Integration of care is important for patients’ wellbeing.

Health services in low and middle-income countries have yet to adapt to their growing burden of non-communicable diseases (NCDs) and still prioritise infectious diseases, according to a new report launched on Thursday by the NCD Alliance.

Treatment “silos” for HIV and tuberculosis need to be transformed into integrated universal healthcare services to better serve people in LMICs, many of whom are living with both infectious diseases and NCDs, according to the report.

“COVID-19 has brought about a greater recognition that the long-held distinctions between infectious and non-communicable diseases are not as clear cut as once thought – those with chronic conditions have a significantly higher risk of hospitalisation or death from the virus,” according to the NCD Alliance. 

The vast majority of people who have become seriously ill or died from COVID-19 had an underlying condition, particularly hypertension, cardiovascular disease and diabetes, it notes.

Integrated care ‘is the future’

“We urgently need a reset of healthcare delivery in poorer countries that actually reflects the needs of those who need it most,” said Katie Dain, CEO of the NCD Alliance. 

“Integrated care is the future of healthcare. The reality today is that ever more people are living with multiple chronic conditions. This needs to be better recognised in health systems. 

Dain added that infectious diseases and NCDs were entwined: “People living with HIV have a significantly higher risk of cardiovascular disease and some cancers. People living with TB are much more susceptible to diabetes and vice-versa. 

“Hypertensive disorders and gestational diabetes affect many pregnancies, risking potential lifelong health impacts for both mother and child if not effectively treated.”

“LMICs are experiencing a rapid transition from population disease profiles shaped by communicable diseases and conditions impacting mothers and their children, to those dominated by NCDs and injuries. Today, 85% of people dying from NCDs between ages 30 and 70 are in LMICs,” according to the NCD Alliance.

One in three diseases among the poorest billion people in the world are NCDs, according to the Lancet NCDI Poverty Commission.

Cardiovascular diseases account for most NCD deaths (17.9 million people annually), followed by cancers (9.3 million), respiratory diseases (4.1 million), and diabetes (1.5 million). These four groups of diseases account for over 80 percent of all  NCD deaths before the age of 70.

“Health centres that reflect this changing epidemiology are the future,” said Dain. “But this will also mean that we have to change the way we do business. The COVID-19 pandemic has been catastrophic for people living with NCDs and it is clear we need a health infrastructure in LMICs that is fit for purpose if we are to build back better.”

HIV, TB funding influences health system

The report’s lead author, Dr Gill Schierhout from the George Institute for Global Health, said that many LMIC health systems were still influenced by funding for HIV, TB, malaria and maternal health.

“The shape of this [funding] has critical impacts on the health care available – or not available – for the growing number of people who are living with NCDs in LMICs,” said Schierhout.

The report was based on an online survey that was sent to health workers in LMIC. Survey respondents identified that there were particular challenges posed by staffing siloes, and organisational ambivalence around the integration effort.

In addition, specialist managers of global health initiatives are sometimes “well versed in disease-focused areas, but not as well versed in whole-of-person care or primary health care. Therefore, programmes often struggle to gain the necessary management support”, according to the report.

However, the report documents a number of integration  successes. In Zambia, for example,  a cervical cancer screening has been integrated into an HIV care programme. It modelled that, for every 46 HIV-positive women screened, a woman’s life was saved who otherwise would likely have died of undetected cervical cancer.

More than a decade ago Ministers of Health resolved at the first UN High-Level Meeting on NCDs to “encourage the development, integration and implementation of vertical programmes, including disease-specific programmes, in the context of integrated primary health care”. 

“However, progress in this area has been patchy at best,” noted the NCD Alliance.

 

 

Image Credits: NCD Alliance, WHO/A. Loke.

Ethiopia vaccines
AstraZeneca COVID-19 vaccine arrive at Bole International Airport in Addis Ababa, Ethiopia, in March.

As Africa prepares to get even fewer COVID-19 vaccines than expected in the coming months thanks to the supply shortage at COVAX, the continent is also battling with vaccine hesitancy – exacerbated by the lack of vaccinated role models.

Africa could receive 155 million fewer vaccines than expected this year from the global vaccine platform, COVAX, which announced on Wednesday that it has had to cut its supply forecast by 25% as it has been affected by export bans, particularly from India, bilateral deals between manufacturers and countries, production challenges and delays in vaccine regulatory approval. (COVAX had previously said it will provide 520 million doses to the WHO Afro region by the end of the year.)

As a result, said Dr Matshidiso Moeti, head of the World Health Organization (WHO) Africa, the continent would have to continue to rely on economically crippling lockdowns, and other public health prevention measures instead of vaccinations to control the pandemic.

However, Moeti also conceded that the continent was facing vaccine hesitancy in some countries, notably the Democratic Republic of Congo (DRC) – which is also battling a meningitis outbreak.

“It’s true that vaccine rejection, denial, has been a strong feature of the response in the DRC,” Moeti told a WHO Africa media briefing on Thursday. 

“The demand was so little that the country, at some point had to redistribute some vaccine supplies that it had been provided for to other countries.

“Some surveys have shown that [vaccine hesitancy] has started to shift in other countries as the vaccines have been rolled out more and more people are interested now in getting vaccinated,” she added.

This was partly because people who have already been vaccinated can act as “role  models” to show that vaccines are safe, can prevent severe illness and death, she said.

Dr Matshidiso Moeti, head of the World Health Organization Africa region.

Only 20 African countries may reach 10% target this month

But vaccinated Africans currently make up a tiny minority.

“As of today, Africa as a whole has received around 138 million doses only,” said Dr Richard Mihigo, WHO’s Program Area Manager for Immunisation.

 “Only around 40 million people have received the two doses that are required to be fully vaccinated, and this represents merely 3% of the African population.When you look at sub-Saharan Africa, it’s around 1.7%,” added Mihigo.

Fewer than 20 out of the 54 African countries were likely to reach the WHO target of 10% of their population vaccinated by the end of this month, he added.

However, Mihigo said that despite the COVAX shortfall, vaccine supply was fluid and the continent could still get the vaccines it needed to vaccinate 40% of Africans by the end of the year, WHO’s next target.

Meanwhile, Moeti stressed that increasing vaccine supply was the biggest priority for the country.

She noted that while COVAX had recently supplied around five million vaccines to Africa, three times as many doses – 15 million had been thrown away in the US due to wastage.

“This is enough vaccines to cover everyone over 18 years in Liberia, Mauritania, and the Gambia,” she observed. “Every dose is precious and has the potential to save a life.”

She noted that, while high-income countries have pledged to share one billion doses globally, and so far 120 million doses have been released.

Prioritize vaccine equity

“Manufacturers are now producing 1.5 billion COVID vaccine doses globally each month, and two billion doses are required to reach 40% of people in every country. If producing countries and companies prioritise vaccine equity, this pandemic, can be over quickly,” she noted.

However instead, COVAX had announced that its shipment forecast for the rest of the year had been revised downwards by 25% “in part because of the prioritisation of bilateral deals over international solidarity”, she said. 

“G20 Health Ministers this week expressed their support for the global 40% vaccination target. This goodwill needs to be accompanied by concrete actions and financing for the global fight against COVID-19, to succeed,” she added.

Image Credits: UNICEF, WHO.

COVID booster vaccines have gained traction in several countries – US, Israel, Germany, UK, and others, but low- and middle-income countries lag significantly behind in shots.

The World Health Organization (WHO) has called for its global moratorium on COVID-19 boosters to be extended until the end of the year to enable vaccines to be directed to countries that have not yet been able to reach their vulnerable citizens.

“A month ago, I called for a global moratorium on booster doses at least until the end of September to prioritise vaccinating the most at-risk people around the world who are yet to receive their first dose,” WHO Director-General Tedros Adhanom Ghebreyesus told the body’s media briefing on Wednesday.

“There has been little change in the global situation since then, so today I am calling for an extension of the moratorium until at least the end of the year, to enable every country to vaccinate at least 40 percent of its population.”

The WHO’s global target is for every country to vaccinate at least 10% of its population by the end of this month, at least 40% by the end of this year and 70% of the world’s population by the middle of next year – but the September target so far is likely to be missed due to the failure of rich countries to donate sufficient doses to low- and middle-income countries.  And current commitments to COVAX, the WHO co-sponsored global vaccine facility, are running several hundred million doses short of the 40% end-year goal. 

Dr Kate O’Brien

Dr Kate O’Brien, WHO’s director of immunisations, also stressed that there was neither scientific consensus nor enough evidence to support giving COVID-19 boosters.

“We’re not asking [countries] to withhold something for which there is a strong set of evidence,” said O’Brien. “The vaccines are holding up very, very well against the severe end of the disease spectrum. The actual focus of the vaccine programme is to prevent severe disease, hospitalizations and deaths, and we see in the evidence that, in fact, the vaccines are performing extremely well over time, and against the variants,” she said. 

According to a technical report issued by the European Centre for Disease Prevention and Control (ECDC) last week, “based on current evidence, there is no urgent need for the administration of booster doses of vaccines to fully vaccinated individuals in the general population” but that ”additional doses should already be considered for people with severely weakened immune systems as part of their primary vaccination”.

“We will continue to watch the evidence very carefully, but our expert advisory committees continue to see that there is not a compelling case to move forward with a generalised recommendation for booster doses,” added O’Brien.

No more promises, just vaccine delivery

Tedros hit out at high-income countries that have promised to donate more than one billion doses as “less than 15 % of those doses have materialised”. 

“Manufacturers have promised to prioritize COVAX and low-income countries. We don’t want any more promises. We just want the vaccines,” Tedros added.

Although 5.5 billion vaccine doses have been administered globally, 80% have been administered in high- and upper-middle-income countries, according to the WHO.

Reiterating his weekend appeal to G20 health ministers, Tedros said that “the world’s largest producers, consumers and donors of vaccines, the world’s 20 leading economies, hold the key to vaccine equity and ending the pandemic”.

They could do so by swapping their near-term vaccine deliveries with COVAX, fulfilling their dose-sharing pledges by the end of this month and “facilitating the sharing of technology, know-how and intellectual property to support regional vaccine manufacturing”, he added.

WHO’s Bruce Aylward

Dr Bruce Aylward, the WHO representative on COVAX, said that despite promises made by the G7 and others, the global vaccine platform had to reduce its supply forecast this week as there had been a 25% reduction in the number of doses that will go through COVAX – unless there is urgent action by the world’s G20 countries and vaccine manufacturers. 

“People have come out and said, ‘Well, it’s only 100 million doses if we do boosters’, but we’ve just had to downgrade supply by a few 100 million doses. It makes a real difference in the face of scarcity,” added Aylward.

“To get all the world to 40% [vaccination] coverage in every single country requires two billion doses of vaccine,” he added.  

According to its latest Supply Forecast, COVAX expects to have access to 1.425 billion doses of vaccine in 2021 “in the most likely scenario and in the absence of urgent action by producers and high-coverage countries to prioritize COVAX”.

COVAX supply forecast, 8 September 2021

COVAX added that its work was being hampered by “export bans, the prioritisation of bilateral deals by manufacturers and countries, ongoing challenges in scaling up production by some key producers, and delays in filing for regulatory approval”.

Tedros ‘appalled’ by IFPMA comments

Tedros also lashed out directly at the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA), for comments made in an media briefing on Tuesday.

He complained that the IFPMA was calling for dose-sharing with poorer nations – but only after rich countries had vaccinated virtually everyone who wanted a jab.

“Yesterday, the IFPMA said that G7 countries now have enough vaccines for all their adults and teenagers, and to offer booster doses to at-risk groups, and that manufacturing scale-up should now shift to delivering global vaccine equity, including dose sharing,” said Tedros.

“When I read this, I was appalled,” said Tedros. “In reality, manufacturers and high-income countries have long had the capacity to, not only vaccinate their own priority groups, but to simultaneously support the vaccination of those same groups in all countries.

“We have been calling for vaccine equity from the beginning, not after the richest countries have been lower-middle-income- and lower-middle income countries are not the second or third priority. Their health workers, older people, and other at-risk groups have the same right to be protected. I will not stay silent when the companies and countries that control the global supply of vaccines think the world’s poor should be satisfied with leftovers,” Tedros said.

In the IFPMA statement, the pharmaceutical body stated that: “The biopharmaceutical industry continues to call for dose sharing and renew its commitment to work with governments to support their efforts.

“From now on, G7 countries have sufficient stocks of doses to vaccinate adults, teenagers and roll out boosters programmes to protect the most at-risk groups as well as substantially increase the number of doses available to low- and lower-middle-income countries. Political leadership is critical to enable dose deliveries as quickly as possible.

“Reducing the toll of the pandemic on lives and livelihoods requires equitable access to vaccines and country readiness for vaccination.”

WHO Director General Dr Tedros Adhanom Ghebreyesus.

Aylward, meanwhile, took a less combative position, recognising that vaccine inequity was no longer an issue of supply constraints.

“We had the IFPMA came out yesterday and said ‘Look, global production is 1.5 billion doses a month now’. The absorptive capacity of the world is less than a billion right now… So, the volumes are there. This is a fixable problem, but it’s only going to get fixed if the political will and the will of the manufacturers come together to solve it,” he said.

Israel, currently facing one of the highest infection rates in the world due to a Delta variant surge, has already implemented boosters shots for any residents who got their jabs more than five months ago.  And the White House has also announced it would begin offering boosters in September for everyone immunised eight months ago or longer – although regulatory authorities are still debating authorization of the plan. Several other countries including France, Germany, Thailand and the United Arab Emirates are offering boosters.

But Aylward noted that many other countries had already consulted the WHO on whether booster policies can be delayed. 

“Some countries may be going ahead with [booster] decisions, others may not. But our role is to make sure that we put forward the strongest possible arguments for the way out of this pandemic, and the way out is an extended moratorium because, since the last time we called for it, the equity gaps have got greater, the amount of vaccine available in low-income countries has gone down,” he added.

Recognise all WHO-listed vaccines

Tedros also condemned the refusal of some countries to allow travellers who have been fully vaccinated with a vaccine that has WHO Emergency Use Listing (EUL) entry on the basis that their vaccines have not been approved by their national regulators.

“WHO Emergency Use Listing follows a rigorous process based on internationally recognized standards. All vaccines that have received WHO Emergency Use Listing are safe and effective in preventing severe disease and death, including against the Delta variant,” said Tedros, urging all countries to recognize all vaccines with WHO EUL.

This follows reports that some European countries are still not allowing travellers vaccinated with Covishield, the AstraZeneca vaccine produced by the Serum Institute of India, to enter their countries – even though the European Union has approved the AstraZeneca vaccine made elsewhere.

 

Image Credits: Marco Verch/Flickr.

Vials of the Pfizer-BioNTech COVID-19 vaccine.

COVID-19 vaccine manufacturers are expected to produce 12 billion doses by the end of the year – almost half made by China – and there could be a vaccine surplus by mid-next year.

In addition, by the end of this month, around 500 million doses should be ready for “redistribution” from wealthy to low-and middle-income countries.

This emerged at a media briefing organised by the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) on Tuesday.

“By January 2022, there will be sufficient vaccines produced for every adult on every continent,” according to IFPMA.

“Modelling by Airfinity indicates that even if vaccine advisory committees and governments in G7 countries vaccinate teenagers and adults and decide to give boosters to at-risk populations, there would still be over 1.2 billion doses available for redistribution in 2021 alone. This means that each month for the foreseeable year, over 200 million doses would be, with effective planning, available for low- and lower-middle-income countries,” it added.

 

Describing the vaccine production increase as “absolutely extraordinary”, Rasmus Bech Hansen, CEO of research forecast group Airfinity, said that it had been “a surprise to pretty much everyone how fast China has scaled up vaccine production”.

Hansen added that, even when third booster shots for citizens in high-income countries were factored in, Infinity estimated that, “by the end of September, there will be around 500 million doses available in the US, UK, European Union and Canada that could be redistributed” through donations, swaps or reselling.

“In the last G7 summit, one billion doses were pledged [to LMIC] and it actually seems that these stocks will be available by the end of the year so G7 countries could meet those pledges,” he added.

IFPMA Director General Thomas Cueni told the briefing that ‘by June 2022, we expect that we will have more than 24 billion doses of COVID-19 vaccines available”.

IFPMA Director General Thomas Cueni

“At this point, vaccine supplies may actually outstrip global demand,” added Cueni. “Vaccine manufacturers are now producing 1.5 billion doses per month, and are expected to continue manufacturing at that scale on the basis of the most conservative protection projections.”

Hansen noted that 73% of the production increases were the result of pharmaceutical companies enhancing their in-house capacity, supported by an array of collaboration agreements within the industry – Affinity had counted 231.

Pfizer doses mostly allocated for next year 

Pfizer CEO Dr Albert Bourla said that his company had doubled its production capacity in the past six months and was on track to produce three billion doses by the end of the year, thanks to “sleepless nights, and a lot of effort from thousands of people”.

While it was testing a version of its vaccine that had been tweaked to combat the Delta variant, Bourla said this didn’t seem necessary as the current vaccine is highly efficacious.

One of the key challenges Pfizer faced in scaling up was access to raw material to make it’s mRNA vaccine.

“We literally created new suppliers” by giving companies financial, scientific and technical support, said Bourla.

However, in response to a Health Policy Watch question, Bourla dismissed joining the mRNA technology transfer hub established recently in South Africa by the World Health Organization (WHO) to assist Africa to develop its own mRNA vaccines.

Pfizer CEO Dr Albert Bourla

“I’m not sure what is the point of transferring technology that it is going to take years to transfer. And, by the way, this is what we do. I’m not sure I understand what they want, to give it someone else to do?” asked Bourla.

Pfizer expects to make four billion doses in 2022, but Bourla but urged all countries to place their vaccine orders as soon as possible.

“We have allocated doses already for this year and frankly, we have allocated a very big part of the doses that we are going to be producing next year also to countries that they have placed orders for these doses,” said Bourla, adding that 41% of this year’s production had been allocated to LMICs.

Bourla said most orders for 2022 were from high-income countries, with boosters fueling demand. While Pfizer would like to allocate at least one billion doses to LMIC for 2022, it had  yet to receive orders for this amount.

“When it comes to the ability to pay, we implemented tiered pricing. High-income countries were receiving one tier of pricing, mainly the cost of a meal in their country. Middle-income countries received half of this price, and the low-income countries received doses at cost,” said Bourla, who is also IFPMA’s vice-president.

Johnson & Johnson has policy of technology transfer

Dr Paul Stoffels, Chief Scientific Officer for Johnson & Johnson

Dr Paul Stoffels, Chief Scientific Officer for Johnson & Johnson, said that his company had established a global vaccine manufacturing network across four continents with 11 manufacturing  sites

“We made a commitment to equitable access and committed by putting a billion doses forward for low and middle-income countries in the next 12 to 18 months,” said Stoffels, adding that over half the company’s vaccines would go to LMICs in the coming year.

“Our strategy of focusing on technology transfer brought us to partnering with Aspen Pharmacare in South Africa. Aspen is now fully in production and we anticipate that all supplies produced by Aspen from now on will go to COVAX countries and African Union. And we are also transferring our technology as we speak to BioE in India,” said Stoffels.

This follows a recent report by The New York Times that Aspen, which has a ‘fill and finish’ contract with J&J, had been exporting millions of vaccines to Europe while lagging behind in its African deliveries. The EU recently agreed to send these vaccines back to South Africa.

However, Stoffels warned that technology transfers are “highly technical by nature and highly complex”. 

“We need to work with many partners. Multiple steps are needed, including biological manufacturing, quality testing and release, regulatory inspections and controls. Most critical is the training of workforce and new technologies,” he added. 

Progress in therapeutics

Cueni reported that “a handful of authorised COVID-19 treatments are becoming standard of care for COVID-19 patients that have been hospitalised and are saving lives”. 

“Monoclonal antibody treatments are beginning to offer promise as are novel antivirals,” said Cueni.

Some of the key treatments that have been authorised for emergency use include the anti-viral, Remdesivir (Gilead Sciences), Monoclonal IL-6 blocker, Tocilizumab (Roche), Monoclonal Casirivimab and  Imdevimab (REGEN-COV Roche Regeneron) and Monoclonal Sotrovimab (GlaxoSmithKline).

“Getting the therapeutic rollout right will be important for all countries to be able to benefit from future innovation, such as the anticipated oral outpatient COVID-19 therapeutic candidates,” he added.

Roche has been involved in 10 experimental treatments for COVID-19 “focused on preventing progression to mechanical ventilation and preventing death”– but testing these was complex and difficult, said its CEO, Bill Anderson.

Roche CEO Bill Anderson

One of these, tocilizumab (Actemra), is a monoclonal antibody that reduces inflammation by blocking the interleukin-6 receptor.

“As it suppresses the immune system, we thought, ‘you don’t want to give it to patients that are newly diagnosed’. It’s really for patients who’ve progressed to a severe illness where their immune system may actually be more doing more damage than good. So we had to run multiple studies. I think we’ve run ultimately, we’ve run seven pivotal studies,” said Anderson, adding that the first pivotal study had failed to show any results.

“Many people thought, well, that’s the answer. But we had seen enough to think, hmm, you know, I don’t think that’s a complete story. And ultimately, we’ve shown that Actemra does decrease need for mechanical ventilation and death quite significantly in hospitalised patients,” he added. 

But there are only so many facilities in the world capable of producing monoclonal antibodies, said Anderson, and the treatments needed large quantities.

“We ultimately did a partnership with Regeneron, which is a company that we compete with in many other fields, but we felt like they were farthest along,” added Anderson.

“We made an exceptional decision that we would not assert patent rights if companies could make a product of a biosimilar to Actemra and deliver it to LMICs, and that, in fact, it looks to be happening,” he added.

However, Anderson added that Roche was only prepared to support technology transfer to companies with the capacity to produce large amounts of monoclonal antibodies.

“Tech transfer is very laborious, and we can’t afford to take our people that are producing Actemra and that are also doing tech transfer with the existing external contracts, unless we have somebody who can produce large quantities.”

 

Image Credits: Twitter: @WHOAFRO, US Centers for Disease Control.

air quality

Over a third of the world’s countries – 37% – have either not created or are not enforcing legally mandated ambient air quality standards (AAQS), according to a new report released by the United Nation Environment Programme (UNEP).

The report, “First Global Assessment of Air Pollution Legislation” assesses national air quality legislation in 194 states and the European Union, and found  persistent policy, capacity, and implementation gaps to prevent more effective action against air pollution.

Approximately 60% of countries, accounting for 1.3 billion people, have no annual ground-based monitoring for fine particulate matter (PM 2.5), while at least 31% of countries with the ability to introduce sub-standards for ambient air quality standards (AAQS) have not done so. 

Unregulated air pollution continues to pose the greatest environmental threat to health. There are over seven million premature deaths every year due to the combined effects of outdoor and household air pollution – with millions more people falling ill from breathing polluted air, according to the WHO. More than half of these deaths are recorded in low- and middle-income countries.

UNEP calls for multi-sectoral action, in light of the report’s launch coinciding with International Day of Clean Air for Blue Skies, that can enable cleaner air for all. 

“Investments in air quality will [not only] enhance our health, but also job creation, energy efficiency, clean transport, sustainable agriculture, and green and resilient cities,” said UNEP Executive Director Inger Andersen, during a Tuesday launch event of the report. 

“We can’t clean the air overnight, and we can’t clean the air without the full engagement of every sector of society. But if we put the work in today, we can one day soon breathe easier.”

‘Lack of ambition’ in heterogeneous approach to air quality control

Eloise Scotford, one of the co-authors of the UNEP report

While the majority of countries (64%) embed AAQS in legislation, the global picture of national air quality is one of heterogeneity, with some cases of implementation masking a “lack of ambition”, said Eloise Scotford, Professor of Environmental Law at the University College London and one of the co-authors of the study.

Poor enforcement of air quality laws has led to 43% of countries lacking a legal definition of air pollution and only 51% of national air quality laws globally with explicit public health, or public and ecosystem health as their main objective.

“We found that processes for setting AAQS are often not transparent, or accountable, or accessible,” said Scotford, noting that standards could often be made more ambitious.

Although the heterogeneous approach to embedding air quality standards reflects specific air quality challenges and diverse legal cultures, in addition to acknowledging that there is no one-size fits-all approach to air quality control, this also risks masking weak ambition and legalizing unclean air.

In addition, only 33% of countries impose requirements on governments to achieve AAQS, indicating that the institutional responsibility on air pollution is quite weak and are the bare legal standards, added Scotford. 

The lack of level playing field for AAQS may keep the world at odds with the demanding requisites on global policies on climate change expressed in the 2015 Paris Agreement.

Legal standards need to be established

Figure 1 is a conceptual map explaining how legislative incorporation of AQS may sit within, and provide the foundation for a domestic “system of air quality governance”.

Regulating and controlling the different sources of air pollution remains a “coordination challenge”, according to Scotford, with the first step establishing legal standards for air quality. 

“Once you have legal standards for air quality, that’s really important. Ambition is important. But that is not enough. More needs to be done to have a full system of quality governance that is robust, to ensure the achievement of clean air.” 

The UNEP report notes that a robust system of air quality governance is one which: 

  • requires governments to develop and regularly review applicable air quality standards in light of public health objectives;
  • determines institutional responsibility for those standards;
  • monitors compliance with air quality standards;
  • defines consequences for failure to meet them;
  • supports the implementation of air quality standards with appropriate and coordinated air quality plans, regulatory measures and administrative capacity;
  • is transparent and participatory.

WHO air quality guidelines launching end of the month

Maria Neira, WHO Director of Environment, Climate Change and Health

In light of the launch of the UNEP report, WHO has announced that they will be launching their 2021 Air Quality Guidelines on 22 September.

These guidelines will serve as a global target for national, regional, and city governments to work towards reducing air pollution. 

WHO Director of Public Health, Environmental and Social Determinants of Health Maria Neira echoed UNEP’s calls for urgent and collective action in reducing air pollution.   

“It is time to stop with those fossil fuels. It is time to accelerate towards a very ambitious and quick transition to clean sources of energy. We need to do it for the economy, we need to do it for our society, but we also need to do it for our health. The more we postpone this transition, the more we will have death and disease on our shoulders.”

Image Credits: Flickr, UNEP, UNEP.

 

Climate change: A firefighter fighting a battle against a fire in South Africa

“The greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1·5°C, and to restore nature. Urgent, society-wide changes must be made and will lead to a fairer and healthier world,” according to an editorial published simultaneously in 200 journals world-wide.

The aim of the editorial is to help develop momentum for “urgent action to keep average global temperature increases below 1·5°C, halt the destruction of nature, and protect health” in the run-up to the UN General Assembly which starts on 14 September,  the biodiversity summit in Kunming, China, and the UN Climate Change Conference of the Parties (COP26) in Glasgow, UK. 

“The science is unequivocal; a global increase of 1·5°C above the pre-industrial average and the continued loss of biodiversity risk catastrophic harm to health that will be impossible to reverse. Despite the world’s necessary preoccupation with COVID-19, we cannot wait for the pandemic to pass to rapidly reduce emissions,” states the editorial, published in journals that are usually in competition with one another.

The editorial warns that temperature rises of above 1·5°C ”increase the chance of reaching tipping points in natural systems that could lock the world into an acutely unstable state” and “critically impair our ability to mitigate harms and to prevent catastrophic, runaway environmental change”.

It says that targets set by many governments, financial institutions, and businesses “are not enough”. 

“They are yet to be matched with credible short-term and longer-term plans to accelerate cleaner technologies and transform societies. Emissions reduction plans do not adequately incorporate health considerations.

“Concern is growing that temperature rises above 1·5°C are beginning to be seen as inevitable, or even acceptable, to powerful members of the global community,” states the editorial.

“Relatedly, current strategies for reducing emissions to net-zero by the middle of the 21st century implausibly assume that the world will acquire great capabilities to remove greenhouse gases from the atmosphere.

“This insufficient action means that temperature increases are likely to be well in excess of 2°C, a catastrophic outcome for health and environmental stability. Crucially, the destruction of nature does not have parity of esteem with the climate element of the crisis, and every single global target to restore biodiversity loss by 2020 was missed. This is an overall environmental crisis.

“Health professionals are united with environmental scientists, businesses, and many others in rejecting that this outcome is inevitable.”

 

Image Credits: Commons Wikimedia.

European Commission head Ursula von der Leyen has agreed to return to Africa millions of Johnson & Johnson  (J&J) COVID-19 vaccines that were imported from a South African manufacturer following a meeting with South Africa’s President Cyril Ramaphosa last week.

This was revealed by African Union envoy Strive Masiyiwa said at an Africa Centres for Disease Control (CDC) press conference on Thursday.

News that J&J had fallen behind in vaccine deliveries to African countries while the Aspen Pharmacare manufacturing facility in South Africa was busy exporting millions of the J&J/ Janssen vaccines to Europe was exposed by the New York Times in mid-August.

The report was met with outrage from civil society activists, African governments and the World Health Organization (WHO) – particularly as Aspen has been lagging behind in its J&J vaccines deliveries to African countries.

However, after Ramaphosa raised the issue with Von der Leyen at the G20 Compact with Africa event on 27 August, she agreed to reverse the imports, said Masiyiwa, who heads the African Vaccine Acquisition Trust (AVAT).

“All the vaccines produced at Aspen will stay in Africa and will be distributed to Africa,” said Masiyiwa on Thursday.

He added that J&J’s “finish and fill” contract with Aspen would be converted to a license agreement in which J&J would no longer control where the vaccines went. 

But Fatima Hassan, head of the South African Health Justice Initiative (HJI), said that the AU and South African government should not take credit for the EU’s U-turn.

“Civil Society shone a lone light with two New York Times investigative journalists. Mostly, governments were caught napping and unaware,” said Hassan, adding that she was reserving her celebrations until the J&J vaccines were actually returned to the continent.

Meanwhile, AVAT also facilitated the delivery of 12,000 J&J vaccines to the African Union Commission staff, AU embassy staff and their dependents in Addis Ababa this week.

Only a quarter of this group is vaccinated, according to AU Commission Deputy Chairperson Dr Monique Nsanzabaganwa.

“This figure is far below where we need to be, in order to be near normalcy and return to work.  It is therefore pertinent that all staff and supervisors should encourage colleagues to get vaccinated as this is the only way for us to return to our previous working environment”, she said.

The doses, which had been paid for by donors, were delivered by AVAT on Wednesday alongside the first batch of a large J&J order for Ethiopia.

Numerous countries are facing oxygen shortages, while readily available oxygen products are in short supply.

As some 32 countries worldwide, including seven African nations, face “code red” oxygen shortages, WHO and its partners are in the midst of a major effort to recruit sufficient supplies to meet countries’ urgent needs for life-saving oxygen.  

But while over US$500 million is now available in funds and finance for oxygen through the Access to COVID-19 Tools (ACT) Accelerator initiative, many African countries at risk of oxygen shortages have yet to apply for available funding to bolster their oxygen supplies – including Algeria, South Africa and the Democratic Republic of Congo.  

Delays in asking for funding, or asking for the wrong mix of supplies, can make response to oxygen demand surges an even bigger challenge, warned experts at an event Thursday co-organised by Unitaid, Waci Health, and the Every Breath Counts partnership, a coalition of UN agencies, businesses, donors and NGO.

They urged countries to fine-tune requests and accelerate their applications to meet the next deadline for financing requests – as well as to fine-tune demands to ensure a faster and more flexible response to shortages – including a “very dire” situation in some African nations.

‘Very dire’ situation in Africa

Globally 70 countries are at risk of oxygen shortages. Surges in COVID cases – due in large part to the Delta variant (B.1.617.2) – and hospitalizations are overwhelming health systems and driving up deaths.  

Among the African countries facing dangerous levels of oxygen shortages are: Ethiopia, Nigeria, Ghana, Benin, Togo, Cote d’Ivoire, and Somalia. Meanwhile, Somalia and nine other African at-risk countries have yet to even apply for funding for oxygen supplies. They include: Algeria, Libya, Mauritania, Guinea, the Democratic Republic of Congo, South Africa, eSwatini, Mozambique, and Botswana. 

As a result of health systems lacking oxygen and other supplies needed to manage serious COVID cases, the African region is also witnessing “worrying mortality trends,” according to WHO. Last week eight African countries reported increases of over 50% in weekly deaths.

“[There are] large and critical surges in the need for oxygen and too many unacceptable deaths [have been] associated with the lack of access to it,” said Robert Matiru, Director of Programmes at Unitaid, at the event.

Robert Matiru, Director of Programmes at Unitaid, at an event on Thursday co-organized by Unitaid, Every Breath Counts, and Waci Health.

“Medical grade oxygen is one of the most critical medicines for people with severe and critical COVID-19…but unfortunately it is not something that is readily available,” said Dr Raji Tajudeen, Head of the Division of Public Health Institutes and Research at Africa Center for Disease Control and Prevention (CDC). “When oxygen is available, the cost is prohibitive.”

Financing requests exceed available oxygen supplies 

The ACT-Accelerator’s COVID-19 Oxygen Emergency Taskforce, which was launched in February, has mobilised over US$340 million for oxygen-related products in low- and middle-income countries (LMICs) through the Global Fund’s COVID-19 Response Mechanism (C19RM). 

In addition, some US$182 million has been donated to the therapeutics pillar of UNICEF’s Access to COVID-19 Tools Accelerator Supplies Financing Facility (ACT-A SFF). The finance mechanism is dedicated to the procurement and delivery of therapeutics for LMICs, including oxygen. 

But while this represents significant progress toward ACT-A’s goal of raising US$1.2 billion for COVID oxygen needs – bottlenecks in the manufacture of oxygen cylinders and long lead times required for the construction of large-scale pressure swing absorption (PSA) oxygen generating plants are delaying the acute deployment of crisis support, officials said. 

Challenges faced by the Access to COVID-19 Tools (ACT) Accelerator’s COVID-19 Oxygen Emergency Taskforce to address the immediate demand surges in oxygen.

“Even though it’s really encouraging news that we have almost US$340 million awarded, we don’t have enough supply to meet that once procurement and delivery actually begin,” said Robert Matiru, Director of Programmes at Unitaid, at the event on Thursday.

“That is why it’s really critical to already be putting in place interventions to accelerate procurement and delivery and also medium-term measures to ensure that these lead times are cut dramatically for subsequent suppliers and awards,” he added.

Countries urged to fine-tune demands & prioritise oxygen sourcing options that could accelerate access

A breakdown of the approved funding requests from the Global Fund’s COVID-19 Response Mechanism (C19RM).

He urged countries to fine-tune their oxygen supply plans and finance requests accordingly – by considering a wider range of oxygen supply options.

Rather than prioritizing the construction of new PSA facilities, which take a long time to build, countries should consider alternatives like the repair of existing PSA systems, and procurement of bulk liquid oxygen supplies, Matiru said.

“Once you have massive surges, you really need a larger generation capacity and a larger supply capacity than PSA can provide,” said Matiru. 

Procurement of liquid oxygen, which can be stored in bulk at facilities or converted to oxygen cylinders for delivery, may be the fastest way to increase oxygen supply in countries that have existing supply lines for deliveries, he said.

Repairing existing PSA plants may also be more cost-effective and faster than constructing new facilities, as new plants can cost up to US$250,000 and take three to 12 months to complete. 

Algeria, DRC, South Africa and other countries yet to apply for oxygen support finance

In addition, more LMICs should be encouraged to apply for funding for oxygen supplies through the Global Fund’s COVID-19 Response Mechanism, said Matiru.

The deadline to submit the financing request is fast approaching on 17 September, he warned, urging countries to meet it.

Officials from organisations on the ACT-A taskforce also said that there was room for improvement among partners in their coordination of efficient procurement and delivery services. 

“We know as a taskforce we need to be more effective as partners to more effectively attract demand, financing, technical cooperation, and supply, so that we can ensure tight coordination, avoid duplication and be efficient with these resources that are being channelled at unprecedented rates in countries,” said Matiru.

Building local technical and manufacturing capacity – avoiding ‘white elephants’

Along with increasing the supply of oxygen products, building technical capacity and human capital is essential for the sustainable continuation of oxygen infrastructure, said the experts. 

Investing in the health workforce, and expanding biomedical human capital in member states, is important for the service and maintenance of oxygen services and facilities. 

“This unprecedented amount of equipment and supplies has to be maintained and sustained,” said Matiru. “We can’t afford to have white elephants and not sustain the benefit of these investments through this pandemic and even beyond this pandemic for the critical needs we know are out there and predated this pandemic: childhood pneumonia, trauma, complications in childbirth, sepsis and so on.”

One of the key steps moving forward is investing in local manufacturing capacity and developing a “new public health order” in Africa, said Tajudeen.

Dr Raji Tajudeen, Head of the Division of Public Health Institutes and Research at Africa Center for Disease Control and Prevention (CDC).

“To guarantee continental health security, we cannot continue to rely on importation of [oxygen products] from the outside,” Tajudeen said. 

“We know that with new COVID-19 waves there will definitely be new variants,” he added. “And with the low level of vaccine coverage on the continent, we need to continue to make the case for the investment in medical grade oxygen.” 

Some 2.8% of the African population are fully vaccinated, compared to 47.7% in Europe and 42.3% in North America. 

“Going forward [we] really need to begin to look at investing in an oxygen infrastructure so that people with severe COVID and those who…cannot afford oxygen will be able to have access to this oxygen,” said Tajudeen.

Image Credits: WHO/Blink Media – Nada Harib, UNICEF/Ralaivita, Unitaid.

Only a quarter of countries worldwide have a national plan to support people with dementia and their families, according to the World Health Organization’s (WHO)  ‘Global status report on the public health response to dementia’ released on Thursday. 

More than 55 million people globally are living with dementia and the number is estimated to increase by almost 40% to 139 million by 2050,  according to WHO.

While most countries have made progress in implementing public awareness campaigns to improve public understanding of dementia, only a quarter of countries have a national policy, strategy or plan for supporting people with dementia and their families, prompting WHO to call for renewed commitment from governments. 

Half the countries with national policies, strategies or plans are in WHO’s European Region, yet even in Europe, many plans are expiring or have already expired.

The COVID-19 pandemic has also resulted in “profound” disruption for people living with dementia, including hampering dementia risk reduction programmes.

“The world is failing people with dementia, and that hurts all of us,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “ Four years ago, governments agreed on a clear set of targets to improve dementia care. But targets alone are not enough. We need concerted action to ensure that all people with dementia are able to live with the support and dignity they deserve.”

WHO’s Western Pacific Region has the highest number of people with dementia (20.1m), followed by the European Region (14.1m), the Region of the Americas (10.3m), the South-East Asia Region (6.5m), the Eastern Mediterranean Region (2.3 m) and the African Region (1.9m). 

If left unaddressed, the increase would significantly undermine social and economic development globally, warned Tedros.

Dementia is caused by a variety of diseases and injuries that affect the brain, including Alzheimer’s disease or stroke. It affects memory and other cognitive functions, as well as the ability to perform everyday tasks.

In 2019, 1.6 million dementia-related deaths were recorded, making it the seventh leading cause of death. Nearly half of these deaths occurred in high-income countries with women representing roughly 65% of the total number of dementia-related deaths.

The global cost of dementia was estimated to be $1.3 trillion in 2019,  projected to increase to $1.7 trillion by 2030, or $2.8 trillion if corrected for increases in care costs. 

“A challenge of this size cannot be tackled by working in silos. We must combine forces, improve the capacity of health systems to prevent and treat dementia, share quality data, reach beyond our traditional ways of conducting research, and address dementia as a global community,” said Dévora Kestel, WHO Director Department Mental Health and Substance Use.

“Dementia robs millions of people of their memories, independence and dignity, but it also robs the rest of us of the people we know and love,” said Dr Tedros.

COVID-19 and dementia

In addition to the high number of COVID-19 deaths in long-term care facilities, some countries reported unexplained increased numbers of deaths among people with dementia. England and Wales recorded 83% more deaths in people with dementia in April 2020.

“These increased deaths reported in 2020 may be due to factors such as interruptions in routine care, breaks in medication supply chains and resultant medication stock-outs, decreased access to emergency services, and the psychosocial impacts of public health measures designed to control the pandemic,” states the report.

It highlights numerous barriers that impede the progress of dementia reduction including stigma and the lack of public awareness of its importance, lack of financial resources available for dementia risk reduction programmes, inequitable distribution of services, human resource limitations, and lack of coordination between sectors both nationally and locally. 

In terms of COVID-19’s impact on dementia carers, the report found that lockdowns limited the services offered to people living with dementia resulting in delayed access to diagnostic and post-diagnostic care and a significant impact on cognitive health.

Urgent need for more support 

A stand-out finding of the report is the urgent need to strengthen support, of care for people with dementia, and in support for the people who provide that care, in both formal and informal settings.

Some 75% of primarily high-income countries reported that they offer some level of support for carers – carers spent on average five hours a day caring for those suffering from dementia, with 70% of care being provided by women.

Dementia sufferers require various degrees of care including primary health care, specialist care, community-based services, rehabilitation, long-term care, and palliative care.

Most countries (89%) reporting to WHO’s Global Dementia Observatory say they provide some community-based services for dementia, but provision is higher in high-income countries than in low- and middle-income countries. In low- and middle-income countries, two-thirds of dementia care costs are attributable to informal care as opposed to 40% in richer countries. 

Dementia research 

High costs of research and development coupled with several unsuccessful clinical trials have led to a decline in new efforts, the report found.

However, countries like Canada and the US have recently allocated funds towards more dementia research. The US increased its annual investment in Alzheimer’s disease research from US$ 631 million in 2015 to an estimated $ 2.8 billion in 2020. 

“To have a better chance of success, dementia research efforts need to have a clear direction and be better coordinated,” said Dr Tarun Dua, Head of the Brain Health Unit at WHO. “This is why WHO is developing the Dementia Research Blueprint, a global coordination mechanism to provide structure to research efforts and stimulate new initiatives.” 

Future research efforts, states the report, should focus on the people living with dementia and their carers and family.

 

Image Credits: WHO/I. Montilla, WHO/Cathy Greenblat.

Dr Chikwe Ihekweazu, head of the new WHO Hub for Pandemic and Epidemic Intelligence, speaking at the hub’s launch in Berlin.

Monkey Pox, Lassa Fever, Yellow Fever, Cerebrospinal Meningitis, and COVID-19 are some of the epidemics that Dr Chikwe Ihekweazu has addressed as head of the Nigeria Centre for Disease Control (NCDC).

Now, however, Ihekweazu’s repertoire of disease experience is about to expand exponentially, following his appointment as the head of the World Health Organization’s (WHO) new Hub for Pandemic and Epidemic Intelligence.

The hub was formally launched in Berlin on Wednesday in event co-hosted by WHO Director General Dr Tedros Adhanom Ghebreyesus and outgoing German Chancellor Angela Merkel.

The aim of the hub is to create the tools and data needed to enable countries to better “prepare, detect and respond to pandemic and epidemic risks,” according to WHO.

Ihekweazu, an infectious disease epidemiologist, is widely credited with modernising and transforming the Nigerian CDC to address the multitude of epidemics that Africa’s most populous country faces every year.

Believing in themselves

Speaking at the hub’s launch, Ihekweazu said that his biggest lesson from working at the NCDC was empowering its staff to believe in themselves.

“I met a group of people that really didn’t believe that they could do what was expected of them,” he said.  “By believing that they could stretch a little bit beyond what they would normally do, they started trying. And once they started trying and succeeding in small steps, they started believing that they could do more.”

He frankly admitted that the new WHO hub faces “a lot of uncertainty, and sometimes a lack of definition in terms of where exactly we want to go.”

Said Ihekweazu: “We have to be comfortable with that uncertainty, but really look for people that would believe the vision and once they believe the vision and … the threats that we face, that we can work together, despite some of the political challenges, despite some of the economic differences between countries.” 

Ihekweazu, who will now be based in Berlin, has a German mother and Nigerian father. He has a Master’s in Public Health degree from the Heinrich-Heine University in Dusseldorf and worked for the Robert Koch Institute in Berlin, Germany’s national global health research and surveillance hub.

Ihekweazu was appointed as CEO of the NCDC in August 2016, just as the devastating, two-year West African Ebola epidemic was finally coming to an end.  Although the epidemic struck hardest in Guinea, Liberia and Sierra Leone, bruising Nigeria with only about 20 cases, it underscored the immense risks faced by the country of more than 210 million people, where many of the 32 200 health facilities were ill-equipped to address basic health needs.

Ihekweazu spent his first months in office assessing the country’s readiness for other future epidemics – including a range of threats that could potentially be as deadly as Ebola, or even less so, but more infectious, as COVID has proven to be.

“I met Disease Surveillance and Notification Officers without laptops and laboratory technicians with no laboratories,” Ihekweazu wrote in a blog a few months after his appointment.

“Motivated and properly equipped health workers at the frontline of our surveillance work are critical to our disease control efforts. An effective public health laboratory is critical. Proper supply chain management for our medical supplies will ensure that we are always ready for any outbreak.”

Sleepless nights about Ebola

He admitted to having sleepless nights, asking himself: “If we were to have another case of Ebola in Nigeria, would we have the laboratory infrastructure to make a timely diagnosis to recognise it and prevent a large outbreak?”

In June 2017, a WHO team conducted a Joint External Evaluation (JEE) to test Nigeria’s capacity to implement the International Health Regulations (IHR), a set of mandatory laws aimed at ensuring that member states are able to prevent the spread of diseases.

Nigeria’s JEE scorecard was littered with red warnings, and the country’s overall score was 39 percent. But the JEE highlighted the positive role of the NCDC, describing it as “among the most noteworthy best practices observed in Nigeria”.

It described the NCDC’s outbreak investigations as “robust and timely”, and praised the Emergency Operations Centre (EOC) activated to respond to outbreaks, and its call centre, which the public uses extensively during public health emergencies.

By 2018, Ihekweazu had doubled the staff of the NCDC and set up laboratories across the country.

In November 2020, the NCDC and external evaluators conducted a midterm JEE and the country’s score had increased to 46%, bringing them from the “not ready” category into the “work to do” category, according to Prevent Epidemics.

New fire

“The NCDC has given the nation a sense of pride,” said Dr Ifeanyi Nsofor, Director of Policy and Advocacy for Nigeria Health Watch, a civil society organisation that advocates for improved health for Nigerians.

In an interview with me a few years ago, Nsofor described Ihekweazu as being “really instrumental in the changes” made to Nigeria’s approach to fighting epidemics.

“He is the new fire in the agency. It is no longer business as usual. He has brought in the right way of doing things. He has the knowledge, the personality and the networks.”

After Ebola, one of Ihekweazu’s next challenges was to deal with Lassa Fever, a viral hemorrhagic fever from the same family as Ebola spread by rats that is endemic in West Africa.

During an outbreak in 2018, the NCDC proved that it was able to act fast to save lives, which Nsofor attributes to the center’s ability to “conduct research while an outbreak was happening”.

“There was real-time gene sequencing of the virus and the NCDC was able to establish that there was not just one strain of the virus but different strains. This meant a different diagnostic process,” said Nsofor.

His new appointment has been praised across Twitter by health experts and ordinary Nigerians.

Speaking at the launch of the new pandemics hub, WHO’s Tedros said of Ihekweazu: “he brings a wealth of experience, and will serve a dual role as head of the hub here in Berlin and as Assistant Director-General for health emergency intelligence in Geneva.”