INB co-chair Precious Matsoso (centre) ends the 12th meeting, flanked by co-chair Anne-Claire Amprou and Dr Tedros.

There will be no pandemic agreement by year-end and, with only 10 days of formal talks set aside in 2025, some parties doubt whether an agreement can be reached by the May 2025 deadline.

The week-long extended 12th meeting of the Intergovernmental Negotiating Body (INB) made progress, particularly on research and development (Article 9) and financing (Article 20). 

While disagreement remains on a couple of key obstacles, informal talks will continue alongside the formal talks.

Dr Tedros Adhanom Ghebreyesus, the World Health Organization’s (WHO) Director General, suggested at the close of the meeting on Friday evening that delegates consider negotiating on “packages” rather than clause by clause to “break the stalemate”.

“When I see what’s left, I believe – and this is honest from my heart – it is not really difficult to conclude in a few days of negotiation, but between now and the next meeting it would be good to think about the issues left and find a middle ground,” said Tedros.

Earlier in the day, INB co-chair Anne-Claire Amprou took exception to criticism of the process and lack of progress from some NGO observers.

Noting that the nature of multilateral negotiations means finding a “landing zone” that is acceptable to everyone, France’s Amprou said sharply: “I don’t agree when you say that nobody gains anything. I invite everyone – delegations, stakeholders – to look at what we have already achieved. We have achieved a lot.”

She stressed that the INB would deliver on its mandate: “We need a pandemic agreement which is meaningful, and it will be.”

‘Not a colouring book’

Amprou’s response came after Medicines Law and Policy commented that while there is some new “green text”, indicating agreement on the draft agreement, “it’s important to remember that the pandemic agreement is not a colouring book”. 

The European think-tank continued: “Substantive provisions on very difficult issues such as equity and access, transfer of technology, intellectual property and [pathogen] access and benefit-sharing remain largely absent, or are, at best, weak.”

Third World Network (TWN) followed, saying: “Every time we hear a new text is green, we are looking to figure out what has been compromised, especially in terms of equity.

TWN added that the agreement lacks “a baseline of legal rights and obligations”, and  “protects the interest of business, not people’s rights”.

Oxfam presented a list of questions and objections on behalf of 26 stakeholders including that member states appeared to be under “extreme pressure” to defer agreement on a pathogen access and benefit-sharing (PABS) scheme to an annex, the contents of which would be decided on after the pandemic agreement had been signed.

The Pandemic Action Network (PAN) and the Panel for Global Health Convention both urged negotiators to keep the momentum going and asked for clarity on the way forward.

Rafael Gracia of Pandemic Action Network and Dame Barbara Stocking representing he Panel for Global Health Convention

Eloise Todd, PAN’s executive director, told Health Policy Watch after the meeting that while the INB has not reached a conclusion, “there is a more urgent sense of progress around the negotiations which we need to encourage”.

Todd called on “high-income countries in particular to dig deep and remember the reason why we need this agreement is because of the deep-seated inequality in the COVID response”. 

“⁠⁠It is crucial for negotiators to see the bigger picture with these negotiations. The pandemic agreement will serves as an important marker the world’s coordination and cooperation in times of pandemic threats – which we know will become more and more frequent. It’s time to deliver on this vital step forward that will benefit people in every country,” said Todd.

However, Spark Street Advisors’  CEO and long-time talks observer Nina Schwalbe was less positive: “They have missed a once-in-a-generation opportunity to make a difference because national interests prevailed over global solidarity.”

Crux of the stalement

The stalemate centres on differences between the European Union (EU) and the Africa Group. The EU wants an annex linked to Article 4 (pandemic prevention) that outlines countries’ responsibilities to prevent pandemics. The Africa Group is reluctant to agree to costly responsibilities and it wants an annex related to the operationalising of a system for pathogen access and benefit-sharing (PABS) in exchange.

What the Africa Group wants from PABS is preferential access to any pandemic-related products that are developed from them sharing information about pathogens that could cause pandemics. This is anathema to the pharmaceutical industry, largely represented by the EU and the US.

The Africa group is also concerned that a prevention annex could impose costly requirements that they are unable to finance. However, the first beneficiaries of prevention measures are individual countries’ citizens who would be protected by, for example, heightened surveillance of bats that harbour Ebola and Marburg.

“These two areas are the make-or-break articles of the negotiations. If we can reach agreement on these, we will make the deal,” co-chair Precious Matsoso noted in an address to scientists recently.

Health leaders wanted an early agreement

Tedros has long urged delegates to reach agreement sooner rather than later and Dr Jean Kaseya, head of Africa CDC, has also expressed hope for an early agreement.

On a recent visit to South Africa, Matsoso noted: “We don’t have six months left to finish negotiations. We only have a couple of days left, precisely because the geopolitical environment is so challenging. There is huge, huge pressure on the talks and we don’t know what the outcome will be.”

The elephant in the room is the Donald Trump presidency, largely expected to take an axe to what Team Trump terms “globalism” – virtually anything that puts global good before national interest.

Delegates paid tribute to US Ambassador Pamela Hamamoto for her positive contribution to the pandemic agreement, as that was her last INB meeting.

Further INB meetings are scheduled for February and April, with a completed agreement supposed to be ready to be voted on at the World Health Assembly in May.

Mosquito and dengue
Mosquitoes, which can carry dengue virus, thrive at warmer temperatures. Climate change is already fueling increases in dengue cases globally.

Nearly one fifth of dengue cases in Latin America and the Caribbean, or about 45 million infections a year, are attributable to climate change, in the past decade, according to a new study by researchers at Harvard and Stanford Universities. 

Rising temperatures combined with mosquito species uniquely suited to sprawling urbanization and deforestation are fueling the staggering increase in dengue cases, with a proportion of cases measurably attributable to climate change, according to the first ever study to “meaningfully” quantify that number. 

Over the past year, both Latin America and the Caribbean saw a record-breaking number of cases – and fatalities – of the so-called “break-bone” fever. Even with the recent regulatory approval of two new vaccines, Takeda Pharma’s Qdenga® and Sanofi’s Dengvaxia, slow rollout and continued challenges in production scale-up have meant the jabs made little impact so far. 

The researchers compiled data from 21 countries in the Americas and in Asia to identify the causal effect of climate change-related temperature increases and dengue cases. The study was presented at the Annual Meeting of the American Society of Tropical Medicine and Hygiene (ASTMH) 13-17 November, and is available in pre-print form.

The researchers also estimated how different climate change scenarios will impact dengue burden. By 2050 under a high CO2 emissions scenario, the authors predicted  a 61% increase in dengue incidence. Active climate mitigation would cut that figure to roughly 40%. 

At least 257 million people now live in countries where warming temperatures could cause dengue to double by mid-century in either scenario. 

“We can see the direct policy implications of reducing emissions at the global scale,” Dr Kelsey Lyberger, an ecologist at Arizona State University and one of the study authors, told Health Policy Watch. The magnitude of dengue cases will not increase equally, either, Lyberger noted. “Some of the highest relative increases are in places where they don’t necessarily have a high burden currently.”

Dengue and climate change projections
Countries in cooler climates are projected to have the largest increase in climate change-related dengue cases.

But already now, increasing temperatures and extreme weather events are already changing the burden of infectious diseases – particularly vector-borne diseases. These temperature increases are already responsible for 45 million excess dengue cases, which the studied identified.  

The study, whose release coincided with the UN Climate Conference (COP29) in Baku, provides further evidence that climate action is “health action,” as termed in a recent WHO COP29 special report.

Cooler regions will see largest change

Dengue responds non-linearly to average daily temperature, with cases peaking at average temperatures of 28℃, and then decreasing. This creates “optimal” conditions for the two primary dengue mosquito vectors, Aedes aegypti and Aedes albopictus, where both species breed and feed faster. But in places where average temperatures are cooler – 15-20℃ on average – climate-change related warming has the largest effect on dengue caseload. 

As a result, projected warming will fuel dengue cases unequally across the globe. “It’s not across the board that we see this increase,” said Lyberger.  

Some cooler regions of Mexico, Peru, Bolivia, and Brazil, for instance, are predicted to see over 150% increases in dengue incidence due to climate change under any emission scenario, the study notes. 

Lack of surveillance data excludes Africa, India, Western Pacific from analysis

Dengue infographic
WHO’s Western Pacific region was among those excluded from the study due to a lack of reliable surveillance data.

While dengue cases continue to rise globally, including in much of the African continent, the lack of high quality surveillance systems means experts are left to guess the impact of climate change on dengue in these regions. 

Countries in the America, Brazil in particular, have felt the burden of dengue cases most acutely, but they often have surveillance methods in place to track infection rate fluctuations.

“We needed a long enough time series of cases to estimate a baseline level of dengue,” said Lyberger. Many African countries face surveillance hurdles in detection, reporting and management, the lack of local laboratory capacity, and the misclassification of cases, noted researchers at Africa CDC. Without a solid surveillance system, countries are at a critical disadvantage–including little early warning systems for dengue surges.

In India, the country’s “poor” surveillance network leads to “huge” under-reporting and a lack of public health response to outbreaks, as a Lancet editorial comments in India’s 2015 dengue season. A 2020 assessment of the country’s surveillance efforts found that dengue surveillance needs to be strengthened, and integrated into existing government initiatives. In that time frame alone, from 2015-2019, cases in the South Asian region increased by 46% according to WHO estimates. The organization attributes climate change, in addition to “high rates of population growth, inadequate water supply and poor waste management systems” coupled with the absence of effective treatment and suitable vector control to the high burden of dengue in the region. 

Preparing for the future

With these new estimates of how climate change will increase dengue cases, researchers hope that such high-burden countries will be motivated to do more tracking and reporting, while those that historically have had few cases can prepare with funding for surveillance and integrated vector management. 

“Since we’ve established this relationship between temperature and cases, the next step is to see how warming, both in the past and in the future, is going to affect the number of cases that we have or will see,” explained Lyberger.

This led researchers to compile data from 21 countries where dengue is endemic – including Brazil, Cambodia, Colombia, and Vietnam – and to examine other factors that could affect dengue infection rates like rainfall, seasonal changes, viral strains, economic shocks, and population density, to isolate the distinct effect of temperature. 

“We were able to pin down that historical warming has already increased dengue cases by about 20%,” said Lyberger. 

“It’s evidence that climate change already has become a significant threat to human health and, for dengue in particular, our data suggests the impact could get much worse,” said Erin Mordecai, PhD, an infectious disease ecologist at Stanford’s Woods Institute for the Environment and the study’s senior author in a press release. 

See Health Policy Watch’s ongoing coverage of dengue here.

Image Credits: Marissa L. Childs, Kelsey Lyberger, Mallory Harris, Marshall Burke, Erin A. Mordecai, WHO.

DRC Director-General of Health, Dr Dieudonné Mwamba.

The Democratic Republic of Congo (DRC) expects to diagnose ‘Disease X’, which has killed at least 79 people in the Panzi district of Kwango Province by the weekend, according to the country’s Director-General of Health, Dr Dieudonné Mwamba.

“The disease is characterised by fever, headaches, cough and sometimes difficulty breathing,” Mwamba told a media briefing hosted by Africa’s Centre for Disease Control and Prevention on Thursday. 

So far, around 376 people have been infected and the disease appears to be airborne, he added. Females are slightly more affected than males, and the majority of cases (52%) are under the age of 5. The second biggest group of patients is people aged over 25 (almost 30%).

“Given that we do not have a specific diagnosis, we don’t know whether we are faced with a viral or bacterial disease, but we believe that, in under 48 hours, the results of the laboratories will help us,” he said.

However, he noted that people in the impoverished rural Panzi district were “vulnerable” as there is a malnutrition rate of almost 40%, it recently experienced a serious typhoid outbreak. The DRC is also experiencing a seasonal influenza outbreak.

Panzi does not have the capacity to test the specimens taken from patients with the unknown disease, so they have been sent to a laboratory in Kikwit some 500km away.

The first case of the unknown illness was identified on 24 October in the largely rural south-eastern province bordering Angola. However, central authorities were only notified of a possible outbreak on 1 December, according to Dr Jean Kaseya, Africa CDC Director-General, who addressed the briefing from the DRC.

“We want to reinforce the surveillance. We have a delay of almost five to six weeks, and in [that time], so many things can happen. This is why we are supporting the country to build strong capacity for surveillance,” said Kaseya.

A team from Africa CDC, including an epidemiologist and laboratory and infection prevention control (IPC) experts, is being sent to Panzi on Friday to assist officials, he added.

Mpox continues to spread

Meanwhile, Mpox continues to spread, particularly in Central Africa, with 2,700 new cases in the past week, up from 2,618 new cases the previous week,  said Kaseya.

The outbreak has affected 20 African countries. After laboratory testing, Zambia and Zimbabwe have confirmed that their outbreaks are Clade 1b.

“In total, we have 62,171 cases. Last week, we lost 36 people, and that brings a total of 1200 deaths since January 2024,” said Kaseya.

However, only 13, 579 of the cases have been clinically confirmed as laboratory testing remains a challenge in many areas.

The DRC remains the worst affected by mpox, with both clade 1a and 1b circulating. The lion’s share of the week’s new cases – 2,115 – were identified in the DRC and all 36 of the week’s deaths were in the DRC.

However, testing remains a challenge in the country, with only 20% of cases confirmed by laboratories.

Africa CDC also flagged the links between high burdens of mpox cases and measles cases in DRC, but has not yet established a causal link between the two diseases.

 

Sudanese women, many of whom became leaders of the 2019 revolution, are being targeted by soldiers using rape as a weapon of war.

Rape is common across Africa yet inadequate laws, weak implementation and cultural barriers mean that many perpetrators go unpunished, according to new research by Equality Now.

“After examining rape laws across Africa, it is clear that to end impunity for perpetrators, governments urgently need to carry out comprehensive legal reform of rape laws, strengthen enforcement mechanisms, and improve access to justice and support for survivors,” said Jean Paul Murunga, a human rights lawyer and the report’s lead author. 

The report looked at rape laws and their enforcement in 47 African countries with an in-depth analysis of nine of these: Cameroon,  Democratic Republic of Congo, Madagascar, Rwanda, Senegal, Sierra Leone, South Africa, South Sudan, and Zambia.

Equality Now Africa Director Faiza Jama Mohamed says that the report identifies “key gaps in rape law that result in routine denial of justice to survivors of sexual violence”. 

“The gaps include laws allowing the perpetrator to walk free on reaching some form of ‘settlement’, including marrying the victim; laws framed in terms of morality rather than bodily integrity, thereby perpetuating a cycle of violence and discrimination; laws that explicitly permit rape in marriage, even of children,” notes Mohamed, writing in the foreword of the report.

Narrow definition of rape

Approximately 33% of women in Africa have experienced intimate partner violence or sexual violence in their lifetime, while in West, East, Central, and Southern Africa, the rate 44%, according to UN Women.

The African Development Bank’s Gender Data Index 2019 reported that intimate partner sexual or physical violence ranges from 10% to 40% across the continen

“It is critical for its definitions in the various jurisdictions within Africa, both in the context of conflict and peace, to be clear and based on human rights standards,” adds the report.

Rape is when a person has not given voluntary, genuine, and willing consent for sexual interaction – and that this consent can be withdrawn anytime during the interaction.

“True consent is impossible in situations of dependency or extreme vulnerability, for example, in educational settings, correctional facilities, or when a victim is incapacitated, such as being intoxicated or infirm,” according to the report.

Several countries’ definitions of rape or legal frameworks fail to recognise all forms of unwanted sexual penetration (anal, oral, or vaginal by use of any body part or object) as rape .

Some 25 African countries have penal codes that are “incomplete or ambiguous and do not meet international standards” by, for example, confining the definition to acts of violence and failing to recognise rape involving intimidation, coercion, fraud, and unequal power dynamics. 

Marital rape not recognised

Justice for rape survivors

Cote D’Ivoire, Gambia, Seychelles, Equatorial Guinea, Ethiopia and South Sudan do not criminalise marital rape. South Sudan explicitly notes that non-consensual sexual intercourse within marriage does not constitute rape. 

The Penal Code of Côte d’Ivoire provides for the presumption of married couples’ consent to the sexual act unless proven otherwise. 

Eritrea only criminalize marital rape when spouses are not living together, while Tanzania criminalizes it if the couple is not living together. Lesotho recognises marital rape under certain conditions.

In Gabon, where child marriage is legal, if an abductor has married an abducted minor, he can only be prosecuted after the marriage is annulled.

“International human rights standards require states to criminalise all forms of rape, irrespective of the relationship between the perpetrator and their victim,” says Murunga. 

“Failing to specifically criminalise marital rape ignores how consent must be ongoing and freely given, regardless of marital status. Legal recognition provides clarity to law enforcement, prosecutors, and judges that marital rape must be treated as a serious crime and prosecuted accordingly.”

Harmful traditional beliefs

Although 20 African countries have consent-based definitions of rape, rapists are often shielded by traditional beliefs and societal attitudes towards sex. 

“Rape survivors and their families frequently face stigma, victim-blaming, and threats. This is commonly accompanied by pressure to remain silent, withdraw criminal complaints, and settle cases out-of-court through informal community mediation,” according to the report.

In Equatorial Guinea, for example, out-of-court settlements are legally permitted when a rape victim explicitly or tacitly forgives the perpetrator. 

This often results in rape survivors being pressurised to agree to this route.

In several countries, officials opt not to investigate, prosecute, or convict rape cases unless there is physical evidence, especially which indicates a victim fought back. 

“Many jurisdictions emphasize force, morality, or circumstances and apply gender-discriminatory concepts such as ‘honour’ and ‘modesty’. This prejudices judgments over victims’ behavior and “chastity” and whether they are perceived as deserving justice for having been raped,” the report notes.

Rape survivors and their families frequently face stigma, victim-blaming, and threats. This is commonly accompanied by pressure to remain silent, withdraw criminal complaints, and settle cases out-of-court through informal community mediation. 

Inadequate punishment

Sudanese women wait for treatment at Fashir Reproductive health centre. Many women are pregnant as a result of being raped during the conflict.

The African Commission on Human and People’s Rights recommends 16 years imprisonment for rape, but many countries have thresholds well below this. 

In Equatorial Guinea, Article 429 of the Criminal Code states that “rape of a woman shall be punished with minor confinement.

Guinea Bissau includes an exemption where ‘the behavior of the victim has considerably contributed” to the rape.

Even where not elaborated in the law, settlements with respect to rape are reportedly common in Benin, Cameroon, Chad, Côte d’Ivoire, The Gambia, Ghana, Guinea, Liberia, Nigeria and South Sudan.

In South Africa, there is a serious backlog of rape cases and insufficient funding for the justice delivery system. In May 2022, the Minister of Justice announced that only 19% of reported cases were going through the courts.

With the breakdown of the rule of law and security in conflicts, women and girls are rmore vulerable. In addition, rape is still being used as “a weapon of war to denigrate, disempower, demoralize and destroy communities”, the report notes. 

During conflict, reporting cases, collecting evidence and prosecution are often huge challenges.

Providing justice to survivors of sexual violence and ensuring perpetrators do not enjoy impunity is critical in preventing and addressing rape

With so many legal, procedural, and societal obstacles to addressing rape, very few cases make it to court, and even fewer result in conviction.

Urgent reform 

Urgent reform is needed to ensure legal definitions of rape encompass all acts of non-consensual sexual penetration, with no exceptions for marital rape, according to the report.

It also calls for adequate training of government officials to ensure laws are implemented and other measures including a register of sex offenders. 

“Effective legal implementation is equally crucial, requiring robust mechanisms to enforce justice and hold perpetrators accountable. Transparency and accountability are essential to building trust and ensuring fairness in how cases are handled,” the report notes.

It advocates for supportive systems for rape survivors that” facilitate healing and enable them to pursue justice if they choose”

Rwanda is highlighted as a positive example for promoting a “victim-centered approach to investigating and prosecuting sexual violence cases” that includes .gender-based violence recovery centers in numerous districts, providing survivors with witness protection, medical and psychosocial support, and legal aid.

Image Credits: CC, Mohamed Zakaria/ UNICEF.

Ambassador John Nkengasong, head of PEPFAR.

As a political appointee, Ambassador John Nkengasong, head of the US President’s Emergency Plan for AIDS Relief (PEPFAR), said that he will be obliged to resign when President-elect Donald Trump is inaugurated on 20 January.

“The rules that govern a transition are that all the political appointees have to resign on the 20th and then their resignation is either accepted or they are asked to stay,” Nkengasong told a Global Fund media briefing on Monday.

However, he stressed that PEPFAR has been a bipartisan programme since its inception in 2003 when it was launched by Republican President George W Bush.

“It has since enjoyed the support of all administrations,” said Nkengasong, the US Global AIDS Coordinator in the Bureau of Health Security and Diplomacy.

Nkengasong was appointed by President Joe Biden, confirmed by the US Senate in May 2022, and he started work the following month. 

PEPFAR achievements 2024
PEPFAR’s achievements by 2024.

Nkengasong is a Cameronian-born US citizen, who first attracted global attention as the first head of the Africa Centres for Disease Control and Prevention (Africa CDC), where he led the continent’s response to the COVID-19 pandemic. Prior to that, he had worked for the US Centers for Disease Control and Prevention, as well as at the World Health Organization. 

“We should always think about PEPFAR, not the individual – 26 million lives saved over the last 21 years,” Nkengasong stressed at the briefing, although his re-appointment prospects are regarded as slim.

“PEPFAR was reauthorised [by the US Congress] for one year last year. That reauthorisation expires in March, and we are hoping that we’ll get a clean five-year reauthorisation going forward,” he added.

But this may not be plain sailing. PEPFAR has come under attack from US and African conservatives who claim – incorrectly – that some aid recipients are promoting abortion. This is why the programme only received a one-year extension rather than the usual five years.

Trump has made cutting government spending and opposing abortion cornerstones of his election campaign, which does not augur well for the campaign to end AIDS by 2030.

HIV money is drying up

HIV is incurable but thanks to antiretroviral (ARV) drugs, it has become a controllable chronic disease and if people living with the virus have an undetectable viral load, they don’t transmit HIV.

As many as 25 million people depend on PEPFAR and the Global Fund to subsidise their ARVs, which they need to take for life. 

Yet money is drying up. About 60% of the HIV response is paid by domestic finances, and this fell for the fourth consecutive year, with a 6% drop in 2023. Meanwhile, donor resources for HIV dropped by 5%, UNAIDS Deputy Director Christine Stegling told the briefing.

UNAIDS deputy director Christine Stegling.

Global Fund executive director Peter Sands said that global overseas development assistance is under pressure, and health has lost its “prime spot” to both climate change and conflict.

“There is a particular issue with funding for HIV/ AIDS, which is that we run the risk of being a victim of our own success. Because the number of people dying has dropped so much, and because HIV/ AIDS is no longer seen as that much of a threat in donor nations themselves, it’s dropped off the radar screen and seems like an old problem; one that’s largely won or gone away,” said Sands.

“But HIV is a formidable adversary. We are nowhere near getting a vaccine, and we don’t have a cure for it yet.”

But the single-minded focus on eliminating HIV has made “extraordinary progress”, Sands added.

“AIDS-related deaths have come down by 51% since 2010 and more than three-quarters of people living with HIV are on treatment, but we still have another nine million people not on treatment and we still have 1.3 million new infections each year,” according to Stegling.

Shift to domestic financing

Economist Professor Dean Jamison, co-chair of the Lancet Commission on investing in health, says it is unlikely that for a better response to funding HIV globally. 

“So that does put greater emphasis on a transition to domestic finance where the reliance has been substantially on donors. It’s not to say that the external finance is likely to go away and then there won’t be important additions to that. I would be looking to parts of Asia for external finance, but on the domestic side, what are the range of options?” asked Jamison, who is an emeritus professor of Global Health Financing at UCSF, UCLA and the University of Washington.

Poor countries would prioritise HIV spending, likely focusing on preventive interventions and treatment. Drawing on private resources, perhaps through payroll taxes, may also be a solution.

Professor Dean Jamison

Stegling singled out debt, low economic growth and insufficient revenue as the main obstacles to domestic financing for HIV.

“Last year in GDP term, Sierra Leone spent 15 times more on public debt servicing than on health. Chad spent 12 times more on debt servicing than on health,” she noted.

Meanwhile, sub-Saharan Africa loses about $80 billion in uncollected tax revenue.

Debt relief, future financing at affordable rates and better tax revenue collection are the solutions UNAIDS is focusing on.

“These are the issues of the future that we need to look into if we’re talking about self reliance, more resilient systems for health that are financed by countries, by every country themselves,” Stegling noted.

With South Africa being the chair of the G20 next year, she sees “an amazing opportunity” for African leadership debt restructuring and different financing mechanisms. 

What lies ahead?

Stegling says donors are likely to move into “gaps”, such as human rights protections for particular marginalized groups that might not immediately find support from their governments.

Meanwhile, Nkengasong stressed that progress should not be confused with success.

“The progress that we have made is very fragile,” Nkengasong stressed.

PEPFAR did an analysis of 10 to 12 high-burden countries that it supports and found that, to maintain their programmes if PEPFAR was unable to fund them would result in debt risk increasing by 400 percentage point,.

“Are we ready to live with this? We pride ourselves with the success we’ve made over the last 25 years or so against HIV. But the response to HIV is extremely fragile. It’s extremely fragile because it requires that the millions of people that are receiving treatment receive that treatment every day.

“We cannot afford to leave them behind. If we do that, the billions that we’ve put into the fight against HIV AIDS will be completely wasted.”

Image Credits: US State Department.

A policy panel held at the World Vaccine Congress Europe.

From being a largely unknown pathogen, Respiratory Syncytial Virus (RSV) is now almost a household word – and a fearful one for families with infants and young children at risk. But new solutions, such as long-acting monoclonal antibodies (mAbs) and maternal vaccination, both recently recommended by the World Health Organization (WHO), could dramatically alter the RSV landscape.  

Scientific experts and health policy advocates explored these new preventative tools for RSV and their initial uptake in  Italy and Spain at a recent panel discussion at the recent European World Vaccines Congress.

Lower respiratory tract infections (LRTI) are the leading cause of death, and hospitalisation for infants globally. The global incidence of RSV-associated LRTI is estimated at over 30 million cases in children under the age of five, resulting in 3.2 million hospitalisations.

The impact of RSV in high-income and upper-middle-income countries is best documented insofar as it is associated with high hospitalisation rates and significant healthcare costs. But the impact may be even more severe in low and middle-income countries, but less well-recognized. 

“Almost three-quarters of the deaths associated with severe respiratory diseases in infants occur outside hospitals because of issues of access to care,” said Professor Heather Zar, head of the Department of Paediatrics and Child Health and director of the Unit on Child and Adolescent Health at the University of Cape Town in South Africa.

Impact on families

Hospitalisations for respiratory diseases, particularly RSV, place a considerable financial and emotional burden on families, with stress that extends beyond the child. 

According to a survey conducted by the National Coalition for Infant Health in the US, close to 68% of parents said watching their child suffer from RSV impacted their mental health. More than one-third said the experience strained their relationship with their partner.

The survey also found that many parents had to make difficult sacrifices, with 10% quitting their jobs to care for their child and 7% even being fired for taking time off. These hardships underscore the importance of preventive measures to lessen the multifaceted impacts on families.

Long-term burden of respiratory illnesses

Respiratory illnesses can have lasting consequences on a child’s health. Zar shared insights from research that connects early-life RSV with chronic respiratory issues such as asthma and recurrent lung infections: “Children who experience early RSV infections are more likely to suffer from recurrent pneumonia, and face a significantly higher risk of asthma later in life.”

This chronic burden reinforces the necessity of early intervention.

RSV hospitalisations are longer than those for respiratory viruses such as influenza and rhinovirus, exacerbating the strain on healthcare systems.

The ReSViNET Foundation, an international non-profit organisation that works towards reducing the burden of RSV, observed in its studies that parents often went to their GP multiple times before RSV was recognised, sometimes resulting in a dangerous escalation to the point where the child needed to be taken to hospital by  ambulance. 

New tools to prevent RSV 

With recent advances in preventive care, experts believe that tools such as long-acting monoclonal antibodies (mAbs) and maternal vaccination could dramatically alter the RSV landscape. 

The WHO’s Strategic Advisory Group of Experts (SAGE) has recommended that all countries introduce maternal vaccination and/ or long-acting mAbs for RSV prevention in young infants. 

“Long-acting monoclonal antibodies and maternal vaccines provide passive immunity and last through the RSV season, protecting infants during the most vulnerable period of life,” said Zar.

Spain’s recent RSV immunisation campaign offers a glimpse into the potential effectiveness of these new tools. Professor Federico Martinón-Torres reported that Galicia’s RSV mAbs campaign achieved over 90% uptake in high-risk and newborn cohorts, with an 82% reduction in hospitalisations for severe RSV.

This success showcases the efficacy of long-acting mAbs. It underscores the potential of universal immunisation programmes to mitigate the seasonal burden of infant RSV, reducing the toll on infants and their families.

Italy is now taking steps to introduce RSV mAbs for infant immunisation this season, said Professor Elena Bozzola, national counsellor of the Italian Paediatric Society (SIP).  “Since the national health service fully subsidises the immunisation of children in Italy, it is a great opportunity to protect all infants with RSV mAbs,” she added. 

Challenges in implementing technologies

Barriers persist in ensuring that scientific advances reach all infants. Disparities in access, cultural misconceptions about vaccine safety, and inconsistent national guidelines pose significant roadblocks to the widespread adoption of new tools for RSV prevention. 

For instance, in the US many hospitals do not administer RSV immunisations to newborns due to reimbursement complications. Hospitals receive a bundled payment for each birth, and modifying this to cover RSV immunisations can take years of negotiation with insurers.

Spain’s programme, while effective, also encountered obstacles: “We didn’t know how the population or healthcare providers would accept this. However, following a robust awareness campaign, the results were remarkable,” said Martinón-Torres.

The path to universal access remains challenging, especially in regions with weaker healthcare infrastructure and limited funding.

Pivotal moment

The emerging tools for RSV prevention represent a pivotal moment in infant health. Their successful implementation will lay the groundwork for future prevention of other diseases using mAbs and could be a model for introducing other new technologies. “The coming years will be exciting to see as more countries explore these technologies for wider adoption,” Zar said.  

Today, effective prevention strategies for RSV can reduce infant mortality and alleviate the broader societal and economic impacts on families, healthcare systems, and communities, the experts in our meeting agreed. 

Our health systems and policies must evolve alongside these innovations. For instance, our thinking needs to extend beyond traditional delivery methods and create additional access points for administration. 

The journey to wider access requires continued advocacy, funding, and collaborative efforts. With a concerted approach from healthcare professionals, policymakers, and society, we can make a major stride in infant health.

This article is based on the discussions of a policy panel held at the World Vaccine Congress Europe, and sponsored by MSD.

Susan Hepworth is executive director of the  National Coalition for Infant Health.

Leyla Kragten-Tabatabaie is on the board of directors of ReSViNET Foundation

A new report cautions that land degradation, if not reversed in time, could harm generations.

The world needs to urgently change the way food is grown and land is used in order to avoid irreparable harm to global food production capacity, according to a major new scientific report released Sunday.

Currently seven out of nine ‘planetary boundaries’ have been negatively impacted by unsustainable land use, mostly related to unsustainable agriculture, warns the report produced by the German-based Potsdam Institute for Climate Impact Research (PIK) along with  the UN Convention to Combat Desertification (UNCCD).

Approximately 15 million km² of land area, or 10% of the world’s terrestrial space, is already severely degraded, as measured by the extent of deforestation, diminished food production capacity, and the disappearance of freshwater resources. And this degraded land area is expanding each year by about 1 million km², according to the report.

“We stand at a precipice and must decide whether to step back and take transformative action, or continue on a path of irreversible environmental change,” said Johan Rockström, Director at PIK who is also the lead author of the report.

There are conflicting figures on the extent of global land degradation, due to differences in definitions and indicators according to a paper by Jiang et al (2024).

Shifting food production to “regenerative agriculture” practices as well as land restoration to improve the health of lakes, rivers and underground aquifers are among the immediate solutions needed to make a course correction.

Without rapid adoption of such measures, the Earth’s capacity to support human life and wellbeing could be irretrievably harmed, the report warns. This harm can be in the form of the collapse of the Arctic ice sheets and the weakening of the land’s ability to act as a carbon sink.

Failure to reverse land degradation trends that result in deforestation and impoverished soils will also have long-term, knock-on impacts with respect to hunger, migration, and conflict, the report warns.

“If we fail to acknowledge the pivotal role of land and take appropriate action, the consequences will ripple through every aspect of life and extend well into the future, intensifying difficulties for future generations,” said Ibrahim Thiaw, Executive Secretary of the UNCCD.

Land is under threat from human activities, climate change

The concept of planetary boundaries is anchored in nine critical thresholds essential for maintaining Earth’s stability. Rockström was the lead author of the study that introduced the concept of planetary boundaries in 2009.

How humanity uses or abuses land directly impacts seven of these planetary boundaries, which include: climate change, species loss and ecosystem viability, freshwater systems, and the circulation of naturally occurring nitrogen and phosphorus, the report said. Land use changes, such as deforestation, also broach a planetary boundary.

“The aim of the planetary boundaries framework is to provide a measure for achieving human wellbeing within Earth’s ecological limits,” said Johan Rockström, lead author of the report.

Currently, the only boundary that is within its “safe operating space” is the stratospheric ozone as that was addressed through a 1989 treaty called the Montreal Protocol that sought to reduce ozone-depleting chemicals in the atmosphere. This also is an example of how taking action can have a positive long-term impact.

Along with unsustainable agricultural practices and the conversion of natural ecosystems to monocultures of cultivation, deforestation and urbanisation all are putting these planetary limits under pressure. Agriculture alone accounts for 23% of the greenhouse gas emissions, 80% deforestation and 70% freshwater use.

In addition, challenges such as climate change and biodiversity loss are worsening land degradation creating a vicious cycle, according to the report.

What governments must do

The report urges the use of ‘regenerative agriculture’ that focuses on improving soil health, carbon sequestration and biodiversity enhancement.

Agroecology that emphasizes holistic land management, including the integration of forestry, crops and livestock management, is another solution.

In addition, woodland regeneration, no-till farming that causes less disturbance to soil, improved grazing, water conservation, efficient irrigation and the use of organic fertilisers, are some of the other solutions that have been highlighted.

For water conservation the report urges reforestation, floodplain restoration, forest conservation and recharging aquifers, along with improving the delivery of chemical fertilizers – the majority of which currently runs off into freshwater bodies.

Transformative actions can halt land degradation

Numerous multilateral agreements on land-system change exist but have largely failed to deliver. The Glasgow Declaration to halt deforestation and land degradation by 2030 for instance was signed by 145 countries at the Glasgow climate summit in 2021, but deforestation has increased since then.

Keeping forest cover above 75% keeps the planet within safe bounds for instance, but forest cover has already been reduced to only 60% of its original area, according to the most recent update of the planetary boundaries framework by Katherine Richardson and colleagues.

Authors of the report added that the principles of fairness and justice are key when designing and implementing transformative actions to stop land degradation so that the benefits and burdens are equitably distributed.

They also said that action must be supported by an enabling environment, substantial investments, and a closer collaboration between science and policy.

This report was launched ahead of the UNCCD summit that is being called COP16 this year, and is taking place in Riyadh, Saudi Arabia. Following a disappointing COP29 in Baku, there is concern that actions are falling short in the face of climate crisis.

Image Credits: Unsplash, UNCCD report.

WHO’s Dr Maria Von Kerkhove warns against drinking raw milk.

“Much stronger surveillance” of deadly H5N1 and other avian influenza strains in both domestic and wild animals is needed both in The United States as well as globally so as to head off pandemic risks from variants that could mutate to infect humans more directly. 

A senior World Health Organization official, Dr Maria Van Kerkkove, issued the appeal at a WHO press briefing on Thursday. She also said that WHO ‘always’ recommends drinking pasteurized, instead of raw, milk – due to the risks of contamination by a number of pathogens, including H5N1 virus.

At the briefing, WHO Director General Dr Tedros Adhanom Ghebreyesus also welcomed  the new cease-fire between Israel and Lebanon.  But he said that much more still needs to be done to end hostilities between Israel and Hamas in Gaza – where 90% of Gaza Palestinians are now facing winter in tents, with risks of respiratory diseases, cold exposure and malnutrition even more acute than last year. See related story:

WHO Welcomes Israel-Lebanon Ceasefire – But Onset of Winter Increasing Desperation in Gaza   

‘Epizotic’ of Avian flu in animals worldwide 

While the number of human infections from H5N1 is “still small, relatively speaking,” it is also growing  “not only in the US, but around the world over the last several years,”  Van Kerkhove told journalists.

But what is really “concerning” she added, is the “massive epizootic of avian influenza, including H5N1, but not just H5N1, in wild birds, in poultry, expanding to other animals, livestock, dairy cattle in the United States, but also land mammals, marine mammals. 

“And over the last couple of years, this expansion of H5N1 of avian influenza is putting more people at risk,” she added.  

So far, there have been about 55 human infections reported in 2024, she said, 52 in the United States. All but two of others had “known exposure” to infected animals. And there are extensive investigations that are underway looking at the pathway of exposures in the different cases, to see how people were in fact infected, she added. 

“But what we really need globally, in the US and abroad, is much stronger surveillance in animals, in wild birds, in poultry, in animals that are known to be susceptible to infection, which includes swine, which include dairy cattle to better understand the circulation in these animals, ,” stressed Van Kerkhove. And, she added, “we need much stronger efforts in terms of reducing the risk of infection between animals to new species and to humans.”

The US Department of Agriculture has confirmed cases of infected cattle in some 505 dairy herds in 15 US states since the outbreak was first reported in March, as well as in 50 commercial poultry flocks, according to the latest government data.

H5N1 outbreaks in cattle since beginning of outbreak in March 2024.

More protection of people occupationally exposed also needed

Van Kerkhove also called for more protection of people most at risk – those working with, or handling animals, “making sure that they have the right personal protective equipment, that it’s worn appropriately and properly when they are handling infected animals or even suspected infected animals. 

“We need to make sure that they have testing, that they have access to care, so that we can mitigate any potential spread. We have not seen evidence of human to human infection, but again, for each of these human detected cases, we want to see a very thorough investigation taking place, including further testing of context.

Finally, she added that WHO recommends that the public always drink pasteurized milk rather than raw milk products “for a number of different health benefits…. This is just as important for H5N1 as it is for other pathogens, other bacteria.”

WHO appeals risk a chilly reception from the new US administration 

Robert Kennedy Junior’s photo on X. The nominee for US Secretary of Health and Human Services advocates raw milk consumption and has promised to shift attention from infectious to chronic disases.

The recommendations for stepped-up surveillance of H5N1 in animals and people, as well as  avoidance of raw milk consumption, are likely to meet with a chilly reception in the new US administration of President-elect Donald Trump, who will be inaugurated on 20 January 2024.  

Although US dairy cattle are currently at the epicenter of an outbreak of H5N1 surveillance of both human and animal cases has so far been based largely on voluntary testing and reporting. 

And Robert F Kennedy Jr, Trump’s nominee for the head of the US Department of Health and Human Services (HHS), has long been a proponent of expanding raw milk consumption, and he wants to put a bigger focus on the US epidemic of non-communicable diseases, as compared to infectious disease risks.  

At the same time, concerns over raw milk contamination are rising after some state and county health officials, notably in California, recently began testing bulk milk supplies – finding traces of avian flu in one lot just last week, produced by Raw Farm LLC of Fresno. The company voluntarily recalled the lot.  

A lot of raw milk, was voluntarily recalled by a California manufacturer after Fresno County authorities reportedly found traces of H5N1 virus during bulk testing.

The enhanced testing followed an announcement by the US Department of Agriculture, 30 October, that it would support more bulk milk sampling as well as enhanced testing of dairy cattle herds’ milk samples for H5N1 nationally, in collaboration with veterinarian groups.  

But it remains unclear if Trump’s new DOA nominee, Brooke Rollins, a conservative lawyer and Trump loyalist who grew up on a Texas cattle farm, would continue to expand or restrict such surveillance.  

Meanwhile, Trump’s nominee for the head of the US Food and Drug Administration, Johns Hopkins Professor Martin Makary, is a more conventional pick. But his track record during the COVID-19 pandemic, when he argued against lockdowns, masking, questioned the benefits of vaccine boosters, and incorrectly predicted in February 2021 that “COVID-19  will be mostly gone by April” due to acquired herd immunity, bodes ill for closer tracking of H1N1 infections, or future pandemic preparedness measures. 

Image Credits: Raw_farm_USA, US Department of Agriculture.

Most families in Gaza facing winter cold and rain in tents.

WHO’s Director General Dr Tedros Adhanom Ghebreyesus welcomed the new ceasefire deal between Israel and Lebanon, which took effect Wednesday, but he noted that health needs in Gaza remain huge and “will only increase” with the onset of winter cold and rains.  

While there is an opportunity now to rebuild southern Lebanon’s shattered health infrastructure, the plight of Gazans is only getting worse, he said: 

“A year ago, almost all those displaced by the conflict were sheltered in public buildings or by family members. Now, 90% are living in tents,” Tedros observed, referring to the massive military destruction of schools and other public spaces that has since occurred over the course of the war. 

“This leaves them vulnerable to respiratory and other diseases, cold weather, rain and flooding are expected to exacerbate food insecurity and malnutrition,” Tedros said. 

Northern Gaza ‘blockade’ still limiting access to aid – Tedros

WHO Director General Dr Tedros Adhanom Ghebreyesus.

A continuing Israeli blockade of northern Gaza is limiting the entry of essential resources, “including blankets, fuel and food, all of which are already in short supply,” Tedros added.   

Israel has denied that it is limiting aid deliveries to the area, but it admits that aid distribution is a growing challenge due to the hijacking of deliveries by criminal gangs. Some 101 Israeli and foreign hostages also remain in Hamas captivity in Gaza, for the 14th month, with dwindling prospects for their survival as time goes on. 

Over the past month, Israel leveled thousands of homes and ordered the relocation of tens of thousands of Palestinians away from the sprawling Jabaliya refugee camp and other northernmost Gazan communities in the course of fierce battles with still-active Hamas forces in the area. 

The displacement has occured amidst growing signs that Israel’s hard right leadership bloc and its settler supporters are planning to reoccupy depopulated areas of northern Gaza, contrary to international law – and despite the denials of Prime Minister Benjamin Netanyahu and other top military and foreign ministry officials. 

Critical shortages of medicine and fuel  

Al Shifa hospital 23 November: WHO describes critical shortages of medicines and fuel following recent visit to northern Gaza hospitals.

Most immediately, however,  severe shortages of fuel and medicines, as well as food, in the besieged area pose continued challenges even to the limited functionality of the area’s hospitals, said WHO officials.  

“This week, WHO and our partners conducted a three day visit to the north of Gaza,” Tedros said. “The team visited 17 health facilities, including five hospitals. They saw a high number of trauma patients and increasing numbers of patients with chronic disease needing treatment. 

“There are critical shortages of essential medicines,” he asserted adding, “WHO and our partners are doing everything we can, everything Israel allows us to do, to deliver health services and supplies.”  

Tens of thousands of Palestinians who were displaced from Jabaliya and areas along the border with Israel have now moved south to Gaza City, added said Rick Peeperkorn, head of WHO’s Office in the Occupied Palestinian Territory (OPT). 

“There’s between 100 to 150,000 people from the north who are now actually camping in Gaza City,” he said. 

Huge increase in insecurity, crime and looting

Dr Rick Peeperkorn, head of WHO’s Office for the Occupied Palestinian Territory (OPT)

“There’s a huge need for mental health, psychosocial support, especially also for the health workers,” Peeperkorn said. “And of course, the shortages in supplies, staffing, but also the high influx of trauma patients. And the shortages remain in the key area, energy, as well as antibiotics, surgical supplies, oxygen, IV fluids, etc.” 

In the wake of the progressive destruction of Hamas,  “we have seen a huge increase in insecurity, crime and looting,” Peeperkorn admitted, compounding the problems with delivery of aid.  

On a faintly positive note, WHO this week facilitated the medical evacuation of some 70 patients to Jordan and elsewhere abroad for medical treatment – one of the largest groups to be moved out of the conflict zone since the  Rafah crossing closed, Peeperkorn noted. 

But he called for the re-establishment of more “consistent” medical corridors abroad, noting that with 12,000 chronically ill or injured people waiting to be referred out of Gaza  “if we continue at this pace, we’ll be busy for the next 10 years.” 

Added Tedros, “Once again, the ultimate solution to the suffering is not aid but peace. As we always say, the best medicine is peace.”

Image Credits: @WHO.

Burundi health officials conduct medical consultations and awareness sessions about sexual and reproductive health and mpox with displaced people in camps in Mubimbi and Rumonge.

Despite having the second biggest mpox outbreak in Africa, Burundi has no immediate plans to vaccinate those at risk.

Donated vaccine doses are available to Burundi for free but “vaccine hesitancy” might be playing a part in the government’s reluctance to vaccinate people, according to Dr Ngashi Ngongo, mpox lead for the Africa Centres for Disease Control and Prevention.

Over the past week, Burundi has registered 273 new mpox cases – an 13.8% increase over the previous week – and its first death. Overall, it has over 2,000 cases.

“The problem is not really the availability of vaccines. The problem is more on the country’s side,” Ngongo told an Africa CDC briefing on Thursday.

“During the COVID-19 time, it was a similar experience, where there was hesitancy to embrace vaccination. But toward the end of the response, the government of Burundi had accepted for vaccinations to be introduced in Burundi. We are hoping that it will be the same here.”

Ngongo confirmed that “there was really some hesitation” from the government, who wanted more information. 

“That information is being provided in order to get to the point where we can then convince the government of Burundi to move ahead with vaccines,” said Ngongo.

“The vaccines are ready. As soon as they accept, we should be able to deploy them.”

Burundi is one of the poorest countries on earth and two-thirds of the population live below the poverty line, according to the World Bank.

While 44 of the country’s 49 districts have registered mpox cases, the heart of the outbreak is in the economic capital of Bujumbura, where almost 60% of cases are, according to Ngongo.

Children under the age of 15 account for 42.9% of the country’s cases, the highest percentage on the continent. Clade 1B is dominant. 

Former President Pierre Nkurunziza failed to impose public health measures to control COVID-19. But after his death in 2020, his successor, Évariste Ndayishimiye, gave the go-ahead to vaccinations.

Misinformation campaign

However, vaccination campaigns particularly in Francophone Africa have become the target of disinformation campaigns allegedly fueled by Russia, according to The New York Times. 

Pro-Russian social media influencer Egountchi Behanzin has campaigned against malaria vaccines solely because they were developed in Western countries.

More recently, Behanzin – who has a large social media following and posts daily videos – took aim at mpox vaccines and urged Congolese people to reject them.

He claimed Western countries were involved in “health terrorism”.

Steady growth of mpox

In the past week, Africa has recorded 2,680 new cases (492 have been confirmed) and 22 deaths.

Some 84% of cases are located in the Democratic Republic of Congo (DRC), which recorded 2,261 new cases. The country also recorded 21 deaths, representing 95% of the continental total. 

Burundi and Uganda account for most of the remaining cases, while there are smaller outbreaks in Cameroon, Central African Republic and Liberia.

Gabon, Guinea and South Africa have moved from “active” to controlled, with no new cases in the past six weeks.

Meanwhile, the US and Canada have recorded their first mpox cases in people who have traveled to African countries with outbreaks.

Vaccination campaigns

In contrast to Burundi, Rwanda, DRC and Nigeria have started to vaccinate people at risk. Almost 56,000 people have been vaccinated in seven provinces of the DRC.

Rwanda has already reached 44% of its initial target, and is planning a new strategy for the next phase – “cluster vaccination in hot spots”, said Ngongo.

“Given that in some of the areas, the identification of contacts has remained a challenge, I think entire households are also being considered where there’s clear evidence of proximity and increased risk to those around the confirmed case,” said Ngongo.

The Japanese LC16 has now been included in the World Health Organization’s (WHO) emergency use listing for people aged one year and above.

“Now we are just waiting for the confirmation now from the Japanese government when the three million doses going to arrive in the DRC,” Ngongo noted.

Still a public health emergency

The International Health Regulations (IHR) Emergency Committee has resolved that mpox is still an public health emergency of international concern (PHEIC), WHO Director-General Dr Tedros Adhanom Ghebreyesus told a media briefing on Thursday.

According to a statement from the emergency committee meeting held last Friday (22 November), the “observed dynamics of transmission” of mpox clade 1b in DRC “are changing over time and are diverse across affected health zones”.

Infections have “shifted from adults, where transmission was first observed and appears to have been sustained by contact within commercial sexual networks, to younger age groups, including children, and sustained by household and likely broader community transmission through close physical contact”, it notes.

“Regardless of the circulating mpox clades, adults of 50 years of age or older are less affected, likely due to the immunity conferred by prior vaccination against smallpox,” it notes.

“As we have said many times, we’re not dealing with one outbreak of one virus, but several simultaneous and overlapping outbreaks of different strains or clades of the virus affecting different groups in different places,” added Tedros.

“We still face many challenges to bring these outbreaks under control. We need stronger political commitment to scale up responses activities. We need fully resourced preparedness and response plans. We need further contributions of medical countermeasures, including diagnostics and vaccines. And we need continued transparency and collaboration between affected countries and partners.”