A severe disruption of reproductive and children’s health services during the pandemic could cause more deaths in women, children, and adolescents than COVID-19 itself,  according to World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus.

“The indirect effects of COVID19 on this group may be greater than the number of deaths due to the virus itself,” warned Dr Tedros. “Because the pandemic has overwhelmed health systems in many places, women may have a heightened risk of dying from complications of pregnancy and childbirth.”

As health facilities pivot towards providing COVID-19 care, reports of women unable to reach childbirth facilities have emerged in countries like Peru. Many maternity hospitals have also shut down.   

“Maternity and child health services are not functioning, or only partially functioning in over 150 locations around the world. Many thousands could die from preventable complications in childbirth and pregnancy,” said Executive Director for the UN Family Population Fund (UNFPA) Natalia Kanem.

Amidst the scarcity of health services, unintended pregnancies and child marriages could shoot up, as women, children, and adolescents lose access to health programmes. For every six months of lockdown, some 47 million women could lose access to contraception, leading to 7 million more unintended pregnancies. 

With people stuck at home during lockdowns, domestic violence has also shot up, as survivors quarantine with their abusers. 

“It’s truly an emergency pandemic within the pandemic,” said Kanem. “We are joining WHO to sound a ‘red alert’ to stop gender based violence – to offer timely assistance to women and girls who are now trapped in abusive situations.”  

Image Credits: Twitter: @Atayeshe.

Roberto Azevêdo (left) meets with the United States President, Donald Trump, at the World Economic Forum Annual Meeting in Davos, Switzerland.

The early resignation of Roberto Azevedo from the post of Director General (DG) of the World Trade Organization (WTO), sets the stage for a highly politicized competition over his successor – who will face a major challenge in demands to reshape the WTO in the wake of repeated US complaints about its trade dispute rulings and policies with an alleged pro-China tilt.

Azevedo announced in May that he would be resigning from the position as of 31 August 2020, a year before his term formally ends. Azevedo, a seasoned and well-regarded member of Brazil’s diplomatic corps before taking on the role of WTO DG, presided over a period when the WTO’s effectiveness as a negotiating forum was eroded. Political conflict between economically powerful Members, most recently precipitated by the United States, brought its highly regarded dispute settlement system to a standstill. Now, as the COVID-19 crisis has sent global trade into a tailspin, the question is who – if anyone – can revitalize the Organization and reassert its preeminence in trade governance.

The new Director General will face a range of sharp debates around trade issues that are critical to health – including the need to ensure wide global access to new COVID-19 medicines and vaccines. But beyond the current pandemic, the WTO may also play a lead role on other critical  policies that affect health as well as broader economic well-being, including: import and export barriers affecting fragile economies; policies around trade in agriculture and food products; and ever more urgent questions surrounding trade, climate and sustainability.

The Candidates
(left-right) formally nominated WTO DG candidates; Jesús Seade Kuri, Ngozi Okonjo-Iweala, Abdel-Hamid Mamdouh

So far, four candidates have been formally nominated: Jesús Seade Kuri, Mexico’s chief negotiator for the ‘New NAFTA’; Abdel-Hamid Mamdouh, former director of the Trade in Services Division of the WTO; and Ngozi Okonjo-Iweala, board chair of Gavi, the Vaccine Alliance and former Nigerian Finance Minister, who also spent 25 years in Washington, DC with the World Bank. The Republic of Moldova’s Minister of Foreign Affairs, Tudor Ulianovschi, also had his name thrown in the ring on June 16.

On Tuesday, June 9, European Trade Commissioner Phil Hogan told reporters that he was also considering a bid to become WTO Director General. At a meeting with European Union trade ministers he identified trade and health issues, and the urgency of addressing the COVID-19 crisis, as priorities. Hogan also suggested that the European Union should put forward a single candidate, saying: “The EU has very strong multilateral credentials and is recognized as a force that could shore up the WTO and protect the multilateral trading system. This puts the EU in a legitimate position to offer a Director General to the WTO.” The Croatian Foreign Minister confirmed that EU members would discuss whether to unify around a single EU candidate during the next month.

The fact that Phil Hogan has put his name forward does not assure his position as the EU nominee. Other Europeans also reported to have expressed interest include: Arancha González-Laya, Spain’s Minister of Foreign Affairs and a former WTO Chief of Staff; and; Sigrid Kaag of The Netherlands, currently Dutch Trade Minister, formerly UN Under-Secretary-General, with experience at UNICEF and UNDP. (An interesting – if perhaps academic – question: The EU has exclusive authority over trade matters for its member states, while the EU and each of its member states are Members of the WTO, with a unique voting arrangement. If the EU nominates a DG candidate, does that preclude individual member states from nominating their own candidates?) Peter Mandelson, of the United Kingdom (now no longer EU!), but a former EU Trade Commissioner and UK Secretary of State for Trade and Treasury, has signaled interest too. While there is a long history of European heads of the WTO antecedent, the General Agreement on Tariffs and Trade, whether this argues for or against a new DG from Europe is not clear.

Jockeying between the power blocs
Two workers pin rolls of fabric in a large clothing factory in Cape Town, South Africa.

Appointments to leadership posts at multilateral organizations take account of the merits of the candidates, but realistically they must be viewed through the lens of political gaming and the exercise of power. Neither China nor the United States have as yet nominated a candidate, and perhaps neither country will because of the almost-certain divisiveness this would evoke. But it would be a mistake to think that either Beijing or Washington view this appointment exercise as one of identifying the smartest trade expert in the room. The recent battle over the appointment of a Director General for the World Intellectual Property Organization (WIPO) was hard-fought between US and China-sponsored candidates. With the US having prevailed, China will be looking again to assert its growing power. And, we have not yet heard from India.

Also, tradition holds that the leading positions in the United Nations and other multilateral organizations are divided up between regions – and that balance will play a role in the debate over whether a candidate from Asia, Africa, Europe or the Americas will succeed.

A candidate from Africa, such as Ngozi Okonjo-Iweala, might seem a “neutral” prospect as compared to candidates from one of the major trading powers. Okonjo-Iweala, who studied at Harvard and earned a PhD from MIT, might also be someone who the Americans would support. Kenya’s Amina Mohamed, former Ambassador and Permanent Representative for Kenya in Geneva, served as the first woman to chair the WTO General Council and as chair of the 10th WTO Ministerial Conference in Nairobi, and is certainly qualified, as is Abdel-Hamid Mamdouh of Egypt. Yonov Fredrick Agah, of Nigeria, currently a WTO Deputy Director-General, and previously Nigeria’s Ambassador to the WTO is said to have expressed interest, along with Eloi Laourou, of Benin, currently Ambassador and Permanent Representative of Benin to the UN in Geneva.

In terms of UN agency heads, Dr. Tedros Adhanom Ghebreyesus of Ethiopia is currently leading the WHO and Mukhis Kituyi of Kenya is leading UN Conference on Trade and Development (UNCTAD). Viewed through the lens of regional diversity, this might seem an obstacle to appointment of another Geneva DG from Africa. (Asia is poised at the top of WIPO, with Daren Tang of Singapore elected to succeed Francis Gurry.) Through a wider UN and global lens, however, the UN (António Guterres) and the International Monetary Fund (Kristalina Georgieva) Secretariats are headed by Europeans, and an American (David Malpass) is leading the World Bank. Seen from that perspective, the prospects for a third African Geneva leader may look brighter.

In years past, despite their differences, the United States and European Union were allies with shared trading system interests that would ultimately cooperate over the selection of a WTO (or former GATT) Director General, even if each had a candidate in the running. However, the Trump Administration has done everything it can to blow up the US relationship with the EU, so a prospective alliance over the choice of a candidate for WTO right now is in doubt.

As if to illustrate that doubt, following a recent statement by EU Trade Commissioner Phil Hogan that the US trade representative (USTR) Robert Lighthizer supported a WTO DG candidate from a developed country, USTR Lighthizer’s office responded saying, “Ambassador Lighthizer does not support any candidate at this time, nor does he feel that a candidate must necessarily be from a developed country.”

The Selection Process
Pepper farming in India

This is not the best time to be “counting chickens” as we still are at relatively early days in the nominating process – which is scheduled to run until 8 July 2020.

Following that, candidates “will have a period of time to make themselves known to members,” according to the process outlined by WTO. That is to include a special meeting of the WTO’s General Council, which includes all WTO member states, “where the candidates will be invited to make presentations, followed by the consensus-building phase devoted to selecting and appointing one of the candidates.”

However, the final appointment date remains unclear. General Council Chair, Ambassador David Walker (New Zealand) has said only that he will be “will be consulting with members in order to establish expedited deadlines for the post-nomination phases so that members may have clarity on the timeline for the appointment process by the end of the nomination period.”

In theory, then, the DG appointment could also be delayed beyond the US Presidential elections scheduled for November.

Public Health and the WTO

The choice of WTO DG is important to the future of public health. Through the implementation of the Agreement on Trade-Related Aspects of Intellectual Property Rights (“TRIPS Agreement”), the WTO sets the ground rules for the granting and use of intellectual property rights, including patents, for  diagnostics, medicines, treatments and vaccines. The TRIPS Agreement embodies important “flexibilities” that allow governments to take measures to promote and protect public health, including to grant compulsory patent and government use licenses for the generic production or import of patented drugs, and to make use of other exceptions to IP rights. Historically, the exercise of these flexibilities has provoked controversy. The COVID-19 crisis, whereby hundreds of existing and new drug formulations, as well as vaccines, are currently being trialed in combat against the virus, is expected to further test those WTO TRIPS flexibilities – and the ability of WTO to support comprehensive and equitable distribution of health products.

The new WTO Director General will thus be called upon to reassure member states that they can provide for vital national health needs – without facing undue pressure over Intellectual property interests or issues.

COVID-19 In the shadow of the HIV Legacy 
fixed-dose, antiretroviral HIV treatment

The new WTO director will be confronting COVID-19 in the shadow of the historic dispute over access to medicine that raged while the HIV-AIDS epidemic grew unchecked in the mid- and late-1990s. At that time, the government of South Africa came under intense pressure from the United States, the European Union and the innovator pharmaceutical industry based on unsupported allegations that South Africa’s 1997 health legislation amendments, permitting measures such as the parallel import of patented HIV/AIDS drugs, violated the TRIPS Agreement. Collapse of the industry case was followed by adoption of the WTO Doha Declaration on the TRIPS and Public Health along with the TRIPS Article 31bis amendment on compulsory patent licensing predominantly for export. This further clarified the rights of countries to produce or import generics of vitally needed health products in times of need.

Throughout the saga, either one of the two successive WTO Director General’s, including Renato Ruggiero (to September 1999) or Mike Moore (to September 2002), could have issued a clear public statement that the South African legislation did not violate the TRIPS Agreement, a fact which no serious trade and IP expert doubted (and which has been confirmed not only by the Doha Declaration, but even by the US Supreme Court).

Had they done so, the pharmaceutical industry would have had a very difficult time justifying its litigation, and the EU would also have been under considerable pressure to withdraw its trade threats (which the US did earlier on). But neither Director General spoke out. Not only did the failure to support  South African prolong insecurity in South Africa’s health system, but it damaged the public perception of the WTO as an institution, because the basic charge of the pharmaceutical industry was “we have these patent rights given to us by the WTO that are under threat”, while in fact WTO rules allocated no such rights.

Pandemic Will Test Mettle of WTO Flexibilities

In case you were on the recent space shuttle mission, and missed entirely the start of the COVID-19 pandemic, international interest in the legal mechanisms that will be used to develop and distribute vaccines, treatments, diagnostics and medical devices to address the pandemic is at a historic high – and WTO once again has an important role to play.

In fact, several governments, several governments – including France and Germany — already have modified their legislation to facilitate the compulsory licensing of patented health products to address the pandemic.  Israel has issued a compulsory license.

Along with the much-touted WHO-supported voluntary COVID-19 patent pool launched two weeks ago, proposals for compulsory patent pools are in the works, as are suggestions for taking advantage of the TRIPS Article 31bis provision allowing compulsory licensing predominantly for export. So, the mettle of WTO rules regarding intellectual property are likely to be tested again, perhaps even more severely than before, as the current pandemic has touched rich and poor countries alike in the greatest global public health crisis of a century. The new WTO DG will thus be called upon to provide leadership in assuring that TRIPS Agreement and other WTO flexibilities are respected.

In addition, there are critical health-related issues involving export restrictions on critical health products, subsidies to the pharmaceutical sector, and others that involve complex questions of WTO law and will need to be addressed. Again, a strong DG voice at the WTO may be important.

Economic well-being is also a health issue
Restaurants, bars and shopping centers reopen in Geneva, Switzerland after two months of lockdown

Finally, economic well-being is a major determinant of health, and the WTO has an important role to play in assuring that its Members are able to continue to export and import to support their fragile economies. The new DG will confront serious obstacles as he or she seeks to counterbalance the current trend towards higher national barriers in international trade.

The COVID-19 pandemic has had devastating economic consequences everywhere; but developing countries have been hit particularly hard because of the inherent vulnerability of their economies, and jobs dependent on international trade.

The consequences of sharply falling income, particularly among economically vulnerable groups, can be as severe as a deadly virus.

The fact that some middle- and high-income countries have started to “pull up the drawbridges” and to re-shore production will have significant consequences for developing countries. One task of the WTO DG will be to help remind and persuade developed country political constituencies that trade is not a zero-sum game, in which export success by one country means that other countries are losing. At the same time, the WTO DG must help address unfair trading practices, that damage the system and consequently hurt all participants in the long run.

Trade and Sustainability
Commercial fishing boat

And at the same time, in an era when climate has been described as the next global health crisis, the WTO and its Director General may be asked to re-examine longstanding WTO rules and frameworks that ignore the oft-heavy carbon costs of international trade, and thereby hinder the development of sustainable, local industries.

For example, the WTO Appellate Body ruled that India’s legislative preference for locally-produced solar panels was inconsistent with WTO national treatment rules. The Appellate Body correctly interpreted existing WTO law. But from a policy standpoint telling India to buy its solar panels from China (or the United States) when India faces tremendous requirements for new energy supplies, as well as wide underemployment, was not good climate or development policy. Particularly in light of the fact that the main alternative to solar power is massive new coal power plant construction. The WTO needs to adjust its rules to accommodate the large-scale changes in energy supply needed to reduce carbon output and promote development.

WTO negotiations on fisheries subsidies which are critical to reducing overfishing of depleted fish stocks are stalled. This represent another important area where leadership of the new WTO DG may be important.

Changes to government policies that encourage transition to sustainable agricultural practices, that facilitate the development of industries transitioning away from reliance on fossil fuels, and that recognize the damage done by industries employing outsize carbon intensity should be pursued under the direction of new WTO leadership.

Does it Really Matter? The Director General’s Authority
World Trade Organization building in Geneva, Switzerland

As the electioneering commences, the WTO is at a critical, nearly life-or-death, juncture.

Yet in the final analysis, the WTO Director General has rather limited “actual authority” – rather like the head of the World Health Organization. The constitutional document of the WTO,  the 1995 Agreement Establishing the World Trade Organization, provides that the WTO Secretariat will be headed by a Director General, appointed by the Ministerial Conference (of member states), which will also “adopt regulations setting out the powers, duties, conditions of service and term of office”.

Significantly, WTO members never adopted the called-for regulations setting out the powers and duties of the DG, although they have established the term of office and conditions of employment.

Even so, along with staff appointments and budget management, a recurring and significant role of the Director General involves the appointment of expert panelists at the first level of WTO dispute settlement proceedings, should disputing parties fail to agree.

The Director General traditionally has also played a major role in the negotiation of new WTO (and former GATT) agreements. The DG has acted as Chair of the Trade Negotiations Committee that coordinates the proposals and drafts of the agreements that are ultimately presented to the Members for adoption, and through that function, past Director Generals have played a critical role in facilitating compromise texts and solutions to disagreements between member states. The DG brings interested groups of WTO delegates together for face-to-face discussions as they address issues in various negotiating contexts.

Yet with these things said, the WTO DG is mainly a political figure at the head of the institution who gives the appearance of “leading”. The extent to which that leadership is taken seriously by WTO Members or the wider public may also depend on the personal character and charisma of the individual. He or she – bearing in mind there has never been a female Director General at the WTO – can only persuade. The DG does not issue orders, other than to the Secretariat staff.

Efforts to accommodate what may be some legitimate US concerns are problematic because President Trump appears to have no real interest in “solving” the technical problems with the way the WTO works. He requires some grand gesture for which he can claim victory — or to use his current jargon “total domination”.

Grand gestures are all the more important to Trump as the DG appointment process coincides with the lead-up to the US presidential elections in November.  While a new DG should, in theory, be put into place by 1 September, it’s not at all clear that will happen in the current environment.

Selection of a strong and charismatic figure to “right the ship” of the WTO is thus important for many reasons, including for public health. Developing economies remain dependent on an open international trading system, and the health of people around the world is certainly affected by their economic conditions. As discussed, there are specific WTO rules that may have a significant impact on health affairs, and how the WTO manages its rule system makes a difference. But multilateral cooperation in economic affairs, as in other spheres, is important not only for the particular end that an institution seeks to achieve, but also to avoid devolution of international relations that ultimately might come to a bad end.

It is far from clear that any single individual will be able to pull the WTO out of its current difficulties. But the right appointment is likely to have meaningful consequences in terms of giving the organization a fighting chance. And the next WTO DG must be committed to improving standards of living, including standards of healthcare, for all. The world could use a WTO DG who can actually help make that happen.

___________________________________________

Frederick Abbott, Professor of International Law at Florida State University College.

Frederick M. Abbott is Edward Ball Eminent Scholar Professor of International Law at Florida State University College of Law, USA. He has served as expert consultant and legal representative for numerous international organizations, governments and NGOs, mainly in the fields of trade, intellectual property, public health, technology transfer, and sustainable development. He served as Rapporteur for the International Trade Law Committee of the International Law Association (ILA) (1993-2014) and presently is Co-Chair of the ILA Committee on Global Health Law. He has served as counsel in dispute settlement at the WTO, and has advised governments on TRIPS-related negotiations and implementation. He is on the Board of Editors of the Journal of International Economic Law (Oxford), and of the WIPO-WTO Colloquium Series. http://frederickabbott.com

Image Credits: World Trade Organization, WTO, King & Spalding Law, World Trade Organization, Bread for the World, Government ZA/GCIS, S. Lustig Vijay/HP-Watch, World Trade Organization, World Trade Organization.

Dr Tedros at the June 10 WHO COVID-19 press briefing

Asymptomatic transmission is possible, but the World Health Organization is still unsure as to what extent asymptomatic COVID-19 infections contribute to the spread of the virus, according to WHO Director-General Dr Tedros Adhanom Ghebreyesus on Wednesday.

“Since early February, we have said that there are asymptomatic people that can transmit COVID-19. But we need more research to establish the extent of asymptomatic transmission, and that research is ongoing,” said Dr Tedros.

The WHO Director-General attempted to clarify seemingly contradicting statements made by WHO COVID-19 Technical Lead Maria Van Kerkhove on Tuesday and Monday regarding asymptomatic transmission, the onwards spread of COVID-19 by an infected person who never develops symptoms.

Van Kerkhove had on Monday said that transmission of COVID-19 by asymptomatic people was “very rare,” according to reports from countries doing detailed contact tracing 

“We have a number of reports from countries who are doing very detailed contact tracing. They’re following asymptomatic cases, they’re following contacts and they’re not finding secondary transmission… It is very rare,” said Van Kherkhove at WHO’s regular press briefing on Monday. “From the data we have it still seems to be rare that an asymptomatic person actually transmits onward to a secondary individual.”

The comment seemed to contradict United States Centers for Disease Control guidelines that advise pandemic preparedness teams to assume that 35% of all COVID-19 infections are asymptomatic, and asymptomatic persons are just as likely to transmit the infection as symptomatic persons. The modeling guidelines are based on COVID-19 estimates from the US CDC, and US Health and Human Services Office of the Assistant Secretary for Preparedness and Response (ASPR).

WHO COVID-19 Technical Lead Clarifies “Rare” Asymptomatic Transmission Comment After Concerns 

WHO COVID-19 Technical Lead Maria van Kerkhove attempts to clear up confusion around claim that asymptomatic transmission of COVID-19 is ‘rare’

Van Kerkhove walked back on her comments on Tuesday, after receiving backlash from scientists concerned that WHO was writing off the threat of asymptomatic transmission.

She clarified that her comment designating asymptomatic transmission as “rare” was based on a small subset of 2 to 3 studies following asymptomatic people and their contacts, and the true extent of asymptomatic transmission was still unknown.

“”The majority of transmission that we know about is that people who have symptoms transmit the virus to other people through infectious droplets. There are a subset of people who do not develop symptoms,” said Van Kerkhove at a Twitter livestream on the issue on Tuesday. “To truly understand how many people don’t develop symptoms – we don’t have that answer yet.

“I wasn’t stating a policy of WHO or anything like that, I was just trying to articulate what we know. In that, I used the phrase ‘very rare’ – and I think that’s misunderstanding to state that asymptomatic transmission globally is very rare.”

Van Kerkhove highlighted that due to the many unknowns, infectious disease modeling groups have used their own estimates of the contribution of asymptomatic transmission.

“What I didn’t report yesterday, was because this is a major unknown, some modeling groups have tried to estimate what is the proportion of asymptomatic people that may transmit,” she said. “And there is a big range, depending on how the models are done, from which country…They can be [quite high].

“Some estimates are around 40% of transmission may be due to asymptomatic [infections],” said Van Kerkhove, a potential nod to the CDC modeling guidelines.

Photo Credit: Marco Verch

In what he described as a great “public health victory,” the World Trade Organization has ruled that Australia’s plain packaging requirements for tobacco products did not infringe on international trade, said the World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus on Wednesday.

The decision by the WTO on Tuesday comes just as it also opened nominations for the selection of its next Director General, following an earlier announcement by Roberto Azevedo that he would resign from his post on August 31st.

So far, three candidates have been formally nominated, including chair of Gavi, the Vaccine Alliance’s Board Ngozi Okonjo-Iweala; Mexico’s chief negotiator for the ‘New NAFTA’, Jesús Seade Kuri; and former director of the Trade in Services Division of the WTO, Abdel-Hamid Mamdouh.

The decision on the case against Australia, the first country to introduce mandatory ‘plain packaging’ for tobacco products in 2012, was described as the final nail in the coffin of the tobacco industry’s nearly decade-long campaign against plain packaging, which has now completely run out of international avenues to appeal such laws.

“This WTO ruling means the tobacco industry has run out of options to challenge plain packaging internationally,” said Dr Tedros in a press briefing.

The WTO decision upheld a 2018 ruling that Australia’s plain packaging laws did not violate WTO rules. That decision was appealed by Honduras and the Dominican Republic on behalf of a bloc of countries, leading to a final ruling on Tuesday that ended the international litigation against Australia.

“This is a fantastic win not just for Australia, but for governments around the world who want to reduce the terrible toll of sickness and death caused by smoking,” Australian Health Minister Greg Hunt said in a statement released Wednesday.

Appellate Body Rules ‘Plain Packaging’ Laws Do Not Violate International Trade Agreements

Australia’s ‘plain packaging’ laws require the display of graphic public health warnings on tobacco products

An WTO Appellate Body ruled Tuesday that the bloc of countries opposing Australia’s laws “had not succeeded in establishing that Australia’s tobacco plain packaging measures are inconsistent with the provisions of the covered [trade] agreements at issue.” 

Therefore, the committee made no recommendations to change Australia’s plain packaging laws.

“This WTO ruling reaffirms that this legislation is within the international trade rules,” said Australia’s Federal Trade Minister Simon Birmingham.

Australia’s precedent-setting ‘plain packaging’  law for tobacco products, adopted in 2012, bars tobacco packaging from using prominent logos or promotional text, and requires the display of graphic public health warnings.

The WHO has said that there is evidence that such packaging, combined with other interventions recommended by the WHO Framework Convention for Tobacco Control (FCTC), helps reduce demand for tobacco products. Smoking is a leading risk factor of deadly non-communicable diseases like heart disease, lung cancer, and chronic obstructive pulmonary disorder (COPD). 

Other countries that have since adopted similar ‘plain packaging laws,’ include France, Ireland, Northern Ireland, and the United Kingdom. Singapore, New Zealand, and more are now in the process of introducing such laws.

Honduras first submitted a request to the WTO to challenge the Australian laws in April 2012, under the claim that the ‘plain packaging’ requirements put up barriers to international trade as outlined under the WTO Agreement on Trade Related Aspects of Intellectual Property (TRIPS Agreement) and the corresponding Technical Barriers to Trade Agreement. 

Image Credits: Flickr: Marco Verch Professional Photographer and Speaker, Twitter: @FCTCofficial.

Switzerland is now the world’s safest country since the pandemic started, followed by Germany and Israel, according to a Regional Safety Assessment of 200 territories and regions during the COVID-19 pandemic.

Overall, Asia and Europe were the regions most successful in fighting the coronavirus although there were wide variations within Europe in terms of how countries really performed, according to the report by Deep Knowledge Group, an international consortium of commercial and non-profit organizations that applies progressive data-driven solutions to healthcare.

Said the report: “On average, Asia and Europe appear to be maintaining regional safety more efficiently than the rest of the world.” 

The study offers policymakers an opportunity to assess and improve their COVID-19 responses by learning from their neighbours, and reveals why some countries fared better than others in the worldwide scramble to curb the pandemic.

Most Critical Finding – Avoid Reckless Reopenings

The quality of specific governmental policies designed to combat the pandemic were a bigger key to success than the quality of its healthcare system in ‘non-pandemic times’, the study found.

The ‘most critical’ finding of the study is that countries should avoid reckless reopenings in the name of short-term economic recovery, or “all the sacrifices” made will have been meaningless”, the reports authors also warned.   

By compiling some eleven thousand data points from over 500 reputable, publicly available sources of data, researchers created a Regional Safety Index – A composite index that ranked, categorized and analyzed health system preparedness of about 200 regions.

The Regional Safety Index is based on a range of social, economic and health indicators, as well as six categories, including – quarantine efficiency; government efficiency of risk management; monitoring and detection; health readiness; regional resilience; and emergency preparedness. 

Switzerland, Germany and Israel ranked ‘exceptionally high’ in the risk assessment, with scores hovering around 750, in comparison to the USA, the UK and France – which performed “much less favourably” than expected given the sophistication of their health systems, at about 530 on the Regional Safety Index.

Sophisticated Healthcare Systems Not Necessary To Effectively Curb Outbreaks – But Timely Policies Are Crucial 

Strikingly, while the European and Asian countries that scored well on the index all have good healthcare systems, the sophistication of the health system was less a predictor of success than might be expected. What was ‘critical’, the study reported, was  timely adoption of evidence-based policies:

“One of the most critical factors impacting regional safety and stability is not the general level of healthcare sophistication in non-pandemic times, but the specific governmental crisis management strategies and policies used to combat pandemics.”

But countries that successfully curbed the pandemic shared a handful of common features, mainly health systems that operate with high levels of emergency preparedness, which enabled: early and proactive government responses; quick and efficient testing, tracing and isolating efforts to prevent overburdening of healthcare systems; and rapid resource mobilization. Such countries include Switzerland, Germany, Israel, Singapore and Japan.

Another similarity between high-performing countries on the Index was a ‘cautious’, evidence-based unfreezing of lockdowns without sacrificing public health and safety.

In contrast, while technological and economic superpowers like the United Kingdom, the United States and France have very sophisticated healthcare systems, they were ‘surprising outliers’ faring much worse in the ratings “than expected by any basic logic”, the study reported:

“We do see a number of so-called outliers in the [European] region as well, i.e., countries who should score well given their generally high degrees of healthcare robustness, such as France and especially the United Kingdom, but which do not,” said the authors. These countries also were among those that suffered from “the highest infection spread and mortality rates, which is a surprising result.”

Significantly, some lower-middle and middle-income ranked better than others as well.  For instance, South Africa and India, as well as Argentina, Uruguay and Ecuador, in Latin America, ranked higher than other neighbours in their region of similar socio-economic levels.

Countries that scored badly on the Index tended to lack whole-government approaches, leading to considerable delays in physical distancing measures and limited COVID-19 testing.

The “Most Critical Risk” – Hasty Economic Recovery Will Make All Efforts ‘Meaningless’

Countries that were battered by the coronavirus have also started to unfreeze lockdowns too fast, warned last week’s study – The “most critical risk” is reckless prioritization of economic concerns over healthcare priorities without the necessary increases in testing, tracing and isolation:

“Above all else, regions should not put economic recovery above public health and safety…or all the sacrifice and joint work of citizens, governments and organizations will have been meaningless,” states the report.  

While countries such as the United Kingdom have erred more on the side of caution since Prime Minister Boris Johnson himself was briefly hospitalized in an intensive care ward for COVID-19 in early April, US President Donald Trump has been adamant about reopening business across the United States, regardless of infection trends, in an attempt to revive the economy.

Image Credits: Deep Knowledge Group .

Shoppers mob malls in Geneva, Switzerland after restaurants and stores reopened on 6 June – following nearly two months of lockdown

Stay-at-home orders and lockdown measures helped greatly limit the spread of coronavirus in 11 European countries from the start of the epidemic to May 4th, according to a new modeling paper published in Nature on Monday. 

Some 3.1 million deaths were averted across the study countries thanks to “non-pharmaceutical measures” such as lockdowns and social distancing policies, according to the study.

Meanwhile, the World Health Organization said that the disease was accelerating in South Asia and Latin America, even as European countries saw declines and began lifting lockdown measures. Switzerland, which reported only 20 new cases on Sunday, reopened restaurants, nightclubs, and red-light district services on June 6, and allowed mass demonstrations of up to 300.

“Yesterday, more than 136,000 cases were reported, the most in a single day so far. Almost 75% of yesterday’s cases come from 10 countries, mostly in the Americas and South Asia,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus.

“We’re seeing acceleration of disease now in Central and South America,” said WHO Health Emergencies Executive Director Mike Ryan. “And we’re seeing a similar acceleration and path for South Asia.”

In his strongest statement to date, the WHO Director-General also expressed support for worldwide demonstrations against police brutality and racism, sparked by the death of a black man, George Floyd, after an officer put him in a knee hold in the United States.

“WHO fully supports equality and the global movement against racism. We reject discrimination of all kinds. We encourage all those protesting around the world to do so safely, as much as possible,” said Dr Tedros, the first African leader of the UN’s health agency.

“As much as possible, keep at least 1 metre from others, clean your hands, cover your cough and wear a mask if you attend a protest. We remind all people to stay home if you are sick and contact a health care provider,” he added.

As the US entered its third week of protests, countries around the world have rallied in support of the movement. Similar demonstrations drew masses of people in Switzerland, the United Kingdom, the Republic of Korea, Spain, and other countries.

US Embassy issues alerts on planned demonstrations on “racial discrimination” in Geneva, Switzerland

Nature Paper Finds Non-Pharmaceutical Interventions Lowered Reproductive Number, R0

Only 3.2-4.0% of the total population, or between 12 to 15 million people, were estimated to be infected in 11 countries from the beginning of the epidemic in Europe until May 4th, according to the Nature study.

“Our results show that major non-pharmaceutical interventions and lockdown in particular have had a large effect on reducing transmission. Continued intervention should be considered to keep transmission of SARS-CoV-2 under control,” the authors, a group of researchers from Imperial College London and Oxford, wrote in the analysis.

Empty streets in Italy during lockdown

Non-pharmaceutical measures were able to successfully lower the reproduction number R0, which estimates the average number of susceptible people that will contract the disease from one infected person. When the R0 drops below 1, the epidemic will decline. 

 “Current interventions have been sufficient to drive the reproduction number R0 below 1, and achieve epidemic control,” according to the authors. 

The analysis found that the average R0 was reduced by 82% across the 11 countries, dropping to 0.66 compared to 3.8 at the beginning of the study period, before any “non-pharmaceutical interventions” were put in place. R0 values in individual countries ranged from 0.44 in Norway to 0.82 in Belgium.

The authors used death data from the European Centers for Disease Control to estimate infections across Austria, Belgium, Denmark, France, Germany, Italy, Norway, Spain, Sweden, Switzerland, and the United Kingdom.

Pandemic Hotspots Shift From Europe + US to Latin America + South Asia

Active cases of COVID-19 world wide as of 8 June 2020 evening. Numbers change rapidly

New infections are growing at an alarming rate in several countries in South America. The trends are real, not just due to increased testing and better surveillance, according to Mike Ryan.

In the past day, about 70% of COVID-19 deaths were in the Americas. Brazil overtook the United States in recording the highest number of new cases late last week, and 60% of the world’s new cases were reported in the Americas.

“I would say right now the epidemic in Central and South America is the most complex of all of the situations we face globally.. We’re seeing from Mexico all the way to Chile is an increasing pattern across the Americas across Latin America, with some notable exceptions,” said Ryan on Monday. “I think it’s a time of great concern.

“It’s not one country, it’s many many countries experiencing very severe epidemics [similar to] what we saw in Europe and North America….There’s been an increase of about 50% of cases in Guatemala over the last week, with a worrying over 100% increase in the number of fatalities [for example].”

“The pandemic epicentre moved from China & East Asia to Europe & North America, now to South Asia & Latin America. [We’re] still in the growth phase in many countries,” tweeted  Devi Sridhar, Professor & Chair of Global Public Health at University of Edinburgh.

Locals gather outside public office in Hyderabad, Pakistan

Pakistan, now reporting the highest number of new cases per day in WHO’s Eastern Mediterranean region, reported 4,960 new cases on Sunday.

Some 70% of new cases in WHO’s Southeast Asian Region were recorded in India, now hosting the 6th highest number of COVID-19 cases. The country reported 11,000 new cases in the past 24 hours, some 500 more than the previous day.

The New Delhi’s Department of Health, Family and Welfare overrode a controversial order restricting hospital services for COVID-19 to residents of Delhi on Monday. The order, published on Sunday, limited hospital services for COVID-19 to “bona fide residents of the National Capital Territory of Delhi” – leaving Indian migrants in the capital. About 40% of New Delhi’s population are migrants, and the capital has the highest concentration of inter-state migrants compared to any other region in India.

In the WHO European region, half of Sunday’s new cases were in the Russian Federation, which reported 9000 cases. New cases in Russia have plateaued around 8,000-9,000 per day since mid-May. 

Still, the Russian Federation plans to lift its months-long lockdown starting Tuesday, said Moscow’s Mayor Sergei Sobyanin on Monday. “Moscow can practically get back to its usual rhythm of life,” said Sobyanin on his personal blog.

On Monday, New Zealand Prime Minister Jacinda Ardern declared the country ‘virus-free’, and announced that virtually all COVID-19 restrictions will be dropped reported Reuters. New Zealand last reported new cases of COVID-19 on 19 May, but the country has still taken a cautious approach to reopening, which has been largely supported by the public. 

Image Credits: S. Lustig Vijay/HP-Watch, Flickr: Nicola, Johns Hopkins CSSE, Tasleem Ul Haq.

United Kingdom Prime Minister Boris Johnson announcing total pledges to Gavi’s 2021-2025 replenishment cycle

Gavi, the Vaccine Alliance raised a whopping US $8.8 billion at the first ever virtual Global Vaccine Summit co-hosted Thursday by the United Kingdom, surpassing the fundraising goal of US $7.4 billion.

“We have secured a fantastic US $8.8. billion for Gavi’s work over the next five years and I’d like to thank everyone very, very much,” said UK Prime Minister Boris Johnson. 

In a rare show of multilateralism, United States President Donald Trump sent a video message of support after Johnson personally reached out – but did not specify the US pledge in his speech. The United States Agency for International Development (USAID) had announced in February a pledge of US $1.16 billion to Gavi for 2020 to 2023.

US President Donald Trump makes rare show of global health solidarity in a video message at the Global Vaccine Summit

”There are no borders, [the virus] doesn’t discriminate, it’s been it’s nasty but we can all take care of it together. It’s great to be partnering with [Gavi]. We will work hard, we will work strong…good luck, let’s get the answer,” said Trump.

Over 25 Heads of State and 50 leaders of agencies, regional associations, and private industry attended the fundraising event for Gavi, a public-private partnership that finances vaccine programs in over 80 low income countries. Germany’s Chancellor Angela Merkel, UN Secretary General Antonio Guterres, the European Commission President Ursula von der Leyen, and World Health Organization Director-General Dr Tedros Adhanom Ghebreyesus were among those who sent messages of support.

“There is an important lesson we need to understand – the vaccine by itself is not enough. Now is the time for global solidarity…to ensure that every person everywhere gets access to the vaccine,” said Antonio Guterres. “In our global village, our individual health depends on our collective health.”

Since COVID-19 struck the world, Gavi’s role has become more important than ever, as 80 million children are at risk of missing out on routine vaccines for TB, pneumonia and diarrhea, said WHO’s Director-General Dr. Tedros.

With the money pledged, Gavi aims to immunise an additional 300 million children in low- and lower-middle income countries, saving an estimated additional 8 million lives between 2020-2025. 

COVID-19 Vaccine Advanced Market Commitment Fund Created to Secure Supply For Low-Income Countries

Gavi also announced an anticipated COVID-19 Advanced Market Commitment (Covax AMC), which will be used to make volume guarantees to sellers of effective COVID-19 vaccines, and make sure a portion of the global supply will be set aside for low-income countries. 

“Donors commit funds upfront to guarantee the price of vaccines once they’ve been developed. This provides vaccine manufacturers with the incentive to invest in vaccine R&D, and to scale up manufacturing capacity,” explained Gavi CEO Seth Berkley. “GAVI’s role is to address [vaccine] market failures when market forces don’t deliver the best outcome for the public.”

GAVI’s CEO Seth Berkley explains how advanced market commitments function

AstraZeneca became the first pharma manufacturer to sign up for the Covax AMC, guaranteeing a supply of at least 300 million doses once their vaccine candidate, developed in conjunction with Oxford University, receives regulatory approval. AstraZeneca had announced the intention to sell any COVID-19 vaccines ‘not-for-profit.’

However, the price-per-vaccine has not yet been disclosed. Médecins Sans Frontières (MSF) released a call ahead of the launch for the vaccine to be sold ‘at-cost,’ and for a price to be set as soon as possible.

“We won’t know whether a vaccine is indeed sold at “not-for-profit” prices if large manufacturers don’t make their investments and cost of goods as well as the final prices publicly available,” Manuel Martin, innovation & access advisor at MSF Access Campaign told Health Policy Watch.

The Gavi Covax AMC has an initial goal of raising US$ 2 billion; enough for Gavi-supported countries to immunise health care workers and high-risk individuals, as well as create a flexible buffer of doses to be deployed where needed most. 

The AMC model had been previously used to provide volume guarantees for the pneumococcal vaccine, giving producers incentive to scale up production and sell to low-income countries. Some US $177.5 million from the PCV advanced market commitment will be rolled over into COVAX.

The initiative is part of a broader COVID-19 Global Vaccine Access Facility (Covax Facility) that will be available for all countries to access.

Donors & Pharma Show Strong Support For Gavi

The top three historical donors, The United Kingdom, the United States, and Norway, each upped their contributions to Gavi in this funding round. 

Johnson kicked off the replenishment event with a £1.6. billion pledge from the UK. The United States pledge stands at US $1.16 billion, and Norway followed closely with a $1 billion commitment. 

“We know from our own experience that investing in vaccines is one of the best public health investments we can make, ” said Norway Prime Minister Erna Solberg. “Norway was one of the founders of Gavi 20 years ago. We believed, and still believe in innovation and the mission to improve the world one vaccine at a time. We must continue to make sure no one is left behind.”

Norway Prime Minister Erna Solberg

Among other major pledges, Germany committed €600 million; Canada committed CAD $600 million, Australia, and Japan pledged US $300 million, and Italy upped it’s pledge to €287.5 million.

China, meanwhile, contributed US $20 million, in stark comparison to its massive contribution at the World Health Assembly of US$2 billion towards the COVID-19 effort and to accelerate the completion of Africa’s CDC headquarters.

Leaders and executives from the pharmaceutical sector also voiced strong support for GAVI, and announced increased supply commitments for the human papillomavirus (HPV) vaccine.

Merck Sharpe&Dohme, Glaxosmithkline, Innovax, The Serum Institute of India, and Chinese vaccine manufacturer Walvax have pledged to ramp up HPV vaccine production to supply Gavi-supported countries with enough doses to vaccinate 84 million girls, an increase from a original commitment to vaccinate 50 million girls.

Pharma is working at “unprecedented levels of collaboration and speed”, said Director General of the International Federation of Pharmaceutical Manufacturers (IFPMA) Thomas Cueni. “Thankfully, what is not unprecedented is the notion that collaborative efforts and partnerships can deliver and can transform lives. We will succeed by working openly.”

GSK CEO Emma Walmsley emphasized that “global, fair access to COVIDー19 vaccines is an absolute priority.” GSK leadership, along with executives from AstraZeneca and Johnson&Johnson announced their companies’ intentions to sell vaccines at a “no-profit” price last week.

“We do it not-for-profit for the pandemic period, as we want to [ensure] equitable access over the world…and especially to get vaccines to make sure we get a stop to the pandemic,” said CSO of Johnson & Johnson Paul Stoffels last week.

(Left-right): Mike Ryan, Dr Tedros Adhanom Ghebreyesus, Maria Van Kerkhove, and Soumya Swaminathan at WHO press briefing Wednesday

The World Health Organization finally appears poised to recommend wider public use of masks as an additional measure to prevent transmission of COVID-19 – after months of hesitation while countries took unilateral action mandating face coverings, particularly for busy shops, transport systems and public settings.

The WHO move, announced at a Wednesday press briefing, follows new recommendations by its Strategic and Technical Advisory Group for Infectious Hazards (STAG-IH),  supporting ” mask use by the general public in the community to decrease the risk of infection.”

In another statement at Wednesday’s briefing, WHO’s Chief Scientist Soumya Swaminathan, said that enrollment would resume in WHO co-sponsored clinical trials of the anti-malarial and lupus drug hydroxychloroquine – after a review of the evidence so far found no significant rise in mortality among people using the treatment.

“The advisory committee of both Solidarity and Recovery have recommended that the trials can continue,” said Swaminathan, referring to the consortiums that are guiding the research with WHO. “We hope that the ongoing trials will continue until we have definite answers. That is what the world needs.” 

WHO suspended the trial last week, in the wake of a Lancet study that seemed to find a higher mortality rates among people taking the drug – although the observational study was later criticized for not adequately taking into account the baseline condition of the patients considered in its analysis of death rates.

Said Swaminathan: “The only way to get definite answers is to do well conducted randomized trials, to see which [treatments] will reduce illness and infection rates in the communities, we should be guided by the science and the evidence.”

STAG Report and Lancet Study Tip the Balance on Mask Recommendations

The STAG advisory group recommendations were released shortly before a WHO-sponsored meta-analysis published by The Lancet, concluded that public use of masks could be an effective infection control measure – although there remains a dearth of robust studies on the topic. 

“Face mask use could result in a large reduction in risk of infection…., with stronger associations with N95 or similar respirators compared with disposable surgical masks or similar (eg, reusable
12–16-layer cotton masks,” the Lancet study concluded.

The STAG advisory group particularly recommended the use of masks in settings where there is “active and widespread community transmission occurring with high attack rates in the population… [for] activities in closed environments without efficient air exchanges, such as commuting on public transportation and over-the-counter consultations in pharmacies.” 

Commuters wear masks to protect against transmission of COVID-19 on a train in Singapore

Public use of facial coverings can also be useful “as part of a transitional package from a ‘confinement’ or ‘stay-at-home’ order to demonstrate solidarity, community empowerment, understanding of the seriousness of the situation,” according to the STAG note.

WHO’s COVID-19 Technical lead Maria Van Kerkove said that updated guidance would be forthcoming in light of the STAG Committee’s recommendations. 

“We are planning to update and release new guidance on use of masks in the coming days,” said Van Kerkhove, in response to a query from Health Policy Watch at a Wednesday press briefing. 

Masks  – As Part of A Continuum of Management

However, Health Emergencies Executive Director Mike Ryan stressed, “We see masks as part of a continuum of risk management, not as an alternative to public health interventions, physical distancing, or surveillance.

“As we move back to work and back to school, everyone is concerned [about] how I can reduce risk. How I can manage the risk to me or my family?

“With regard to the use of masks at the community level, they would mainly be used for the purposes of source control. In other words, [they are recommended] for people who may be infectious, reducing the chances that they will infect someone else,” said Ryan. But mounting evidence of asymptomatic transmission makes it impossible for some people to know if they are indeed infectious or not, and thus the move to wider public mask use may be justified, he acknowledged. 

Wearing masks to protect from COVID-19 in Nigeria Credit: @CRSPHCDA1

The STAG recommendations also underline that the use of masks helps prevent transmission of the virus by asymptomatic or presymptomatic individuals – those who may be infected but not yet showing symptoms. 

“The primary role of masks (of any kind) in the community is to reduce exposure risk for others from infected persons in the pre-symptomatic period,” the STAG-IH group writes. “Infections from such persons are not considered a major driver of the pandemic, but there are concerns that viral loads are highest during the early phase of the disease.”

The WHO move towards wider use of masks has been slow. In the early days of the pandemic, Ryan, Kerkhove and others repeatedly stressed that masks should be limited to health clinics or caring for a sick person at home.  Widespread public use of masks in Asia was described by Ryan as a “cultural” habit – although that habit also clearly originated in the Asian experience with previous pandemics such as the 2003 SARS.

Masked protest in Minneapolis against the death of George Floyd

The WHO message evolved slowly, as  the evidence grew about potential virus transmisison by people with no symptoms, and through simple actions like speaking or singing. The number of countries recommending or requiring facial coverings in public also grew well beyond Asia to Africa, where public health leaders stressed that social distancing is almost impossible, as well as more affluent countries such as Hungary, the Czech Republic, Israel, and some US states.

 

Mask use has become even more significant as countries begin to lift stay-at-home orders. Israel, for instance, which had one of the lowest per capita mortality rates in the height of the pandemic, has seen a rapid rise in cases after lifting its lockdown, and has since strengthened its enforcement of requirements to don masks in schools, stores and other public places. In the US, protestors have been circulating advice via social media to wear masks while attending the massive rallies protesting the death of a Minnesota black man, George Floyd, while in police custody. The mass gatherings have put millions of people into much closer contact with each other in the world’s pandemic epicentre, albeit in outdoors environments. 

 

Image Credits: Jade Lee , Cross River State Primary Health Care, Nigeria , Jenny Salita.

The six dogs being trained in the UK to detect COVID-19

Dogs could be trained to discern COVID-19 in humans, reported researchers from The London School of Hygiene and Tropical Medicine (LSHTM), Medical Detection Dogs and Durham University in a podcast last Wednesday. The study has received £500,000 from the UK government and hopes to be able to train dogs for rapid virus detection in airports and other ports of entry. 

The work builds on previous malaria research, which successfully trained dogs to detect malaria in people based on its characteristic odour.

Over 10 years ago, anecdotal evidence suggested that dogs could detect cancer in urine samples, leading to formal studies that confirmed the theory. Ever since, dogs have been used to detect a wide range of conditions – including bladder cancer, but also rapid changes in blood sugar levels in advanced diabetics.

Dogs are an ideal candidate to detect subtle smells because their sense of smell is highly developed. They have over 350 million olfactory receptors, allowing them to sniff out a teaspoon of sugar in the volume of water held in two Olympic-sized swimming pools, said researchers at the podcast. Another advantage of using dogs is that they are used to working alongside humans and are ‘highly trainable’- their use is already widespread in security programs and agriculture, among other uses.

Dogs could also screen up to 250 people an hour, said researchers. But if dogs were used in the future to detect COVID-19, they would not replace swab tests or antibody tests; rather, they would augment the testing capacity in specific locations. The team is looking to scale up the venture and apply it to other countries, if it proves to be successful. 

The study on malaria detection — which used foot odours from socks worn by Gambian children, that dogs could detect at a high accuracy — provides a template for the COVID-19 study and could help “prevent a second wave by identifying people from high-risk countries at ports of entry”. 

In the case of COVID-19, dogs will be given samples from face masks or the feet of people with COVID-19, as well as placebos, and researchers will evaluate whether the dogs can recognise COVID-19 odours, which they will communicate to researchers through physical gestures. The samples collected will also be analysed in laboratories to identify whether there are volatile biomarkers associated with COVID-19 infection. 

If there are odours associated with COVID-19, dogs could take about eight weeks to train, before practicing in more realistic scenarios.

Currently, six dogs (cocker spaniels, retrievers and mixes) are being trained to identify the odours of COVID-19. These dogs are experienced bio-detection dogs as well as assistance dogs that monitor the health of people with life-threatening diseases. 

 

Image Credits: MDD/BexArts/Nigel Harper.

Antimicrobials are becoming less effective at treating infections

As the COVID-19 pandemic spawns increased antibiotic use all over the world, more drug-resistant microbes are bound to bite us back , said Dr. Tedros at a WHO press conference on Monday. The repercussions on disease treatment and deaths will be severe, given that the world is running out of effective ways to treat antimicrobial resistance (AMR).

“COVID-19 has led to an increased use of antibiotics, which ultimately will lead to higher bacterial resistance rates that will impact the burden of disease and deaths during the pandemic and beyond,” Dr Tedros said.  He was referring to the fact that patients seriously ill with the SARS-COV-2 virus are often receiving antibiotics to prevent secondary bacterial lung and other infections.

“As we gather more evidence, it’s clear that the world is losing its ability to use critically important antimicrobial medicines, all over the world…In some countries, there is an overuse of antibiotics and antimicrobial agents in both humans and animals,” Dr Tedros said.

That is the picture painted by the latest data updates of WHO’s Global Antimicrobial Resistance (AMR) and Use Surveillance System (GLASS).  The trends reflect ‘”disturbing” rates of increases in antimicrobial resistance, WHO says. On the positive side, participation in the surveillance has grown exponentially since the system was created in 2018.

Microbe Resistance to Some Common Drugs – Running as High as 93%

Among the worrisome indicators, the rate of resistance to ciprofloxacin, an antibiotic commonly used to treat urinary tract infections, varied from 8.4% to 92.9% in 33 reporting countries, the WHO data found.

The WHO data comes a year after the major UN interagency report “No Time to Wait” predicted that mortality from drug resistant infections could increase more than ten-fold, causing up to 10 million deaths a year by 2050, in business-as-usual scenarios.

And as antimicrobial resistance increases, the R&D pipeline to bring effective antimicrobials to the market is drying up.

“There has been very little market incentive to develop new antibiotics and antimicrobial agents, which has led to multiple market failures of very promising tools in the past few years,” Dr Tedros also said.  

Antibiotics are ubiquitous in modern medicine – They are used in most surgical procedures like joint replacement, but also in patients with conditions like cancer, cystic fibrosis or diabetes. When antimicrobials like antibiotics are used excessively, microorganisms can mutate to become drug-resistant.

R&D for antibiotics has declined for over three decades
Record Number Of Countries Are Participating In WHO’s Surveillance System For AMR

Despite the looming threat of antimicrobial resistance, a record number of countries are now monitoring and reporting antibiotic resistance through WHO’s GLASS system – marking a major step forward in the global fight against drug resistance. 

“This step is extremely important so we can look into the magnitude of the problem within different countries. And we hope that more will engage,” said WHO’s Assistant Director-General for Antimicrobial Resistance Hanan Balkhy, at Monday’s press conference.

Since 2018, GLASS has grown ‘exponentially’, she said, with over 64,000 surveillance sites, across 66 countries, as compared to only 729 sites across 22 countries when the system was founded. That led to some two million patient reports in 2020. 

AMR Is A Global Health Priority That Disproportionately Affects Low And Middle Income Countries 
Distribution of antimicrobial resistance around the world

Many low and middle-income countries already have high AMR rates – And AMR was projected to grow faster in these contexts than in high-income countries, according to a 2018 report by the Organisation for Economic Co-operation and Development (OECD).

In Brazil, Indonesia and the Russian Federation, for example, about half of infections are caused by drug resistant microorganisms – and resistance in these countries is predicted to rise 4–7 times faster than in other OECD countries.

With increasing globalization, tackling AMR is a “global health priority” because microorganisms know no borders, said Assistant Professor at Warwick University Marco Haenssgen, at a webinar on Tuesday hosted by the London School of Tropical Hygiene and Medicine.

In the late 1950’s and early 1960’s, South East Asia was one of the first regions to report about the development of drug-resistant strains of malaria (plasmodium) parasites. Since then, drug-resistant malaria has even spread to high-income countries like the UK, said Haessgen. 

Rationalizing Antibiotics Use in Humans and Animals Requires ‘Multi-Sectoral’ and ‘Customized’ Solutions
WHO Assistant Director-General Hanan Balkhy

Resolving AMR is ‘very complex’, said Balkhy, as it is ‘extremely difficult to identify’. Another issue is that the drivers of resistance are “very different” in each country.

In some contexts, AMR may be caused by over-prescription of antibiotics in human patients. In OECD countries, about half of antibiotics were inappropriately prescribed by general practitioners, which either prescribed the wrong antibiotic, or prescribed unecessarily. reported a 2018 OECD study. The same OECD study projected that AMR could cost up to $3.5 billion per year. 

In other settings and countries, AMR may be largely due to excessive use of antibiotics in agriculture. Antibiotic consumption in livestock was projected to increase by almost 70% in the most populated countries of the world by 2030, according to a 2014 study published in the Proceedings of the National Academy of Sciences. And livestock consumption of antimicrobials will be 99% higher in Brazil, Russia, India, China, and South Africa (BRICS) compared to other countries, the study estimated. 

Whether antimicrobials are used in livestock or humans, they are not a panacea for ‘good hygiene’, said Balkhy. “It is important that we do not replace good hygiene in either context by the excessive use of antimicrobials.”

WHO’s Interim Guidance on mitigating antimicrobial resistance during COVID-19

Given the complexity of the problem, the WHO has “taken a big step” to address AMR in a “customized, multi-sectoral fashion” by working directly with countries and regularly updating technical advice.

In the WHO’s latest interim guidance for clinical management of COVID-19 from late last month, it has outlined how antibiotic therapy can be used to treat patients in a way that mitigates antimicrobial resistance.

But to accelerate the development of viable candidates, new R&D models and public-private partnerships will be needed to incentivize “sustainable innovation” of newer, and more effective antimicrobials, said Dr. Tedros.

“We must bolster global cooperation and partnerships including between the public and private sectors to provide financial and non-financial incentives for the development of new and innovative antimicrobials”, added Balkhy.

Image Credits: WHO / Sergey Volkov, OECD, WHO, FAO and OIE, PNAS, WHO.