A session of the 2020 World Health Assembly.

Some civil society organisations (CSO) are sceptical about whether a ‘pandemic treaty’ is the best way to address future global health crises, while treaty supporters say it will provide a legal framework binding countries and global health bodies to more agile and rapid responses to future outbreaks. 

A session Monday sponsored by the Geneva Global Health Hub (G2H2) brought leading CSOs, diplomats, academics and even WHO’s chief legal counsel face to face to air those views, in the context of a research initiative on the treaty being undertaken by the hub. 

The debate comes just weeks ahead of a planned special session of the World Health Assembly which is to determine whether the global body will indeed move forward on a Treaty, as a key measure for improving pandemic response. 

The treaty initiative has been supported most visibly by European countries, led by European Commission President, Charles Michel, who in a separate session at the World Health Summit in Berlin that the treaty would guarantee “access to information, financing, vaccines and countermeasures. It would increase capacity and resilience – at all levels.” 

Diversion or game changer?

25 heads of government and international agencies have come together in support of the new pandemic treaty

Some of the civil society organisations that have expressed disquiet about the treaty proposal perceive it as a potential distraction or diversion by wealthy countries from the so-called TRIPS waiver proposal, currently under consideration by thee World Trade Organization. The proposal by South Africa and India for a broad-based intellectual property waiver on COVID vaccines and treatments, now being debated by the WTO’s TRIPS Council , is perceived by civil society as a game changer that would help open the doors to despearately needed COVID vaccine and medicines manufacturing in Africa and the global South. 

Many of the European countries that have been among the most staunch opponents of the TRIPS waiver are also key pandemic treaty supporters, noted journalist Priti Patnaik, who is researching stakeholders’ views on the pandemic treaty for G2H2 -giving rise to the CSO suspicions.

And yet at the same time, some developing countries have supported a pandemic treaty because they believe it would “rein in the influence of non-state actors, including powerful foundations, and get some binding obligations to apply to industry to avoid vaccine inequities in the future,” she added. 

‘Switch-and-bait’ tactic

Unni Karunakara, senior fellow at Yale’s Global Health Justice Partnership, said that the major focus should be on deploying available tools and medicines to every corner of the world, rather than negotiations over a new treaty: “Shouldn’t global vaccination coverage be an overwhelming priority now?” he asked.

“We do have frameworks and tools. They’re not perfect, but there are enough tools for us to overcome this crisis together,” said Karunakara, a former president of Medecins sans Frontieres.

“What is lacking, however, is the political will to share essential resources and tools, even with all of the treaties in place.”

His comments reflecting the cynicism of other civil society activists who see “a big overlap between the countries that are blocking the TRIPS waiver, and the countries that are supporting the pandemic treaty.

“So there’s a perception of a ‘switch-and-bait’ tactic that reeks of bad faith,” he added.

And while transparency measures – such as the mandatory sharing of genetic materials by countries where outbreaks are suspected – have been discussed as key treaty features, similar mandates for transparency or sharing of vaccines and medicines technologies have been fiercely opposed by the EU, he pointed out.

“TRIPS waiver-blocking countries have made the case for voluntary actions by pharma to ensure access to essential COVID-19 medical tools, so they treat Big Pharma with kid gloves,” Karunakara observered.

“Interestingly, they take a very different tone and approach to the global south in the treaty, insisting on enforceability in the sharing of information and materials with WHO and other governments to allow for independent verification.” 

“The assumption here is that global south is the problem, that diseases originated in poor country, and pose national security risks to rich countries.”

If you are against the treaty – what is your multilateral alternative?

Björn Kümmel, at the WHO Executive Board’s January 2021 meeting.

Björn Kümmel, deputy head of the global health unit in the German Federal Ministry of Health, disputed that there is any direct political link between the treaty and the TRIPS waiver – or the kinds of hidden agendas that civil society groups fear.

“I doubt that it’s, from a logical point of view, right to say that even though a country has it stands on the TRIPS waiver, you can’t tackle other equity issues,” he told the G2H2 session.

“That’s one angle to look at, the TRIPS waiver, but there are many more angles to be looked at. So to say that that is the only magic bullet, I think that would be fully wrong, I wouldn’t limit it to this.

“I think that equity goes far beyond, and certainly, if a treaty was negotiated, it’s quite clear that this [TRIPS waive] will be put on the table, and that all governments will have to look at the different interests that are on the table and negotiate them with an open outcome.”

He noted that the treaty was first proposed formally by Chile, not the European Commission, and has the support of a wide array of countries, including South Africa, Kenya, and Tunisia, as well as Thailand and Indonesia.  

Anything better than ‘Chaos’ we see now

Describing the current global health situation as “dysfunctional”, Kümmel asked the G2H2 session: “If you are against the treaty, tell us what is your multilateral alternative to it, to be realistically implemented, lets say in the next five years?”  

“What the countries who are proposing a treaty are trying to say is:  anything is better, than compared to the chaos that we’re seeing currently.

“Legal clarity is needed, and it will be …a painful exercise for many of us, and most likely a difficult one for many governments, including mine, most likely also others. But in the end, it’s this is multilateralism.”

Uniquely in the global health landscape – and unlike environment, trade or finance – there is a dearth of global treaty instruments. In fact, among the dozens of international treaties in force today, the only two binding instruments in global health today are the IHR and and the Framework Convention on Tobacco Control (FCTC), he pointed out.

Pandemic is a ‘window of opportunity’ for bigger changes

In light of the outstanding questions, however, the working group of countries that are preparing for the WHA special session had devised a “three-step approach” to their deliberations on a way forward.

They are considering in parallel: WHO internal reform measures; revisions in the existing International Health Regulations that currently govern global emergency response; and finally, the Pandemic Treaty alternative. 

In terms of WHO reform,  the conclusion has been that such measures would “not be sufficient in order to overcome the next pandemic,” Kümmel said. 

Amendments to the International Health Regulations (IHR) also would take time to negotiate.  And a key question here is: “would they be a game changer for the next pandemic to come? Certainly not,” he added, noting that there is “no compliance mechanism that currently is foreseen in the IHR.”

So against the other options, “an international binding agreement is interesting,” he said. “And why are many colleagues pushing for this to happen now? Well, it’s the reality that after Ebola and past pandemics the global community was unable to implement the lessons learned,” he said.

And if negotiations don’t begin now, in the heat of the ongoing crisis, they will never happen at all.

“Many of the international independent panels have called for bold recommendations to be implemented,” Kümmel reminded the group. “One of them is the treaty. But many of those recommendations have never reached successful implementation, because the window of opportunity for real structural changes normally vanishes with the next crisis to come after the pandemic.”

The treaty would also retain WHO’s centrality as the nerve center of the global health architecture – amidst a plethora of new health initiatives emerging in Europe  and elsewhere:

“There are a multitude of ideas and recommendations, and the treaty is a legal framework into which most of the other recommendations would fit,” he said, in reference to recent proposals such as one by the Pan European Commission on Health and Sustainable Development to create a new global health board under G-20 auspices. Others have talked about a new global health finance board in association with the World Bank and/or a new UN-level Global Health Threats Council, under the auspices of the UN General Assembly.

So the Pandemic Treaty is “also a mechanism to provide WHO with legitimacy after this crisis,” he stressed. “Obviously there are voices out there who could see alternative approaches.  However, I think the ones who are in favour of this treaty have clearly articulated that WHO is the right forum because its the truly multilateral forum for global health.”

WHO precedents for equitable access to vaccines?

Germany is not the only actor that sees the treaty as a means of keeping WHO as the world’s main global health meeting place.

WHO’s Director General Dr Tedros Adhanom Ghebreyesus has himself come out in support for the pandemic treaty measure – breaking ranks with previous agency heads who usually remained aloof of controversial measures under consideration by member states.

WHO is therefore keenly interested in how civil society groups may help lead or shape views on the treaty negotiations – and this interest was reflected in a cameo appearance at the G2H2 event by Stephen Solomon, WHO’s principal legal officer.

Solomon said it was “really helpful” to understand some of the “scepticism” around the pandemic treaty initiatives. 

“Understanding the the concern about an agenda driven issue here is very important for the [WHO]  Secretariat,” Solomon told the group.

At the same time, beyond the immediate COVID crisis, other WHO emergency response frameworks already in place also could perhaps benefit from the stronger legal backpone that a pandemic treaty might provide, he pointed out.

One example is the Pandemic Influenza Preparedness (PIP) framework, which mandates that 10% of global flu pandemic vaccine production supply goes to WHO for direct distribution, based upon public health needs. Another is WHO’s Global Action Plan for influenza vaccines.

These “are meant to address equity issues in a number of epidemics, not necessarily pandemics,” Solomon said. 

“I would be very interested in reactions to particular frameworks meant to address inequities, like the pandemic influenza preparedness (PIP) framework, not legally binding. Or like the WHO Global Action Plan (GAP) for influenza vaccines, also not legally binding. 

“But both are interesting and potentially of important reference to pandemic preparedness and response. PIP basically says 10% of global pandemic vaccine production supply goes to WHO for distribution on the declaration of an influenza pandemic for distribution based on public health needs, and we have legally binding contracts for that 10%,” said Solomon.

“Could that be a reference point for responding to future pandemics?

“If so, would it be useful to put that in more of a legal framework because of weaknesses within that structure –  particularly the idea of countries not allowing export for vaccines already under contract?” Solomon asked.

Similarly, the Global Action Plan for influenza vaccines was a 10-year, non-binding arrangement that aimed to better distribute capacity for flu vaccine production, including among low- and middle-income member states, he pointed out, asking:

“Could that also benefit, or not, from a normatively binding architecture?”

The final research report will be launched by G2H2 on 24 November.

–Elaine Ruth Fletcher contributed to the writing of this story.

Image Credits: WHO / Antoine Tardy, EU Council, C Black, WHO.

Climate change: Scientists have long predicted climate disruption will lead to more extreme weather, such as heatwaves, droughts and floods

The latest climate commitments from 165 of the 192 countries that are signatories to the 2015 Paris Climate Agreement would still lead to a global temperature rise of 2.7°C by the end of the century, according to an updated United Nations analysis of climate commitments and their impacts.

Major emitters including China and India, remain among those 27 countries to have not yet submitted any updated commitments at all in advance of the decisive days of the Glasgow Climate Conference (COP26), which begins on Sunday.

UN Secretary-General Antonio Guterres on Monday called on China to present an “ambitious” contribution at COP 26.

Guterres also said the UN also fully supports the Chinese presidency of the COP15 Biodiversity Conference, happening in Kunming 25 April-8 May of next year. For him, “ambition on biodiversity and climate are mutually reinforcing.”

“Both in Glasgow and Kunming, we must do our part to make peace with nature and safeguard our planet for future generations”, he added.

The analysis of all “Nationally Determined Commitments” to have been received so far by the UN Framework Convention on Climate Change (UNFCCC) found that global greenhouse gas (GHG) emissions would still increase by about 16% by 2030, as compared to 2010 – even if all of the commitments were met.

“Comparison to the latest findings by the Intergovernmental Panel on Climate Change (IPCC) shows that such an increase, unless changed quickly, may lead to a temperature rise of about 2.7°C by the end of the century,” said a UNFCCC press statement.

The updated analysis was published ahead of the COP26 to ensure that countries have the latest information at hand on the impact political commitments so far would make to climate trends, UNFCCC said.

Countries far from reaching targets to keep emissions under 1.5°C warming mark

climate commitments
Nationally determined commitments (NDCs) are still not enough to prevent the rise of global temperatures by 1.5 Celsius

But it dramatically underlines how far away countries remain from meeting the goal to keep global emissions under the 1.5°C warming mark that scientists say is needed to prevent a spiral of increasingly and destabilizing changes, as well as to the ecosystems of forests, glaciers and oceans, as well as freshwater access and food production.   

“This latest report from the UNFCCC makes clear, to protect the world from the most devastating impacts of climate change, countries must take more ambitious action on emissions, and they must act now,” said Alok Sharma, COP26 President, saying that the report underlines why countries need to show ambitious climate action at COP26.

 “If countries deliver on their 2030 NDCs and net zero commitments which have been announced by mid-October, we will be heading towards average global temperature rises of just above 2°C,” he noted. 

That’s an improvement over the commitments made in 2015, which would have led to a temperature rise of just under 4 °C – “So there has been progress, but not enough,” Sharma said.

“That is why we especially need the biggest emitters, the G20 nations, to come forward with stronger commitments if we are to keep 1.5 °C in reach over this critical decade. Glasgow must launch a decade of ever-increasing ambition. At COP26 we must come together for ourselves, future generations and our planet,” he said.

GHG emissions would begin to decline around 2025 

Total emission levels by 2030 would only be about 9% below 2010 levels.

On the more positive side, the updated report also confirms that emissions reduction efforts could be more effective over time.  For the group of 143 Parties that submitted new or updated NDCs, total GHG emissions are estimated to be about 9% below the 2010 level by 2030. 

Further, within that group, some 71 Parties communicated a carbon neutrality goal around mid-century. The report finds that these Parties’ total GHG emission level could be 83–88% lower in 2050 than in 2019.

Monday’s report updates an earlier UNFCCC report, published last month, which had compiled only 86 country commitments.

Patricia Espinosa, Executive Secretary of the UNFCCC, said: “I thank and congratulate all Parties that have submitted a new or updated NDC since the publication of the full report in September. These NDCs clearly represent a commitment to acting on climate change.”  

“At the same time, the message from this update is loud and clear: Parties must urgently redouble their climate efforts if they are to prevent global temperature increases beyond the Paris Agreement’s goal of well below 2°C – ideally 1.5°C – by the end of the century.

Overshooting the temperature goals will lead to a destabilised world and endless suffering, especially among those who have contributed the least to the GHG emissions in the atmosphere. This updated report unfortunately confirms the trend already indicated in the full Synthesis Report, which is that we are nowhere near where science says we should be,” she cautioned.

The IPCC has estimated that limiting global average temperature increases to 1.5C requires a reduction of CO2 emissions of 45% in 2030 or a 25% reduction by 2030 to limit warming to 2°C. If emissions are not reduced by 2030, they will need to be substantially reduced thereafter to compensate for the slow start on the path to net zero emissions, but likely at a higher cost.

 

Image Credits: Commons Wikimedia, UNFCCC.

Panelists address the vaccine equity panel at the World Health Summit in Berlin, including Seth Berkley (top right) and Ethopian health minister Lia Tadesse (bottom left).

Of the 1.3 billion COVID-19 vaccine dose donations promised to COVAX by wealthy countries, only 150 million doses have actually arrived – around 9% – Gavi CEO Dr Seth Berkley told the World Health Summit in Berlin on Monday.

Ensuring that countries delivered their promised doses “now” was COVAX’s “core ask”, said Berkley, who added that the global vaccine facility was also pushing vaccine manufacturers for greater transparency about deliveries. 

“Our perception is that delays often occur in [COVAX], whereas manufacturers provide vaccines through their bilateral mechanisms,” he added.

Germany’s Dr Lars-Hendrik Röller, Director-General for Economic and Financial Policy in the Federal Chancellery, said that it was very important that the G7 countries delivered on their dose-sharing commitments.

The G20 countries meet in Rome over the weekend, and Röller said he was heading to the city on Tuesday to start pre-meeting negotiations on both vaccine equity and climate financing.

‘Stop-start’ vaccine delivery compounds hesitancy

Ethiopia, Africa’s second-most populous country with a population of over 115 million people, has only been able to administer 4.2 million vaccines due to vaccine shortages, Health minister told the summit.

“When you get very few doses, the demand is high but it is hard to keep the momentum,” said Tadesse, adding that the stop-start supply from COVAX has compounded vaccine hesitancy.

“We initially launched with two million doses of AstraZeneca, which we rolled out but then we could get the second dose on time,” she said, adding that it was very challenging for a country as big as Ethiopia to schedule deliveries for vaccines that arrived “every now and then”.

Ethiopia aims to vaccinate 20% of its citizens by the end of the year – only half the World Health Organization’s (WHO) global target – but even that will be difficult because of delivery challenges, said Tadesse.

Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers & Associations (IFPMA), said that he believed COVAX was finally on the right track to deliver vaccines to all as there were “sufficient supplies”

“We will exceed 9.3 billion doses manufactured by the end of October, more than 12 billion by the end of the year and probably 24 billion next year,” said Cueni.

COVAX hopes to get one billion of these doses by the end of the year, to add to the 400 million doses it has delivered so far.

Predictability of delivery

Acknowledging Berkley’s call, Cueni agreed that manufacturers “really need to find ways and means to improve to transparency on the predictability of the deliveries”.

“Be it from COVAX contracts, or be it actually sitting down with countries willing to share doses to address all the complexities, be they logistically or be they legal, to make sure that these doses can be shipped before the shelf life expires,” said Cueni.

Other short-term priorities to get vaccines where they are needed, include optimising production, eliminating trade barriers, including on special syringes needed for the Pfizer-BioNtech vaccine, and ensuring country readiness, said Cueni.

Elhadi As Sy, Chairperson of the board of the Kofi Annan Foundation

Röller, who is also co-chair of the COVAX Vaccine Manufacturing Working Group, said that the group would table a number of proposals at the G20 meeting, based on short, medium and long-run workstreams.

Immediate priorities focused on vaccine delivery, including “swaps and more transparency in the contracts”, and less restrictive trade and custom rules in the area of trade and customs. 

“Boosters, we discussed for a long time and the working group made a pretty sensible suggestion that [they] should be based on clinical evidence,” said Röller.

“And the final one is the long run, which is the localised production,” he added. “There are several models you can think about localising production and in particular we have an mRNA hub in South Africa, which is the first one, but there’ll be others to follow,” said Röller, adding that German companies were exploring joint venture options in Senegal and Ghana.

Elhadi As Sy, Chairperson of the board of the Kofi Annan Foundation, warned of the erosion to trust caused by vaccine inequity, saying that the world was “crying out for strong leadership”.

“The data suggests that 90% of doses have gone to 10% of countries. So this says that the place where you live becomes the biggest determinant of your health status, and also determines your access to commodities, and mostly determines if you survive,” said As Sy.

“A truly global response has to be in an inclusive response. What civil organisations are feeling is that they’ve been betrayed in many ways. So many promises have been made, and so many promises have been broken without any consequences. Leaders can meet in UN General Assembly special sessions and make commitments. Very few deliver. And then so what? The consequence of that is your trust is being eroded, and there will be no inclusion, no real partnership, without trust between leaders and citizens.”


Warning: Attempt to read property "post_title" on null in /home/clients/58f2a29976672af522a8f4d82ffa28b6/web/wp-content/plugins/better-image-credits/better-image-credits.php on line 227
UK Prime Minister Boris Johnson at the Covid-19 Vaccine Centre, Guy’s Hospital in central London earlier this year.

Amid soaring COVID-19 cases in the UK, the government is prioritising giving third booster shots to people as it banks on the country’s high COVID-19 vaccination rate being able to prevent severe illness and death.

Over the past week, COVID-19 cases in the UK increased by almost 18% – with 52,000 new cases confirmed on Thursday alone. 

COVID-19 deaths have also increased by almost 11% in the past week, and some medical experts believe that the country should consider returning to additional safety measures such as masks and social distancing.

However, Prime Minister Boris Johnson said this week that the pandemic’s current trajectory is not unexpected and has so far ruled out any additional measures to curb cases.

The UK has been counting on its high vaccination rate to enable its residents to live relatively normally alongside the virus, but its sheer volume of cases is starting to put pressure on the health system.

Almost 80% of Britons over the age of 12 are fully vaccinated, while around one in nine people – 5.3 million – have had booster shots.

During the current surge, around 2% of people infected have been hospitalised in comparison to 9% in January when vaccinations were less available. Around 14% of unvaccinated people with COVID-19 have ended up in hospital.

In last year’s peak (October – January) there were 2,7 million cases and 185,000 of these were hospitalised whereas in the current phase (July – October) around 3 million people have been infected yet only 79,000 people have ended up in hospital.

“The important thing is that is the fact that our vaccination programme has been successful in breaking the link between cases and hospitalisations and deaths,” said a UK government spokesperson this week. “Our focus remains on ensuring we get boosters out to those who are eligible.”

 

However, the UK Scientific Advisory Group for Emergencies (SAGE) said that a higher death toll was unlikely, but SAGE warned that a variant of Delta becoming dominant is a very real possibility.

The UK Health Security Agency has designated the Delta mutation, known as AY.4.2, as a variant under investigation. By Wednesday, there there were 15,120 confirmed cases in England since it was first detected in July.

Fourth wave in Europe

Europe is the only World Health Organization (WHO) region to report an increase in cases for the third week in a row. Cases increased by 7% in the past week, exacerbated by colder weather driving more people indoors.

Cases in Belgium, Czechia, Hungary and Poland have increased by 50% over the past week, according to the WHO.

Belgian Health Minister Frank Vandenbroucke said on Wednesday night that the country’s fourth wave had started, with the country experiencing over 3,200 new daily cases. Some 86% of Belgian adults have now been fully vaccinated.

Belgian Prime Minister Alexander De Croo told VTM Nieuws this week that people might need to go back to wearing masks.

“The first priority must be to vaccinate those who have not been vaccinated as soon as possible. We are really monitoring the situation in detail to see if we need to intervene at a certain point,” De Croo added.

Poland is experiencing over 5000 new cases per day, the highest rate since May, and it has vaccinated 61% of its population.

 

‘It’s this easy’ rabies awareness drive.

In the US, cases of dogs infected with the rabies virus being brought into the country are significant enough to warrant national headlines and a year-long dog importation ban on dogs from hundreds of countries worldwide.

Yet, in India, rabies does not get much media attention but it accounts for a shocking total of 20,000 human deaths each year – that’s more than 50 a day.

While the US has eliminated the dog rabies virus variant and is able to keep it controlled through active border controls, surveillance and comprehensive dog vaccination programmes, rabies in India, and at least 100 other countries throughout the world remains a significant challenge.

In these countries, people are forced to live alongside one of the deadliest diseases known to humankind. Rabies is 99% fatal to humans once symptoms appear. By the time a person shows symptoms of the virus, it is usually too late for effective treatment.

This is despite the fact that the first vaccinations for rabies date back to the 19th century.

This imbalance can, and needs to be, addressed. Although there is far less global competition for rabies vaccines than for COVID-19 vaccines, many countries are still not benefitting from the full suite of inexpensive and effective rabies control tools that exist throughout the world.

Applying what works

By combining what we already know works in controlling rabies and the extensive lessons of the COVID-19 pandemic, we can ensure the countries that need vital vaccines and resources can get them.

Firstly, knowing where the disease is most prevalent is crucial to directing vaccines, mass vaccination efforts, and other tools and resources, to effectively control rabies. 

Measures such as the Global Alliance for Rabies Control’s Rabies Epidemiological Bulletin (REB), which provides comprehensive rabies data, particularly for countries who do not have the resources or capacity to build their own systems, are leading the way in surveillance.

Likewise, technical innovation in health information systems and in-field diagnostics can also allow resource-poor countries the opportunity to build their own rabies surveillance systems in a timely and efficient manner, tracking and containing the spread of the virus.

The Community-Based Rabies Surveillance (CBRS) system, which has been used by GARC in the Philippines, links information about the biting animal from the field to laboratory and pairs this with human treatment data from clinics.

This ensures that the best treatment decisions are made, and that dog vaccinations are carried out where the rabies exposure occurred to prevent further cases in the future.

Animal health is a cornerstone of public health

Secondly, much as the COVID-19 pandemic has been managed at a country level, efforts to combat and control rabies need to be led by countries and fine-tuned to address the specific challenges that are faced in different regional contexts.

Rabies-affected countries need to be encouraged to build their own national strategies that address their unique challenges, whether they are related to funding for surveillance and rabies control, the availability of expertise or access to community animal health workers.

Finally, governments and health authorities must adopt a “One Health” outlook and prioritise animal health as a cornerstone of public health, ensuring that the vaccination of dogs can continue amid lockdowns and other restrictions that have arisen during the pandemic.

Improving the coordination between sectors and departments will be key to a holistic vision of public health which treats the disease at source, in the dogs, alongside access to human vaccines.

If dog vaccination coverage is low, particularly because of a slowdown in vaccinations during the pandemic, it is essential that dog bite victims, who may be exposed to rabies, can receive quick and life-saving treatment.

Effective surveillance

Ultimately, the persistence of rabies clearly illustrates how difficult it is to control a zoonotic disease, especially one which requires the close cooperation of countries across animal and human health departments.

Despite these difficulties, this approach is essential to create a more robust and resilient health infrastructure, for rabies and beyond.

The countries that have ended human deaths from dog rabies have done so in large part thanks to dog vaccination, access to crucial human post-exposure treatment and surveillance to monitor the disease and ensure that it is not being introduced into rabies-free zones.

That is why we must continue to strive to provide countries with support for vaccine-led strategies alongside more effective surveillance for the disease, which have also formed the centrepiece to the response of the current Covid-19 pandemic.

Rabies, despite its long history, is no less a deadly threat. Yet, while most governments have accepted that “Zero Covid” is not possible, the elimination of rabies is entirely possible through proven methods such as dog vaccination, as long as every country is adequately prepared with the tools and resources we know can work.

Professor Louis Nel is the Executive Director of the Global Alliance for Rabies Control.

Image Credits: WHO/ Daniel Stewart.

Gordon Brown, WHO Ambassador for Global Health Financing,

Western stockpiles of surplus COVID-19 vaccines are predicted to reach 600 million doses by the end of the year and millions might expire – yet the global vaccine facility COVAX is still short of 500 million doses to vaccinate 40% of the population by December.

This is according to former UK Prime Minister Gordon Brown, recently appointed as the World Health Organisation’s (WHO) Ambassador for Global Health Financing, who addressed the WHO’s media briefing on Thursday.

He described the next 10 days leading up to the G20 meeting in Italy at month-end as “decisive”.

“If at the G20 summit in Italy, the world’s richest countries cannot mobilise an extraordinary, expedited airlift of doses to the unvaccinated and unprotected of the world, and do so starting immediately, an epidemiological economic and ethical dereliction of duty will shame us all,” said Brown.

He called for a “globally coordinated, month by month operational plan and timetable” to transfer unused vaccines being held by the richest countries of the world to the world’s poorest countries.

Medecins san Frontiers (MSF) has estimated the figure of Western surplus doses for the 10 richest countries to be in the region of 870-million doses by year-end, while Brown said that this figure could balloon to one billion by February.

COVID kills thousands of health workers

At least 115,000 health workers have died of COVID-19 between January 2020 and May 2021 yet millions are still unvaccinated, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus.

“In Africa, less than one in 10 health workers have been fully vaccinated. Meanwhile, in most high-income countries, more than 80% of health workers are fully vaccinated,” Tedros told the briefing.

This is not a vaccine manufacturing problem, he added, but “an indictment on the countries and companies that control the global supply of vaccines”. 

“High and upper-middle-income countries have now administered almost half as many booster shots as the total number of vaccines administered in low-income countries,” said Tedros – but COVAX was in the dark about how many doses it would be getting and when.

It needed 500 million vaccine doses to vaccinate 40% of the world’s population by the end of the year, but 82 countries were in danger of missing this target, mostly because of a lack of supply.

“The G20 countries have pledged to donate more than $1.2 million to COVAX. So far only 150 million doses have been delivered,” said Tedros.

“For most donations, we have no timeline. We don’t know what’s coming and when manufacturers have not told us how much COVAX will receive, or when we receive it. We cannot have equity, without transparency.”

Tedros also called on wealthy countries and vaccine manufacturers to “share know-how, technology, licences and waive intellectual property rights”, adding  “we’re not asking for charity; we’re calling for a common-sense investment in the global recovery”.

Ahead of next week’s G20 summit next week, the ACT Accelerator is going to release a new 12-month strategic plan and budget to set out the actions and resources needed to achieve the WHO’s global vaccination targets. 

“It’s clear what needs to happen. The countries that have already reached the 40% target, which includes all the G20 countries, must give their spot in the vaccine delivery queue to COVAX and AVAT [the African Vaccine Acquisition Trust],” said Tedros.

Huge nurses’ shortage looms

Annette Kennedy, President of the International Council of Nurses

The WHO and partners have called on all countries to improve monitoring and reporting of infections and deaths among health and care workers, ensure they are prioritised for COVID-19 vaccines and enjoy “safe and healthy working conditions” including regular salaries, pay equity, appropriate education, career opportunities, and social protection. 

Describing the deaths as an underestimate, Annette Kennedy, President of the International Council of Nurses (ICN), said that deceased nurses’ families did not get compensation because COVID-19 was not recognised as an occupational health injury.

Lamenting the deaths, Kennedy asked: “Is it that health care workers lives mean so little? Is that governments do not realise that they have a duty of care to their health workers, the most valuable resource?” 

She added that nurses were “burnt out, devastated and physically and mentally exhausted” from working long hours in dangerous conditions, often without personal protective equipment (PPE), during the pandemic.

She also predicted a dire shortage of nurses in the next decade, with as many as 13 million – half the global workforce – could leave the profession in the next decade, mostly retiring or looking for better working conditions.

Image Credits: Adnan Abidi/Flickr.

German Chancellor Angela Merkel arriving at the EUCO. Germany is one of the key opponents of the TRIPS waiver.

Health activists have appealed to the European Council (EUCO) to discuss a waiver on Trade-Related aspects of Intellectual Property (TRIPS) on all health goods necessary to address the COVID-19 pandemic, but there is no indication that this is on the agenda of the meeting which started in Brussels on Thursday afternoon.

While COVID-19 is on the agenda, the invitation letter from EUCO President Charles Michel to Member States simply states that “we will touch upon international solidarity, to ensure the speedy delivery of vaccines to countries most in need”. 

The main focus of the COVID-19 discussion will be on vaccination within Europe itself in the face of rising COVID-19 cases in some countries despite vaccinations.

“The pandemic is not over yet and figures are on the rise in several member states,” Michel notes in his letter. “Vaccination has brought significant progress in the fight against COVID-19 but more still needs to be done, especially regarding vaccine hesitancy and disinformation.”

Health Action International, Human Rights Watch, One Campaign, Oxfam, The People’s Vaccine Alliance have written to Michel requesting that the TRIPS waiver be discussed at the meeting, which ends on Friday.

Pointing out that “massive Covid-19 vaccination campaigns have allowed European Union (EU) Member States to scale back restrictions and those living within the EU are gradually going back to offices, classrooms and dining venues”, the letter adds that “for many outside the EU there is no semblance of a return to normal as access to vaccines and other life-saving technologies are still not guaranteed, and their human right to health not fulfilled.”

Noting that “the need for scaling up vaccine production and therapeutics was never more acute”, the letter points out that South Africa and India submitted a proposal to waive certain rights and obligations of the World Trade Organization (WTO) TRIPS treaty over a year ago.

“Despite growing support from governments, civil society and academics, and the calls from European Parliament and elected officials, a handful of governments, led by the European Commission, oppose the proposal and refuse to engage in meaningful negotiations,” the letter notes.

However, it adds, governments have human rights obligations concerning international cooperation. 

EUCO only considered, briefly, the issue of the waiver in November 2020, but hasn’t addressed it since, according to the activists.

“This is unacceptable. The institutional separation of powers must not impede the accountability of actions taken on behalf of the EU, especially when there is no unanimity among members and when such actions have consequences for global health and the EU’s reputation as a human rights and moral leader,” it adds.

They call on Michel to allow countries to discuss the TRIPS waiver at EUCO, and raise it at the next G20 meeting t on 30-31 October, and at the WTO Ministerial Conference from 30 November to 3 December.

 

Teenage TB patients in a hospital in Vietnam.

The days of people with rifampicin-resistant tuberculosis (TB) taking up to 20 pills daily, interspersed with injections,  for up to 20 months might be over.

This follows the release on Wednesday of the preliminary results of a trial of a six-month oral treatment that researchers found to be substantially more effective than the current standard of care.

The TB-Practecal trial tested a six-month regimen of bedaquiline, pretomanid, linezolid and moxifloxacin (BPaLM), against the locally accepted standard of care. 

The trial involved 552 patients at seven trial sites across Belarus, South Africa and Uzbekistan.

“Some  89% of patients in the BPaLM group were cured, compared to 52% in the standard of care group. Tragically four patients died from TB or treatment side effects in the control group,” according to trial leaders Medecins Sans Frontieres (MSF), who revealed the findings at the 52nd Union World Conference on Lung Health.

“Patients were telling us how hard it was to adhere to treatment, but little progress was being made to find kinder treatments because diseases most prevalent in low- and middle-income countries don’t attract investment. So we were compelled to pursue new treatment options ourselves. These results will give patients, their families and healthcare workers worldwide, hope for the future of DR-TB treatment,” Dr Bern-Thomas Nyang’wa, MSF Medical Director and Chief Investigator of the trial, told the Union press conference on Wednesday.

Around 500,000 people develop rifampicin resistant tuberculosis (RR-TB) annually, and this intervention could save lives and substantially improve the quality of life of people with rifampicin-resistant TB.

Genome sequencing

Meanwhile, the conference also heard from researchers who used genome sequencing to effectively predict strains of tuberculosis susceptible to antibiotics that were likely to develop drug resistance.

The researchers looked at drug-susceptible bacteria and aimed to identify mutations that would increase the probability of a bacteria becoming resistant in the future. The mutations confer “pre-resistance”. Monitoring these mutations could prevent the amplification of drug resistance in the population by targeting those bacteria more likely to become resistant. 

We found that isoniazid mono-resistance backgrounds have a much higher risk of acquiring further rifampicin resistance than susceptible backgrounds,” said lead author Arturo Torres Ortiz, a PHD Student at  Imperial College in the UK.

“Rapid molecular tests usually focus on rifampicin resistance, which means that isoniazid mono-resistance is missed. This results in amplification into multi-drug resistance. We thus recommend that rapid molecular tests also identify regions associated to isoniazid resistance-conferring mutations.”

Image Credits: globalgiving.org.

COVAX
COVAX vaccine deliveries in Africa.

The global vaccine facility, COVAX, is on the cusp of delivering large amounts of vaccines to countries that need them the most – but will poorer countries have the ability to properly absorb these?

And how can COVAX ensure that it has the trust of low and middle-income countries (LMICs) who need the vaccines most, given complaints about its lack of transparency by the African Union’s vaccine envoy?

These are some of the issues flagged in a recent review of the Access to COVID Tools Accelerator,(ACT-A) of which COVAX is the most prominent project, with diagnostics and therapeutics forming the other pillars

The global vaccine alliance, Gavi, which manages COVAX, told Health Policy Watch that the coming months “will represent the busiest period of the largest and most complex roll-out of vaccines in history”. 

COVAX’s latest public supply forecast projects that it will have around 1.4 billion vaccine doses ready for delivery by end of year – 1.2 billion for the world’s poorest 92 countries to enable them to vaccinate 20% of their populations.

More support for countries to absorb vaccines

The review recommends “greater downstream support” to help LMIC to absorb more vaccines, something that Gavi says has been addressing over the past few months.

For instance, there has been a massive roll-out of ultra-cold storage facilities as the mRNA vaccines Pfizer and Moderna vaccines need to be stored at very cold temperatures.

“Over the last few months we’ve seen the largest roll-out of ultra-cold chain in history: hundreds of units to 47 countries in under five months,” a Gavi spokesperson said.

However, Gavi added that “ultimately, however, delivery is the responsibility of participating countries and so it is important that countries are able to access all sources of support for delivery”. 

Gavi and its alliance members, including WHO and UNICEF, have been working with many of these countries for two decades, and work closely with national governments and partners to monitor, identify and help to resolve delivery challenges. 

While Gavi acknowledges that new challenges will emerge once doses start arriving in larger volumes, it is “confident at least that systems are in place to ensure that when there is a risk of wastage, to ensure doses are redeployed rapidly to other countries”.

The cold storage facility at Pfizer’s warehouse in Kalamazoo, Michigan.

COVAX undermined by bilateral deals

When COVAX was set up, it declared its aims to be “speeding up the search for effective vaccines for all countries” and “supporting the building of manufacturing capabilities and buying supply, ahead of time, so that two billion doses can be distributed fairly in the places of greatest need, worldwide, by the end of 2021”. 

COVAX aimed to pool investment in candidate vaccines and, if any were successful, become the procurement facility for the entire world, wealthy and poor countries alike. Wealthy countries would pay for their own doses while the Advance Market Commitment (AMC) would use donor funds to help buy vaccines to cover 20% of people living in the world’s 92 poorest countries.

But COVAX was so underfunded that it couldn’t buy enough vaccines, and its paralysis fuelled bilateral deals between pharmaceutical companies and the high-income countries (HIC) that were also COVAX members.

“The critical lesson to be learned from this experience, and the current inequity in access to vaccines between HICs and LMICs, is the need for dedicated resourcing to be in place – before a pandemic occurs,” the Gavi spokesperson told Health Policy Watch. 

“It is notable that, building on the initial $4 billion raised via upfront payments and donor pledges in 2020, the COVAX AMC was only fully funded in June 2021 – by which time bilateral deals between governments and manufacturers had locked up most of the doses available in 2021,” said Gavi.

If funding had been available to COVAX earlier, says Gavi, the facility “would have been able to secure earlier supplies of vaccine from the manufacturers who are currently prioritising those bilateral customers”. 

“This, combined with transparency and accountability from manufacturers on which deals are being prioritised and when, could have avoided many of the supply challenges COVAX has faced to date.”

Gavi believes that it was important to include all countries “given the unknowns” about vaccine development at the start, but it is currently finalising new rules of engagement for the wealthy self-financing countries for next year.

Lack of LMIC representation

A COVAX vaccine delivery of vaccines is offloaded in Abuja in March

The ACT-A review notes “a lack of inclusion and meaningful engagement of LMICs, regional bodies, civil society organisations (CSO), and community representatives” in the ACT-A.

Some LMICs have felt left in the lurch as COVAX has failed to deliver vaccines while those countries that broke ranks and did private deals with pharmaceutical companies 

In July, Strive Masiyiwa, African Union Envoy on Vaccines and head of the African Vaccines Acquisition Task Team, accused COVAX of not being upfront about its vaccine supply problem early enough, resulting in false complacency amongst members who thought their vaccine supply was secure.

Other civil society members have said that COVAX was based on a Western charity model.

Dr Bruce Aylward, the World Health Organization’s (WHO) lead on COVAX, said the concern that the ACT-A Council was not balanced across low, middle and high-income countries “is going to have to be addressed and rebalanced”.

“We need to go back and look at every single one of the engagement mechanisms that already exists…  if it’s not working, we need to fix it,” Aylward told a WHO media briefing last week.

The Global Fund to Fight AIDS, TB and Malaria, which manages the diagnostics pillar of the ACT-A, said that the limitations identified by the review would be addressed by a “revised strategy and budget which is being prepared by the ACT-A partners for publication by the end of October”, a Global Fund spokesperson told Health Policy Watch.

However, Gavi says that lower-income countries are on the Gavi Board and committee structures as well as in the COVAX AMC Engagement Group and the WHO also gives member states regular briefings on COVAX. 

“All of these groups are actively involved in the governance and decision making for COVAX design, strategy and policy,” says Gavi, adding that “each country involved in COVAX has a dedicated team focused on providing tailored information and support, both at the Gavi Secretariat or COVAX Office level as well as via UNICEF and WHO country offices”. 

“These teams liaise directly with country-appointed focal points, usually at ministries of health, and communicate on a daily basis to receive participants’ feedback on various COVAX processes,” said Gavi.

Diagnostics and therapeutics

The review complemented ACT-A’s COVID-19 Response Mechanism (C19RM), which is based on the Global Fund’s well-established health procurement and distribution system, which was already operating in 100 countries. 

To address its three priority diseases – HIV, TB and malaria – the Global Fund had developed wambo.org, an online marketplace for medicines and health commodities that enables  countries to get cheaper prices through pooled procurement.

“When the COVID-19 crisis hit, we opened wambo.org to all countries and organisations so they can access pooled procurement volumes of quality-assured health products, including COVID-19 products,” said the Global Fund spokesperson.

Over 38 million diagnostic tests have already been procured for 90 countries through the Global Fund’s Pooled Procurement Mechanism and wambo.org. Countries could also buy oxygen and PPE on wambo.org. 

While many countries are not doing nearly enough COVID-19 testing, the Global Fund identifies those with the lowest number of tests (less than seven tests per 1000 population per week for 24 months) and offers support to procure rapid tests or laboratory strengthening support.

The review noted that the ACT-A therapeutics pillar “does not yet have a clearly articulated procurement structure to supply countries or to negotiate contracts”.

Tanzanian and US officials celebrate the arrival of the first COVID-19 vaccine donations in the country.

Funding the gap

The review notes that there is a funding gap of $16.6 billion and warns that some of the country pledges to COVAX have not yet been turned into contributions agreements. 

It also recommends that ACT-A should ensure “regular access to up-to-date consolidated financial data to enhance trust and accountability between donors and agencies”. 

WHO’s Aylward puts the shortfall over the next year to be closer to $20 billion “to get equitable rollout” of vaccines, diagnostics and therapeutics to defeat COVID-19. 

“If we go forward next year with the same gaps we had last year, the pandemic will be prolonged,” said Aylward, adding that WHO Director-General Dr Tedros Adhanom Ghebreysus was lobbying G20 finance and health ministers to close the financing gap.

 

Image Credits: UNICEF, Pfizer, NPHCDA.

Researchers describe new findings about TB transmission and diagnosis tools, on the first day of the 52nd Union World Conference on Lung Health

New research published at the opening of the 52nd Union World Conference on Lung Health has demonstrated that routine breathing can transmit tuberculosis even more effectively than coughing – in a finding that also echoes one of the signature lessons from the COVID-19 pandemic about SARS-CoV2 transmission. 

While large droplets jammed with bacteria produced by coughing has long been assumed to be the main course of TB transmission – the new study published on the pre-print server bioRxiv, demonstrates how even more TB bacterium, like COVID, may be transmitted by tinier aerosol droplets released during the course of natural breathing. 

The study by a team of University of Cape Town researchers was just one of a number of new findings released at the opening day of the iconic Union conference – which is meeting virtually for the second year in a row. 

Other new findings released in the first day of the three day, global event (19-22 October)  include a new gene-based blood-prick test for initial TB screening – particularly useful for children who do not produce sputum-filled coughs; and the use of face masks to capture, and screen for, TB and multi-drug resistant tuberculosis (MDR-TB)  as yet another novel diagnostic tool.   

But it is the new study on aerosol TB transmission that is one of the most revolutionary – challenging the fundamental dogmas around TB transmission. Using sensitive measurement devices, the study documents how so-called ‘tidal breathing’ – routine inhalation and exhalation by a TB-infected person – will typically release over 90% TB bacteria (Mycobacterium tuberculosis –Mtb), over the course of a routine day – as compared to only 7% by coughing. 

That’s partly because an infected person will simply breathe many more times  – some 22,000 times in fact, as compared to about 500 coughs.  In contrast to the large droplets released by a cough, most of the bacteria released by breathing are in the form of tinier aerosols, which can remain suspended in the air and travel much further as well. 

Findings on Aerosols Echo lessons from SARS-CoV2 – But Research Preceded the Pandemic 

The signature findings echo lessons learned from the COVID pandemic – where the big aerosol transmission risks of SARS CoV2 have now been well acknowledged – despite fierce resistance among some experts – including at the World Health Organization – in the pandemic’s early days.   

They also illustrate why traditional public health measures such as better housing, less crowding, and improved ventilation may deserve more attention in modern TB control – strategies that have perhaps been too often sidelined to the shadows by modern drug therapies.

Despite the comparisons, the research team at the University of Cape Town has been studying the aerosol transmission of TB long before COVID appeared on the horizon, asserted the study’s lead author, Ryan Dinkele, in a press briefing on Tuesday morning.  

They did so with the help of a device developed by Robin Wood, another University of Cape Town researcher and study co-author, which can more sensitively detect the bacteria in aerosols emitted by a TB-infected person’s breath or cough.

“We have been working on this technique for a long period of time,” Dinkele said. “We did chat about whether we should implement our system for COVID. COVID came across our lines during this process.”

Conference sheds light on a neglected disease 

Tereza Kaseva, director of the WHO Global TB Programme

The three-day conference on lung health, attended by several thousand specialists and policymakers from around the world also casts its net on a wider array of respiratory diseases  – including pneumonia, asthma, chronic obstructive pulmonary disease (COPD) – and COVID-19.  Sessions also will address the two biggest environmental risk factors for lung health – tobacco smoke and air pollution.

However, most of the conference’s attention is focused on TB, which paradoxically remains one of the deadliest diseases on the planet, despite the fact that it is also one of the oldest.  And the COVID pandemic has only made that worse – dramatically reducing the number of TB-infected people who are being diagnosed and treated in 2020 – according to the latest Global TB Report, released by WHO just last week. 

“TB remains critically underfunded,” said Tereza Kaseva, director of the WHO Global TB Programme. “Global spending on TB is $5.3 billion, less than half of the $13 billion annually that we need,” she stressed, saying that the world urgently needs to invest in new TB diagnostics, treatments, and ultimately, vaccines.     

Additionally, TB is a “social disease” whose transmission is facilitated by poverty and marginalization, making it a disease endemic to many migrant groups and informal communities, she and others emphasized.  

Co-morbidities of TB & COVID are unexplored

Uvistra Naidoo, South African pediatric doctor and TB/COVID survivor

“TB is grossly underfunded, and that is why we are behind in the race,” said Uvistra Naidoo, a pediatric doctor and himself both a TB and COVID survivor. Not only governments are to blame, however, he added: 

“When I compare with HIV or cancer,” he added, “there is a lot more activism that happens on behalf of the patient in the latter.”

The COVID pandemic has only added fuel to the fire in another way – not only shifting resources but also saddling many former TB patients, like himself, with additional COVID disease risks.

Those co-morbidities are still poorly understood, said Naidoo who knows this from bitter first hand experience.

After beating drug resistant TB in a difficult three-year battle –  he came down with COVID in 2020, and continues to battle the effects of long COVID today.

“I picked up severe COVID-19 twice,” he said, speaking at The Union session with the aid of a nasal oxygen cannula.

“I’ve got complications to my heart, my lungs, and my adrenal glands recently. We’ve just found out and as you can see, I’m still intermittently oxygen dependent,” said Naidoo. He described how COVID, when it struck South Africa, infected almost everyone in his family  – as well as many in his professional community.

“I’ve lost a father, I’ve lost 25 medical colleagues, doctors and nurses. I’m beyond humbled. I think the courageous thing that we can show the general public out there is that to actually just describe with the TB front and the COVID-19 front, that we don’t know what we’re doing just yet.” 

Image Credits: Roche , The Union .