISGlobal – Barcelona Institute of Global Health , Maayan Hoffman, GAHP , Screenshot of PowerPoint presented by Rachael Kupka on May 5, 2022 at the Geneva Health Forum, Screenshot, PowerPoint Slide, Cristina O’Callaghan on May 5, 2022, O'Callaghan-Gordo, C, et al. Environment International 2021, Mohammad Hossein Taaghi, GAHP.

  Excess deaths during the first two years of the COVID-19 pandemic are almost triple officially-reported deaths – around 14.9 million deaths rather than the 5.4 million currently reported, according to new figures released by the World Health Organization (WHO).

These much-delayed excess death statistics were finally released on Thursday after being contested by India, which appears to have massively under-estimated its mortality between January 2020 and December 2021.

The Indian government had reported 481,000 deaths in the two-year period whereas the WHO expert panel pegged India’s deaths as almost 10 times higher – at 4.75 million – WHO’s data technical officer, Dr William Msemburi, told a media briefing.

Ten countries are responsible for 68% of all deaths, namely Brazil, Egypt, India, Indonesia, Mexico, Peru, Russia, South Africa, Turkey and the US (alphabetical order), added Msemburi.

More men (57%) than women (43%) died, while 82% of those who died were over the age of 60, he added.

Direct and indirect deaths

Dr William Msemburi, WHO Technical Officer, Department of Data and Analytics

Excess mortality is the difference between the number of deaths that have occurred and the number that would be expected in the absence of the pandemic based on data from earlier years.

Explaining the “excess deaths” over the past two years, WHO’s Dr Samira Asma said that they included deaths caused directly by COVID-19 and deaths indirectly associated with the pandemic due to unmet health needs.

Meanwhile, 70 countries did not have accurate measures of their population’s mortality, 42 of these in Africa, and figures for these countries were reached purely by modelling.

“This is a staggering toll, and there are staggering data gaps,” said Asma, WHO’s Assistant Director-General for Data and Analytics.

Dr Samira Asma, WHO Assistant Director-General, Data, Analytics

WHO Director-General Dr Tedros Adhanom Ghebreyesus, said that the “sobering data not only point to the impact of the pandemic but also to the need for all countries to invest in more resilient health systems that can sustain essential health services during crises, including stronger health information systems”.

“WHO is committed to working with all countries to strengthen their health information systems to generate better data for better decisions and better outcomes,” added Tedros.

Dr Jeremy Farrar, Director of Wellcome, said that “this devastating death toll was not inevitable”.

“Even now a third of the world’s population remains unvaccinated,” added Farrar. “More must be done to protect people from the ongoing Covid-19 pandemic and shield humanity against future risks.

“Climate change, shifting patterns of animal and human interaction, urbanisation and increasing travel and trade are creating more opportunities for new and dangerous infectious disease risks to emerge, amplify and then spread.”

The WHO and the United Nations Department of Social, Economic and Social Affairs worked together on the data, guided by a technical advisory group of 40 global experts.

“Underlying this process is WHO’s commitment to producing a completely transparent audit trail of all these estimates that we put out,” said WHO senior data advisor Dr Somnath Chatterji.

“This means that we make available all the input data, the method that we have used to generate these estimates as well as the code that has been used. If a country would like to look at this estimate they can, first of all, understand the entire process. Then they can take their own input data if needed, and rerun these models to generate their estimates.”

Mechanical ventilators can help patients with severe COVID-19 breathe.

The COVID-19 pandemic has increased the level of worldwide investment in respiratory care and now that cases are on the decline, countries need to develop long-term strategies to use oxygen, according to health experts.

“Severe pneumonia, sepsis, trauma complications – there are many patients that would benefit from oxygen,” explained Janet Diaz, a team lead at the World Health Organization (WHO) who spoke about oxygen redeployment on Thursday morning at the Geneva Health Forum.

Every year, 7.2 million newborns in low-and-middle-income countries (LMICs) suffer from severe pneumonia and need medical oxygen to survive. To date, fewer than one in five children actually gets it, making pneumonia the biggest infectious killer of these children.

“It is always important to think about where patients get oxygen – emergency departments, critical care areas, acute care areas – and the different populations of patients that could be oxygen candidates,” Diaz continued. “The investments made are a big win. Now we have to ask, ‘what’s next?’”

Diaz stressed that oxygen redeployment “won’t just happen.” Specific plans to integrate COVID-19 equipment into the health system will be required for the transition. She cited the first steps of this plan as creating a roadmap, entering high-level national planning with donors and engaging and training the workforce to build their capacity to properly administer oxygen to the right people at the right time.

The ACT-A Oxygen Emergency Task Force

The ACT-A Oxygen Emergency Task Force was established by UNITAID in February 2021, about a year into the pandemic, to help LMICs gain access to secure oxygen supplies and the technical support and skills to manage them – and is expected to continue to play a key role in the transition.

More than 20 United Nations and global health agencies partnered on the task force, mobilising more than $700 million in grant financing in the first year. In December 2021, the US government announced plans to infuse another $75 million for additional support of USAID’s Rapid Response efforts, which includes investment to help strengthen oxygen market systems from production to delivery.

The task force was initially focused on five key objectives, which were outlined by a UNITAID representative on Thursday: assessment of acute and long-term oxygen needs in LMICs; support and review of funding requests to the task force; procuring oxygen; increasing LMIC access to liquid oxygen, oxygen plant repairs and critical parts; and strengthening advocacy and communication efforts to highlight the importance of oxygen.

Towards the end of the first year, the task force shifted slightly to focus on identifying priority countries; coordinating action on quick wins with a special focus on monitoring pressure swing adsorption (PSA) plant repairs; and resolving supply gaps and bottlenecks.

Now, as a result of this work, many LMICs have started this year with a greater capacity to meet the needs of their citizens – those with COVID-19 and others who are suffering from respiratory diseases, the representative said.

Nigerian physician Adamu Isah speaks via video at the Geneva Health Forum on May 5, 2022.
Nigerian physician Adamu Isah speaks via video at the Geneva Health Forum on May 5, 2022.

Nigeria: Six lessons learned

Adamu Isah, a Nigerian physician who works with the country’s Save the Children program, highlighted the lessons that his country learned over the past two-and-a-half years, which he said could be translated to other LMICs.

Nigeria is a federal republic with state governments that have their own autonomous parliaments.

“When you run a program, you have to take note of this and make sure there is coordination between the national efforts and those on the state and local level or it will not be sustainable,” Isah stressed.

Nigeria’s Health Ministry established an oxygen desk where regular meetings between all engagement parties to share ideas. Now, the country is preparing to conduct a nationwide assessment to harmonize the assessments done by individual partners.

He also said Nigeria was evaluating how to ensure it could sustain its oxygen supply.

The current policy is that, for the first six months that people need oxygen in Nigeria, they receive it free of charge. But this was becoming unsustainable – the lesson being that programs need to be evaluated for their sustainability from the beginning. He said the country is now considering either looking for alternative and supplementary funding sources or asking patients to pay for some of the cost.

They also learned to document the oxygen being given to patients.

“Before COVID, no one was talking about oxygen in hospitals,” Isah said, but they quickly learned the need to document the type and amount of oxygen being given, and for what indication it was being used, to ensure proper use and also anticipate future needs.

Nigeria also understood that some people may be hesitant to give their children oxygen and therefore learned to engage religious leaders and traditional rules to promote its use.

Lastly, the country has begun to evaluate if it is better to procure oxygen devices or to develop the capability of manufacturing them in-house.

“In the days of COVID there were long delays,” Isah said. “The question is could we make our own?”

Rahel Belete says there needs to be international cooperation around oxygen. She spoke at the Geneva Health Forum on May 5, 2022.
Rahel Belete says there needs to be international cooperation around oxygen. She spoke at the Geneva Health Forum on May 5, 2022.

Ethiopia: A head start

When COVID struck, Ethiopia was in a better place than most LMICs due to work it had been doing since 2015 in collaboration with the Clinton Health Access Initiative (CHAI) to improve oxygen services at public hospitals, explained Rahel Belete, who runs CHAI’s Ethiopian program.

The country had already developed new policies and guidelines, procured more oxygen equipment and trained health workers to better diagnose and treat hypoxemia. By 2019, oxygen was available in 100% and pulse oximeters in 96% of in-patient pediatric departments where the program ran. Clinical practice had also improved.

Certainly, the investments the country made gave Ethiopia a head start, Belete said. However, the demand for oxygen during the pandemic far exceeded Ethiopia’s capacity, especially given the country had the fourth highest COVID-19 caseload in Africa.

There have been 470,647 infections and 7,510 coronavirus-related deaths reported in Ethiopia since the start of the pandemic, according to Reuters. Today, Ethiopia is only reporting an average of 22 new daily infections.

The pandemic propelled CHAI to look forward and consider a next phase of its oxygen roadmap, Belete explained.

The components of the new roadmap are focused on:

1. boosting the capacity of existing oxygen plants;

2. tracking and more effectively using data to inform decisions;

3. training healthcare workers to adopt standardized oxygen therapies, while at the same time ensuring staff knows how to use the systems and therapies that do exist so that they don’t end up in the junkyard;

4. making sure any new oxygen tools are standardized to make it easier to find and fund replacement parts, as well as putting a reliable maintenance program in palace;

5 sustainability – making sure the funding is in place to continue growing the program.

“It is important that we have a platform in which there can be international cohesion in the thinking, brainstorming and coordination,” she concluded.

Image Credits: Sky News, Agência Brasília , Maayan Hoffman.

Francoise Vanni, Director of External Relations at The Global Fund

The Global Fund intends to further prioritise integrated health systems and boost people-centred approaches, it was announced at the Geneva Health Forum on Wednesday.

Although urgent improvements in health and community systems only made up about 14% of its $3.4 billion COVID-19 budget, the organisation expressed strong commitment to these themes in future. 

New priorities emerge 

According to the World Health Organization (WHO), “integrated health systems” is a humanistic method of organising and managing health services that focuses on delivering to people the care that they need, in ways that are prompt, effective, user-friendly, and cost-effective.

Speaking at the Geneva Health Forum on Wednesday, Francoise Vanni, Director of External Relations at The Global Fund, noted that this new strategy reinforces The Global Fund’s mission, as the needs of people take centre-stage more than ever. 

“We will be focusing and incorporating this on things like supply chains, digital health information systems, digital health, community health workers and other key areas of health systems,” Vanni said.

She noted that integrated health systems have become necessary considering the growing challenges in accessing healthcare and burgeoning health issues affecting the population. 

Change necessitated by COVID-19

The COVID-19 pandemic has proven a major eye-opener for the global health financing landscape, setting new standards and models for successful programme implementation. 

It is therefore no wonder that the Global Fund, one of the largest global health financing and partnership organisations, has shifted its focus to integrated health systems  as part of its aim to invest additional resources in fighting epidemics. 

To date, the Fund’s COVID-19 Response Mechanism (C19RM) has supported countries to mitigate the impact of the pandemic on more routine HIV, TB and malaria programmes. It is largely because of its partnerships with communities and local stakeholders, Vanni says, that The Global Fund was able to respond so quickly to the COVID-19 pandemic. “These frontline responders were key”, she added, and were part of the inspiration to reboot the organisation’s future priorities.

Increasing preparation and prevention budgets

Out of The Global Fund’s Total COVID-19 approved 2021 funding of nearly $3.4 billion, nearly $472 million was spent on urgent improvements in health and community systems. This represented less than 14% of the total amount but Vanni revealed this would significantly improve in preparation for future pandemics.

 

 

 

Vaccinating dogs against rabies prevents the disease in people.

As many neglected tropical diseases (NTDs) spread via vectors like ticks or domestic mammals, human-centric prevention programmes alone are inadequate – and adopting more holistic approaches such as the routine vaccination of animals is logical. 

This was the key message conveyed by health and policy experts at a panel discussion, “For a new approach to NTDs based on One Health”, at the Geneva Health Forum on Wednesday. 

‘One Health’ is a perspective that acknowledges the interconnectedness of human health with animals, microorganisms and the wider environment. A solution aiming at more lasting, sustainable health development, it moves beyond treating disease in humans to tackle the root causes of the spread of diseases.

Dirk Engels, former NTD director at the World Health Organization (WHO)  and a member of the Swiss Alliance Against Neglected Tropical Diseases (SANTD), highlighted the potential of One Health approaches to eradicate diseases in animal reservoirs, reduce the population growth of infected animals, and consequently save more human lives.

Rabies, with its high mortality rate of 80% and explicit animal-to-human transmission, is particularly amenable to holistic control methods. As the WHO’s Bernadette Abela-Ridder remarked, rabies control is often restricted to post-exposure prophylaxis in humans, despite the potential of mass vaccination in dogs to curb rabies deaths quickly, cheaply and effectively – as 99% of rabies cases are dog-mediated.

“We know vaccinating dogs prevents rabies,” she said – yet outside the South American continent, where several countries have successfully brought down rabies deaths through mass dog vaccination campaigns, “nobody actually does it”.

“If you want to stop rabies in humans very quickly, you vaccinate the dogs,” she added. “Dogs are part of the patchwork of our society, yet nobody is responsible for them: who will take care of dogs and pay for costs of vaccination?”

Not only would this One Health-inspired strategy address the root cause of the disease, it would also circumvent the hassles of current human prophylaxis, which involves a combined multi-dose treatment administered over two weeks.  

NTDs are a group of 20 preventable and treatable diseases that disproportionately affect marginalized populations in Africa, Latin America, and Asia

Developing ‘bite-sized’ strategies 

For novel strategies against NTDs to persist, countries need to buy into the value of the approach. Indeed, a barrier to embracing One Health is its breadth, noted Abela-Ridder, being a concept that encompasses virtually any component of our environment. This can understandably feel overwhelming for governments. 

However, segmenting such preventive strategies into “bite-sized” pieces will make them far more manageable to implement. In the case of rabies control, for example, this might look like identifying one high-priority target vector, and one single intervention mode – that is, dogs and vaccination. 

This, together with strong and motivated leadership at the national level, is the key for holistic approaches to function as effectively and sustainably as possible. Encouragingly, some countries have already set up dedicated supra-ministerial units for cross-cutting action on One Health. 

For successful provincial, district and community level implementation, the best place to start is building on existing intersectoral collaboration. To achieve this, José María Gutiérrez, a One Health expert at the University of Costa Rica, raised the importance of cooperating with local administrators and parliamentarians on novel NTD prevention. They “have the key” to the intersectoral resources that will cement local programmes, even if the changes start by being “small, but incremental”. 

Galvanising the private sector 

Meanwhile, in another GHF session on One Health, speakers acknowledged that the private sector could play an important role in operationalising this approach.

The speakers stressed that, in a resource-constrained world, every sector intersects with another in a web rather than a linear value chain – and more companies are starting to understand this inter-dependency.

Uta Jungermann of the World Business Council For Sustainable Development said one of the entry points for private sector involvement was in improving health systems: “There’s a question of how to exchange the know-how, innovative capabilities, stakeholder networks, and what unique expertise businesses can bring to the table and identifying health system resilience gaps and then developing strategies to close them,” she said. 

Ilona Kickbusch of the WHO Council on the Economics of Health for All, called for the private sector to be “activated”.

“I think there are good opportunities,” said Kickbusch. “There are so-called CEO roundtables. There are pharmaceutical associations. But they talk among themselves. And then here we talk a bit among ourselves. So this dialogue needs to happen and I know that the World Economic Forum is doing a great job in bringing this together, but we need more, especially for the One Health concept”.

* Additional reporting by Shadi Khan Saif.

Image Credits: Daniel Stewart, Our World in Data.