Hans Kluge, WHO European Regional Director

Cancer services remain backlogged in many parts of the world due to the effects of the two-year-long COVID pandemic – even as Europe hopes a pandemic “ceasefire that could bring us enduring peace” , said WHO’s European Regional Director Hans Kluge Thursday on the eve of World Cancer Day.  

Meanwhile, in Latin America, routine childhood immunizations are down by around 10% as a result of setbacks from the COVID-19 pandemic, leaving the region at very “high-risk” for new and re-emergent vaccine-preventable diseases, said Carissa Etienne, Regional Director of the Pan American Health Organization in a briefing Wednesday evening.

Both WHO regions, which include some of the world’s highest income countries, as well as middle income nations, alongside low-income states, continue to face striking regional imbalances in vaccine distribution, top officials in the two regions also stress – with some countries reaching 70% COVID vaccine countries or more – while others only have reached about 30% of eligible adults with jabs, both Etienne and Kluge stressed in separate press briefings. 

And that still leaves some countries disproportionately vulnerable to the ongoing effects of the Omicron variant – as well as to risks of new emerging variants. 

Cancer – knock-on effects will last for years 

cancer
Cancer services were disrupted up to 50% in the WHO Europe region.

The two-year ongoing pandemic has had “catastrophic” effects on people with cancer, said Kluge, in his remarks – “going far beyond the disease itself.”

One in four people in WHO’s European Region will receive a cancer diagnosis at some point in their lives – and cancer accounts for more than 20% of morbidity and mortality in the WHO region that extends from the Central Asian republics to the United Kingdom, he noted. 

In the European region, cancer diagnosis and treatment services saw disruptions of up to 50% in the early stages of the pandemic he noted. 

And while many EU countries have since rebounded, the picture remains uneven regionally and around the world.

The latest WHO Global Pulse survey on disruptions in essential health service found that in the last quarter of 2021, countries worldwide were still experiencing disruptions in cancer screening and treatment services of between 5-50%, Kluge said. 

“The knock-on effects of this disruption will be felt for years,” Kluge added, noting that 44% of countries worldwide were reporting backlogs in cancer screening in the second half of 2021. 

Any post-Omicron ‘respite’ must be used to restore other essential health services 

Problems are compounded, he added, by the fact that the “health workforce is overstretched and exhausted – after being repurposed to address the direct impact of the virus.  

“Any respite the widespread immunity provides, thanks to vaccination and in the wake of the less severe Omicron, together with the coming spring and summer season, must be used immediately to enable health workers to return to other important health care functions, in order to bring backlogs for chronic care services down. 

“As we go forward, maintenance of essential health services, including services along the journey of cancer care, from prevention, early detection, diagnosis, treatment and quality of care will be a component of emergency planning and response,” he said. 

Americas also struggling to overcome disruptions in routine childhood vaccinations 

A child receives a routine vaccination in Cuba, which is a world leader in childhood immunization.

Meanwhile, speaking from Washington DC, PAHO’s Etienne sounded a similar theme. 

But her message was focused around pandemic-related setbacks in childhood vaccinations across the WHO’s Americas’ region – which includes the affluent USA and Canada, alongside high, middle and low income countries of Latin America and the Caribbean. 

Routine childhood vaccinations for a third dose of diphtheria, tetanus, pertussis (DTP) vaccine has declined by 10% in the region, as a result of setbacks from the COVID-19 pandemic, leaving the region at very “high-risk” for new and re-emergent vaccine-preventable diseases because of lower immunization coverage, she said: 

“Despite the tremendous achievements of immunization programs in past decades, that progress has stalled in some countries, and has even reversed in this region.”  

Carissa Etienne, Director of the Pan American Health Organization/WHO Region of the Americas

While the goal was to fully cover at least 95% of eligible children in 2020 with the DTP vaccine, 26 countries and territories of the Americas did not reach that goal. And some 14 countries in the region had particularly low coverage with the third dose – of 10% or less. 

As in Europe, she attributed the setbacks to the reassignment of healthcare professionals from primary care centers to hospitals and intensive care units – alongside public hesitations about getting vaccinated during the pandemic.  

PAHO is currently working with Ministries of Health across the Americas to revitalize family immunization programs as one of their “highest priorities”.

“We are at a juncture where it is urgent to look at routine immunization programs,” said Etienne. 

As countries reopen – uneven vaccination coverage exacerbates future variant risks 

Both Europe and the Americas also are facing major inconsistencies in vaccine coverage rates within countries of the region, the officials also noted. 

And that poses additional risks as countries relax restrictions, Kluge stressed. 

“We in the European region have a unique situation,” Kluge said. “Once the Omicron wave has subsided, there will be a large capital of [SARS-CoV2]  immunity, due to the infection in general, and quite high vaccination rates generally.”

That offers opportunities to restore normalcy and “respond to new variants that will inevitably emerge without reinstalling the kind of disruptive measures that we needed before,” he said. 

Can the pandemic ceasefire bring enduring peace?

“This period of higher protection should be seen as a ‘ceasefire’ that could bring us enduring peace,” he said.  But he insisted that his message does not contradict those coming from Geneva, either, where WHO’s Director General Tedros Adhanom Ghebreyesus urged caution in reopening economies at a briefing earlier in the week.

“The pandemic is not over, as Dr Tedros is rightly saying.”    

In particular, vaccination rates need to be pushed higher in undercovered parts of the Europe – as well as worldwide – to expand protection against the emergence of still newer, and potentially more dangerous variants, Kluge stressed. 

“It is because we see the opportunity that the top priority is to bring all countries to a level of protection which allows them to grasp this opportunity and look ahead towards more stable days

“And that means that we need a drastic and uncompromising increase in vaccine-sharing.” 

For instance, while 66% of people across WHO’s vast European region have received a second vaccine dose, the numbers go as high as 70% in high income countries – where 40% of the population also has boosters, said Oleg Benes, another WHO European region official. 

But in the region’s lower middle income countries, rates remain much lower. “Booster courses are just starting to roll out.” Vaccine rates are as low as 30% in some countries, with only one in 3 older adults, on average protected.” That, he admitted, is also due in part to higher rates of vaccine hesitation among older people in some countries. 

Inconsistent vaccination coverage in the Americas ‘worrisome’ 

Similar inconsistencies in vaccination coverage prevail in the Americas – where average vaccination rates are also 60% or more. And that remains a “worrisome sign”, said Etienne. 

That is particularly true as the Americas region overall is still seeing rising rates of the Omicron variant – even while Europe seems to have turned the corner.

While 14 countries and territories have immunized 70% of their populations, the same number of countries have yet to protect 40% of their people. 

More than 25% of people across the region have yet to receive a single dose of protection – rising to 54% in low- and middle-income countries, PAHO officials said. 

As in other parts of the world, countries that have experienced civil conflict, unrest and natural disasters lag even further behind. 

Haiti, notably, has less than 1% of its population fully vaccinated against COVID-19. The country  began its vaccine drive late last year, having only received donations from donors such as the WHO-co sponsored COVAX initiative in July. 

Jamaica also is behind in its vaccinations – with only 21% of people fully vaccinated. 

Meanwhile, COVID-related deaths have increased for the fourth consecutive week in all subregions of north and south America and the Caribbean, with an increase of 33% last week over the week previous.  That, officials added, further underscores the impacts of uneven vaccination rates – which continue to leave unvaccinated older and more vulnerable groups more prone to serious disease.

Image Credits: Daily Caller/Twitter , Radio Metropolitana Cuba/Twitter .

Child COVID vaccinations – now the FDA has invited Pfizer to submit for approval of vaccines for under-5s.

What does the FDA know that we don’t? Hopefully a lot.

Without offering much detail, the FDA yesterday afternoon asked Pfizer to send over a rolling submission to amend its Covid-19 vaccine Emergency Use Authorization to include children 6 months to under 5 years of age.

The tricky part in making such a request is that last month, Pfizer announced that its vaccine (a 3 µg dose for the youngest population) had performed better in the 6- to 24-month-old population, than in children ages 2-4 – that is as compared to the results of the vaccine among 16- to 25-year-olds, in which high efficacy was demonstrated.

But the company wants to test a third jab for all of the under-5s to see if it will even out the results somehow for older tots. And it doesn’t seem to be changing its tune, even with this latest FDA request.

“Ultimately, we believe that three doses of the vaccine will be needed for children 6 months through 4 years of age to achieve high levels of protection against current and potential future variants. If two doses are authorized, parents will have the opportunity to begin a COVID-19 vaccination series for their children while awaiting potential authorization of a third dose,” Pfizer CEO Albert Bourla said in a statement.

No safety concerns were identified in that prior analysis of the 3 µg dose data among children 6 months to under 5 years of age, Pfizer said.

While the FDA often requests that companies provide additional safety or efficacy data (usually before a new drug or vaccine is approved or authorized), the agency rarely requests a specific submission, but acting FDA commissioner Janet Woodcock said this is a priority right now for the agency.

But others are not so sure:

“I don’t think authorizing two doses in children ages 2 to 4 years of age where effectiveness in this age group hasn’t been confirmed is going to convince the majority of parents to vaccinate their children,” Norman Baylor, president and CEO of Biologics Consulting and a former head of the FDA’s vaccine office, told STAT News. “If the vaccine in this age cohort is a three-dose vaccine, FDA should review the data from the three-dose series before authorizing the vaccine.”

See ENDPOINTS News: FDA takes a rare step and asks Pfizer to submit a COVID-19 vaccine EUA for the youngest children.

Image Credits: Quinn Dombrowski.

Moderna and the nonprofit science research organization IAVI have administered the first doses in a Phase I clinical trial of an experimental HIV vaccine, delivered by messenger RNA (mRNA) – the technology that revolutionized vaccines against COVID-19.

The trial kicked off last week at George Washington University School of Medicine and Health Sciences in Washington, D.C. It is partially funded by the Bill & Melinda Gates Foundation.

The Phase I trial, IAVI G002, is testing the hypothesis that sequential administration of priming and boosting HIV immunogens delivered by messenger RNA (mRNA) can induce specific classes of B-cell responses and guide their maturation to generate broadly neutralizing antibodies (bnAb) that would protect against disease, a joint statement by Moderna and IAVI explained.

The immunogens being tested were developed by scientific teams at IAVI and the Scripps Research Institute, and will be delivered via Moderna’s mRNA technology.

“The search for an HIV vaccine has been long and challenging, and having new tools in terms of immunogens and platforms could be the key to making rapid progress toward an urgently needed, effective HIV vaccine,” said Mark Feinberg, CEO of IAVI – whose board includes prominent names from industry, research, The Global Fund, and the Africa Centers for Disease Control.

More than 36 million people have died of AIDS-related illnesses

As of June 2021, 28.2 million people were using antiretroviral therapy for the treatment of HIV, according to UNAIDS, and 37.7 million people were living with the disease in 2020.

Some 680,000 people died of AIDS-related illnesses in 2020. A total of 36.3 million people have died of AIDS since the virus exploded into a pandemic in the late 1980s.

Photo: UNAIDS/Sydelle Willow Smith

The mRNA vaccine strategy centers on stimulating the immune system to produce bnAbs against HIV, a process known as “germline-targeting.” Antibodies are produced by B cells, which start out in a “germline” state.

BnAbs are believed to be capable of neutralizing different HIV strains by binding to hard-to-reach but consistent regions of the virus surface. If it works, the germline targeting strategy could offer protection against millions of different HIV strains circulating in various parts of the world.

Last year, Dr William Schief, a professor at Scripps Research Institute and executive director of vaccine design at IAVI’s Neutralizing Antibody Center – who developed the HIV vaccine antigens  being evaluated in mRNA formats in this study – announced results from the IAVI G001 clinical trial, showing that an adjuvanted protein-based version of the priming immunogen induced the desired B-cell response in 97% of recipients.

Until now, no HIV vaccine candidate has been able to induce a protective bnAb response in humans.

The release said that “given the speed with which mRNA vaccines can be produced,” using the platform could shave off years from typical vaccine development timelines – like it did for the development of an emergency coronavirus vaccine.

“We believe advancing this HIV vaccine program in partnership with IAVI and Scripps Research is an important step in our mission to deliver on the potential for mRNA to improve human health,” said Moderna’s president Dr Stephen Hoge.

Image Credits: Moderna, UNAIDS/Sydelle Willow Smith.

Denmark’s capital, Copenhagen, is expected to return to pre-pandemic life as the country scraps most COVID-19 restrictions.

The world is “sick and tired” of COVID-19, World Health Organization (WHO) Director General Dr Tedros Adhanom Ghebreyesus acknowledged but warned that Omicron posed a substantial threat to global health, having caused 90 million infections in the past 10 weeks – more than all the cases recorded in 2021.

Tedros’s appeal came as Denmark lifted most COVID-19 restrictions including wearing masks this week despite registering over 40,000 new cases daily, with Norway and Sweden poised to follow suit. 

The UK eased many restrictions last month but kept masking, while South Africa’s Cabinet announced on Monday that people with asymptomatic COVID-19 no longer had to isolate and reduced quarantine days from 10 to seven.

Denmark’s rationale is that over 80% of its population is vaccinated, and that Omicron is substantially less infectious than previous variants.

But deaths in four of the WHO’s six regions have increased in the past week and Tedros urged countries to “protect their people using every tool in the toolkit” at a media briefing on Tuesday.

‘Premature to declare victory or surrender’

“It is premature for any country either to surrender or to declare victory. This virus is dangerous and it continues to evolve,” warned Tedros, adding that  the WHO is currently tracking for sub-variants of Omicron.

Dr Maria van Kerkhove, the WHO’s lead on COVID-19, cautioned that “now is not the time to lift everything all at once”.

“We have always urged caution in applying interventions as well as lifting those interventions in a steady and slow way,” said Van Kerkhove, although she acknowledged that countries are in very different situations around the world, and there was no “one solution”. 

Responding to South Africa’s changes to its isolation policies, Van Kerkhove said while the WHO recommended isolation is to prevent onward transmission some countries had so many cases they had to shorten isolation period and quarantine period “because they need to keep operating”.

“Most people still transmit the [Omicron] virus right around the time they develop symptoms from about two days before symptom onset up through the first five to nine days if you’re mild. It can be longer if you have severe disease,” added Van Kerkhove.

Dr Maria Van Kerkhove

Celebrate a new phase of disease control

Dr Michael Ryan, WHO Executive Director of Health Emergencies, said that the Scandinavian countries had a very high vaccination rates and strong health systems.

Every country in the world was trying to calculate “how do we have maximum protection of our population while minimising the impact on our society and our economy”, added Ryan.

He urged them not to “follow blindly” the decisions of other countries but to make decisions “based on your current epidemiology, your demographics, the population of risk, your vaccination levels, your population immunity, your access to tools, the strength of your health service”.

He also said that countries also needed to allow individual choice: “There are many, many people in my own personal view, who will be well advised to continue wearing masks in crowded situations and public transport even if it’s not mandated by government”.

In addition, “communities need to understand that measures may have to be reintroduced in order to moderate transmission if there is an unexpected rise in transmission or a new variant emerges”

Ryan urged “flexibility, agility, the ability to adjust, making good decisions based on your situation, and being ready to change that if needed”.

“We should be in some ways, celebrating when countries get to another stage of disease control, but at the same time being cautious and know that not all paths are straight,” he added.

Omicron sub-variants

Dr Tedros said that the WHO was researching four sub-variants of Omicron, including BA.2 which is more infectious that the original variant (BA.1).

Van Kerkhove said that there was some evidence that the prevalence of BA.2 was increasing in countries including Denmark and in India but that “there’s not a lot of information that we have on this particular sub-variant yet”.

“There is a suggestion from some of the initial data on BA.2 that there’s a slight increase in growth rate above BA.1. But what beyond that the data is really quite limited.”

New SARS-CoV2 origins group report weeks away

Van Kerkhove confirmed that the new Scientific Advisory Group for the Origins of Novel Pathogens (SAGO) had already had six meetings since it was constituted in late November.

Made up of 27 people, the WHO Secretariat expected guidance from SAGO “in the next few weeks” on the way forward in trying to ascertain the origins of SARS-CO-V2.

They were working on three issues: developing a framework for the study of any emerging pathogen; looking at the origins of this particular pandemic, building upon previous missions that have gone to China, and thirdly, looking at all of the literature and evidence that exists to look at studies that have been conducted since the original team had returned form China last March. 

“This group is currently working on their first set of recommendations to WHO on what is needed next, focusing on the urgent needs in terms of the studies that are necessary,” said Van Kerkhove.

 

Image Credits: Febiyan/ Unsplash.

Gaudenz Silberschmidt, WHO Director of Health and Multilateral Partnerships.

The World Health Organization (WHO) is considering changing how it relates to non-state actors (NSAs), but some of these organisations are concerned that the changes envisaged by the global body may weaken their voices.

In 2016, the WHO’s World Health Assembly (WHA) adopted a Framework for Engagement with NSAs – known as FENSA –  to enable closer collaboration with a wide range of organisations to respond to national and global health challenges. An initial evaluation of its implementation was conducted in 2019, and a two-year timeframe was set to fully operationalise the framework.

Over the past weekend, the WHO Executive Board considered a report on progress to implement FENSA , as well as inputs from various NSAs on how their relationships with the global body could be improved.

According to the report, the WHO said it seeks to improve NSAs’ role, voice and contribution in its governance system including by introducing a global constituency for NSAs and grouping NSA statements accordingly. While welcoming the WHO’s intentions, a number of NSAs noted that the proposal could weaken and soften the NSAs’ contributions to WHO’s agenda. 

International humanitarian medical non-governmental organization Médecins Sans Frontières (MSF) expressed concern with the proposal, saying that it fails to acknowledge the value of diversity and expertise inherent in NSA. 

MSF’s Dr Maria Guevara

“The creation of a global constituency and the grouping of NSA statements risk diluting these voices and limiting their meaningful participation in the dialogue and in finding solutions to current health challenges,” MSF’s Dr Maria Guevara argued. 

The International Council of Nurses said that while it supports informal meetings before WHO meeting, it called for more notice and added that the selection of the agenda items must be agreed on between NSAsand WHO member states. 

“After testing [introducing] constituency statements at the 75th WHA, we strongly encourage consultation with NSAs before making a final decision on their implementation,” said the ICN, adding that constituency statements should not prevent individual statements.

In its submission, the European Society for Medical Oncology (ESMO) also called for the WHO to allow non-state actors to still be able to make individual statements on issues that are in line with their core areas of expertise. To accommodate the contribution of more non-state actors, the society called for the WHO to publish each non-state actor’s statement on its website and for these to be included in meetings’ official minutes.

“Non-state actors can submit individual statements on the WHO website and in a way that they are translated and reported in the official minutes of WHO meetings, allowing non-state actors for each agenda item,” ESMO’s Gracemarie Bricalli recommended.

Meanwhile, the Save the Children Fund called on WHO Member States to also prioritize interactions with NSAs, especially the civil society, by actively participating in informal sessions and systematically sharing draft documents and resolutions for civil society organizations to engage in policy making.

It also slammed the WHO Secretariat over lack of time and support provided to NSAs regarding new processes, including constituency statements. It said the process lacked transparency and open dialogue among the different actors.

“We welcome all opportunities to engage with member states and the Secretariat to ensure the meaningful engagement of NSAs including when it comes to the development of a civil society engagement strategy.”

IPPF’s Estelle Wagner

The International Planned Parenthood Federation (IPPF) urged Member States to compel the Secretariat to constitute a diverse working group of member states and civil society organizations to review and develop proposals and report back at the 152nd executive board meeting next year on more robust recommendations to involve NSAs at the WHO beyond making general statements on agenda items.

“More than ever, the pandemic has shown the essential role of NSAs in the work of the WHO and we look forward to a constructive and transparent process to define mechanisms for truly meaningful engagement with WHO governing bodies beyond generalized statements at the end of agenda items,” the federation’s Estelle Wagner stated. 

Canada, USA and UK side with NSAs

Canada’s Elizabeth King

The government of Canada noted that the positions of NSAs on topical issues need to be taken more seriously, adding member states need to hear from NSAs before positions are finalized. It pledged its continuous support for meeting with NSAs prior to the WHA in May, adding that sufficient notice should be provided.

Canada also supported that NSAs should continue to have the option to deliver individual statements on all agenda items to ensure that member states benefit from the diversity of NSAs’ views. 

“This could be combined with a reasonable limit to the number of individual statements an NSA can deliver,” Canada stated.

Canada and the United Kingdom also agreed that the WHO Secretariat should work with NSAs to identify the agenda items where constituency statements would be more valuable, rather than identifying them independently.

“We’d like to reaffirm that hearing and understanding the voices of non state actors in all of our efforts to more meaningfully engage will increase our chances of success,” Canada’s Elizabeth King concluded. 

The US said the priority should be on ensuring WHO’s engagements and involvement of NSAs in its agenda are more meaningful and routine.

It noted that NSAs were critical to the development of vaccines, therapeutics and other medical medical countermeasures, as well as their distribution and delivery to individuals across the globe. By working together with NSAs, the United States said the WHO and the global health community can become more effective, efficient and avoid duplication or miscommunications that could undermine joint aims and efforts. 

A concluding remark from Gaudenz Silberschmidt, Director of Health and Multilateral Partnerships at the WHO said the global health body is committed to making the engagements and interactions between NSAs, member states and the WHO Secretariat to be more meaningful.

The challenge, according to him, is that the increased number of agenda items and interest have put pressure on the time for interventions for NSAs and delegates. He announced plans to organize a meeting with NSAs in February 2022 to consult both on the planning of the informal pre-meeting and on the constituency statements.

“We propose to include a session on those engagement modalities in the informal pre-meeting of the World Health Assembly,” he added.

Amoth and Tedros
WHO Executive Board Chair Dr Patrick Amoth and Director-General Dr Tedros at Friday’s EB150 session.

An innovative WHO “Health for Peace Initiative” that aims to build bridges in conflict zone and humanitarian settings through global health initiatives ran into some rough waters at last week’s Executive Board meeting – with the United States saying that it should include a human rights element – while Russia warned WHO against “politicizing” its agenda.  

The initiative, conceived in 2019-2020, was planned and developed together with the International Labour Organization, the UN Peacebuilding Support Office, and the Swiss-based organization Interpeace, with some initial projects now being implemented in areas like the Ukraine. 

The initiative builds on earlier WHO “Bridges for Peace” projects that took place during the 1980s and 1990s. But this new GHPI edition also aims to “work on conflict” by ensuring that such programmes help address conflict’s underlying causes – while avoiding unintentionally fuelling of tensions. 

Other aims of the initiative include developing “innovative ways to address conflict, strengthen resilience to violence and empower people to (re)build peaceful relations with each other”.

It aims to covers a wide range of areas – from infectious diseases to maternal and child health, nutrition, tobacco use and health systems strengthening. 

Synopsis of the health for peace initiative.

Russia – don’t stray into other areas

However, some leading member states gave the initiative a mixed reception in a discussion WHO Executive Board on Friday, the day before the 150th session closed. 

Russia warned WHO that it needs to to avoid “politicising” its agenda, asking for more discussion about the nuts and bolts of the initiative.

It also warned WHO against “straying” into areas beyond its mandate, saying focusing on the core WHO mission of strengthening health systems already helps build trust between countries. 

“Russia continues to speak out against the politicization of the WHO agenda… We call upon WHO to strictly follow its mandate and not stray into other areas, those covered by other [United Nations] bodies, specialized agencies and so on,” Russia’s EB  representative said.

Russia also highlighted that the initiative had launched, based on discussion with only 24 countries and partners.

“This issue has not been investigated by governing bodies of the WHO at another stage,” the Russian representative said. “We believe that there should be more broad discussions.”

Representatives from WHO’s Eastern Mediterranean region also appeared hesitant, with one delegate stressing that “first and foremost, we should avoid causing any harm.”

“Many interventions of health for peace will only be successful if they are well prepared and well designed, and therefore we need to coordinate our experiences and expertise,” he said. 

US asks for human rights inclusion

Health for Peace Initiative as it was presented at the Paris Peace Conference in 2020.

In contrast, the United States asked that human rights be included as one of the pillars of the initiative. 

While the US supports the draft of the GHPI, it said that the country “regrets that the text … fails to incorporate human rights as a fundamental pillar in addition to peace and development.

“The WHO has an important role to play in promoting respect for human rights and fundamental freedoms in coordination with other UN agencies,” the US representative said.

Building vaccine confidence, including the need to address issues of vaccine misinformation and disinformation, could also be a valuable arena in which the new GHPI could act.  

In response to the concerns, WHO officials stated that discussions on the initiative with member states are ongoing, and would be managed in an open and inclusive manner.

“I think that we have been very open to date,” said a WHO emergencies official. “It’s not a political initiative. Obviously, political decisions do have an impact on health and on peace and we’re all aware of this.”

‘There cannot be health without peace’ 

“There cannot be health without peace, and there cannot be peace without health,” WHO Director-General Tedros Adhanom Ghebreyesus, who has championed the initiative, has explained. 

“Health can also be a bridge to peace.  Health can contribute to peace by delivering services equitably to all people in society- especially disadvantaged groups,” he said in a recent message. “This can also help address the triggers of conflict, such as unequal access to health care, which can often leave to feelings of exclusion and resentment.

“Equitable health services strengthen community trust, which in turn contribute to health systems and peacebuilding efforts.” 

Data and technology sharing key to managing pandemics

In other discussions Friday, China, Singapore and Indonesia all stressed the need to address benefits and information sharing. 

“The current pandemic has shown us how important it is to make such information free and publicly available,” a representative from Singapore said, noting that the country “sees the sharing of such data … as part of ‘global public goods’” and that should be included in a larger conversation on the financing of such goods.

Singapore also recommended that WHO establish a global health threats fund, invested in by nations based on pre-agreed contributions as a means of being better prepared for the next pandemic. 

“We would like to caution against lies in the lack of levels of preparedness with regard to the response to pandemics around our region,” a second representative from the Eastern Mediterranean region said. “We would like to see the continuation of the support for our preparedness in this regard.”

He said that there should be better coordination among member states with regard to health, security, and preparation of emergency plans and plans with regard to specific diseases. 

Image Credits: WHO EB 150.

food
Food experts proposed a return to ‘real’ food over what is just ‘edible’

The explosion of unhealthy diets received considerable attention at last week’s WHO Executive Board meeting, as well as at last year’s UN Food Systems Summit – as key contributors to the global epidemic of chronic diseases such as obesity, diabetes, and cardiovascular diseases – which have also exacerbated the health risks of billions of people to COVID-19.

Now, what is really needed, post-pandemic, is a return to healthy and sustainable ‘real’ foods that both dimish these disease risks – as well as the risks of another pathogen escape from the wild into human societies as a result of unsafe and unsustainable food practices – particularly around both wild and domestic meat production and consumption.

This was a key message of a group of civil society experts at a recent panel – who also drew a distinction between what is merely “edible” food and what is “real”, healthy food.  

Making that seemingly simple distinction will be crucial post-COVID recovery to stem rising noncommunicable diseases while also ensuring that our planet remains within the boundaries of sustainable food production as well as making , nutrition experts emphasized during a recent Geneva Global Health Hub (G2H2) event. 

The event, “Sustainable healthy diets: Why are they so crucial after COVID-19?”, was hosted in collaboration with the Society for International Development (SID).

Featured speakers from Mexico, Brazil, and Colombia discussed a broad range of proposed solutions that would alter the way food is produced, distributed, and consumed.  

Exiting the corporate food system

Attaining healthier and more sustainable diets requires an ‘exit’ from the corporate food system, said Hernando Salcedo Fidalgo, of the Colombian NGO, FIAN. “The exit must make a distinction between real foods over what we call ‘edible products’”.

Fidalgo described solutions as a “continued process” that would have to begin at the very foundations of government – with approaches that distinguish between “real food and just edible products.” 

SID Director Nicoletta Dentico added: “If we don’t want to see things as they are, for the reality they represent, after years of the pandemic – this is going to be a kind of criminal blindness.” 

Mexico as a case study example of the need to return to traditional ‘real’ foods 

A sustainable healthy diet requires increased vegetable and fruit intake, as well more whole grains.

At the session, Mexico was cited as one example of a country in the crosshairs of pressures from corporate food manufactuers – who have undermined the once healthy diet of indigenous Mexican foods, leading to soaring problems with obesity and diabetes.

Reverting back to a traditional Mexican diet – rich in beans, fibre and micronutrients – is one way to both promote both sustainability and health,  said Juan Angel Rivera Dommarco, Director-General of the National Institute for Public Health in Mexico. 

“Our food system is really contributing to the degradation of the planet, and at the same time has created an epidemic of obesity and chronic illness without solving the undernutrition problems of the world.”

He bemoaned the gradual encroachment of meat, fat, and sugar-heavy  ‘American diets’ into Mexico.  

“We lost so many years of building healthy diets in Mexico as a result of trying to imitate the consumption of food in the north, which is not a good example at all,” he noted. 

The traditional Mexican diet means reverting to a diet high in vegetables, fruits, legumes, nuts or seeds, and whole grains – except in rural areas, where whole grains are already highly consumed. 

Milk and dairy intake also would need to be increased across rural populations, but decreased in urban ones. 

Substantial reductions in ultra-processed foods and reduced animal-source protein would also be needed to return back to the traditional Mexican diet. 

Average cost (MXN$) per capita per day of current Mexican diet vs Mexican healthy and sustainable diet

Moving towards this healthy diet would also be beneficial to the Mexican economy, Dommarco added.

The current average Mexican diet has been costed at $3.54 per day, whereas a traditionally healthy and sustainable Mexican diet would cost $3.06, while that proposed by the EAT-Lancet Commission would cost $2.52.

Shift government subsidies from ‘wrong foods’ to healthy ones 

Schools are one place to implement healthy food use.

Noting that the Mexican government currently offers too many subsidies for the “wrong foods”, he called on politcymakers to shift money and policy support to healthier foods – also providing  a model for other countries to follow.  

Working with GISAMAC (Inter-Sectoral Group for Health Agriculture Environment and Competitiveness), Dommarco has helped to develop a Mexican toolkit with a full set of policy proposals to address the need for healthy diets in the country. 

Their proposals included increasing the availability of healthy foods in underserved areas, prioritizing these foods for government subsidies and procurement, and prioritizing healthy, fresh foods in school nutrition programs. 

Taxes from sugar-sweetened beverages and ultra-processed junk food should be doubled, with tax revenues used to ensure drinking water in underserved communities, he added. 

Policies from the toolkit emphasize a multisectoral and multisystemic intervention, including not only food systems and the food environment, but education, nutrition, community, and health systems.

“The idea is that we really need a set of policies rather than one single policy that has a multi-systemic view,” said Dommarco. 

Image Credits: Noranna/Flickr, Juan Rivera Dommarco , Juan Rivera Dommarco, Flickr: Bart Verweij / World Bank.

National health systems are needed in tackling global health threats.

As the world enters the third year of the COVID-19 pandemic, an increasing number of important efforts are underway to strengthen global health security.  However, it is vital that, while strengthening our global health architecture, we do not lose sight of the fundamental role played by national level health systems in tackling global health threats.

Throughout this and previous pandemics, the strength of countries’ national health systems has been a critical success factor against pathogens. For example, even many countries with well-organised, well-financed and well-staffed health systems suffered throughout COVID-19. Viewed through these lenses, global health security may exist only as the sum total of the performance of all national health systems of all countries, rather than as a standalone and separate entity.

Since the onset of the pandemic, we have seen a plethora of new institutions and new ideas for improving global health governance. These include the Access to COVID-19 Tools (ACT) Accelerator and the COVAX Facility in April 2020, the Independent Panel on Pandemic Preparedness and Response proposal in May 2021 for a Global Health Threats Council and the World Health Assembly (WHA) agreement in December 2021 to proceed with the negotiation and drafting of a new international instrument to strengthen pandemic prevention, preparedness and response.

It is hoped that these new international institutions and platforms will support better pandemic governance and financing at the global level. However, although a strong global focus is essential for ensuring equitable distribution of those goods that are necessary for fighting COVID-19 and future pandemics, national efforts must be equally prioritised. 

In other words, global leaders must resist two great temptations: the desire to build new institutions instead of strengthening existing ones such as the WHO and the International Health Regulations, and the tendency to ‘securitize’ health at the global level instead of implementing strong public health measures at the national level.

Three functions to achieve resilient health systems

global health security
One interlocking function needed is resilient healthcare systems.

Global health security demands strong and resilient health systems that can prevent, detect and respond to infectious disease threats, wherever they occur in the world.  Therefore, we propose a new understanding that approaches this goal through the lens of three interlocking functions at the national level. 

The first key function is building resilient national healthcare systems. It is critical that they have built-in surge capacity (including for primary healthcare) to manage patients who have been infected and require care, while at the same time continuing and sustaining routine health services for those who have not been affected.  In addition to deaths from infection during the COVID-19 pandemic, there have been an excess of deaths of non-infected persons over what would be expected, likely due to the fact that they were not able to access routine health care, especially that which required frequent attention.  The same occurred in West Africa during outbreaks of Ebola in 2014 – health facilities could not accommodate most of the patients with Ebola infection resulting in a high level of death from Ebola virus diseases, and also, the number of deaths from children who could not get care for malaria and other childhood diseases because of the lack of resilience in the health system was documented as being higher than the number of deaths from Ebola virus disease.   

The second key function is developing strong core public health capacities that meet the WHO’s International Health Regulations. Countries with early detection surveillance systems that identified outbreaks rapidly at the start of the pandemic, and those that had strong response mechanisms including outbreak responses – especially Singapore, Japan, and South Korea – showed the importance of strong public health core capacities to manage pandemics.  And rather than using blunt lockdowns of the entire economies, they were able to save lives by outbreak investigation, identification of sources of infection and then shutting them down with precision, rather than blunt lockdowns.    

Thirdly, countries need to invest in broader supportive environments that enable the health and wellbeing of their populations. Infection with SAR CoV2, as with many other viral and bacterial infections, resulted in more serious illness and death among the elderly and those with comorbidities such as diabetes, cardiac disease and obesity.  By using smart regulations and other healthy-lifestyle-enabling measures, governments can ensure populations are healthier and more resistant to serious illness after infection, decreasing morbidity and mortality in an outbreak and/or pandemic. Healthy populations also require adequate health financing, strong health literacy and health-seeking behaviours, and improving the social determinants of health, like education, housing and working conditions.

Synergistic approach as opposed to mutually exclusive strategies

This synergistic approach to universal health coverage, health security, and health promotion is necessary to prepare for future pandemics. Currently, many countries seem to assume that public health, universal health coverage and creating the enabling environment for healthy populations are mutually exclusive strategies.  This can be due to limited resources and/or donor funding pushing governments towards “false choices”. 

Such false distinctions are further enhanced by the “global nature” of global health security with accountability towards the international community, contrasted with the domestic nature of universal health coverage and health promotion, with accountability towards local voters, taxpayers and citizens. 

A strategy focused on the three interlocking functions provides countries with a middle way – an integrated approach that equally prioritises national and global health security. Each of the functions has a strong conceptual framework and large body of evidence to support its positive impact on global health security.  Each is closely aligned with well-established and highly-visible health frameworks. 

 It will take political and health leaders with courage, vision and ambition to rethink some of the many vertical (albeit well-meaning) global implementation and funding streams to ensure that they serve to strengthen these three functions and not bypass or weaken them. They will need understanding and support from the global health community.

If implemented correctly, the three interlocking functions would be mutually synergistic, with progress in one function accelerating or enhancing progress in another. Taken together, they represent a more balanced approach to global health security and reduce the risk of over-globalizing, over-engineering or over-securitizing health. By better linking these three functions within WHO, and within its guidelines for epidemic and pandemic preparedness, WHO technical support to countries could provide better preparedness and response capacity for the next major outbreak or pandemic.

Biographies

Professor David Heymann is professor of infectious disease epidemiology, London School of Hygiene & Tropical Medicine.

Professor Ilona Kickbusch is the Founder of the Global Health Centre at the Graduate Institute in Geneva.

Chikwe Ihekweazu is the WHO assistant Director General of health emergency intelligence, the former Director General of the Nigeria Centre for Disease Control (NCDC) and was previously the Acting Director of the West Africa Regional Centre for Disease Control.

Doctor Swee Kheng Khor is a physician specializing in health systems & policies and global health, focusing on south-east Asia.

 

 

Image Credits: Nigeria Centre for Disease Control , Flickr: Maxim Malov/CDC.

17 January 2019 – Beni, North Kivu region, Democratic Republic of Congo.
Families go the Ebola Treatment Center to visit a family member who is held in quarantine in the centre.

WHO needs to reform lines of authority and responsibility across all aspects of its emergencies response operations in order to effectively prevent, report, and take measures against sexual exploitation and harrassment.  

Those were the highlights of a final report by an Independent Oversight Advisory Committee (IOAC) of the WHO Health Emergencies Programme, examining the claims of sexual exploitation and harrassment that first emerged in connection with WHO’s 2018-2020 Ebola response in the Democratic Republic of Congo. 

The report, presented in a Friday afternoon session of the WHO Executive Board, marked another milestone in the follow-up to reports of sexual exploitation and abuse claims by some 75 Congolese women against 25 WHO workers deployed to the Democratic Republic of Congo’s 2018-2020 Ebola response – which was first reported by the New Humanitarian in 2020. 

Following the reports, WHO initiated an independent investigation, as well as initial internal reforms to improve staff training in the prevention of sexual exploitation and harrassment (PRSEH); deployment of more training staff; and new recruitment standards that also consider any exploitation and abuse issues in a candidate’s background, the IOAC report states.

But there remains “ deep, lingering frustration expressed by Member States and staff about the lack of transparency, delays in responding to incidents and holding perpetrators accountable, and the defensiveness with which the Organization has dealt with SEAH in the past,” states the report, presented to the EB. 

response to drc claims
Felicity Harvey, co-chair IOAC

And more comprehensive cultural and structural changes need to occur across WHO to reduce the risks of abuse from ever occurring in the first place, said Felicity Harvey, co-chair of the IOAC committee, in her presentation of the report to the WHO Executive Board on Friday. 

“The second edition of The WHO Emergency Response framework should be further revised to provide greater clarity on the accountabilities and lines of authority across offices, regional offices and headquarters with explicit roles and responsibilities given to each player and updated procedures for all hazards emergency risk management,” she said. 

The IOAC report outlines five priority areas where more action is needed. Those include: 

  • Clarifying the lines of responsibility and delegation of authority across the three levels of the organization; Strengthening the accountability framework for emergency response and other field teams; 
  • Reform the organization’s PRSEH management structure, and accelerate  organizational capacity to implement a “victim survivor-centered” approach to PRSEH; 
  • Financial investment in PRSEH programmes as an essential WHO function – and particularly in field operations, where WHO is currently responding to some 80 emergencies around the world; 
  • Periodic assessments of PRSEH in acute emergency response settings, including a mapping of community and local resources; identification of trusted local partners for PRSEH incident management; ensuring that field operations include a balance of  experienced male and female personnel. 
  • Building a culture of equity, diversity and transparency 

“WHO needs to promote or advocate for institutionalized culture change to strengthen PRSEH,  including greater gender and racial diversity, improved performance management, and a renewed commitment to WHO values – to build a culture of equity, diversity and transparency,” said Harvey, a former director-general of international health in the United Kingdom Department of Health.  

DG Proposal – separate line of investigation for sex abuse complaints

WHO Director General Dr Tedros Adhanom Ghebreyesus

Responding to the IOAC report, WHO Director General Dr Tedros Adhanom Ghebreyesus noted that WHO has recently engaged an external investigator to follow up on further on the abuse allegations – and their perpetrators.

“This is the first time a UN Organization has installed an independent investigation, opening up to an external investigator,” he noted.  

“One of the things that our member states emphasized is transparency; we are doing that, and we will continue to do more. We will continue to build on this, because more should be done,” Tedros said. 

Tedros also asked the EB to approve a draft decision that would create a separate line of authority to the investigator heading up the Organization’s investigations of sexual exploitation and abuse allegations – and reporting directly to the Director General.  

All sexual exploitation and abuse allegations would thus be treated separately from other WHO internal justice investigations, at least temporarily, according to the draft WHO proposal. 

The WHO DG also noted that in the last two weeks, the Organization had received three new complaints of alleged sexual harrassment and exploitation from the Central African Republic, DR Brazzavile, and the Democratic Republic of Congo (DRC) – the latter where Tedros also said that WHO was creating a model for rehabilitation and support to victims, helping them access livelihoods as well as other means of support. 

“We support zero tolerance and we will do everything to build a better culture,” he said. 

The DG’s proposal to create a separate chain of authority for sexual exploitation and harrassment cases churned up some initial resistance among some EB members – who said that it should have been discussed even before the EB convened, at a meeting of member states’ Planning and Budget Advisory Committee (PBAC).  

Harvey, however, said that the IOAC would “strongly endorse the decision to keep the PRSEH Investigation Unit separate from general investigations,” att least for the moment until progress has been made on the investigations still ongoing in the DR Congo and elsewhere.  

The EB members deferred debate on the draft WHO decision until Saturday morning.

Country responses commend WHO and emphasize survivor-centered approach and ‘zero tolerance’ policy

WHO Representative of France

Representatives across Member States otherwise commended the WHO for its efforts towards prevention of sexual exploitation, abuse, and harrassment, with some emphasing the need to adopt a survivor-centered approach in responding to the allegations. 

“It is important that we create an environment conducive to effectively preventing sexual exploitation and abuse, and that means asking ourselves hard questions about responsibility,” said Tunisia, on behalf of the WHO Eastern Meditterean Region. 

Tunisia, and many other Member States noted that a zero tolerance policy is needed, and proposed that a common UN database be created. The database would be consulted before staff recruitment, ensuring that the necessary checks can be made. 

“We need to do this, making effective and efficient use of the resources we have available on gender equality.”

France, on behalf of the European Union, echoed these sentiments, and also reiterated the need for “accountable culture within the organization.”

“We think it is better to have people providing the information because peace is being swept under the carpet.”

Concern and clarification needed on transparency and accountability 

Bathsheba Nell Crocker, US Ambassador to the United Nations

However, some representatives continued to express their concern regarding the WHO’s work on sexual exploitation and abuse, including China and the United States. 

China noted the need for clarification from the WHO on the interim report and “transparency and accountability of the related work.”

“We hope that WHO will further clarify on how it will communicate on concrete action taken both within and outside of the organization.” 

The US representative, Bathsheba Nell Crocker, acknowledged the recent progress of the WHO, but added that “broader organization reforms are needed, as well as the dedicated effort now required to translate division laid out for WHO’s work in this area into concrete results on the ground.”

She also pointed out that WHO’s efforts to increase awareness, conduct training, and fill capacity are “essential but insufficient.” 

“[There is] absence of investment in evidence-driven survivor centered prevention, risk mitigation, and response protocols.”  

Crocker noted that WHO must encourage prompt reporting and delivery of survivor centered services. 

“Organizational change starts at the top with leadership. We call on WHO to ensure that roles and expectations are clear and to enforce whistleblower protections.”

Image Credits: Flickr: World Bank / Vincent Tremeau, WHO EB 150.

lassa fever
Nigeria has set up an emergency response centre to deal with outbreaks of the deadly Lassa fever in parts of the country.

Following reports of an unusually large number of cases in January 2022 across some 12 states, Nigeria is stepping up its surveillance of Lassa fever, the deadly viral hemorrhagic illness transmitted by infected rodents, or through other infected people or tainted food. 

This year marks the fourth year in a row in which large outbreaks of the  disease are being reported by Africa’s most populous state..   

According to the Nigeria Center for Disease Control (NCDC), there have been a total of 759 suspected cases, 170 confirmed cases and 32 confirmed deaths in January – following the emergence of the first cluster of new LF cases in December.

In a worrisome trend,  January’s cases were reported from 37 local government areas (LGAs) spread across 12 states. 

That is about twice the number of LGAs and states where cases of Lassa fever were reported within the same period in 2021 (17 and 6 respectively).

While the number of cases and states so far affected by the 2022 Lassa fever outbreak are higher, the case fatality rate of 18.8% remains lower than that of the  2021 outbreak where one out of four confirmed cases resulted in death (CFR — 25%).

Notably, is also about 16 times higher than the CFR for COVID-19 in Nigeria (1.2%), Nigerian health authorities underline.

Although cases have been reported from 12 states, three states (Edo, Ondo and Bauchi) are the epicenters for the outbreak, accounting for 74% of all confirmed cases.

Expanding range nationally and global health threats

This year mark’s the fourth in a row when large clusters of cases have been reported in Nigeria, “raising concerns about an ongoing, systematic emergence of LF nationally,” according to a recent Nature Communications review of the disease’s gradual expansion country-wide.

In 2019, there were 833 confirmed cases of Lassa fever in Nigeria with 174 deaths (CFR — 20.9%). In 2020, Nigeria recorded a total of 1181 confirmed cases of Lassa fever and 244 deaths (a CFR of 20.7%) but the following year (2021), the number of confirmed cases reduced to 510 with 102 deaths among confirmed cases (CFR - 20%). 

In addition to the national and regional risks, Lassa Fever is a “WHO-listed priority pathogen and a major focus of international vaccine development funding3 and, although often framed as a global health threat.”

Lassa fever is an acute viral illness and a viral haemorrhagic fever that is associated with high morbidity and mortality, and it thus has both economic and health security consequences.

Some cases, however, can be mild and thus go undetected or be confused with other common febrile conditions, like malaria - underlining the need for surveillance and vigilance to stop its spread. 

First reported in Nigeria’s state of Borno in 1969 when two missionary nurses died from an unusual febrile illness, Lassa fever cases and outbreaks continue to be reported in Nigeria and the diseases is increasingly recognised to be endemic in many parts of West Africa, including Nigeria, Benin, Ghana, Mali and the Mano River region (Sierra Leone, Liberia and Guinea).

The disease has typically been characterised as having two main endemic foci in West Africa, one centered around Sierra Leone and Liberia, and the other in Nigeria, but in recent years, Nigeria, in particular, has continued to record a trend of increasing numbers of cases - although most countries in the region have reported regular or sporadic cases, researchers report.


Response measures

In a statement this week, NCDC said it has activated the country’s national multi-sectoral and multi-disciplinary Lassa fever Emergency Operations Centre (EOC) in response to the Lassa fever outbreak in some parts of the country. 

“This became necessary given the increase in the number of confirmed Lassa fever cases across the country and a joint risk assessment with partners and sister agencies,” the center said in the statement.

It described the reports in weeks 1 and 2 as the highest number of confirmed cases recorded in Nigeria in the last four years for the same period. It however reassured Nigerians of its preparedness which hinged on the center’s experience in responding to Lassa fever outbreaks. 

“Since 2016, NCDC has worked hard to improve diagnostic capacity for the disease. Currently, seven laboratories can conduct confirmatory tests for Lassa fever in Nigeria and are coordinated by the NCDC National Reference Laboratory (NRL). This has improved active case detection for the disease,” NCDC stated. 

In the same vein, care for affected individuals has improved. NCDC said it is providing support to states including the provision of emergency medical and laboratory supplies as well as oral and intravenous Ribavirin for preventive and curative treatment to treatment centres across the country. 

“In addition, Nigeria through NCDC is participating in the largest-ever Lassa fever study that aims to provide an accurate assessment of the incidence of the disease in West Africa. This will also accelerate the development of vaccines and therapeutics for Lassa fever,” NCDC added.

It has also commenced training for healthcare workers in Nigeria’s tertiary health institutions on Lassa fever case management and infection prevention control.

Risk factors for exposure 

Contact with the rodent Mastomys natalensis is thought to be the reason for Lassa fever.

According to a research report published in Nature Communications in October, 2021, the significant majority of observed LF cases—including those from recent years in Nigeria—are thought to arise directly from contact with the rodent rodent Mastomys natalensis, the main viral reservoir host and a common agricultural pest. Other cases have occured, however, via hospital-acquired infections and potentially, in other small clusters of human-to-human transmission.

Risk factors for spillover of the virus, while not well understood, are thought to include factors that increase direct and indirect contact between rodents and people through poor food storage and housing quality, as well as certain crop processing practices.

Correlations between human case surges and seasonal rainfall patterns “suggests that LF is a climate-sensitive disease whose incidence may be increasing with regional climatic change,” according to the Nature Communications study, led by David Redding of University College London and and Chikwe Ihekweazu, of the Nigerian Centre for Disease Control (NCDC). 

Image Credits: Channel Africa/Twitter, Sahara Reporters/Nigeria.