South African President Cyril Ramaphosa

Four months after South Africa implemented one of the strictest lockdowns in the world, it appears that neither lives nor livelihoods have been spared.

South African President Cyril Ramaphosa was widely praised for taking decisive action when he introduced one of the fastest and strictest lockdowns in the world in late March. Within three weeks of the country’s first case being identified, all residents had been ordered to stay at home for five weeks, and for a while it appeared as if the country was going to escape the worst of the pandemic.

But four months later, South Africa has the fifth highest COVID-19 caseload in the world after the US, Brazil, India and Russia. It accounts for over half of all African cases and the economic cost of the lockdown seems to have been in vain as the country is following the worst-case scenario sketched by epidemiologists.

And while the country recorded over half a million cases the first weekend in August, SA president Cyril Ramaphosa said that “the national lockdown succeeded in delaying the spread of the virus by more than two months, preventing a sudden and uncontrolled increase in infections in late March. Had South Africans not acted together to prevent this outcome, our health system would have been overwhelmed in every province. This would have resulted in a dramatic loss of life.”

Ramaphosa added that “the daily increase in infections appears to be stabilising, particularly in the Western Cape, Gauteng and Eastern Cape. Our case fatality rate – which is the number of deaths as a proportion of confirmed cases – remains at 1.6%, significantly lower than the global average.

“We have empowered our law enforcement to investigate all reports of alleged corruption and irregularities in the procurement of medical and other supplies. It is unconscionable that there are people who may be using this health crisis to unlawfully enrich themselves.”

But official COVID-19 death toll – reported to be 7,812 on 30 July – is also in doubt after the SA Medical Research Council reported on 22 July that there were 22,279 more natural deaths between 10 June and July 20 than expected, and these were concentrated in provinces with the highest COVID-19 cases.

South Africa saw a spike in deaths by natural causes between 6 May and 21 May 2020
Lockdowns Hurt Day Wage Workers

The dramatic effects of the lockdown were evident within days in a country where millions of people – citizens and economic migrants from neighbouring countries – are heavily dependent on a hand-to-mouth existence in the informal economy.

Feeding schemes were soon inundated and some reported queues up to four kilometres long, as people used to eking out a daily living from selling at markets became instantly destitute because they weren’t allowed to trade.

Some 47% of households reported running out of money for food in April, according to the National Income Dynamics Coronavirus Rapid Mobile Survey which was recently released.

The South African government appeared not to have anticipated such a rapid and dramatic economic catastrophe and it was forced to relax lockdown regulations on 1 May, and allow most sectors of the economy to open from 1 June.

“We are damned if we do, and damned if we don’t,” said Professor Salim Abdool Karim, the chairperson of the ministerial advisory committee (MAC), which provides scientific advice to the health minister.

“The WHO recommends an easing of restrictions only when cases start going down, but we would have had a lockdown for a very long time and had to deal with starvation. The regulations were not sustainable and we had to ease some,” Abdool Karim said in a radio interview last week.

“We were not in a position to ease restrictions on 1 June to allow for 70 to 80% of economic activity to resume, as cases were going up at the time. But each decision requires a fine balance. Right now, the economic decisions are a really a high priority,”  said Karim.

Volunteers in Philippi, Cape Town packing food parcels to be given out to the needy during the COVID 19 pandemic lockdown.
Contradictory Lockdown Policies Based On Politics Rather Than Science

But as the government seeks to balance health and the economy, its pandemic response has degenerated into a morass of contradictory regulations. Worse still, many appear to have been influenced by powerful lobby groups rather than by science or even economics.

Churches, casinos and restaurants  – identified as super-spreaders in other countries – have been allowed to operate for some time with certain restrictions.  But public parks and beaches remain closed.

From mid-July, minibus taxis, the main mode of transport for most South Africans, have also been permitted to operate at 100% capacity although Abdool Karim admitted that 50% capacity would be best from a health point of view.

At the same time, domestic leisure travel is banned even if people want to drive in their own cars to self-catering accommodation.

There is a curfew between 9pm and 5am, although scientists on the ministerial advisory committee say it will have no bearing on the spread of the virus. However, it has a significant impact on businesses such as restaurants need to close by 8pm to allow their staff to get home in time.

Sturks Tobacco Shop, considered one of the oldest businesses in Cape Town, South Africa. It was closed in 2020 due to COVID-19.

The sale of cigarettes has been banned since the lockdown started – ostensibly to get smokers to quit and thus protect them from severe COVID-19 illness. But this too has been condemned, even by scientists.

A large study of over 12,000 smokers released in late May found that only 16% had quit while over 90% had been able to buy cigarettes on the black market.

“The ban may well have undone the progress the South African Revenue Service had made in reducing illegal cigarettes prior to lockdown. It has given illicit traders a larger foothold in the cigarette market, and has created an opportunity for these traders to develop their distribution channels,” according to the researchers from the  University of Cape Town.

In addition, diabetes – rather than smoking-related conditions – has emerged as one of the most dangerous co-morbidities. Yet government has not banned junk food or sugary drinks that are fueling the country’s type two diabetes epidemic.

Last week, Ramaphosa announced that schools would be closed until 24 August against scientists’ advice who advocated that neither children nor teachers were more at risk in schools than communities.

However, a recent court order has compelled school feeding schemes to remain open, so children from low-income schools will still go to school to get food.

Political Corruption Difficult To Control

Depressingly, the pandemic has also provided opportunities for corrupt government officials to profit from tenders awarded to friends and relatives for a range of pandemic-related good and services, including the supply of food relief and personal protective equipment.

Numerous workers who have lost their jobs during the pandemic have also reported not getting the unemployment insurance fund (UIF) payments owed to them, while government has been slow to pay out a miniscule R350 (around 18 Euros) it promised to all unemployed South Africans between May and October.

Shoppers queue outside to observe social distancing measures during South Africa’s Level 4 lockdown.

Ramaphosa announced last week that he had empowered the corruption-busting special investigative unit (SIU) to investigate “allegations of corruption in areas such as the distribution of food parcels, social relief grants, the procurement of personal protective equipment and other medical supplies as well as the UIF special COVID-19 scheme”.

Media reports say that 90 companies are being investigated in one province alone, and that the corruption is estimated to have cost R2,2-billion (Euros 113 078 507) so far.

Sandile Zungu, head of Business Unity South Africa, described businesses profiteering from the pandemic as “parasitic COVID-pruners”.

“South Africa is becoming a nation of thieves, with the most unscrupulous enablers in official positions all too ready to feast on the relief meant for the most vulnerable in our society,” Zungu told a leading Sunday newspaper.

Ramaphosa’s promise to address the corruption has been met by skepticism. His administration has so far failed to act against his predecessor, Jacob Zuma, who looted billions and has brought the economy to its knees.

Ramaphosa beat Zuma by a narrow margin and was forced to make deals with various corrupt factions and individuals to do so, and lacks the power to take them on.

In addition, a number of his key allies in government have been infected with the virus and been forced to step aside. Four Cabinet ministers, three provincial premiers and the treasurer general of the ruling party are amongst those infected.

In the meantime, frustration and anger is building in communities as more people lose their jobs and young people lose hope of ever being able to find work.

This story was updated 3 August 2020 to included a public statement from Cyril Ramaphosa.

Image Credits: Wikimedia Commons: Discott, GovernmentZA, SA Medical Research Council, Wikimedia Commons: Discott, WIkimedia Commons: Thuvak.

Methicillin-Resistant Staphylococcus aureus (MRSA), a notorious bacteria resistant to many antibiotics.

The United Nations Interagency Coordination Group (IACG) is seeking candidates for a  “One Health Global Leaders Group” that will be established to fight the growing threat of antimicrobial resistance (AMR). 

Individuals from civil society and the private sector  are invited to submit an application to serve in the Global Leaders Group by 31 August 2020. Former Ministers of Health or senior government officials with experience in battling AMR will be nominated and considered through a separate process.

The One Health Leaders Group aims to advise global and national stakeholders to help control AMR, and advocate for more resources to be dedicated to controlling AMR. Membership will be 2-3 years long, with the possibility of a second 2-year term with agreement from the co-chairs and Secretariat.

Disease-causing microbes that are becoming resistant to common antimicrobials claim around 700,000 lives a year, according to the IACG, which represents the World Health Organization, the Food and Agricultural Organization, and the World Organisation for Animal Health. Rising antimicrobial resistance is caused by misuse and overuse of antimicrobials in humans and plants, pouring pharmaceutical waste in water sources and poor infection control measures.

Low and middle-IACG discussed Low and Middle Income Countries (LMIC’s) experiencing a greater burden of AMR;within poor basic services and weak healthcare systems while many are still suffering with implementing National Antimicrobial Resistance Action Plans. The Organization for Economic Cooperation and Development (OECD) anticipated 2.4 million deaths due to antimicrobial resistance in Europe, North America and Australia between 2015 and 2050.

Applications to the “One Health Leaders Group” must include Curriculum vitae (CV) of 2 pages (500 words) maximum and a motivation letter of 2 pages (500 words) maximum highlighting their contributions and what they will bring to the Global Leaders Group. Applications should be submitted to amr-tjs@who.int. More information, including terms of reference and an information note about the application, can be found here. 

The deadline for representatives from civil society and the private sector to apply for the “One Health Leaders Group” is 31 August 2020.

Image Credits: NIAID.

Orphan drugs receive ten years of market exclusivity in the EU to promote R&D for rare diseases.

Big pharma has reaped billions in profit off the back of European orphan drug regulations that are supposed to incentivize R&D for rare diseases, according to an analysis of 120 orphan medicines registered in the EU over the past two decades.

Instead of incentivizing R&D for rare maladies, the EU’s orphan drug legislation has turned into a “corporate cash machine” that has enabled market exclusivities to extend well beyond the ten years set by the EU’s regulations, preventing generic competitors to enter the market, said The Investigative Desk, a Dutch cooperative of investigative journalists that undertook the research.  The findings were published in the British Medical Journal (BMJ) and the Dutch Journal of Medicine (NTvG) on Wednesday. 

The number of orphan drugs earning over $1 billion in sales has skyrocketed in the past decade

The Investigative Desk’s research comes almost four months after researchers from international consultancy Technopolis Group presented an EU-commissioned review of the region’s orphan legislation to pharma experts from EU member states. The review suggests that the region’s regulations could be overcompensating big pharma for orphan drugs.

Surprisingly, the review also shows that an overwhelming majority of orphan drugs approved by the EU over the past twenty years would have been rolled-out regardless of receiving the EU’s orphan drug designation, suggesting the 21-year old approval process may not effectively spur R&D for rare diseases.

“The number of new orphan medicines which may be attributed to the EU Orphan Regulation, equates to 18 to 24”, said the review. “While these products would not have been available without the Regulation, the others [about 118 products] would have been introduced anyway, also thanks to their development in other regions, like the US.”

These findings, which will be officially published by the European Commission in a report later this summer, “may raise voices for reform” in the European Parliament, said The Investigative Desk in a press release.

Daan Marselis, Reporter for The Investigative Desk in Holland, and lead author of the BMJ report

The European Commission and the European Medicines Agency declined to comment on the findings until the European Commission’s official report is published, said Daan Marselis from The Investigative Desk, and lead author of the BMJ report, to Health Policy Watch.

Currently, EU legislation makes it “impossible” to withdraw or shorten the ten year market exclusivity once it has been granted to a pharmaceutical company, even if unfair prices are spotted in time by regulatory authorities, said The Investigative Desk in a press release.

Another problem is that companies can apply for multiple “orphan indications” on the same medicine to successfully extend their market protection period beyond ten years, said Marselis to Health Policy Watch. Since 2001, 14 drugs have enjoyed fifteen or even twenty years of market exclusivity, according to The Investigative Desk’s research.

Since 2001, 14 orphan drugs have enjoyed more than ten years of market exclusivity

Orphan Drugs Are More Profitable Than Ever, But 95% Of Rare Diseases Are Still Untreated

Orphan drugs have become five times more profitable in past decades, as annual sales revenues have ballooned from €133 million in 2001 to €723 million in 2019, according to the Holland-based investigative group. Rare cancer drugs are the most lucrative, with an average turnover of € 1.1 billion, or twice as much as other orphan drugs that do not treat cancer.

Although orphan drugs are becoming more profitable, 95% of rare diseases are still untreatable, said the EU-commissioned review. Meanwhile, over two thirds of the 146 orphan drugs introduced in 2001-2016 in Europe were developed for diseases that are already treatable. 

In other words, most rare diseases are still untreatable, and the majority of drugs are developed for rare diseases that are already treatable.  

 “Over time, the [EU orphan drug] Regulation seems to have become less effective in directing research to areas where there are no treatments: only 28% of the 142 authorised orphan medicines targeted diseases for which there were no alternative treatment option (95% of rare diseases remain still without a treatment)”, said the review.

Image Credits: WHO, BMJ, Daan Marselis.

Vitamin D supplements

People who tested positive for COVID-19 had lower Vitamin D levels on average than people who tested negative, according to a massive peer-reviewed Israeli study published in the FEBS Journal.

The study found that the average plasma Vitamin D level – or the level of vitamin D in the liquid part of the blood – was 19.00 nanograms per mililitre (ng/mL) in 782 individuals that tested positive for COVID-19, compared to an average of 20.55 ng/mL in 7,025 individuals who tested negative for the virus. The study was conducted on a cohort of patients who were part of Leumit Health Services.

However, some experts urge caution in reading too much into the study’s findings, saying that other factors may explain the relationship observed in the study.

Still, low plasma Vitamin D was associated with a higher risk of COVID-19 infection and hospitalization, even after taking preexisting conditions, socioeconomic status, age, and gender into account, according to the study. In COVID-19 patients who were hospitalized, the average plasma vitamin D level was even lower at 178.38 ng/mL.

Vitamin D could act like a steroid, study author Milana Frenkel-Morgenstern of Bar Ilan University told the Times of Israel. Some steroids, such as dexamethasone, have been shown in clinical studies to improve outcomes for patients facing more serious COVID-19 disease.

Frenkel-Morganstern encouraged the government to maintain adequate outdoor spaces so that people could get sunlight, which is absorbed through the skin and helps the body make Vitamin D. The vitamin has been associated with a wide variety of health benefits, including maintaining bones and regulating calcium levels in the body.

However, others have said that it is too early to tell whether Vitamin D actually reduces the risk of COVID-19 infection. For example, people who get more exercise could have higher Vitamin D levels, and it could ultimately be exercise that is impacting COVID-19 risk, according to Ella Sklan, head of a molecular virology lab at Tel Aviv University.

And proving whether Vitamin D has any benefits as a potential treatment against COVID-19 requires clinical trials. The World Health Organization did not comment on whether Vitamin D would be considered a candidate for its massive Solidarity clinical trials testing potential COVID-19 treatments at the time of publication.

However, maintaining a healthy diet, and supplementing diets with appropriate vitamins is a “positive way to keep oneself healthy,”  and keeping healthy allows the body to help fight infectious diseases, according to a WHO statement.

“In situations where individuals’ vitamin D status is already marginal or where foods rich in vitamin D (including vitamin D-fortified foods) are not consumed, and exposure to sunlight is limited, a vitamin D supplement in doses of the recommended nutrient intakes (200-600 IU, depending on age) or according to national guidelines may be considered,” added the statement.

This story was updated 30 July to include the WHO’s statement

 

Image Credits: Flickr: Filip Patock.

Head of the Italian Medicines Agency Luca Li Bassi at 72nd World Health Assembly, where he led approval of a historic resolution on price transparency in medicines markets.

Italy has become the first nation to require pharmaceutical companies to disclose secret data about any public subsidies it may have received for the development of a new drug, during negotiations over drug pricing and reimbursement with national regulatory authorities, according to a decree published Friday in the nation’s official gazette.

The decree, following on from last year’s milestone World Health Assembly resolution on transparency of markets for health products, represents a “very important” step towards enabling government authorities to negotiate more effectively with the private sector over new drug prices, Luca Li Bassi, former Director-General of the Italian Medicines Agency (AIFA), told Health Policy Watch.

“The Decree is a very good step forward that addresses the asymmetry of information at the negotiating table with the private sector”, said Li Bassi, who was also the leading architect, on behalf of the Italian Government, of the WHA transparency resolution from 2019. “Having information is vital when you’re negotiating, otherwise you’re negotiating blindly.”

Luca Li Bassi holds his transparency award

The decree was actually approved by Italy’s Ministers of Health and Finance in August 2019.  But after a government reshuffle in the fall, it languished in limbo due to a technicality – as it had not been published in the official Italian government gazette.  Last Friday, it finally surfaced, observers say at an opportune moment as Italy’s badly hit health system recovers from the first wave of the pandemic. COVID-19 has also churned up further debate over issues of drug access, pricing and transparency  – as pharma companies and countries scramble to research and acquire technologies that could better treat the viral disease.

“For a COVID-19 pandemic response to be effective and legitimate, it is critical to ensure that transparency is upheld, particularly when it comes to clinical trials, pricing and supply schemes,” said Jaume Vidal, Senior Policy Advisor of Health Action International, to Health Policy Watch. “The decree clearly shows that the need for greater transparency on medicine prices and R&D costs is still in the agenda more than a year after the historic Italy-led WHA resolution was approved.”

According to Li Bassi, the decree will strengthen AIFA’s negotiating position with pharmaceutical companies as they seek reimbursement for their innovations. It will provide public health authorities not only with data about contributions public sources may have made to the R&D of a new drug, but also about sales revenue, marketing costs and the status of relevant patents. The new regulations also require pharmaceutical companies to submit information to AIFA about reimbursement prices in other countries. That would provide Italian government authorities with a means to compare reimbursements, and thus prices, for the same health products across countries. 

“Most importantly, this decree enables AIFA to make a far better informed analysis of the reimbursements demands made by suppliers, resulting in a significantly transformed negotiation process across the table”.

The decree is also a “very important step” that could encourage other countries to follow in the same direction, and for more collaboration to spearhead the transparency agenda in the future, said Li Bassi: 

“Anything that can be done to enhance transparency in the biopharmaceutical sector is definitely going to be useful.”

Image Credits: Twitter/@Italy_UNGeneva, l'Observatoire Médicaments Transparences.

Vaccination can effectively prevent mother-to-child transmission of hepatitis B

In a landmark achievement, incidence of chronic hepatitis B has successfully dropped below 1% in children under five, reaching the 2020 goal set at the 2016 World Health Assembly, said World Health Organization Director-General Dr. Tedros Adhanon Ghebreyesus on Monday.

The target reduction in hepatitis B virus (HBV) incidence in children was met in 2019, a rare case where global health goals were achieved within the intended timeline. The achievement, announced just ahead of World Hepatitis Day, provides a much-needed boost of morale for the embattled global health community in the wake of this year’s pandemic and its knock-on effects on other disease areas. 

“HBV has been a scourge in many countries for so many decades”, said WHO’s Head of Health Emergencies Mike Ryan. “To see incidence [of hepatitis B] less than 1% in children is just incredible”

“I know it doesn’t sound like it, but we should take these successes because they’re true victories for global health.”

The reductions in HBV incidence in children were largely thanks to the wide deployment of a childhood vaccine against the virus. 

Still, Dr Tedros warned that countries must stay on guard.

Disruption of essential services, like vaccination against Hepatitis B, could result in five million additional chronic hepatitis B (HBV) infections in children born between 2020 and 2030, as well as one million additional HBV-related deaths among those children later on, according to a study by Imperial College London and WHO which has not been published yet. 

Additionally, the hepatitis death toll could skyrocket because of coronavirus-related disruptions, warned Dr. Tedros. Hepatitis infections can cause liver damage and liver cancer, and currently claim 1.3 million lives a year. 

Globally, about 325 million people live with hepatitis B and C, the most deadly of the five types of hepatitis disease.

Hepatitis B Vaccine Coverage Threatened During Coronavirus Pandemic
A healthcare worker in Lao PDR provides the first dose of the hepatitis B vaccine, given within 24 hours of birth.

As a result of the pandemic, disruption of essential hepatitis services, like HBV vaccination of infants, threatens to claim thousands of additional lives, added panelists at the WHO briefing.

“Even in the midst of the COVID-19 pandemic, we must ensure that mothers and their babies have access to life-saving services including hepatitis B vaccinations. Preventing transmission of hepatitis B from mother-to-child and in early childhood is the most important strategy for controlling the disease and saving lives”, said Dr. Tedros.

Mother-to-child transmission is responsible for the brunt of new HBV infections, and the virus claims nearly 900,000 lives each year. Boosting vaccine coverage is particularly important in WHO’s African Region, where HBV vaccine coverage at birth is ten times lower than the global average of 42%.

“For regions such as sub-Saharan Africa with low access to the vaccine, increasing coverage of a timely birth dose is the priority,” emphasized Doherty.

Some countries have successfully maintained essential services for other infectious diseases like measles despite the pandemic, suggesting the same could be done for HBV. Ethiopia, for instance, has successfully vaccinated almost 15 million children against measles during the pandemic, according to a report from WHO’s African region on Monday.

The HBV vaccine can protect against the virus in more than 95% of cases, and has been proven to be safe after nearly four decades of use.

WHO Issues New Hepatitis Guidelines To Prevent Mother-to-Newborn Transmission

On Monday, Dr. Tedros also called on countries to implement two new recommendations to prevent onward transmission of HBV from pregnant women to their newborns.

As part of the new guidance, pregnant women that are HBV-positive and present a high viral load can protect their newborns through preventive antiviral therapy from the 28th week of pregnancy until birth.

The antiviral of choice, tenofovir, only costs $3 per month in many regions of the world.

However, in settings where viral load testing is unavailable, women are encouraged to use the low-cost “HBeAg” antigen test to assess their infection status, recommends the WHO.

Battle Against Hepatitis C Continues Amidst High Medicines Costs and Barriers To Diagnosis
Meg Doherty, WHO’s Director of Global HIV, Hepatitis and STI Programmes

In recent years, so-called “direct acting antivirals” have also prevented thousands of deaths from hepatitis C (HCV) for as little as $60 in some regions, Meg Doherty, WHO’s Director of Global HIV, Hepatitis and STI Programmes, said on Monday. A typical treatment course on these drugs is twelve weeks.

However, these lifesaving drugs are still out of reach for many patients in high- and middle-income countries, where a twelve-week treatment course can even climb to $3000 given the absence of special licenses with generic companies to produce the drugs at a cheaper price, Doherty told Health Policy Watch.

“Not all countries will have access to the [cheaper] generics, though more and more countries have access now [over 105 countries] to some of the direct acting antivirals.”

She also added that without access to testing, “the medicines will remain out of reach”, as she referred to the fact that only 19% of HCV patients (13.1 million) are diagnosed with HCV, and only 7% of people with HCV (5 million) are treated for the disease, according to WHO data from 2017.

People waiting to receive free hepatitis C
testing during World Hepatitis Day 2016, Rwanda

Image Credits: WHO, Flickr: CDC Global, WHO, WHO.

Elyne Kaingu, a 33-year old mother and her 2 -year old son Abdul. Elyne benefitted from IPTp treatment during her second pregnancy.

Kilifi County, Kenya – Elyne Kaingu, a 33-year old mother from the beautiful Mnarani area of Kilifi County, overlooking the Indian Ocean, was extremely wary during her first pregnancy about the silent killer in her midst – malaria.  She knew some other first time mothers had fallen ill with the disease, and had even lost their babies or had premature births.

“I had to be very careful, given the pain caused by the disease to first time mothers, which I had witnessed,” recounts the homemaker, who was born and raised in Kilifi.  

For example, she was aware of the complications that might arise from maternal aneamia attributable to malaria.

Kaingu therefore took extra precautions by seeking medical advice from the village antenatal care (ANC) clinic, “where I was given iron and folic acid tablets, that prevented anemia while helping the development of the baby,” she says.

She was one of the lucky first-time mothers who had a successful and safe birth.

When she became pregnant for a second time in 2018, she discovered something that allowed her to feel even more reassured.  

During a prenatal check at the Mafumbini Dispensary she heard about the fact that Intermittent preventive treatment of malaria in pregnancy (IPTp) could help protect mothers and their babies from malaria, and she decided to take the treatment. 

“For every [ANC] clinic visit, I was given the malaria medicine which had to be taken at the dispensary before leaving for home,” Kaingu said, recalling the trips she made from the second trimester onward. 

There are good reasons for requiring the treatment be done at the clinic, she says, explaining that since the medicine sometimes causes nausea, some women might not take it within the confines of their homes.  

Even so, she made sure to arrive at the clinic with a good meal in her stomach. “It was not advisable to take the medicine on an empty stomach, according to the advice of the clinicians,” she says, explaining this helped ward off possible nausea.

Intermittent preventive treatment in Pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) is effective in preventing maternal death and reducing maternal malaria episodes.

A minimum of three doses of sulfadoxine-pyrimethamine (SP) from the second trimester onwards has been shown to help prevent maternal malaria episodes, maternal and foetal anaemia, and related adverse outcomes like low birth weight and premature birth, according to the Geneva-based Medicines for Malaria Venture.  MMV is working with the World Health Organization, Roll Back Malaria and other partners to help ramp up IPTp treatment worldwide in the malaria-endemic zones at highest risk.  

About 31% of pregnant women that need IPTp treatment in Sub-Saharan Africa get at least two doses of the preventive medicine, according to WHO’s 2019 World Malaria Report. That is a big leap since 2010 when only about 2% of women received treatment, but still a long way to go in terms of ensuring full coverage.    

IPTp Offered in an Integrated Package of Services 

Integrating IPTp treatment with other services important to pregnant women has been one of the scale-up strategies stressed by MMV and others. 

In Kaingu’s case, the integrated approach was evident from the start – giving her extra motivation to return for more ANC care – and IPTp treatments. 

During her visits, for instance, she was provided with an insecticide-treated mosquito net: “Up until that time, I was using an ordinary, untreated mosquito net in my home.” 

Other benefits included being tested for breast cancer; advice on breastfeeding and on saving money specifically to meet the needs of the newborn baby.  Finally, there was the assurance that she could remain safe from malaria. 

“The treatment and the clinic visits have been beneficial to me and my baby, because I have never been attacked by malaria,” says Kaingu.

IPTp reduced malaria in pregnancy – even while Kilifi saw an overall rise in malaria cases
Malaria is still a concern in seaside Kilifi County, nestled by the Indian Ocean in southeast Kenya.

IPTp is one of the most widely used preventive interventions in this coastal region of Kenya as well as in Kenya’s Lake Victoria area – where malaria is endemic and incidence has even risen in recent years.

Expanding access to IPTp is the first objective of the six-phase Kenya Malaria Strategy adopted in 2019, which aims to help everyone in at-risk areas adopt appropriate measures to prevent malaria from the outset – as compared to only taking a curative approach.

Whereas some parts of Kenya have seen gradual declines in malaria incidence, heavy rains seen in the coastal area have led to a rising disease rate in some counties, such as Kilifi, where Kaingu lives. 

In 2018, there were an estimated 20-50 confirmed malaria cases, per 1,000 people, in Kilifi County, according to county malaria records. By 2019, that rate had doubled.  

Even so, malaria incidence among pregnant women in the rural area where Kaingu lives, actually declined over that same period, according to the records of the Kadzinuni Kendrick Dispensary, which serves her area. And the IPTp rollout has had a lot to do with that, in the opinion of Daniel Karisa, the clinical officer in charge of the Dispensary, which covers the northern rural part of Kilifi County. 

Daniel Karisa, a clinician at Kendrick Dispensary Kadzinuni in Kilifi, attending to a patient and his parent.

“There is a significant reduction of malaria cases among pregnant women even though there is an upsurge of malaria cases in the general population, during the rainy season,” Karisa said in an interview with Health Policy Watch. 

Some 200 pregnant women visited the dispensary for ANC treatment last year Karisa said in the interview, in which he constantly referred to the carefully kept dispensary records. Of those, only nine developed malaria in their second trimester and thereafter  – or 4.5% of pregnant women. The rate was 9% per cent on average before IPTp treatment was started.

Karisa believes that the integrated approach taken by the clinic to providing the treatment, in combination with bednets, advice about breastfeeding and breast cancer prevention, has   yielded other benefits. Out of their exposure to such issues, many women have developed better health-seeking behaviors. 

“IPTp is a big part of this change,” Karisa says.

Less Maternal Anaemia, Low-Weight Babies and Involuntary Abortions
Kendrick Dispensary Kadzinuni in Kilifi County on the Kenyan coast, where mothers receive IPTp treatment and other pregnancy-related care.

Karisa cites a long list of other benefits that he has observed, in terms of pregnancy outcomes: 

“There was reduced hospitalization resulting from severe maternal anaemia,” he asserts, referring again to the records. He notes that out of 100 mothers receiving IPTp, and reviewed during their ANC visits, only one was found to be severe anaemic. IPTp treatment helps prevent maternal anaemia by killing malaria parasites in the placenta. 

None of the babies born at the dispensary over the past year were low-birth weight (less than 1.5 kilograms).  Says Karisa: “Following the introduction of IPTp in the community, it is now rare to have low birth weight deliveries.”  

Finally, there has also been a reduced incidence of premature labour as well as a decline in involuntary abortions, he says, noting that the facility used to record an average of 4 cases of involuntary abortion per month for expectant mothers, before IPTp treatment was introduced. 

This year, between January and June, there was only a single case of miscarriage. This occurred among a total of 10 pregnant women who were found to be infected with malaria in their first trimester – when current forms of IPTp cannot be safely administered.  

“This is caused by the malaria parasites lodging inside the womb,” Karisa explains.

COVID-19 Slowed but Didn’t Stop IPTp Services  

In Kenya’s priority areas, IPTp coverage appears to already be slightly higher than it is Africa-wide. According to the Kenya Malaria Indicator Survey (KMIS) some 38 percent of pregnant women in the priority areas of Kilifi and Lake Victoria received IPTp treatment in 2015, the last year for which national data is available.

Based on observations at clinics such as Kadzinuni, the proportion of women being reached also seems to have increased further over the past five years. However, it will be some time before new national data is forthcoming, since the updated malaria survey that had been due to take place in 2020 has been pushed back to 2021, in light of the  COVID-19 pandemic. 

Indeed, coronavirus has been another new challenge that local health facilities have had to address – along with the unusually heavy rains, Karisa says. 

“The fear was that the new disease could severely handicap our ability to dispense malaria treatment to patients,” he explains.  “Fortunately this has not come to pass.”

Initially, in April and May, the number of mothers seeking ANC services dropped by about half, as COVID-19 cases started to spike nationwide.

While the clinic used to receive 100 individuals on average per day, the number dropped to between 50 and 60 in that period. As there was no lockdown in Kilifi, this was largely due to women’s fears of getting infected with the new disease.

“This however, is not to say that the services were interrupted per se; they were delayed,” Karisa says, noting that in June, numbers of women visiting the clinic rebounded  – even though COVID-19 cases began to climb sharply around the country.

Fortunately so far, COVID-19 case counts in Kilifi have also remained relatively low. On 19 July, for instance, six new COVID cases were recorded in the county, out of 603 cases nationally. 

Healthcare workers, like Daniel Karisa, are providing essential malaria care against the background of the COVID-19 pandemic and unusually heavy rains.

Against the uncertain landscape of the pandemic, the determination of health workers like Karisa to maintain routine health services, such as treatment for malaria in pregnancy, is good news to David Reddy, CEO of MMV.  

“As responding to COVID-19 will be a marathon, not a sprint, it is critical that prevention and treatment of leading killers such as malaria not be left behind,” Reddy told Health Policy Watch. “This is particularly the case in sub-Saharan Africa where the malaria disease burden remains so very high particularly among children and pregnant women. In that context, preservation and scale up of essential services such as those that prevent malaria in pregnancy remains critical.”

Malaria Remains a Major Burden to Communities
Elyne Kaingu, a 33-year old mother in Kilifi and her 2 -year old son Abdul.

And despite the progress seen recently on reducing malaria in pregnancy, the parasitic disease  remains a big burden, socially and economically, to communities in Kilifi County, Karisa underlines. 

As many as 40% of people visiting health facilities may receive a malaria diagnosis – at least in the rainy season.  And some people are discouraged from seeking treatment, because they have to travel such long distances to get to a clinic. 

Just like many mothers in her community, Kaingu also has been more wary of visiting the clinic for routine care for fear of COVID-19. “Honestly, I stopped going to the clinic, unless my child fell ill,” she says. 

However, she remains keenly aware of how important IPTp treatment is to pregnant women, even in the coronavirus period, and is actively encouraging other women to seek it. 

She now volunteers to mobilize women in her community whenever there is a health-related drive in her village.

She notes that malaria remains a huge concern, “especially at this time, when we are experiencing a lot of rains.” Mothers like her are particularly vigilant as spikes in early childhood mortality from malaria have been observed.  

In speaking out about the issues, Kaingu is also a model to other women – some of whom may still be fearful about getting treatment, but also fearful about speaking out about the risks.  Indeed, malaria in pregnancy remains a traumatic issue to talk about among women in Kilifi – as there are more than a few women who have suffered the tragic consequences. 

Kaingu says more action is still needed:

“Even though a lot of effort has been made in encouraging expectant women to visit health facilities and seek ANC services, I think more still need to be done to sensitize this population group in the community, on the importance of guarding against malaria in pregnancy.”

A view of the Indian Ocean in Kilifi County, Kenya.

Image Credits: HP-Watch/G Kamadi, Karel Prinsloo/Jhpiego.

COVID-19 responders receive training on how to don and doff protective equipment

Ibadan, Nigeria – As the number of health care worker infections continues to rise in Africa, Health Ministers are calling attention to increasing pressure on Africa’s health system – and the people running it.

Lack of personal protective equipment, adequate infection prevention protocols, and burnout have led to widespread dissatisfaction among doctors in recent weeks, culminating in health worker strikes in some countries.

Over 10,000 health workers across 40 countries in Africa have tested positive for COVID-19, representing about 2% of the continent’s total number of coronavirus cases, according to African Health Ministers and experts present at a World Health Organization press briefing on Thursday.

While globally, some 10% of all cases are among health workers, the large shortage of healthcare workers in Africa predating the pandemic has many experts and Health Ministers concerned. On average, most African countries have less than 1 physician per 1000 people, and less than 2 nurses or midwives per 1000 people, according to World Bank data.

And in four Sub-Saharan countries, health workers make up more than 10% of all infections.

In Gambia, 22% of individuals that tested positive for COVID-19 are health workers, according to the WHO African region’s 21st COVID-19 situation report published July 22. This is followed by Niger Republic, where health workers account for 16.6% of COVID-19 cases in the country. 

In Africa, WHO noted that there is limited information on health worker infections, but health workers make up more than 5% of cases in 14 countries in sub-Saharan Africa.

WHO described the increasing number of health workers infected with COVID-19 as a sign of the challenges that medical staff on the frontlines of the outbreak face. It added that some countries are approaching a critical number of infections that can place stress on health systems as the pandemic continues to wax stronger across the continent further exposing health workers to the virus.

“The growth we are seeing in COVID-19 cases in Africa is placing an ever-greater strain on health services across the continent,” said Dr Matshidiso Moeti, WHO Regional Director for Africa. “This has very real consequences for the individuals who work in them, and there is no more sobering example of this than the rising number of health worker infections.”

Regional Director for WHO Africa Matshidiso Moeti

Aside from personal exposure to COVID-19, Moeti added that health workers are also afraid of taking the virus home, potentially exposing their family members to the pandemic. 

And the availability of personal protective equipment, and infection prevention and control measures were often inadequate and weak in many countries in Africa.

The agency added that health workers can also be exposed to patients who do not show signs of the disease and are in the health facilities for a range of other services. 

“Risks may also arise when health personnel are repurposed for COVID-19 response without adequate briefing, or because of heavy workloads which result in fatigue, burnout and possibly not fully applying the standard operating procedures,” WHO stated.

It is therefore not surprising that health workers in several African countries have expressed their dissatisfaction with a number of industrial actions, including strikes.

African Governments’ Limited Options – Sierra Leone’s Case

In Sierra Leone, three doctors, two community health workers and one nurse have died of COVID-19.

In all, about 10% of the country’s COVID-19 cases are among health workers. Moreover, a row between doctors and the country’s government over what doctors described as misuse of funds for the coronavirus response in the country and a lack of protection and compensation for health workers escalated into strike action early July. Even doctors treating patients with COVID-19 refused to continue working.

The country’s Medical and Dental Association said the government bought about 30 4×4 vehicles for managers from money intended for the fight against the virus rather than drugs and equipment.

But the country’s Minister of Health and Population, Dr Alpha Wurie acknowledged that healthcare workers in Sierra Leone were the first to be affected by COVID-19 while participating in a WHO press conference on Thursday.

Sierra Leone’s Minister of Health and Population Alpha Wurie

“It so happens that while COVID-19 treatment centers were in readiness and had enough PPEs, this was not so in the other hospitals,” Wurie said.

He also described how a doctor and several nurses at one of the country’s designated COVID-19 treatment centres, tested positive, resulting in the closure of the facility.

While admitting that the country has not become fully confident in the ways it is striving to prevent the spread of COVID-19, he countered that the case fatality management for COVID-19 has been satisfactory – compared with the outcomes of the country’s cycles of Ebola outbreak.

“The recovery rate for COVID-19 has been very good and the case fatality rate has been very low at 3.8%,” Wurie said.

Nurses Can’t Social Distance in Ghana

Dr. Jemima Dennis-Antwi, an Accra-based international maternal health and midwifery specialist, decried the paucity of published information on the true magnitude of health professionals’ infectivity which she described as an information that is highly guarded by countries.

Ghana has reported 2,035 cases of health workers infected with COVID-19. Some 91% fully recovered and there have been nine deaths which included four doctors, one nurse and three laboratory workers.

In addition to the use of PPEs, maintaining social distancing is another major COVID-19 prevention measure. But for several health workers, especially nurses, this is unrealistic.

“Nurses and midwives have the majority of infectivity – over 410 nurses and midwives have been affected in Ghana in the line of duty. This is because we are designated to serve our patients 24/7,” Antwi said.

Jemima Dennis-Antwi, an Accra-based international maternal health and midwifery specialist

Increasing exposure of health workers to COVID-19 without adequate provision of PPEs has led to health workers refusing to attend to patients, causing psychological stress to self and families, and constant threat of legal action. She noted that the implication of the development has impacts on a wide array of health issues other COVID-19 and other infectious diseases.

“This has serious implications for quality care, especially reproductive, maternal, newborn, child and adolescent care,” she said.

While calling for urgent action to keep Africa’s health professionals alive to provide the care they are trained to give, Antwi added that health workers on their part also needs to be more proactive and take actions that would boost their immune systems and will also clear respiratory pathways which is the major route of entry for COVID-19.

Tracking & Adjusting to Realities in Burkina Faso

Moeti also admitted that more needs to be done to reveal the true status of the pandemic among the continent’s health workers and to guide the enactment of appropriate policies.

“We are looking at improving the collection of data on health workers so that we can determine the extent of infection at work, and to inform the health workers on how to limit transmission at home,” she said.

In Burkina Faso for example, 8.5% of confirmed cases of COVID-19 are from health workers. While admitting that health professionals in the country are exposed to the pandemic, Dr Léonie Claudine Lougue, Minister of Health of Burkina Faso said the country has introduced a surveillance measure to screen its health workforce for COVID-19.

Léonie Claudine Lougue, Minister of Health of Burkina Faso

But a bigger problem still exists, persisting even as African countries continue to deal with COVID-19 – it is the limited capacity of the continent’s health institutions. 

WHO stated that in many African countries, infection prevention and control measures aimed at preventing infections in health facilities are still not fully implemented. 

“When WHO assessed clinics and hospitals across the continent for these measures, only 16% of the nearly 30 000 facilities surveyed had assessment scores above 75%. Many health centres were found to lack the infrastructure necessary to implement key infection prevention measures, or to prevent overcrowding. Only 7.8% (2213) had isolation capacities and just a third had the capacity to triage patients,” WHO stated.

Wurie however expressed optimism noting that in spite of the weak health systems across the continent, health workers will still be able to handle the pressure and threats from COVID-19 considering the case fatality ratio is rapidly reducing as the number of confirmed cases continues to rise.

“For people that may be infected, most of them are asymptomatic. The confidence of each country in being to manage the pandemic is getting better and the more we provide psychosocial support services for our health workers, the more their confidence also develops,” Wurie said.

 

Image Credits: WHO AFRO, HP-Watch/P Adepoju.


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Mangroves under threat in India

Three of India’s leading environmental websites, including Fridays For Future – India, part of the climate youth movement founded by Sweden’s Greta Thunberg, were blocked this week by Delhi police – after they protested a pending revision in the country’s environmental rules that would pave the way for polluting industries to mount projects without public hearings or appeals.

Late Thursday evening, the Indian police withdrew some of their initial allegations that the Fridays for Future group violated anti-terror laws, eventually allowing it and a second site, LetIndiaBreathe, to resume operations.  But a third Indian environmental site, There Is No Earth B, remained in a blackout Friday evening, even though it had never received any police warning. Meanwhile, environmental advocates expressed worries about the wider implications of the media censorship.

“Government muzzles young environmental voices in India,” said Greta Thunberg Thursday in a retweeted post by India’s Fridays For Future (FFF), protesting the crackdown. “Youth environmental movement @FFFIndia slapped with bizarre allegations by authorities &silenced by digital censorship for facilitating ‘too many emails’ to the MOEFCC.”

The saga began in early July, when Fridays For Future’s internet service provider was sent notices by New Delhi’s Cyber Crime division after the environmental activist group had posted stories and launched email campaigns protesting the hotly debated revisions in the country’s Environmental Impact Assessment (EIA), which would limit or even cancel opportunities for the public to review and object to new industrial projects potentially harmful to health and the environment.  On the other hand, There Is No Earth B, never received a notice in the first place, organizers told Health Policy Watch.

India’s Revisions In EIA Follow Plans For Massive Coal Mining Expansion

The proposed loosening of EIA rules comes as India faces mounting criticism for fueling its post-pandemic recovery with dirty energy by auctioning off 41 Indian coal mines to private investors for the first time ever, in moves announced last month.

Observers called it a significant repression of media freedoms in one of the world’s largest democracies. They said it has been orchestrated by the powerful Minister of Industry, Prakash Javadekar, who is also Minister of Environment as well as the Minister of Public Information and Broadcasting.

They said the new rules would open the way for mining and industrial projects to pour even more pollution into India’s chronically dirty skies and rivers in a country where air pollution killed some 1.2 million people a year in 2017, according to a study in The Lancet, and reduces life expectancy by an average 2.6 years, according to India’s Center for Science and Environment.  

“The draft of the new EIA dilutes several environmental norms which allow for faster environmental clearances bypassing existing safeguards”, Jyoti Pande Lavakare, an environmental journalist and founder of the Delhi-based NGO Care for Air, told Health Policy Watch. She also added that it eases environmental clearance and expands the list of projects exempted from publications or clearances altogether.

Jyoti Pande Lavakare, New Delhi based independent journalist and co-founder of Indian non-profit Care for Air

Industry, Environment and Media Portfolios Concentrated in Hands of One Minister

She attributed the media crackdown to the concentration of industry, environment and media portfolio into the hands of just one minister. 

“The Environment minister is the same as the heavy industries minister, who is the same as the information and broadcasting minister – one man – Prakash Javadekar,” said Pande Lavakare. “So there is a direct conflict here. As industry minister, he wants faster approvals for projects especially now when India is staring at a recession. As information and broadcasting minister, media is afraid to call him out on the environmental front.”

“Unlawful Activities” & “Terrorist Acts” 

In early July, New Delhi’s Deputy Commissioner of Police Anyesh Roy urged FFF’s internet service provider – Endurance Domains Technology LLP – to block the website for its “unlawful activities’:

“The above website [FFF] depicts objectionable contents and unlawful activities or terrorist acts, which are dangerous for the peace, tranquility and sovereignty of India.”

“It is requested that you may take necessary action [block FFF’s website] in this regard and send us a report immediately.”

Said India’s FFF branch in response to the crackdown: “Our movement is based on peaceful protests…It’s a shock to know that our dissent has been reduced to ‘being illegal’ with our site being censored.”

Others added that civil society is “simply carrying out its duty” to compensate for the government’s failure to protect its citizens.

“The Indian Constitution’s Article 51-A (g), says that ‘It shall be duty of every citizen of India to protect and improve the natural environment’ including forests, lakes, rivers & wild life & to have compassion for living creatures.”

“The authorities have repeatedly failed and it’s imperative now that we hold them accountable and demand action”, said There Is No Earth B.

This story was modified on July 24 as two of the websites were partiallly restored, though it is stll unclear whether the website of ThereIsNoEarthB is back online, according to Indian reporting agency Newslaundry.

Image Credits: There Is No Earth B / Sanjay Vann, Twitter: @FFFIndia, Jyoti Pande Lavakare, Fridays For Future.

Dr Tedros responds to US Secretary of State allegations that WHO made a deal with China.

In the strongest and most direct rebuttal yet to United States’ allegations of misconduct by the World Health Organization, WHO Director-General Dr Tedros Adhanom Ghebreyesus emphatically told reporters on Thursday that claims that he was ‘bought off’ by China are “untrue, without any foundation, and unacceptable.”

Dr Tedros called the allegations a “distraction,” saying politicization of the pandemic would hinder the response.

“Our sole focus is on saving lives. WHO will not be distracted by these comments, and we don’t want the entire international community to also be distracted,” Dr Tedros emphasized. “One of the greatest threats we face continues to be the politicization of the pandemic. COVID-19 does not respect borders, ideologies, or political parties.

“I have said it many times – COVID politics should be quarantined. Politics and partisanship have made things worse.”

Other members of WHO’s core COVID-19 response team, including COVID-19 Technical Lead Maria Van Kerkhove, who is an American citizen, echoed Dr Tedros’ response.

“I feel the need to say something as an American and as a proud WHO employee,”  said Van Kerkhove. “I see firsthand, every day, the work that Dr Tedros, Mike and our teams do all over the world. We are firmly focused on saving lives, we will not be distracted.”

WHO Health Emergencies Executive Director Mike Ryan said that it was important to maintain morale of “front-line workers” at the WHO and around the world. He added that while the the agency had room for growth, Dr Tedros’ leadership had been essential in catalyzing a “transformation in the organization.”

“Many of us have worked 20 hours a day, seven days a week for the past seven months,” said Ryan. “We have for years, sent our people in harm’s way every day. Many of us have spent months and years on the front line, risking our lives, worrying our families.

“None of us are perfect. But we all serve to save lives… We have benefited from [Dr Tedros’] leadership and from a transformation in the organization [that I thought would never come], and I can say this as someone who has spent a quarter of a century associated with this organization.”

WHO Team Growing Weary Of Repeated US Attacks

The WHO team was responding to reports of US Secretary of State Mike Pompeo’s claim that China had ‘bought-off’ Dr Tedros, helping him secure the 2017 election as WHO’s Director-General. The alleged deal led to WHO missteps in handling the pandemic, contributing to “dead Britons,” Pompeo was quoted as saying in The Telegraph while in London on Tuesday. The US Secretary of State reportedly made his remarks in a closed door meeting with British Members of Parliament on Tuesday, according to unnamed sources.

The strong response from the WHO reflected the agency’s growing weariness with US claims attacking WHO’s handling of the coronavirus crisis.

In March, the Trump administration threatened to withhold funding from the WHO, claiming that the Organization had yielded to pressure from China to downplay the virus’ seriousness. The ensuing back and forth led to Trump notifying the United Nations and Congress in early July that he was beginning the process to officially withdraw the US from the agency by July 2021.

Dr Tedros’ comments calling the US’ allegations “distracting” echoed comments from critics who have accused the Trump administration of using WHO as a scapegoat for the US’ own botched coronavirus response.

With nearly 4 million cumulative cases and more than 140,000 deaths, the United States has the highest coronavirus burden in the world, and the number of new cases reported daily is rapidly rising. Still, the administration has been pushing for states to reopen, resisted passing a national masking mandate, and encouraged schools to resume in-person learning in the fall, countering advice from their own public health experts.

Cumulative cases of COVID-19 around the world and COVID-19 deaths in the United States (top left) as of 8:00PM CET 23 July 2020, Numbers change rapidly.

 

Image Credits: Johns Hopkins CSSE.