A new BMJ study by French researchers has reinforced the link between consumption of sugar-laced sodas & fruit juices and cancer incidence, in particular breast cancer. The study – the largest ever of its kind – is significant because while the link between sugar consumption and diabetes, obesity, and hypertension has been well documented, there have been fewer studies on sugary drinks as a cancer risk, the authors note.

The BMJ study, “Sugary drink consumption and risk of cancer: results from NutriNet-Santé prospective cohort,” involving 101,257 adults, including 79,724 women, found an increase in daily sugary drink consumption of 100 ml was associated with a sharp raise of overall cancer incidence as well as of breast cancer.

According to Eloi Chazelas, co-author, “We observed that a 100mL per day increase in the consumption of sugary drinks (which represents a small glass) was associated with approximately an 18% increased risk of overall cancer, and approximately 22% for breast cancer.”

In specific sub-analyses, both pure fruit juices and other sugary drinks also were associated with an increased overall risk of cancer, he told Health Policy Watch.

Participants came from the French NutriNet-Santé cohort of an even larger Franco-Belgium study examining the relationship between nutrition and health, in terms of not only cancer incidence, but also cardiovascular diseases, diabetes, and hypertension.

The study began in 2009 with participants added on a rolling basis until 2018; some participants were followed for as long as 9 years, with a median period of 5 years, with the average age of participants 42 years.

The study examined consumption of 97 sugary drink items and 12 artificially sweetened beverage items. The sugary drinks included fruit juices comprising 100 percent fruit juice, without added sugar.

Asked about the study’s findings, WHO Senior External Relations Officer Menno van Hilten told Health Policy Watch that WHO has not so far systematically reviewed potential associations of sugar consumption with cancer risks. WHO has not been looking at cancer as an outcome of free sugars consumption yet,” he said, adding that WHO also doesn’t comment on individual studies. Rather, WHO works on systematic reviews of evidence once evidence has accumulated.

However, overall, WHO has been pressing for stronger policy measures to cut sugar consumption, including guidelines recommending strict limitations in sugar consumption, including in sugary drinks, due to its already well-documented links to obesity, diabetes and tooth decay. It has also supported policies to raise awareness on the health hazards brought by sugary drinks as well as policy measures that make healthier food choices cheaper and more accessible.

Sugar in Drinks: Why Can It Increase Cancer Risk, Not Only Diabetes?

Sugary drinks and the sugar they contain are already known risk factors for obesity, weight gain, insulin resistance, and increased proinflammatory markers, all of which are risk factors for cancer. But a direct link between sugary drinks and cancer has been less explored, according to the authors, with very few prospective studies conducted on the association between sugary drinks and individual cancer sites.

Mechanisms underlying a link between sugary drinks and cancer might involve insulin resistance, according to the study, as foods with a comparatively higher glycaemic index, cause a rapid rise in blood sugar levels, or glycaemic load, and have been linked with breast cancer, hepatocellular cancer, and diabetes-related carcinomas.

Additionally, sugary drink consumption tends to increase weight gain, further adding to their cancer risks: “Excess weight is a strong risk factor for mouth, pharynx, larynx, oesophageal (adenocarcinoma), stomach (cardia), pancreatic, gallbladder, liver, colorectal, breast (postmenopause), ovarian, endometrial, prostate (advanced), and kidney cancers,” the study notes, building on previous results.

But beyond weight gain, sugary drinks might promote gains in visceral adiposity independently of body weight, according to the study. Visceral adiposity, which refers to fat accumulation around the visceral organs, is responsible for much higher chronic disease risk than fat on the thighs, NutriNet-Santé study coordinator Dr Mathilde Touvier told Health Policy Watch.

At this stage, it seems the authors cannot say whether different types of sugar and their different sources produce different effects in the body, and additional research is planned in the context of a new project of the NutriNet-Santé study.

The study found that the median sugar content for sugary drinks was 10.7g/100ml, while most public health agencies set the recommended level at zero. Only water is recommended, even if unsweetened coffee or tea can also participate to the daily liquid intake.

Can the same conclusions be drawn about sugary foods and cancer? According to Touvier, very few studies have been carried out so far and the topic will be investigated in NutriNet-Santé soon.

100 Percent Fruit Juices Also in Culprit Group; What About Whole Fruits?

For those who thought that unsweetened fruit juices were healthy, the conclusion of the study is brutal. Making up 45 percent of all sugary drinks that are consumed overall, 100 percent fruit juices also were positively associated with an overall increased rate of cancer.

If fruit juice is unhealthy, why does WHO recommend eating at least 400 g, or five portions, of fruit and vegetables per day (excluding starchy roots)?

According to Touvier and Chazelas, “entire fruits contain more dietary fibres,” and this means that the body absorbs the sugar contained much more slowly, leading to a lower overall glycaemic load than for fruit juice. Whole fruits also help satiate the appetite more rapidly than juice, as they said “eating an orange is more efficient in filling the stomach than drinking the juice of one orange.”

100% fruit juices generally contain high levels of simple sugar, sometimes higher than regular soda, and their glycaemic indexes are higher than that of whole fruits, the study found.

The recommendation on fruit juices in France is “less than one glass per day.”

Artificial Sweeteners Off the Hook, Not a Blank Check

While study results partly exonerate artificially sweetened drinks, Touvier told Health Policy Watch that those results should be taken cautiously, because the number of consumers of artificially sweetened beverages was limited, as well as the amounts consumed.

Touvier, who also heads the Equipe de Recherche en Epidémiologie Nutritionnelle (EREN) in Paris, warned about drawing hasty conclusions about artificial sweeteners not having an impact on cancer incidence. “The message from this paper should definitively not be to switch from sugary drinks to artificially sweetened beverages.” The adverse cardiometabolic health effects of artificial sweeteners have been reported and some experimental studies suggested potential adverse effects, she explained, adding that further investigation is needed.

For example, there is a lack of human data on cocktails of artificial sweeteners and other food additives, and a large-scale project is being launched by NutriNet-Santé on that topic. In particular, chemical compounds in sugary drinks, such as 4-methylimidazole in drinks containing caramel colourings, could influence cancer incidence.

Policy Implications

Along with guidelines issued in 2015, WHO in 2017 issued guidance suggesting taxation of sugary drinks as a measure to help reduce overall sugar consumption and thus disease risks. Civil society groups also have been active in promoting food labelling and tax policies at the national level to reduce consumption of sugar and sugary drinks.

Last January, at the WHO Executive Board meeting, a large consensus formed in support of a recent WHO review of evidence on the effectiveness of taxes on sugar-sweetened beverages as a means to reduce sugar consumption. The review was part of a report following up on United Nations General Assembly’s high level meeting on the prevention and control of noncommunicable diseases (NCDs). The WHO drew on nine recent peer-reviewed studies of evidence of the impact of reducing sugar consumption through taxation of sugar-sweetened beverages at national and sub-national levels.

The WHO review examined the outcomes of taxes on included fruit juices and sweetened or flavoured milk-based drinks.

Only Italy and the United States pushed back against the findings, asking that the summary of evidence – on how taxes on sugar-sweetened drinks may help reduce unhealthy sugar consumption – be deleted from the progress report on tackling NCDs, and that public awareness-raising measures should rather be the focus of NCD prevention.

Vital Strategies, a large NGO working with governments, notes that there are currently 45 countries which have implemented taxes or levies on sugary drinks. In an interview with Health Policy Watch, Sandra Mullin, Senior Vice President of Vital Strategies for Policy, Advocacy and Communications explained different policy levers that can be used to curb sugary drinks consumption, and make healthier choices easier for consumers.

Besides taxes, other policy levers include restricting the marketing and availability of unhealthy products to children, clear warning labels, communication campaigns to create awareness, and other pricing and policies to make healthy food choice more accessible.

In a related development this month, the World Health Organization’s Regional Office for Europe raised alarm about the high level of sugar found in certain brands of baby foods, incorrectly marketed as suitable for infants under the age of six months.

Earlier this year, the BMJ published another study showing that tobacco industry giants built some of the leading sugary drink brands that have been marketed to children over the past 50 years, using marketing strategies developed by the tobacco industry.

Image Credits: PIXNIO.

[DNDi Press Release]

Geneva/New Delhi – 22 July 2019

The results of an innovative “infectivity” study conducted by the Drugs for Neglected Diseases initiative (DNDi) and the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) confirm that people successfully treated for visceral leishmaniasis in South Asia can still infect others if they develop a skin condition known as post-kala-azar dermal leishmaniasis (PKDL). The results were published in Clinical Infectious Diseases this week.

Patients can develop PKDL – skin lesions in the form of rashes and nodules – usually six months to one year after successfully completing treatment for visceral leishmaniasis, a deadly parasitic disease transmitted by sandflies also known as kala-azar, or black fever. PKDL lesions contain the same parasite that causes kala-azar. The objective of the study was to assess whether parasites in the skin of PKDL patients could be transmitted to the sandflies that transmit kala-azar.

“This is the largest study of its type to date. Until now, information on the role of PKDL was scarce and scattered across decades of different research initiatives,” said Dr Jorge Alvar, Senior Leishmaniasis Advisor at DNDi and co-principal investigator of the study. “The results unequivocally show that PKDL is of pivotal importance for maintaining transmission of the disease in-between epidemics.“

As part of the trial, PKDL patients allowed themselves to be bitten by laboratory-reared sandflies (which were free from infection) by plunging their hands into a cage for 15 minutes containing male and female sandflies. The sandflies were then analysed for the parasites that cause kala-azar.

The results showed that nearly 60% of the 47 PKDL patients in the study passed on the parasites to sandflies. This means the insects could then go on to infect someone else.

“Because PKDL is not fatal it has largely been ignored by public health efforts, and many scientific questions around its role have remained unaddressed,” said Dr Dinesh Mondal, Senior Scientist at the icddr,b and principal investigator of the study. “While these new findings don’t answer all our questions, they do show that early treatment of PKDL patients will be a critical element of any leishmaniasis public health and elimination strategy.“

People with PKDL sometimes remain untreated for a long time. Transmission of the disease could therefore be occurring even when kala-azar is controlled and small numbers are being reported.

“Great strides have been made in the control of kala-azar in South Asia, but this study shows that now we must engage in active PKDL case detection and provide prompt treatment as an integral part of kala-azar control and elimination,” said Dr Suman Rijal, Director of the DNDi Regional Office in India. “PKDL must be addressed in order to sustain elimination or we risk jeopardizing our earlier successes.“

Forty-seven PKDL and 15 kala-azar patients were tested by xenodiagnosis. The results showed that depending on the type of PKDL lesion, 35% (9/26) of the macular to 86% (18/21) of the nodular PKDL patients in the study passed on the parasites to sandflies (p 0,0009), while 67% of the 10/15 kala-azar control patients did. This means the insects biting the skin of a PKDL patient could then go on to infect someone else.

DNDi is now preparing a similar study in Sudan. DNDi is also running clinical trials to test two treatment regimens for patients with PKDL, in South Asia and East Africa, in a bid to make treatments simpler, safer, and more effective. Learn more

Read stories of people struggling with PKDL in Bihar state in India, one of the areas in the country most affected by kala-azar:

Story – The disease that strikes back

About DNDi

A not-for-profit research and development organization, DNDi works to deliver new treatments for neglected patients, those suffering with Chagas disease, sleeping sickness (human African trypanosomiasis), leishmaniasis, filarial infections, mycetoma, paediatric HIV, and hepatitis C. Since its inception in 2003, DNDi has delivered eight new treatments to date, including new drug combinations for kala-azar, two fixed-dose antimalarials, and DNDi’s first successfully developed new chemical entity, fexinidazole, approved in 2018 for the treatment of both stages of sleeping sickness.

Image Credits: DNDi.

Disclosure of costs for drug research and development (R&D) and “alternative financing mechanisms” for new health products remain outstanding points to be resolved by countries in finalising a draft United Nations General Assembly political declaration on universal health coverage (UHC).

A final draft of the declaration had been expected this week, but as of Friday afternoon, language on sexual and reproductive health and rights (SRHR) and drug development issues appeared to be unresolved in the draft text, obtained by Health Policy Watch.

Observers close to the negotiations told Health Policy Watch that they feared that disputes over the SRHR language in particular could extend finalising the declaration beyond this month.

If negotiations around SRHR become divisive, sources warned that the timeline for finalising the declaration could even extend into September, just ahead of the UN General Assembly High-Level meeting on UHC.

That language has been controversial in light of opposition by the US as well as some developing countries to any references to sexual or reproductive health that could imply access to abortion.

Additionally, the Group of 77 (G77), a coalition of 134 developing nations, have experienced sharp differences of opinion on both access to abortion and contraception, and members have decided not to vote as a bloc on the issue, sources said.

United Nations Headquarters in New York

The 12 July draft text of the UHC declaration, obtained by Health Policy Watch and confirmed as authentic by two sources, includes some bracketed text, indicating outright disagreement, and highlighted text, indicating language still up for discussion. The reference to transparency of the “costs” of R&D is bracketed, and much of the language on alternative financing mechanisms for research and development is highlighted.

Despite intense debates over sexual and reproductive health and rights in recent UN fora, the paragraph on SRHR includes no brackets or highlighting, and has remained unchanged from the initial “zero” draft of the text issued in late May.

However, some negotiators still see potential controversy “looming” over the sensitive SRHR language, and say that the timeline for finalising the declaration will largely be determined by the progress of negotiations on this issue.

Other aspects of the declaration, for which there appears to be no controversy, include:

  • Increasing investment in primary health care as the vehicle for UHC;
  • Strengthening health systems to more comprehensively prevent and treat communicable and non-communicable diseases;
  • Addressing environmental factors that negatively affect health including the impacts of climate change;
  • Improving emergency preparedness and response systems;
  • Ensuring affordable access to health services, including “essential, safe, affordable, effective and quality medicines and vaccines.”

Once finalised, the declaration will be issued at the UN General Assembly High-Level Meeting on UHC on 23 September in New York.

R&D Transparency, Alternative Financing for Innovation Still Up for Discussion

This year has already seen intensive debates over the public disclosure of medicines prices and research and development costs at the World Health Assembly (WHA) in May. That was followed by debate last week at the UN Human Rights Council (HRC) over “delinkage” of R&D costs from the price of medicines.

In both fora, several high-income countries had distanced themselves from language in the final adopted texts. In the case of the WHA resolution, the United Kingdom, Germany and Hungary “disassociated” themselves altogether from the final resolution. In the case of the HRC resolution, Japan protested the delinkage clauses.

Sources noted that a similar dynamic could arise with the UHC declaration, as these debates continue as core aspects of member state negotiations in yet another UN forum.

In the UHC draft declaration, paragraph 11.e of the preamble – which is reportedly still up for discussion – recognises that “the high prices for some health products, and inequitable access to such products within and among countries, as well as financial hardships associated with high prices of health products continue to impede progress towards achieving universal health coverage.”

In the so-called operative paragraphs of the resolution, disagreement is said to revolve around a reference in paragraph 47 calling for “increasing transparency of prices [and cost],” of research and development – something which many pharmaceutical companies consider to be proprietary information.

Paragraph 50, which encourages “the use, where appropriate, of alternative financing mechanisms for research and development as a driver of innovation for new medicines and new uses for medicines,” also appears to be the focus of significant discussion, as the entire paragraph is highlighted.

It refers to the concept of delinkage, encouraging support for “voluntary initiatives and incentive mechanisms that separate the cost of investment in research and development from the price and volume of sales, to facilitate equitable and affordable access to new tools and other results to be gained through research and development.”

According to sources close to the negotiations, this paragraph uses the term “separate” rather than “delink,” to avoid any negative association the term could carry among proponents of traditional R&D systems, which rely on exclusive patents to create incentives for private sector investment in R&D.

By instead relying on alternative financing mechanisms to incentivise innovation, such as cash prizes and upfront funding, delinkage provides an alternative to traditional R&D incentives based on exclusive patents, known to create monopolies that drive up drug prices.

In addition to separating price, this paragraph also calls for separating the “volume of sales” from the cost of R&D investment, referring to the critical need to develop new antibiotics while at the same time limiting their use to treat drug-resistant infections caused by antimicrobial resistance.

Lastly, this paragraph mentions that these alternative financing mechanisms be applied “[in potential areas where market failure exists],” which is in brackets, indicating disagreement.

According to sources, critics of traditional R&D systems that incentivise innovation through exclusive patents put this phrase in brackets. They consider the concept of isolated market failures of this R&D system – resulting in neglected diseases and insufficient R&D of new antibiotics – to be inadequate to address the broader reforms they think are needed across the R&D landscape.

Paragraph 48, which references member states’ rights to flexibly apply intellectual property rules for the protection of public health, so far remains unchanged. This is likely due to the fact that this same language was already agreed-upon in the 2018 UN General Assembly declaration on tuberculosis (TB), so the precedent had already been set. These flexibilities enable countries to legally produce affordable generic versions of patented drugs for the purposes of safeguarding public health.

In paragraph 49, the recognition that public health-driven research and development should be guided by the principles of “safety, affordability, effectiveness, efficiency, [and] equity,” was added without controversy, sources said.

Sexual and Reproductive Health and Rights Yet to Be Negotiated?

Currently, the paragraph on sexual and reproductive health and rights in the 12 July draft of the UHC declaration remains unchanged from the zero draft of the declaration, issued just after the close of the World Health Assembly in May.

However, if a disagreement erupts over the SRHR language, it would likely be even deeper than that over the issue of drug R&D. Sources warned that the timeline for finalising the declaration could be delayed beyond the tentative July deadline, and even run the risk of extending into September just ahead of the high-level meeting on UHC.

This was the experience in the negotiations to finalise the 2018 UN declaration on TB – which were stalled by disagreement over the language on intellectual property flexibilities – in the lead-up to the UN High-Level Meeting on Tuberculosis last September.

The United States and some developing countries have previously spoken out against the language on SRHR in the UHC declaration, saying that it can be broadly interpreted to include abortion, and that it encourages countries to change their laws on abortion.

At a WHA meeting on UHC in May, the US emphasised that a country “should develop approaches to make progress on UHC within its own cultural, economic, political, and structural realities and priorities.” The Philippines, where abortion is illegal, supported this position.

At recent negotiations in the Human Rights Council over a resolution on ending early and childhood marriage, a number of countries from the Middle East, Africa and South-East Asia objected to language ensuring freedom for girls to be informed about and make choices on their own sexual and reproductive health.

In the current draft, the paragraph on SRHR reads as follows:

“65.     Ensure universal access to sexual and reproductive health and reproductive rights in accordance with the Programme of Action of the International Conference on Population and Development and the Beijing Platform for Action and the outcome documents of their review conferences, including universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes, and recognizing that the human rights of women include their right to have control over and decide freely and responsibly on all matters related to their sexuality, including sexual and reproductive health, free of coercion, discrimination and violence, as a contribution to the achievement of gender equality and the empowerment of women and the realization of their human rights;”

Image Credits: UN.

Hypertension, which has been called a silent killer because it often goes unnoticed, is one of the world’s leading causes of death – potentially leading to heart attack, stroke, and kidney failure, as well as blindness. Now, a new study in The Lancet has found that two-thirds of people in low- and middle-income countries, where the prevalence of hypertension is rising most rapidly, don’t receive any treatment at all.

People in sub-Saharan Africa, which has the highest incidence of hypertension, or high blood pressure, had the least access to treatment, according to the study, The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults, published Thursday.

Photo: REUTERS/Baz Ratner

The study noted that “even if care is provided free of charge, time lost from income-generating activities and transport costs can still pose a substantial obstacle to accessing care for those with little income and savings.” It added that “individuals with lower educational attainment might be less well equipped to engage with relevant health promotion messages and to actively negotiate an effective treatment plan with health-care providers.”

Lindsay Jaacks, assistant professor of global health at Harvard Chan School School of Public Health and one of the study’s lead authors, told Health Policy Watch that:

“Addressing the gaps in treatment, is going to require government investments to keep out-of-pocket expenses for anti-hypertensive medications low and ensure that they are consistently available at primary health centers. Improving gaps in blood pressure control among hypertensives is a bit more complicated and will involve overcoming challenges outside the health system, such as social awareness of the risks associated with high blood pressure, tobacco, air pollution, and salty diets, among others. Coherent multi-sector actions with robust accountability mechanisms are really what’s going to raise that bar.”

The Lancet study, which examined the data of people living in 44 low- and middle-income countries, also found that less than half of suspected hypertension cases are properly diagnosed. A mere 10 percent of people with hypertension have their blood pressure under control. To evaluate how well health systems were responding, the authors used a “cascade of care approach,” looking country by country at the numbers of people with hypertension who had been screened, diagnosed, treated, and had their condition under control.

Urgent Need for Prevention: Reduce Air Pollution, Sugar, Transfats & Alcohol Consumption

“The low proportion of patients with high blood pressure getting the treatment they need, along with the growing number of patients with high blood pressure, suggests the very urgent need for population-level prevention,” Jaacks was quoted as saying in a press release.

This, she said, refers especially to preventative policies “that get salt and trans-fat out of the food supply, promote fruits and vegetables, reduce air pollution, and address excessive consumption of tobacco and alcohol.”

While countries in sub-Saharan African had the worst performance on average, in terms of access to care along all four steps of the “cascade”, Latin American and Caribbean countries scored the best.

However, wide differences were also noted between countries, with some doing better than might be expected in relation to their level of economic development. The study authors cited Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru, which “performed significantly better on all care cascade steps than predicted based on GDP per capita.”

The study also found that certain factors made it more likely people would advance to diagnosis and treatment regardless of where they live: “Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade.”

Rising Rate of Hypertension Worldwide

The number of people with hypertension has nearly doubled over the past 40 years, says the World Health Organization, increasing from 594 million people in 1975 to 1.13 billion in 2015, with low and middle-income countries bearing most of the increased burden of disease.

According to WHO, the highest hypertension prevalence today is in fact in in Africa (27 percent), closely followed by the Eastern Mediterranean region (26 percent), by South East Asia (25 percent), and by Europe (23 percent). The lowest incidence can be found in the Americas (18 percent), and in the Western Pacific region (19 percent).

The World Health Organization describes hypertension as a “condition in which the blood vessels have persistently raised pressure… Blood pressure is created by the force of blood pushing against the walls of blood vessels (arteries) as it is pumped by the heart. The higher the pressure, the harder the heart has to pump.”

One out of four adult men and one out of five adult women suffer from high blood pressure, according to WHO. However, as few as one in five people with hypertension have it under control.

Main contributors to the rise in hypertension are unhealthy diets, physical inactivity, alcohol and tobacco, and air pollution exposures, according to WHO.

Global HEARTS Initiative

The WHO and the United States Center for Disease Control and Prevention in 2016 launched the “Global HEARTS Initiative” that aims to curb the prevalence of hypertension by 25 percent by 2025. The initiative is primarily geared to support governments to prevent and treat cardiovascular diseases.

Fifteen countries have started implementing HEARTS’ five technical packages: Healthy-lifestyle counseling; Evidence-based treatment protocols; Access to essential medicines and technology; Team-based care; and Systems for monitoring. Those countries are: Barbados, Bhutan, Colombia, Chile, China, Cuba, Ethiopia, India, Iran, Morocco, Nepal, Philippines, Tajikistan, Thailand, and Viet Nam.

Cardiovascular diseases prevention is also promoted through other WHO initiatives: MPOWER (control tobacco), Active (increase physical activity), SHAKE (reduce salt consumption) and REPLACE (eliminate trans-fat).

WHO’s factsheet on hypertension shows no region is escaping the issue, with the greatest prevalence in Africa (27 percent), closely followed by the Eastern Mediterranean region (26 percent), by South East Asia (25 percent), and by Europe (23 percent). The lowest incidence can be found in the Americas (18 percent), and in the Western Pacific region (19 percent).

Image Credits: REUTERS/Baz Ratner.

Against the background of increased cross-border infection risks, the World Health Organization on Wednesday declared the Ebola virus outbreak in the Democratic Republic of the Congo to be a Public Health Emergency of International Concern (PHEIC) – a decision that may help increase aid flows to the disease epicentre but also threaten free-wheeling patterns of regional trade and travel, which are the norm today for local communities, oiling their economies.

Meeting of the International Health Regulations Emergency Committee for Ebola Viral Disease

The WHO decision, announced by Director General Dr Tedros Adhanom Ghebreyesus at an evening press conference broadcast live on Twitter, came against the backdrop of a visibly looming Ebola funding crisis, as well as more subtle disagreements over deployment of a second back-up vaccine, which some proponents say would strengthen preparedness.

WHO officials said money was not the motive for the PHEIC declaration by a special Emergencies Committee on Ebola. But Mike Ryan, WHO’s head of Health Emergencies, stressed that the Organization and its other health partners would require in excess of US$ 230 million to effectively fight the deadly outbreak in the coming months.  And that does not include other support required for security, humanitarian assistance or infrastructure.

Fresh worries about the infection spreading to Uganda also emerged on the same day, heightening concerns about international transmission. The Ugandan Ministry of Health put its public on high alert after a DRC fish trader, who had turned up sick and vomiting in a Ugandan market last week, died of Ebola on Monday upon returning home to the DRC.

In a press release, the Ugandan Ministry appealed to the public to “avoid handshaking, hugging, mass gatherings,” in the wake of the fish trader’s death in Beni, DRC, days after crossing illegally into Uganda on 11 July. Such traffic back and forth is common for not only business but also for meetings between extended families straddling parts of DRC’s porous border. That border is shared not only with Uganda and Rwanda, which have relatively robust surveillance systems, but also fragile states such as Burundi and South Sudan.

Even so, Dr Tedros stressed that regional and international borders to DRC remain open. Hindering trade or travel could spur Ebola’s spread – by driving the heavy traffic of merchants through illegal crossings where there are no infection screening measures, he said.

“I emphasise that WHO does not recommend any restrictions on travel or trade, which rather than stopping Ebola could hinder the fight,” the WHO Director General said. “Closing borders could have disastrous consequences on people who cross the border every day. Such restrictions force people to use informal and un-monitored crossings, increasing the risk of the disease.”

Dr Tedros also stressed that the DRC government was being “completely transparent” about new cases emerging – notifying neighbouring countries of any emerging risks. Under the International Health Regulations (IHR), adopted in 2005, countries are legally committed to respond to a PHEIC, including through measures such as public disclosure of disease incidence.

A front-line Ebola responder meets with a family in the Democratic Republic of the Congo.

Uganda, meanwhile, noted that the fish trader’s Ugandan contacts were being traced and would be “immediately vaccinated.” Along with avoiding public gatherings, the Ministry urged the public to step up infection control measures such as hand-washing. It also stressed that currently, there are no known cases of new Ebola infection in the country – following the deaths of three people in June, also exposed in cross border contacts.

So far, Uganda has been a poster child for preparedness, recruiting local communities and health workers to screen travelers at its border crossings and patrolling illegal crossing points with local communities, among other measures.

However, measures overall remain inadequate, said Robert Steffan, Chair of the WHO Emergency Committee on Ebola Virus Disease, speaking at the WHO press conference, following the conclusion of the meeting of the Emergency Committee.

“Preparedness must be enhanced in neighboring countries. So far there is insufficient preparedness,” Steffan said. But he also stressed that the PHEIC declaration “should not interfere with travel and trade more than needed.”

“Explicitly, there should be no closure of borders by neighbouring countries of the DRC or anywhere else, because that would have a terrible impact on the economy of the affected regions, and negative consequences on the fight against the outbreak,” he emphasised, “This is still a regional emergency and by no way a global threat.”

Rationale of the Emergency Committee Recommendation

Referring to the written recommendations of the Committee, which had met throughout Wednesday afternoon, Steffan said that the Committee had decided to declare an emergency because of the fear of the spread of Ebola from the DRC “gateway” city of Goma along the border with Rwanda, where a pastor from Beni had travelled and fallen ill last week; recurring transmission in Beni, one of the DRC cities at the epicentre of the outbreak in the province of North Kivu; ongoing security risks to responders, and the duration of the outbreak, approaching one year.

According to data released Wednesday evening by the DRC Ministry of Health,  another 10 new Ebola cases had been confirmed in just the past two days, with a total of 2522 confirmed or probable cases of Ebola infection since the outbreak began last August, from which 1698 people have now died and 717 have survived.  Further adding to the complexity, outbreaks of measles and cholera have left over 2000 people dead in DRC between only January and July, according to WHO. Some 198 Ebola responders have been attacked, of which 7 have died.

“There is disappointment that there has been a recurrence of intense transmission in Beni, so that the geographical expansion is now some 500 km,” Steffan told the press conference. “The fight is ongoing for a full year now, and lastly the assassination of two Ebola workers demonstrates the continued risk to responders due to the security situation.”

He also voiced strong concerns about funding gaps, saying “resources have become a limiting factor in technical assistance. Increasingly there is lack of staff and of financial support. There must be more engagement by the global community to end this outbreak.”

At the same time, Steffan praised the performance of WHO and its UN partners as well as the DRC government and NGOs working in the field, saying: “The PHEIC is not declared as a reflection on the sub-optimal performance of those in the field. The rationale is to better cope with the volatile characteristics of the outbreak; the strategy is not to be changed. We need to intensify the actions and also to become more proactive.”

Indeed, the declaration seemed to immediately unleash a flurry of media attention, heightened calls for funding, and new offers of support. John Nkengasong of Africa CDC – Centres for Disease Control and Prevention said Thursday that the PHEIC alert would enable Africa CDC to deploy its African Volunteer Health Corps, a group that was used effectively in West Africa to respond to the 2014-2015 Ebola outbreak.

“This is a declaration that is usually issued when an event is extraordinary, serious and has the potential to cross beyond the country where it is and have a regional and international effect from the public health perspective,” said Nkengasong in a video message. “This is an important declaration because that changes the way that Africa Centers for Disease Control and Prevention and the Africa Union can support the Democratic Republic of Congo to respond to this outbreak.”

USAID Administrator Mark Green meanwhile called upon other donor countries to increase the funding flow to the Ebola response. In a statement posted on the USAID website and Twitter, Green noted that “USAID has provided more than $98 million to the Ebola response in the DRC since the outbreak began in August 2018.  As the single largest donor to this response, the United States encourages other donors to help bring this outbreak to an end as soon as possible.  As donors, international organizations, and NGOs continue to step up, we urge greater financial accountability and full-data sharing to provide clarity on what is being done, and what it will take, to end this outbreak.”

There were also calls in some corners for the World Bank to release more money from its Pandemic Emergency Financing Facility.  So far, some $US 20 million has been released by the Bank to support UNICEF and WHO, with WHO receiving $6.5 million, according to Ryan at the Wednesday press conference.  But some said that amount was woefully inadequate.

“So far the @WorldBank has delivered only $6.5M to @WHO for the #Ebola fight. You have a pandemic fund — release the money! What are you waiting for — another 1,000 dead? Dead Ugandans? Dead Rwandans?” tweeted Laurie Garrett, the Pulitzer Prize-winning journalist.  According to a February press release, the World Bank had announced a commitment of $US 80 million in grants and credits to the Ebola Strategic Response Plan (SRP 3) running from February to July 2019.

While WHO officials said that hundreds of millions of US dollars will be required to support a fourth phase of public health response (SRP 4) to the end of 2019, funding for the current period has only amounted to only $US 48.4 million – or less than half of the $USD 98.4 million needed, officials told Health Policy Watch.

WHO Recommends Deployment of Second Ebola Vaccine 

In what could be one major strategy shift, WHO’s Executive Director of its Health Emergencies Programme acknowledged that the Organization had resumed talks with the DRC government about introducing a second experimental Ebola vaccine, produced by Johnson & Johnson (J&J), into periphery zones of risk.

This was after DRC’s Health Minister Oly Ilunga had declared Monday at a UN high level meeting of Ebola emergencies leadership, that it would not deploy the second vaccine – for fears of creating “confusion” after a hard-fought battle to convince communities in the regions of North Kivu and Ituri that an experimental Merck vaccine now in use is indeed reliable.

Wellcome Trust’s Epidemics Lead, Josie Golding had criticised the DRC decision, saying that holding back deployment of the second vaccine could ultimately harm the response effort – particularly if the Merck vaccine, which has only been produced in a limited supply of about 300,000 doses, runs out. More than 164,000 people already have been vaccinated with the Merck preparation, although since the original vaccine dose has since been reduced by almost half, estimates vary as to how many doses are left.

In an interview today with Health Policy Watch, Golding stressed that while the J&J vaccine requires two successive doses to create immunity, it could be an important “preventative” tool complementing the Merck vaccine. Since there are 1.5 million doses available, it could also be deployed now in areas or populations at more peripheral risk, enhancing preparedness throughout the wider region.

Golding acknowledged that the concerns of the DRC government were understandable, insofar as the Merck vaccine, previously used in the 2014-15 West Africa epidemic, had developed a clear track record in the DRC emergency, provoking a very rapid and effective immune response. Notwithstanding, Golding said that the second vaccine could be used as a second-line of prevention.

“There has never been an assumption that it [the J&J vaccine] would be used directly with those that have come into contact with Ebola where the outbreak is occurring,” said Golding. “This is more about where would the disease go to, how can we think about where to use a preventative vaccine.”

“It is not about the J&J vaccine, it is about having more vaccines available, knowing that these are two vaccines for different uses. One is an emergency vaccine, the other is for prevention.”

While the J&J vaccine lacks the field testing that the Merck product has undergone, it has one further potential advantage, she added. It appears to protect against diverse strains of Ebola virus, while the Merck vaccine only protects against the strain that is presently causing the epidemic in DRC.

Acknowledging a “gap” in Merck vaccine supplies, Ryan told today’s press conference that accelerating production of the emergency vaccine is the first priority.

However, he added that “WHO supports, subject to appropriate national approvals, introduction of a second vaccine,” adding that this had previously been recommended by WHO’s Strategic Advisory Group of Experts (SAGE) on Immunization. He added that the J&J version “seems to be the most likely candidate to be deployed in the field.”

Ryan acknowledged: “Yes, the [DRC] Ministry has expressed concerns about introducing a second vaccine, mainly around confusion of the local population… We are working through those issues with them… They still remain open to deploy in areas not affected. We are working with government and [the vaccine] consortium to find the solutions that would allow the vaccine to be deployed.”

In a follow-up statement just after the press conference, Golding welcomed WHO’s expression of support for the J&J vaccine deployment, saying: “It was good to hear Dr Ryan’s remarks on the matter. We look forward to future discussions on the topic.”

She meanwhile commended WHO for the “tough decision” to declare the Public Health Emergency, saying: “As it moves into a second year, this incredibly challenging epidemic shows no sign of stopping soon. Over 1,600 people have died already, with children accounting for around a third of cases. The teams in the DRC deserve all our thanks, respect and support. There is a grave risk of a major increase in numbers, or spread to new locations – as we’ve seen this week in Goma, again in Uganda and recently close to the border of South Sudan.”

“This is perhaps the most complicated epidemic the world has ever had to face, yet still the response in the DRC remains overstretched and underfunded. The calling of a PHEIC is an opportunity for a change in the response to help stop Ebola spreading and save lives. A step-up in the response, led by the DRC and with full international support, is critical if we are to bring the epidemic to an end. This must include enhanced diplomatic, public health, security and logistic efforts as well as releasing much needed financial resources.”

“There is also a pressing need to introduce a second vaccine, by Johnson and Johnson, in the DRC – to protect communities outside of the current outbreak zone who are likely to be affected next. Countries should not wait for Ebola to spread across borders or appear on their doorstep before acting.”

-Updated 18 July 2019

Image Credits: WHO.

A new UNAIDS report found that while new HIV infections have declined globally since 2010, the rate of progress has slowed, with some regions showing increases in new infections. Available resources for HIV have also dropped by US$ 1 billion in 2018, marking the first time global HIV funding declined since 2000.

UNAIDS’ Global AIDS Update, Communities at the Centre, launched today in South Africa, shows a “mixed picture” of progress, differing across countries and regions. It also shows a decline in HIV funding – US$ 7.2 billion short of the US$ 26.2 billion UNAIDS estimates is needed by 2020 – resulting in slowed progress towards reaching targets to end the AIDS epidemic.

The overall decline in new cases – 16 percent since 2010 – signifies an impressive improvement, which is driven largely by steady progress across eastern and southern Africa, the regions most affected by HIV. However, there have been increases in new HIV infections in eastern Europe and central Asia (29%), in the Middle East and North Africa (10%) and in Latin America (7%), according to a UNAIDS press release.

“While considerable progress has been made, there is a risk that we will lose momentum. If the world is to be on track to end AIDS by 2030, there must be adequate and predictable financing for development. But, for the first time since 2000, the resources available for the AIDS response globally have declined,” Gunilla Carlsson, UNAIDS acting Executive Director, said in the report forward.

Carlsson called on all partners to “step up action and invest in the response,” which includes “fully funding the Global Fund to Fight AIDS, Tuberculosis and Malaria with at least US$ 14 billion at its replenishment in October and through increasing bilateral and domestic funding for HIV.”

“We urgently need increased political leadership to end AIDS,” Carlsson said, quoted in the release. “This starts with investing adequately and smartly and by looking at what’s making some countries so successful. Ending AIDS is possible if we focus on people not diseases, create road maps for the people and locations being left behind, and take a human rights-based approach to reaching people most affected by HIV.”

In 2018, an estimated:

  • 9 million people globally were living with HIV
  • 3 million were accessing antiretroviral therapy
  • 7 million people became newly infected with HIV
  • 770,000 people died from AIDS-related illnesses

Improved Access to HIV Testing and Treatment, Insufficient Progress on Prevention

The report shows that improvements in providing access to testing and treatment options have helped to reduce AIDS-related deaths, which fell by 33 percent to 770,000 between 2010 and 2018. This improvement was made possible through improved delivery of both HIV and tuberculosis services.

Progress has also continued towards UNAIDS’ 90–90–90 targets: that 90 percent people living with HIV know their status; 90 percent of people living with HIV who know their status are on treatment; and 90 percent of people on treatment have suppressed viral loads.

According to the release, some “79% of people living with HIV knew their HIV status in 2018, 78% who knew their HIV status were accessing treatment and 86% of people living with HIV who were accessing treatment were virally suppressed, keeping them alive and well and preventing transmission of the virus.”

This progress towards the 90–90–90 targets, however, has varied greatly by region and by country. “In eastern Europe and central Asia for example, 72% of people living with HIV knew their HIV status in 2018, but just 53% of the people who knew their HIV status had access to treatment.”

The chart below from the report shows progress on each of these targets compared to the total population of people living with HIV.

Additionally, around 82 percent of pregnant women living with HIV now have access to antiretroviral medicines – an increase of more than 90% since 2010 – which has resulted in a 41 percent reduction in new HIV infections among children, “with remarkable reductions achieved in Botswana (85%), Rwanda (83%), Malawi (76%), Namibia (71%), Zimbabwe (69%) and Uganda (65%) since 2010.”

While access to testing and treatment options has improved, “the full range of options available to prevent new HIV infections are not being used for optimal impact,” the release said.

“For example, pre-exposure prophylaxis (PrEP), medicine to prevent HIV, was only being used by an estimated 300,000 people in 2018, 130,000 of whom were in the United States of America. In Kenya, one of the first countries in sub-Saharan Africa to roll out PrEP as a national programme in the public sector, around 30,000 people accessed the preventative medicines in 2018,” indicating that more progress can be made in expanding access to PrEP.

Addressing Needs of Key Populations

In 2018, the report shows that more than half of all new HIV infections – 54 percent – were among key populations, including sex workers; people who use drugs; gay men and other men who have sex with men; transgender people; and prisoners; as well as their partners.

In 2018, these key populations accounted for around 95 percent of new HIV infections in eastern Europe, central Asia, the Middle East and North Africa.

While gains have been made against HIV-related stigma and discrimination in many countries, “discriminatory attitudes towards people living with HIV remain extremely high,” and there remains “an urgency to tackle the underlying structural drivers of inequalities and barriers to HIV prevention and treatment, especially with regard to harmful social norms and laws, stigma and discrimination and gender-based violence,” according to the release.

The report also highlights that community empowerment and ownership has been key to much of the progress across all sectors of the AIDS response. However, insufficient funding for community-led responses, along with negative policy environments, have impeded these successes from reaching full scale and generating maximum impact.

As part of achieving the 2030 Agenda for Sustainable Development, “governments must protect and uphold the human rights of everyone,” Carlsson of UNAIDS said in the report forward. “As the eyes and ears of the AIDS response, communities play a critical role in holding decision-makers to account and demanding political leadership.”

Japan said on Friday that it disagrees with aspects of an already-adopted Human Rights Council (HRC) resolution on access to medicines, claiming that there is no evidence that “delinkage” between the cost of research & development (R&D) and the price of medicines improves access to medicines. Japan also disagreed with pursuing alternative frameworks for R&D incentives, which it said disregards existing R&D frameworks.

These and other provisions had been previously criticised by other developed countries during the informal consultations on the resolution as treading too far out of the Human Rights Council domain and into the technical ground of other UN agencies such as the World Health Organization, the World Trade Organization (WTO) and the World Intellectual Property Organization (WIPO), where such debates are already taking place.

During Friday’s closing session of the HRC, Switzerland, on behalf of Australia, Canada, the Czech Republic, France, Liechtenstein, Slovakia and the United Kingdom, said: “While the Human Rights Council can consider the right to the enjoyment of the highest attainable standard of health, it lacks the necessary technical expertise and competence to address the full complexity thereof.”

Debates abound regarding the best way to create incentives for research and development of new medicines and vaccines while ensuring that the resulting products are widely affordable. Some member states in the HRC see this as a technical matter, while others see it as a human rights imperative.

Delinkage is one model that, according to its proponents, can help to ease the tension between drug innovation and accessible pricing. It refers to delinking R&D incentives from the expectation of receiving exclusive patent rights for the final product, which critics say create monopolies that drive up prices. Delinkage, rather, offers alternative financial incentives to invest in the research and development of new medicines and vaccines. Such incentives may include cash rewards for new innovations that emerge from the drug pipeline, as well as upfront funding in the form of public subsidies, grants, research contracts, or offers of tax credits.

Human Rights Council – Photo: Reuters/Denis Balibouse

Knowledge Ecology International (KEI), a leading NGO promoting access to medicines, describes delinkage as “the idea that temporary monopolies and the associated high drug prices should not be used to fund pharmaceutical research and development.”

The day before Japan’s and Switzerland’s comments, on 11 July, the Human Rights Council passed the resolution on “Access to medicines and vaccines in the context of the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,” which was sponsored by the “core group” of Brazil, China, Egypt, India, Indonesia, Senegal, South Africa and Thailand, and cosponsored by 45 other countries.

Japan explained during Friday’s session of the HRC that it joined the consensus of member states to adopt the resolution “given the importance of access to medicines and vaccines,” but it raised concern that the resolution does not accurately reflect the opinions expressed during the informal consultations with member states, and that it does not appropriately take into account relevant technical discussions occurring at the WHO, the WTO and WIPO.

In the statement, Japan expressed disagreement with paragraph OP5 on delinkage, claiming that “there has been no evidence found to prove that delinkage between the cost of R&D and the price of medicines will improve access to medicines.”

Japan further disagreed with paragraph OP8 on alternative frameworks to reward innovation because “it disregards existing frameworks,” and because a “common understanding on an alternative framework does not exist.”

Japan’s comments regarding delinkage and alternative R&D frameworks follow intense debate among member states at the recent World Health Assembly in May, over a resolution on the transparency of medicines markets. This landmark resolution primarily focused on enhancing the transparency of medicines prices, and due to the intense negotiations, included only watered-down provisions on R&D cost transparency, which emphasised the voluntary nature of such disclosures.

KEI Says Monopolies Cause High Prices, Calls For Delinkage From Monopolies

James Love, Director of Knowledge Ecology International (KEI), a leading NGO promoting models for delinkage, responded to Japan’s statement at the HRC, saying that monopolies cause high prices, and high prices limit access.

“There is certainly plenty of evidence that temporary legal monopolies, such as patents, pediatric, orphan drug or test data exclusivity, lead to high prices,” Love told Health Policy Watch.

There is also “plenty of evidence that when monopolies end, prices fall, dramatically, more than 95 percent for small molecules in the United States, and access expands. Anything that delinks the incentives from the monopoly and high prices is going to expand access, in some cases very dramatically,” he said.

Regarding the definition of delinkage, Love clarified that there is “of course, not much of a direct link between R&D costs and prices, but that is not the point. The monopoly is the primary incentive to invest in R&D, and that incentive is very clearly and very strongly linked to higher prices.”

“As regards evidence, Japan was one of a handful of countries that is seeking to block transparency of R&D costs, so complaining about the lack of evidence is not a good look for Japan, as long as they oppose transparency of R&D costs.”

“The real issues for delinkage,” Love explained, “are (1) how would alternatives be designed, (2) what would they cost, (3) what would be the progressive transition from the status quo, (4) how would they be evaluated, for example, in a feasibility study?”

Love noted that KEI and others including economist Joseph Stiglitz and US Members of Congress are calling for a balanced delinkage regime – one that “includes expanded government funding and subsidies for research, and new market entry rewards to replace the monopoly as the incentive mechanism.” In such a balanced regime, “[d]ifferent governments could embrace different approaches on delinkage, just as they do on pricing and intellectual property policies today.”

“To move the delinkage debate forward,” he said, “there needs to be more transparency, an issue that the World Health Assembly has advanced and other UN bodies are debating, on the entire value chain for medical innovations, including R&D costs, prices, revenues, access and outcomes. There also needs to be clear specifications of the alternatives, including the transitions from the status quo.”

“What you see in these UN debates are efforts to block any questioning of monopolies, and even feasibility studies of alternatives. If Industry did not think alternatives would work, and work better for the public, they would not oppose the feasibility studies.”

Japan detailing concerns on 12 July regarding aspects of the adopted Human Right Council resolution on access to medicines and vaccines. Photo: UN Web TV

Japan Narrowly Interprets Intellectual Property Flexibilities, Disagrees Over HRC Intersessional Seminar

In addition to its concerns over delinkage and alternative frameworks to reward innovation, Japan also disagreed with paragraph PP24 in the preamble, which affirms the rights of states to flexibly apply intellectual property rules. These intellectual property “flexibilities,” enshrined in the WTO TRIPS (Trade-Related Aspects of Intellectual Property Rights) Agreement and its amendments, allow states to override patents and legally manufacture affordable generic versions of patented drugs for the purposes of protecting public health.

Japan described the resolution paragraph affirming the use of these flexibilities by states as “misleading,” and that intellectual property flexibilities such as compulsory licensing of patented drugs “is possible only under certain conditions.”

Lastly, Japan disagreed on the final paragraph OP14 to hold a full-day HRC intersessional seminar “on good practices, key challenges and new developments relevant to access to medicines and vaccines,” because a similar discussion is already being led by the WHO; relevant technical organisations such as the WTO are not being included; and such a seminar has “program budget implications.”

Despite Japan’s complaint about the intersessional seminar, it will proceed as planned and as outlined in the resolution, according to sources.

Image Credits: Reuters/Denis Balibouse, UN Web TV.

In the wake of a new Ebola case in the border city of Goma, WHO and its UN partners are calling on donors to make major new funding commitments to halt the outbreak in the Democratic Republic of Congo (DRC) – while WHO will reconvene an expert Emergency Committee to consider if the outbreak should be considered a “public health emergency of international concern.”

WHO Director General Dr Tedros Adhanom Ghebreyesus made the twin announcements at a high-level meeting in Geneva today on the emergency response, hosted by the UN Office for the Coordination of Humanitarian Affairs (OCHA). The meeting followed confirmation of the first Ebola case in Goma, a major city along the Rwandan border, as well as the weekend murder of two Ebola responders in their homes in Beni, in North Kivu, where the outbreak has raged since last August.

Ring Vaccination in Goma – Photo: WHO/Tania Seburyamo

Dr Tedros’ call for donors to “step up to the bat” was echoed by the British Secretary of State for International Development Rory Stewart and the UN’s Under-Secretary-General for Humanitarian Affairs Mark Lowcock, among others.

The Geneva meeting also included DRC’s Minister of Health, as well as other top WHO and UN emergency response officials speaking live from DRC and Washington DC. The event further included Geneva’s UN representatives of the European Union, USA, Sweden and Norway, as well as the International Committee of the Red Cross, Wellcome Trust, and other civil society groups.

Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization, on 15 July addressed the first case of the Ebola virus in the city of Goma, Congo. (Reuters)

“We need a bigger, more comprehensive response,” Lowcock told a packed room of some 200 people, noting that the global community had spent some US$ 2 billion on the 2014-15 epidemic in West Africa, but only “a fraction of that” in the DRC.

Lowcock said that since January, major improvements in the emergency effort had better aligned the UN agencies with each other, as well as with the DRC government and NGOs on the ground. Local communities in the DRC’s North Kivu and Ituri regions, where the outbreak has festered against a background of chronic civil unrest, have also been engaged more constructively, he said.

“But, if we don’t get an increase in the funding level, treatment centres are going to close, there will be fewer teams to conduct vaccinations, fewer mobile teams available to identify contacts, isolate cases and get them to treatment,” Lowcock warned.

While the USA has so far been the largest national donor to the Ebola response, the United Kingdom took the lead in today’s meeting, pledging more money to a fourth phase of outbreak fund-raising that is getting underway. The Secretary of State for International Development said that the UK would commit some US$ 63 million to the next phase, and challenged “our dear friends from the other G7 [Group of 7 most industrialised] countries” to respond in kind.

“One of the sad truths of the situation is that we are going to need considerably more investment if we are going to get [Ebola transmission] down to zero in eastern DRC,” Stewart said. Reflecting on a recent visit to an Ebola treatment centre in Butembo, at the epicentre of the outbreak, which had been burned down earlier in the year, Stewart praised the work of WHO, civil society, government and other UN partners to rebuild and “address everything from disease prevention to child care in a very difficult environment.”

And at the same time, operations remain “literally on a knife edge,” he added. “You will see that although there is really good medical procedure, there are really worrisome security procedures, with only a few sandbags behind which doctors and nurses can hide if they are attacked. There is still an enormous amount of work to be done.”

Goma Case Highlights Risk of DRC Outbreak Spreading to Other Countries

The Ebola case confirmed in Goma highlights the need to further scale up preparedness in neighboring countries that share a border with the DRC, Lowcock and others underlined. The case involved a pastor who had traveled by bus from the city of Butembo in North Kivu to Goma, a border city of 1 million people that sees heavy foot traffic every day between the DRC and neighboring Rwanda.

While speakers praised Uganda’s response after 3 Ebola cases were identified there several weeks ago, involving people who had crossed over from the DRC along a frontier marked by dense jungle areas, the situation in neighboring Burundi and South Sudan, which also share a border with the DRC, is regarded as far more fragile.

“We also need to scale up the response to deal with the high risk of the virus spreading further,” said Lowcock, adding: “The cheapest strategy is to invest fully and stop the current outbreak, rather than have it linger, and spread further.”

WHO’s Dr Tedros said that since yesterday’s case was identified in Goma, people who had been in contact with the pastor had already been vaccinated with the experimental vaccine that has shown a high degree of efficacy, and other containment measures were also being taken.

However, he stressed that the simultaneous murders of the two Beni health workers underlined the fact that “we are dealing with one of the world’s most dangerous viruses in one of the most dangerous areas of the world. Every attack sets us back, makes it more difficult to trace contacts, vaccinate and perform safe burials. And Ebola gets a free ride.” There have been 198 attacks on responders over the past year, with seven killed, including the Beni victims, he said in remarks that were also published online.

While WHO, UN and DRC government speakers displayed a united front in describing the improved quality of the emergency response, some doubts over vaccine strategy were expressed by Wellcome Trust at the meeting. Dr Josie Golding, Epidemics Lead at Wellcome, questioned if supplies of the current vaccine, approved for “compassionate use” while still undergoing clinical trial development, were indeed sufficient to sustain the massive “ring vaccination strategy” of Ebola case contacts that has dramatically reduced virus transmission. She said that use of a second vaccine in-the-waiting should be reconsidered.

“We are very concerned that supplies of the Merck vaccine currently being used will run out before this epidemic ends, which would have devastating consequences. There is an urgent need to deploy a second vaccine, which has been developed by Johnson & Johnson, complementary to the Merck vaccine and as a primary prevention to protect all who may be at risk,” said Golding to the meeting heads, in a statement also published online.

“We regret the recent announcement against the use of the J&J vaccine and ask for this to be reconsidered. The lives of healthcare workers and the people in North Kivu, across DRC and the region depend on it,” she added, saying: “There is a grave risk of a major increase in numbers, or spread to new locations – as we’ve heard today in Goma. There is also always the potential another Ebola outbreak will begin elsewhere.”

Golding also echoed remarks made by the WHO UN leadership that overall the DRC Ebola response remains, “overstretched and underfunded, with only a small number of countries providing funding. Funding needs to reach the communities affected. A step-up in the national and international response is critical. We need support at the highest political levels, including at the UN and G20. Countries should not wait for Ebola to spread across borders or appear on their doorstep before acting.”

Building Stronger Health Systems Key to Sustained Ebola Control

To be successful over the long term, health and humanitarian efforts need to dispel community mistrust that create fertile ground for violence against Ebola responders – and that means building stronger health systems that tackle other long-standing disease control issues in the DRC, stressed WHO’s Dr Tedros as well as the DRC Health Minister, Oly Ilunga.

“The Ebola epidemic is not a humanitarian crisis, it is a public health crisis,” said DRC’s Ilunga. “Strengthening the health system allows us to maintain the sustainability of the response. It is time to think about the post-Ebola period and about development plans which are properly tailored, ambitious, and the only response to the vital problems faced by the population.”

Since the outbreak began last August, some 2500 people have become infected by the Ebola virus and over 1665 have died, according to the WHO’s Director General, in remarks also published online. However that pales in comparison to malaria, the leading cause of death in the DRC – which kills more than 50,000 people every year in the DRC – or even the current outbreak of measles, which has killed almost 2,000 children since January, said Dr Tedros.

“Frankly, I am embarrassed to talk only about Ebola,” Dr Tedros told the gathering. “Together, we will end this outbreak. But unless we address its root causes – the weak health system, the insecurity and the political instability – there will be another outbreak.”

“This is the moment to practice what we preach. WHO is committed not just to ending this outbreak, but to strengthening DRC’s health system so that it never comes back. That’s also what the community in North Kivu is asking. To build trust, we must demonstrate that we are not simply parachuting in to deal with Ebola and then leaving once it’s finished.”

Find out more about the Ebola outbreak here.

Image Credits: WHO/Tania Seburyamo.

[WHO/UNICEF News Release]

New York/Geneva – 20 million children worldwide – more than 1 in 10 – missed out on lifesaving vaccines such as measles, diphtheria and tetanus in 2018, according to new data from WHO and UNICEF.

Globally, since 2010, vaccination coverage with three doses of diphtheria, tetanus and pertussis (DTP3) and one dose of the measles vaccine has stalled at around 86 percent. While high, this is not sufficient. 95 percent coverage is needed – globally, across countries, and communities – to protect against outbreaks of vaccine-preventable diseases.

“Vaccines are one of our most important tools for preventing outbreaks and keeping the world safe,” said Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “While most children today are being vaccinated, far too many are left behind. Unacceptably, it’s often those who are most at risk– the poorest, the most marginalized, those touched by conflict or forced from their homes – who are persistently missed.”

Child receiving measles vaccination in Guatemala. Photo: WHO

Most unvaccinated children live in the poorest countries, and are disproportionately in fragile or conflict-affected states. Almost half are in just 16 countries – Afghanistan, the Central African Republic, Chad, Democratic Republic of the Congo (DRC), Ethiopia, Haiti, Iraq, Mali, Niger, Nigeria, Pakistan, Somalia, South Sudan, Sudan, Syria and Yemen.

If these children do get sick, they are at risk of the severest health consequences, and least likely to access lifesaving treatment and care.

Measles outbreaks reveal entrenched gaps in coverage, often over many years

Stark disparities in vaccine access persist across and within countries of all income levels. This has resulted in devastating measles outbreaks in many parts of the world – including countries that have high overall vaccination rates.

In 2018, almost 350,000 measles cases were reported globally, more than doubling from 2017.
“Measles is a real time indicator of where we have more work to do to fight preventable diseases,” said Henrietta Fore, UNICEF’s Executive Director. “Because measles is so contagious, an outbreak points to communities that are missing out on vaccines due to access, costs or, in some places, complacency. We have to exhaust every effort to immunize every child.”

Ukraine leads a varied list of countries with the highest reported incidence rate of measles in 2018. While the country has now managed to vaccinate over 90 percent of its infants, coverage had been low for several years, leaving a large number of older children and adults at risk.

Several other countries with high incidence and high coverage have significant groups of people who have missed the measles vaccine in the past. This shows how low coverage over time or discrete communities of unvaccinated people can spark deadly outbreaks.

Human papillomavirus (HPV) vaccine coverage data available for the first time

For the first time, there is also data on the coverage of human papillomavirus (HPV) vaccine, which protects girls against cervical cancer later in life. As of 2018, 90 countries – home to 1 in 3 girls worldwide – had introduced the HPV vaccine into their national programmes. Just 13 of these are lower-income countries. This leaves those most at risk of the devastating impacts of cervical cancer still least likely to have access to the vaccine.

Together with partners like Gavi, the Vaccine Alliance and the Measles & Rubella Initiative, WHO and UNICEF are supporting countries to strengthen their immunization systems and outbreak response, including by vaccinating all children with routine immunization, conducting emergency campaigns, and training and equipping health workers as an essential part of quality primary healthcare.

About the data

Since 2000, WHO and UNICEF jointly produce national immunization coverage estimates for Member States on an annual basis. In addition to producing the immunization coverage estimates for 2018, the WHO and UNICEF estimation process revises the entire historical series of immunization data with the latest available information. The 2018 revision covers 39 years of coverage estimates, from 1980 to 2018. DTP3 coverage is used as an indicator to assess the proportion of children vaccinated and is calculated for children under one year of age. The estimated number of vaccinated children are calculated using population data provided by the 2019 World Population Prospects (WPP) from the UN.

Image Credits: WHO.

[WHO/Europe Press Release]

Brussels, Belgium, 15 July 2019

Two new studies from WHO/Europe show that a high proportion of baby foods are incorrectly marketed as suitable for infants under the age of 6 months, and that many of those foods contain inappropriately high levels of sugar.

WHO’s long-standing recommendation states that children should be breastfed, exclusively, for the first 6 months. Its 2016 global Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children explicitly states that commercial complementary foods should not be advertised for infants under 6 months of age.

“Good nutrition in infancy and early childhood remains key to ensuring optimal child growth and development, and to better health outcomes later in life – including the prevention of overweight, obesity and diet-related noncommunicable diseases (NCDs) – thereby making United Nations Sustainable Development Goal 3 to ensure healthy lives and promote well-being for all at all ages much more achievable,” says Dr Zsuzsanna Jakab, WHO Regional Director for Europe.

Nutritional quality of products

WHO developed a draft Nutrient Profile Model (NPM) for children aged 6–36 months to guide decisions about which foods are inappropriate for promotion for this age group. This was put forward to Member States and stakeholders for consideration and further discussion.

WHO/Europe also developed a methodology for identifying commercial baby foods available in retail settings, and for collecting nutritional content data on labels as well as other information from packaging, labelling and promotion (including claims).

This methodology was used to collect data on 7955 food or drink products marketed for infants and young children from 516 stores in 4 cites in the WHO European Region (Vienna, Austria; Sofia, Bulgaria; Budapest, Hungary; and Haifa, Israel) between November 2017 and January 2018.

In all 4 cities, a substantial proportion of the products – ranging from 28% to 60% – were marketed as being suitable for infants under the age of 6 months.

Although this is permitted under European Union law, it does not pay tribute to the WHO International Code of Marketing of Breastmilk Substitutes or the WHO Guidance. Both explicitly state that commercial complementary foods should not be marketed as suitable for infants under 6 months of age.

“Foods for infants and young children are expected to comply with various established nutrition and compositional recommendations. Nonetheless, there are concerns that many products may still be too high in sugars,” says Dr João Breda, Head of the WHO European Office for the Prevention and Control of Noncommunicable Diseases.

In 3 of the cities, half or more of the products provided over 30% of the calories from total sugars. Around a third of the products listed sugar, concentrated fruit juice or other sweetening agents as an ingredient. These added flavours and sugars could affect the development of children’s taste preferences by increasing their liking for sweeter foods.

Although foods such as fruits and vegetables that naturally contain sugars are appropriate for infants and young children, the very high level of free sugars in puréed commercial products is also cause for concern.

The draft NPM for infants and young children was developed by following recommended WHO steps, and was informed by data from several sources, including a literature review. It refers to existing European Commission directives and Codex Alimentarius standards, and reflects the approach used for the WHO/Europe NPM for children over 36 months.

The draft NPM was validated against label information from 1328 products on the market in 3 countries in 2016–2017, and pilot-tested in 7 additional countries in 2018 with a further 1314 products.

Commercial foods for infants and young children in the WHO European Region (2019)
Ending inappropriate promotion of commercially available complementary foods for infants and young children between 6 and 36 months in Europe (2019)
Sustainable Development Goal 3
Guidance on Ending the Inappropriate Promotion of Foods for Infants and Young Children (2016)
International Code of Marketing of Breastmilk Substitutes (1981)

Image Credits: WHO/Europe.