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.

Dr Tedros speaking at a WHO COVID-19 press briefing.

China stalled for ‘at least’ two weeks in providing the World Health Organization with detailed data on COVID-19 cases, frustrating WHO’s top echelons –  even as they tried to put on a positive public face, according to an investigative report by the Associated Press of exchanges that occured in January.

China also withheld the genome sequence of the COVID-19 virus for over a week, releasing it only on  11 January – though three separate government labs in China had already sequenced the SARS-CoV-2 virus as of 3 January, states the AP report. . 

As the World Health Organization publicly praised Beijing for ‘immediately’ sharing the genetic sequence of the SARS-CoV-2 virus in January, internal WHO meetings record the “considerable frustration” of  WHO officials with the “significant delays” in China’s timely release of the gene sequence and other critical information,  according to the AP report, which it said was based on dozens of confidential interviews as well as written and audio recordings of internal WHO conversations in early January. 

“We have informally and formally been requesting more epidemiological information,” WHO’s top China official, Gauden Galea, was quoted as saying in one critical meeting. “But when asked for specifics, we could get nothing.

“We’re currently at the stage where yes, they’re giving [the necessary information] to us 15 minutes before it appears on CCTV,” Galea added, referring to the state-owned China Central Television.

Mike Ryan, Executive Director of WHO Health Emergencies Programme

In the second week of January, WHO’s chief of emergencies, Dr. Michael Ryan, reportedly told other WHO colleagues it was time to “shift gears” and apply more pressure on China, saying that he feared China’s lack of transparency would lead to a repeat of circumstances similar to those that fueled the spread of Severe Acute Respiratory Syndrome 2002, which began in China but led to the deaths of nearly 800 people worldwide.

“This is exactly the same scenario, endlessly trying to get updates from China about what was going on,” he is quoted as saying. With reference to SARS, he added:  “WHO barely got out of that one with its neck intact given the issues that arose around transparency in southern China.”

In fact, the WHO management of SARS under former director general Gro Harlem Brundtland, who publicly called out Beijing for its lack of transparency, and then issued an unprecedented  advisory against travel to the country, has been heralded, even by US President Donald Trump, as exemplary.

Wedged between Two Superpowers

The AP report comes as WHO has faced a hail of criticism from the United States, culminating in Friday’s decision by Trump to withdraw the United States membership in the UN agency and terminate its funding.

The AP report provides a fresh narrative of the China-WHO dealings, one which ultimately left the global health organization trapped in a bitter United States-China rivalry – even though its own collaboration with China was laced with internal frustrations, which officials were loathe to express publicly at the risk of information flow further drying up.

Already on 6 January, the WHO had privately complained about being kept in the dark as China gave it insufficient information despite the legal provisions of the International Health Regulations: “We’re going on very minimal information,” said WHO’s technical lead for COVID-19, Maria van Kerkhove, at another internal meeting, cited by AP. “It’s clearly not enough for you to do proper planning.”

China’s Xi Jinping in 18 May address before the World Health Assembly

Given the WHO’s position, public praise  of China was probably the only strategy at its disposal to secure access to crucial epidemiological data, public health experts familiar with the organization noted.    

If the WHO pushed too hard on Beijing, WHO officials might even have been expelled from the country, Adam Kamradt-Scott, global health professor at the University of Sydney told AP. In mid-March, China kicked out American journalists from the New York Times, The Wall Street Journal and The Washington Post – most of whom aggressively reported on the evolving COVID-19 epidemic in its earliest days as the Chinese government tried to play down its severity.

WHO – Lack of Enforcement Power

In Friday’s announcement over the severing of ties, Trump charged that WHO had given into Chinese pressures to coverup its mistakes in the coronavirus response, “China has total control over the World Health Organization.”

But the fundamental weakness by the AP report uncovered is not any active collusion, but rather WHO’s lack of enforcement power in health emergencies. This means that WHO must rely entirely on voluntary cooperation from countries. It does not have the power to compel nations to do what it says, nor to independently investigate outbreaks in countries. 

Even so, WHO Director General Dr Tedros Adhanom Ghebreyesus’ efforts to coax China into cooperation while avoiding any public criticism of Beijing for its handling of the pandemic has come at a high price.

“It’s definitely damaged WHO’s credibility,” said Kamradt-Scott told AP. “Did he go too far? I think the evidence on that is clear….it has led to so many questions about the relationship between China and WHO. It is perhaps a cautionary tale.”

AP notes that WHO officials named in its story declined to answer questions posed about the internal meetings, without direct access to audio or written transcripts of the recorded meetings, “which the AP was unable to supply to protect its sources.”

For more details on the unfolding of COVID-19 in its early stages and the politics of China;s response that cost many lives, see AP’s full report here.

Image Credits: WHO/Pierre Virot, WHO.

Police handcuff and arrest protestors in Brooklyn, New York. Even in peaceful protests, social distancing crumbles.

“I can’t breathe” could have been a slogan for those suffering the worst effects of COVID-19. But now it has become the battle cry of Americans angered over the police killing by strangulation of a Minneapolis man, George Floyd, last week. 

While this is the latest in a years-long series of violent events involving African American men and women who were abruptly shot, choked or otherwise killed by police for either minor offenses or no offense at all, it has heightened significance in the wake of the widespread economic and social disparities created by Covid-19 pandemic.   

What the New York Times called the “parallel plagues” of COVID-19 and police brutality have both taken an outsize toll on American’s minorities—sparking outrage and grief across a nation already polarized by racial, ethnic and economic divisions that have been heightened by Covid-19. 

And indeed, civil violence is also a public health threat, both recognized by the World Health Organization as well as tracked by countless experts.

“The same broad-sweeping structural racism that enables police brutality against black Americans is also responsible for higher mortality among black Americans with Covid-19,” Maimuna Majumder, a Harvard epidemiologist also working on the Covid-19 response, told Vox.

African-American Deaths from COVID-19: 2-3 Times More than Expected
Protesters with hands up, symbolic of the Black Lives Matter movement, at a peaceful Minneapolis protest over the death of George Floyd

For Americans, Minneapolis has long had a reputation as a progressive and tolerant city and state, graced with higher than average incomes and educational levels and a strong social welfare net, compared to many other parts of the US. However, the protests that began in Minneapolis quickly spread over the weekend to some 140 other urban centers, which face even sharper racial and economic divides. The circle of violence quickly choked Washington DC, Los Angeles, Atlanta, and New York City – where poor and working class minority communities often live in close proximity to the national power centers of government, business and culture.

The brutal scenes of police pushback against the protestors captured on Twitter and Instagram, fueled a feedback loop of yet more outrage and waves of demonstrations. 

https://twitter.com/i/status/1267306908983218176

“Last night was an ugly night in the state and the country,” remarked New York Governor Andrew Cuomo in a press conference on Sunday.

A national analysis of data from the COVID Racial Tracker, finds that African-American deaths from COVID-19 are nearly two times greater than would be expected based on their share of the population, National Public Radio reported. In four states, the rate is three or more times greater.  In some 42 states plus Washington D.C., Hispanics/Latinos also make up a greater share of confirmed cases than their share of the population. White deaths from COVID-19 are lower than their share of the population in 37 states and the District of Columbia, the analysis also found.  

Other studies have found that low socio-economic status is closely associated with crowded living conditions and a higher rate of other chronic health conditions, all of which raise the risks of serious illness from COVID-19.

African-Americans make up 35 percent of coronavirus cases in Minneapolis, though they are less than 20 percent of the city’s population.” “By one estimate, black people accounted for at least 29 percent of known Covid-19 cases in Minnesota, despite making up about 6 percent of the state’s population, reported VOX.”

Critics have also compared the very hard line taken by US President Donald Trump against the current wave of protests to his much softer line vis a vis the gun-bearing demonstrators that marched around business centers and state capitals, such as Lansing Michigan, only a few weeks ago, demanding that COVID-19 lockdown measures be ended.

Tweet compares President Trump’s reaction to protests against lockdown in early May and police brutality last week.

The United States is not the only COVID-19 epicentre now facing major social upheaval. In Sao Paolo, Brazilians were met by a hail of police rubber bullet fire when they came out into the streets to protest President Jair Bolsonaro’s laissez faire handling of the crisis over the weekend.

Meanwhile, in Brazilia, Bolsonaro joined protestors in Brasilia demanding the total reopening of the country, as well as the shutdown of Congress and the Supreme Court – which is set to hear an investigation over the president’s allegedly illegal interference with Federal Police. The protests rocked major cities as the country marked 500,000 COVID-19 infections, with the fourth highest number of deaths worldwide – outpaced only by the US, the United Kingdom and Italy.  

In a parallel development, the US sent two million doses of hydroxychloroquine to Brazil, reported the White House on Sunday. The anti-malarial drug will be used to treat Brazilians infected with COVID-19, the White House said. This was despite the fact that a growing body of evidence indicates that hydroxychloroquine can increase mortality and lead to heart complications in people with Covid-19.

United States Continues Business Reopenings

While some US cities were put under tough curfews due to the wave of unrest and violence, the reopening of businesses following the COVID-19 lockdown has continued apace. 

In New York, Governor Cuomo announced Sunday that dentists could reopen their offices statewide on Monday. He said that overall cases in the state continued their sharp decline – although there were still 1,110 new infections reported overnight Saturday-Sunday.  New York State has seen a total of some 370,000 virus cases, and more people have died in New York State alone than in any other country, except for Italy and the United Kingdom. 

On the far end of the continent, however, Alaska saw an uptick in cases in the past few days, reporting some 30 new cases  on Sunday, the largest increase seen since April 1-2 when cases peaked at 187. Alaska was one of the first states to open restaurants and rollback business restrictions in mid-April. On May 22, Alaskan Governor Mike said “it will all be open just like it was prior to the virus,” at a press conference.

On Sunday, some 600 Americans died from COVID-19 – in a week that saw mortality nearly double, and then decline again. 

WHO Warns Against Infection Spread From Mass Gatherings  

Protests seen in the US may also increase risks of refueling the US centres of the outbreak, politicians and some public experts have also worried.

Los Angelos Mayor Eric Garcetti warned that the protests could become “super-spreader events” – although other public health experts said that the outdoor settings may mitigate infection spread.

“The outdoor air dilutes the virus and reduces the infectious dose that might be out there, and if there are breezes blowing, that further dilutes the virus in the air,” Dr. William Schaffner, an infectious disease expert at Vanderbilt University, told the New York Times. “There was literally a lot of running around, which means they’re exhaling more profoundly, but also passing each other very quickly.”

However Howard Markel, a medical historian, countred that “Public gatherings are public gatherings — it doesn’t matter what you’re protesting or cheering,” he told The Times. Screaming and shouting slogans during a protest also can accelerate the virus spread, Markel said, while tear gas and pepper spray used to disperse crowds, also cause people to tear up and cough, and further increasing respiratory secretions and the possibility of transmission. Police barricades, arrests and efforts to move in and around crowds also results in more contact in tight spaces.

And while some of the US protestors have been donning masks and attempting to keep a distance, many precautions are thrown to the wind during the kinds of spontaneous protests now being seen in the United States, he added.

The risks of virus spread in uncontrolled mass gatherings were echoed by WHO Director General Dr Tedros Adhanom Ghebreyesus and senior WHO scientists at in a press briefing on Monday.

“Mass gatherings have the potential to act as super spreading events,” Dr Tedros said, even though he made no mention of the wave of US protests.  He announced that WHO was releasing updated guidance to help organizations determine how and when mass gatherings can safely resume.

“The close contact between people can pose a risk,”said WHO’s Technical Lead for COVID-19 Maria van Kerkhove, adding that such events need “rigorous planning” to ensure that physical distancing is not forgotten.

“And we need to ensure that in locations that are considering these…mass gathering events, that you have a system in place to prevent and detect and respond to any such cases.” she added. 

After a tough, public rebuke of protestors that rioted in the city’s streets over the weekend, saying that they had dishonored the memory of the slain George Floyd, Atlanta’s mayor, Keisha Lance Bottoms, had a simple piece of advice. She told them to: “go get a COVID test this week.”

 

Image Credits: G. Ginsberg/HPW, Jenny Salita.