A health facility in DRC’s Maniema receives donated health supplies to address an mpox outbreak in June 2022, but the country has yet to get a single mpox vaccine.

While the Democratic Republic of the Congo (DRC), the epicentre of mpox, has yet to get a single vaccine dose despite battling large outbreaks since 2022, a flurry of activity last week aims to finally change this.

Last Friday, UNICEF announced it had issued an emergency tender for the procurement of mpox vaccines.

Usually, the World Health Organization (WHO) has to issue an emergency use listing (EUL) or full approval before UNICEF or the vaccine alliance, Gavi, can procure vaccines.

But WHO Director-General Dr Tedros Adhanom Ghebreyesus clarified at a media briefing last Friday that the global body has given UNICEF and Gavi authorisation to waive the usual procedure to speed up the procurement of the vaccines.

The emergency tender allows UNICEF to set up conditional supply agreements with vaccine manufacturers that will enable it “to purchase and ship vaccines without delay once countries and partners have secured financing, confirmed demand and readiness, and the regulatory requirements for accepting the vaccines are in place”, said UNICEF.  

UNICEF is also coordinating vaccine donations with the vaccine platform, Gavi, the Africa Centre for Disease Control and Prevention (Africa CDC), WHO and Pan American Health Organization (PAHO).

Derrick Sim, Gavi’s interim chief vaccine programmes officer, said that the tender enables “UNICEF to purchase and deliver vaccines after Gavi and other partners make funding available and sign purchase or donation agreements with manufacturers for the most immediate dose needs”.

“Securing access to supply and financing, delivering doses, and in parallel ensuring countries are ready to administer them, are all vital actions that need to be conducted rapidly but thoroughly, and in a coordinated manner. We welcome this tender as another positive step our alliance and Africa CDC are taking in this response,” added Sims.

Meanwhile, Africa CDC Director General Dr Jean Kaseya said he expects the DRC to start receiving donated vaccines from the US and EU this week.

No approval for mpox vaccines

The WHO decision on EULs for the two vaccines – Bavarian Nordic’s Jynneous (also called MVA-BN) and the Japanese company KM Biologics’ LC16 – is expected in mid-September. As they are already authorised in the European Union and USA, this is expected to be straight forward. 

The DRC issued emergency use approval for the vaccines in late June, but some other African countries with mpox outbreaks – including Burundi, Rwanda, Uganda and Kenya –  have yet to do so.

This will make their access more difficult and once again underscores how useful and important the African Medicines Agency (AMA), currently in the process of being set up, will be in health emergencies. 

Over 18,000 suspected mpox cases, including 629 deaths, have been reported in the DRC so far this year. Four out of five deaths have been in children.

A health worker examines skin lesions that are characteristic of mpox on a child at an mpox treatment
centre near Goma in DRC, on 14 August 2024.

‘Scramble for funds’

The WHO estimates that $135 million is needed to address mpox. Currently, each mpox vaccine costs $100.

Helen Clark, former co-chair of the Independent Panel for Pandemic Preparedness and Response, called on Gavi and other donors to see whether they can use some $1.8 billion left in the COVID-19 vaccine platform, COVAX, for vaccine access for the mpox response. 

“This current scramble for funds is a major reason why The Independent Panel recommended the establishment of an emergency surge finance mechanism – a recommendation which is highly relevant right now,” said Clark in a statement issued on behalf of all active members of the Independent Panel.

“The most urgent focus and investment on the ground must be on rolling out and intensifying basic public health measures,” added Clark.

Focus on public health measures

“It is clear that existing diagnostics cannot be immediately scaled, the vaccines available are insufficient in number and will take time to deploy, and there currently is no proven treatment. 

The spread and harm of mpox can and must be reduced by public health measures that are tailored to the affected communities and to the transmission patterns of the local outbreak. This includes support to health facilities and health workers, and investment in community risk communication and engagement to ensure people understand the risks of both zoonotic infection and human-to-human transmission.”

Over the weekend, over 75 organisations under the Pandemic Action Network sent a letter to the G20 Health Working Group meeting currently underway, urging them to prioritise “the immediate need for resources, including vaccines, to address the mpox outbreak”. 

“The G20 must honour its commitment to prioritising prevention, preparedness, and response to pandemics, including boosting local and regional production of medicines, vaccines, and strategic health supplies,” the letter added.

Image Credits: Eugene Kabambi/ WHO, Guerchom Ndebo/ WHO.

A woman addicted to opium hides her face at a treatment centre in Mazar-i-Sharif.

KABUL, Afghanistan — On Kabul’s eastern outskirts, far from the bustling city centre, lies what locals call “the camp of addicts.” The Avicenna Drug Treatment Center, a massive compound enclosed by towering concrete walls, looms over the Afghan capital.

Within its gates, Afghans face forced rehabilitation in the Taliban’s escalating war on drug addiction, a nationwide crackdown that has intensified since the Islamist militant group reclaimed power in 2021. Nearly 10% of Afghanistan’s population — an estimated four million people — struggle with addiction.

“I was addicted to heroin for 10 years,” said Ehsanullah, a pale man in his late 40s, his voice quivering. “Two months ago, they brought me here to quit drugs. They beat me and warned me not to relapse.”

The Taliban’s methods are often violent. Drug users are forcibly detained using whips and guns, then held for at least 45 days. Their heads are shaved, and they are given inmates’ uniforms.

Overcrowding has forced many drug users into the same prisons that once held Taliban fighters under the previous government’s rule.

Modern drug treatments are virtually non-existent. Medicines like methadone, crucial for managing opioid withdrawal symptoms, are scarce.  International aid, which once supported this treatment, has evaporated since the Taliban’s return to power three years ago.

Ehsanullah’s younger brother, who has witnessed his sibling’s ongoing battle with opioid addiction, said the Taliban’s brutal methods are not working.

“Whenever he gets a chance to escape and return to addiction, he does, because he feels alienated, insecure and stressed in normal settings in society,” he said, adding that the Taliban’s methods are not backed by medical evidence.

Health experts agree. Maiwand Hoshmand, a psychologist at Kabul’s Avicenna Hospital, emphasized the complex nature of addiction, noting that family problems and mental disorders play a major role in Afghanistan’s addiction crisis.

“Forty-five days is considered a standard period for quitting addiction, but for patients who have mental problems, the process of leaving them continues for 90 days,” Hoshmand said.

Many people addicted to drugs spend much longer in recovery facilities and prisons than the 45 days prescribed by Taliban authorities. Radio Azadi, Radio Free Europe’s Afghan arm, reported prison stays of up to six months.

Those who are admitted must sign a pledge to stay off drugs and complete an assessment before their release. If they fail multiple assessments, their time in prison or the recovery facilities can be extended indefinitely.

The United Nations reported that the conditions at Avicenna Hospital – considered the ‘gold standard’ of drug treatment centers in Afghanistan – are “heartbreaking.” International funding has dried up, leaving underpaid, poorly trained staff to deal with patients. Food is scarce, and pharmacy cabinets are practically empty, forcing patients into shock detoxification.

“My children have no one to feed them,” one detainee, held for six months in a Taliban-run rehabilitation program, told the UN.

Afghanistan’s forgotten women addicts

Thousands of women in Kabul with drug addictions face a uniquely harrowing struggle. The women’s drug treatment facility, separated from the men’s and hidden from public view, can house only 150 addicts for 45-day stints.

Overcrowding means that hundreds of women sleep in hallways with barely enough food to survive. Survivors recount prison-like conditions.

Many share similar stories: they became addicted to drugs due to the influence of men or situations where men were the cause.

Mah Gul (a pseudonym), sits upright in her bed, her pale face and frightened eyes telling a story shared by women across Afghanistan.

“I had no idea he was addicted before we got married,” she said, recounting how her husband, unable to afford treatment for her chronic illness, introduced her to opioids to ease her pain. “He gave me poppy, and my pain eased. Whenever I got sick, I used more and more.”

Halima, a 27-year-old mother separated from her husband and children, says she was forced to resort to drugs to endure the separation.

“My husband was addicted and took my children away from me. He went to Iran, leaving me alone with no one,” Halima said. “I became addicted due to the pain of the loss of my children. I searched a lot to find them, but could not.”

The women’s struggles extend beyond addiction, revealing a complex web of substance abuse, domestic violence and societal pressures amid eroding rights under Taliban rule.

“They can’t keep me here for long once my 45 days are completed,” Halima added, her eyes darting nervously. “I am afraid of my husband. I have no place; I don’t have a job. I can’t go from here. What will happen if I stay on the street? I have no home or shelter.”

Women are feeling increasingly isolated under the Taliban with no rights to study or work. Recent edicts ban women’s voices from being heard singing or reading aloud in public, with the regime declaring a woman’s voice “intimate” and forbidden outside the home.

“Women with addiction should not be judged because they are dealing with an illness, with a disorder, that they cannot cure themselves,” said Haibatullah Ebrahimkhil, a psychologist in Kabul. “We should educate them about addiction.”

On Thursday, the Taliban’s Minister of Education extended the ban on women’s education – the only such ban in the world – even further: to speaking about it.

“Just as education for girls is banned,” he said, “questioning it is also banned.”

Taliban celebrates ‘success’ 

Before the Taliban takeover, around 100 drug treatment centres operated across Afghanistan. Today, only 61 remain, according to Taliban government figures. The withdrawal of international aid has left even surviving centres struggling to keep their doors open.

“Public healthcare facilities, especially tertiary hospitals … are struggling to cover essential running costs like staff salaries, medicines and medical supplies, fuel, and oxygen supply,” Médecins Sans Frontières, one of the last international organizations still working in Afghanistan, said in June, noting “the lack of long-term structural support for the health sector in Afghanistan.”

This has not stopped the Taliban regime from celebrating the perceived success of their strict counter-narcotics policies. The regime frequently conducts highly visible — and often violent — raids on addicts’ encampments, presenting these actions as evidence of their commitment to eradicating drug abuse.

In June, the Taliban held an opulent ceremony to mark the ‘Day Against Drug Abuse and Illicit Trafficking’ at Kabul’s Intercontinental Hotel, perched high above the city’s poorest areas where many addicts live.

The Intercontinental, which opened its doors in 1969 as Afghanistan’s first luxury hotel, has been a silent witness to the country’s turbulent history. It has seen seven different governments come and go and has stood through nearly half a century of continuous conflict since 1978.

Once a symbol of Afghanistan’s aspirations for modernity and progress, the hotel is now under Taliban management.

The Intercontinental, Kabul’s largest hotel is perched on the mountains surrounding the city. It has been a symbol of power in Afghanistan’s capital since it opened in 1969.

“Since the establishment of the Islamic Emirate, 54,374 drug addicts have been treated,” Abdul Wali Haqqani, the Taliban’s Deputy Minister of Public Health, declared from the Intercontinental ballroom.

Shams Al-Rahman Minhaj, representing the Ministry of Interior’s Anti-Narcotics Directorate, offered even higher figures: “Since the Islamic Emirate took power, 114,340 drug addicts have been collected and sent to addiction treatment centres. In 2023, 33,226 individuals were collected.”

Talib officials were joined by Jamshid Tanwali, a representative of the World Health Organization (WHO), who spoke on the concerning increase in addiction worldwide.

“In 2011, there were 240 million drug addicts globally; this number rose to 296 million in 2021,” Tanwali said. “Given the global increase, drug use in Afghanistan might also have risen.”

As addiction rates climb, Afghanistan’s opium production has plummeted under Taliban rule. UN figures show poppy cultivation in Afghanistan fell by 95% in 2023. Opium production dropped from 6,200 tons to 333 tons.

Myanmar has overtaken Afghanistan as the world’s largest opium producer, ending Afghanistan’s two-decade dominance of the illicit global market. At its peak in 2007, Afghanistan supplied 93% of the world’s illicit opiates.

Habibullah Aqli, a sociologist, argues that the current approach is insufficient. “There are three basic solutions,” he says, “identifying the main sponsors and drug growers, defining a legal mechanism for drugs and sellers, and developing a policy to address mental aspects of the addicts.”

The decline in opium production comes as the Taliban crackdown on a trade they long profited from. For two decades, the Taliban financed their insurgency through the opium trade, weaving a complex tapestry of economic dependency and addiction throughout Afghan society.

Now in power, the Taliban face the daunting task of dismantling a national crisis they helped create.

Stefan Anderson contributed reporting for this story. 

Image Credits: Jacksoncam, Olaf Kellerhoff.

US officials hand over the mpox vaccines to Nigerian health officials

Nigeria, accounting for just 1% of Africa’s confirmed mpox cases, has become the first African country to receive a vaccine shipment outside a clinical trial. 

This week, Nigeria received 10,000 doses of Jynneos, a vaccine manufactured by Bavarian Nordic and donated by the United States government.

“We are pleased to receive this modest initial donation of the mpox vaccine which is safe and efficacious,” Nigeria’s Minister of Health, Muhammad Ali Pate said. “We will continue to strengthen surveillance and be vigilant to prevent and control mpox.”

Leading up to the vaccine delivery, Dr Jean Kaseya, Director-General of the Africa CDC, confirmed that Nigeria was one of the two African countries to have issued regulatory approval for the vaccine’s introduction. 

Nigeria’s preparedness, marked by a robust vaccination plan, ensured its place at the forefront of receiving these doses.

According to Africa CDC’s latest epidemic intelligence report, nearly 21,000 suspected and fewer than 3,400 confirmed mpox cases have been reported across Africa this year. 

While the Democratic Republic of Congo (DRC) accounts for 95% of suspected and 90% of confirmed cases, Nigeria has only confirmed 40 cases and no deaths — a mere 1% of the continent’s total confirmed cases. 

Despite this relatively low number, Nigerian public health officials have raised the alert level and strengthened outbreak preparedness.

‘Very, very busy’

Dr Jide Idris, head of Nigeria’s frontline agency for disease prevention and control, the Nigeria Centre for Disease Control (NCDC), has had action-packed days since mpox was declared a public health emergency of international concern (PHEIC) – for the second time in two years.

The day after the announcement, Idris was too busy for interviews, his schedule crowded with preparations and briefings. 

The atmosphere at the NCDC’s head office was intense, mirroring the urgency felt across the country as teams worked tirelessly to monitor and coordinate response to multiple outbreaks. 

Meanwhile, requests for guidance on Nigeria’s mpox preparedness poured in. Between briefings for the health minister, press briefings and meetings with health commissioners from Nigeria’s 36 states, he found a few moments to speak to Health Policy Watch.

“It is very busy, very busy,” he said. “We do not have Clade 1b in Nigeria. All cases are Clade 2,” Idris said. 

Clade 1b is the new strain that is spreading fast in the DRC and neighbouring countries.

Idris outlined Nigeria’s three-pronged mpox response strategy: enhancing surveillance at ports of entry, boosting laboratory capacity for testing and genomic surveillance, and providing medical countermeasures (MCM) commodities.

Although mpox is currently classified as a PHEIC, the NCDC’s latest situation report for Nigeria shows a stable outlook: no surprises in case counts, no fatalities, and a consistent pattern in states reporting cases. 

There has been no change in cases since 18 August 18, when the cumulative case count for 2024 stood at 40 across 19 states. Only five states reported more than two confirmed cases: Bayelsa (5), Akwa Ibom, Enugu, and Cross River (4 each), and Benue (3).

Bayelsa, which reported the third highest number of confirmed cases (45) during the 2022 outbreak and ranked second the previous year, has consistently been among the top three states for mpox cases in Nigeria over the past eight years, except in 2020.

So far in 2024, children under the age of 10 years account for 35% of confirmed cases, followed by adults aged 31 to 40 years, who make up 20%.

“Before 2024, most of the confirmed cases were in young adults aged 10-40 years, with males being predominantly affected. In 2024, however, over 33% of confirmed cases are in children aged 0-10 years,” Idris told Health Policy Watch.

Beyond Nigeria and beyond vaccines

According to the official announcement, the 10,000 vaccine doses will be administered in a two-dose schedule to 5,000 individuals most at risk of mpox, including close contacts of confirmed cases and frontline healthcare workers. 

The vaccination exercise will primarily target the five states with recorded cases, with provisions for reactive vaccination in other states as needed.

With DRC not getting the first mpox shipment despite its central status in the outbreak, attention is on the global health players’ ability to let priority guide allocation and delivery of doses. 

Gavi CEO Sania Nishtar revealed that, aside from donations from the US government and the vaccine manufacturer, DRC can also access 65,000 doses of mpox vaccine from Gavi immediately after it makes a request to Gavi. 

However, Nishtar noted that the current supply of mpox vaccines will not be enough to reach everyone in Nigeria, the DRC or elsewhere that needs the shots hence the need to also bring attention to other areas, especially in the short term.

“The first response should be to boost areas such as surveillance, data collection, case management and community engagement: these important foundations are critical for helping us to understand and ultimately contain the outbreak,” Nishtar told Health Policy Watch.

Idris agrees. When asked what he thinks has uniquely positioned Nigeria to fully contain the spread of mpox without having to consider travel restrictions, he did not mention vaccine donations or any medical countermeasures. 

Instead, he acknowledged Nigeria’s vast experience in responding to multiple outbreaks including more fatal ones, and the “surge capacity” it has acquired already – capacity for coordinated response mechanisms, genomic sequencing and molecular diagnosis.

This is why Nigeria is one of the very few African countries reporting cases that do not have a wide gap between suspected and confirmed cases.

Image Credits: WHO.

A UNICEF staff member checks a polio vaccination shipment for Gaza’s vaccine campaign. The proliferation of untreated sewage and waste in wartime Gaza has led to the re-emergence of poliovirus.

BREAKING:  A massive polio vaccine campaign targeting some 640,000 Gaza children is now set to begin on Sunday, 1 September, with agreement by Israel for a three-day humanitarian pause in fighting, a senior WHO official said on Thursday. A second round of the campaign for the two dose vaccine is planned three weeks later. 

“We have had discussions with Israeli authorities and we have agreed to humanitarian pauses…for three days,” said WHO’s Dr. Rik Peeperkorn, speaking to reporters at a briefing at UN Headquarters in New York City.  “I am not going to say this is the ideal way forward. But this is a workable way forward…we have to stop [polio] transmission in Gaza and outside Gaza.”

“Of course, all parties will have stick to this. We have to make sure that everyday we can do this campaign in this humanitarian pause…it is an ambitious target of 90%, but the teams here are ready for it, we are ready to go,” said Peeperkorn.
He was referring to the nearly 11-months of Israeli-Hamas fighting that began 7 October with a bloody Hamas incursion into two dozen Israeli communities near the Gaza enclave in which 1200 people, mostly civilians, were killed and 240 people taken hostage. Following that, Israel launched a devastating invasion of Gaza in which some 40,000 Palestinians have died.
Against the backdrop of continued fighting, some 1.2 million polio vaccine doses reached the Gaza Strip on Sunday via Israel’s Kerem Shalom crossing, after arriving at Tel Aviv’s Ben Gurion airport the week before.
Inside Gaza, some 2,700 medical staff have been trained and poised for deployment at 400 vaccination points to ensure doses can be delivered to all eligible recipients in two stages, Palestinian health officials said.
Trucks carrying special refrigeration equipment for vaccine storage and transportation were also brought into the Gaza Strip by the United Nations Children’s Fund (UNICEF) last Friday. 

Distribution complicated by evacuation orders

UN agencies have pressed ahead with a planned polio vaccination campaign against the background of a rash of new Israeli military evacuation orders imposed on displaced Palestinians sheltering in designated “safe zones”.

Tens of thousands of Palestinians have been ordered move once again from parts of the central Gaza city of Deir al Balah as well as sections of Khan Younis in the south. The areas were among those previously designated by the Israeli army as humanitarian zones for the more than 1.2 million Gazans who have been internally displaced during the grinding war between Israel and the Palestinian Hamas.

“Mass evacuation orders are the latest in a long list of unbearable threats to UN and humanitarian personnel,” Under-Secretary-General Gilles Michaud said in a statement on Tuesday. 

“The timing could hardly be worse,” he added, referring to the polio vaccination programme that was about to start. 

Poliovirus was first detected in Gaza in late June by the Global Polio Laboratory Network. The virus was confirmed in six sewage samples from Khan Younis and Deir al Balah, cities in the south and centre of the 365 square kilometer Gaza Strip. 

In mid-August, three suspected polio cases in children were identified, Health Policy Watch reported, followed by the confirmation of one case in a 10-month old infant last week. As nine out of 10 polio cases are generally asymptomatic, the spread of the virus is likely far wider than reported cases. 

In response, WHO, UNICEF and UN Relief and Works Agency for Palestine Refugees (UNRWA) organised a vaccination campaign targeting over 640,000 children.  

Delaying the vaccinations would have serious consequences, Dr Hamid Jafari, the director of the WHO’s polio eradication programme in the Eastern Mediterranean warned on 23 August.

“The risk of this virus spreading into Israel, into the West Bank and into surrounding countries like Lebanon, Syria, Egypt and Jordan is high. So we need to act fast.”

Humanitarian pauses

To reach the intended vaccination target and gain better population immunity, WHO and other UN agencies had appealed for at least two humanitarian pauses of seven days to deliver the vaccine doses.

The pause in the grinding 11 month Israel-Hamas war is necessary to ensure a cold chain of the vaccines, as well as to guarantee the safety of patients reaching healthcare points and the right timing of the second dose, officials have stressed.

The operation in a conflict zone will be complex, and its outcomes will depend on the conditions on the ground, Sam Rose, Senior Deputy Field Director for UNRWA in Gaza stressed in a statement Monday. 

UN agencies and partners “stand ready to vaccinate children, but need a humanitarian pause. We and the rest of the system involved will do our absolute utmost to deliver the campaign,” Rose said, “because without it, the conditions will be much worse sadly.”

Overcrowding

Polio is a highly infectious viral disease largely affecting children younger than five years of age. It spreads between humans by a fecal-oral route or, in the minority of cases, through contaminated water or food.

One in 200 infections causes permanent paralysis and, in 2-10% of the paralysed, death. While there is no known cure for polio, the disease was mostly eradicated in the World Health Assembly-initiated Global Polio Eradication Initiative starting 1988. 

In some cases, the weakened virus present in the oral polio vaccine (OPV) can mutate and spread in communities not fully vaccinated against polio, especially in poor hygienic conditions or in overcrowded areas. The longer it is allowed to circulate, the higher the chance for further mutations, creating concerns about a large-scale outbreak.

Updated 29 August, 2024.  Elaine Ruth Fletcher contributed to reporting on this story. 

Image Credits: UNICEF.

Dr Faustine Ndugulile (centre) flanked by outgoing WHO Africa

Tanzania’s Dr Faustine Ndugulile has been nominated as the next Regional Director for the World Health Organization (WHO) African Region, defeating more experienced WHO insiders in a closely contested race.

Ndugulile secured 25 of the 46 votes at the WHO Africa regional conference in the Republic of Congo, defeating Dr Ibrahima Socé Fall (proposed by Senegal), Dr Richard Mihigo (proposed by Rwanda) and Dr Boureima Hama Sambo (proposed by Niger). 

Socé Fall has a high-profile position at WHO headquarters in Geneva and Mihigo has held global positions in the vaccine alliance, Gavi, and WHO.

Ndugulile, a former deputy health minister and ICT minister in his country, has represented the Kigamboni constituency in Dar Es Salaam as a Member of Parliament since 2010 and chairs the country’s parliamentary health committee.

He is also vice-chair of the global Inter-parliamentary Union’s advisory group on health. 

Aside from a medical degree, 55-year-old Ndugulile has a Masters degree in public health and a law degree. 

While representing Tanzania at the Pan African Parliament from 2015 to 2018, he chaired the Inter-Parliamentary Union (IPU) Advisory Group on Maternal, Child Health, Newborn, and HIV/AIDS from 2015 to 2017. 

In his CV, Ndugulile lists his notable achievements, including “championing the passage of the Universal Health Insurance Bill in 2023, advocating for the implementation of an integrated and coordinated community health worker program and successfully advocating for the ratification of the African Medicine Agency (AMA) convention”.

Describing himself as a “technocrat, politician and policy maker”, Ndugulile has promised to I “prioritize strengthening of WHO country offices to ensure timely, relevant, optimal and effective support to the member states”.

His nomination will be submitted to the WHO Executive Board meeting in January 2025, and he is expected to take office in February 2025 for a five-year term.

Ndugulile will succeed Botswana’s Dr Matshidiso Moeti, who has served two five-year terms at the helm.

“Dr Ndugulile has earned the confidence and trust of the Member States of the region to be elected the next regional director for WHO Africa. This is a great privilege, and a very great responsibility,” said WHO Director General Dr Tedros Adhanom Ghebreyesus. 

“I and the entire WHO family in Africa and around the world will support you every step of the way.”

Tedros also thanked Moeti “for the example she has set, and the legacy she has left”.

Moeti congratulated Ndugulile, describing the position as “extremely fulfilling”. 

“Despite the many challenges, I know you will take the baton and go on to accelerate the gains already made, putting the health and well-being of the people of Africa at the centre,” said Moeti.

The 50 cities evaluated in the City Heartbeat Index.

Hong Kong and London topped the list of 50 cities ranked for their efforts to prevent and address cardiovascular diseases – while Kathmandu and Cairo languished at the bottom.

The City Heartbeat Index is a first-of-its-kind initiative of the World Heart Federation (WHF), a Geneva-based non-profit that works on cardiovascular disease (CVD) prevention.

CVD is one of the top causes of death worldwide, according to the World Health Organization (WHO).

Preventing them could significantly improve public health and quality of life for the population living in a city.

The index evaluated cities using 44 indicators including social determinants of health such as poverty, environmental factors such as air quality, and health risks like hypertension, access to health services and health policies.

It used data from city government websites, health departments and published literature, along with interviews with local experts to validate findings and fill information gaps.

“This is the first attempt of this kind, and more importantly that it is going to enthuse the governments or the non-governmental organizations or the local bodies to be trying to do better,” said Dr Jagat Narula, president-elect of the WHF. “We are talking about the heartbeat index here, but it is actually going to give you a much broader vision and much better chances of working towards policies.”

While there were a few exceptions, cities in Asia and Africa performed the worst. Even high-income cities such as Riyadh and Kuwait City ranked poorly.

Hong Kong and London topped the list of the City Heartbeat Index.

“I am extremely proud of the work we have done to make London a healthier place to live. We have made real progress improving health outcomes by taking old polluting cars off our roads and bringing cleaner air to millions more Londoners, enabling more walking and cycling and promoting healthier food advertising on our transport network,” said London mayor Sadiq Khan.

The burden of CVD is driving action

Of the 10 highest scoring cities on the Index, four (Berlin, Toronto, Helsinki and New York City) are in countries with high burden of CVD.

Access to universal healthcare has also helped cities’ ranking.

“It is the factors of what is the will, how much is the advocacy, how the policy has resulted in all those things, whether there is a universal care. Or the National Health schemes, for example, in London and Madrid and other places where the healthcare is available to all,” Narula told Health Policy Watch.

Some cities in middle-income countries like Sao Paulo in Brazil and Bogota in Colombia have also done well, said Narula, emphasizing that resources are not a constraint when there is will.

Critical data is still missing

However, critical data is missing to evaluate cities. Few cities have data on food security (42%), cholesterol (22%) or transfat consumption (14%) – key risk factors for CVD.

This data would provide the first step in understanding the scale and scope of how key risk factors are affecting populations.

Only Jakarta and Singapore had data available for all 12 sub-indicators included in the Index, demonstrating intent to understand and address the factors affecting cardiovascular health.

Percentage of cities for which data are available on key factors impacting CVD risk

Cities prioritise some risk factors over others

Based on the average scores across the key CVD risk factors, cities most often prioritise diabetes (78.9), tobacco use (66.5), hypertension (63.0) and obesity (62.9).

High scores on these indicators are due to the presence of city-level data.

Other key risk factors, including levels of consumption of vegetables (45.8) and trans fats (53.9), and levels of physical activity (60.4) and cholesterol (31.8), have lower scores, which may indicate fewer city-level efforts to monitor and address these health concerns.

“The City Heartbeat Index shows that the many efforts by cities – where over half of the world’s population resides – on heart health are visible and increasingly important,” said Dr Vasilisa Sazonov at Novartis who sponsored the index.

“There are opportunities to improve data collection at the city level including prioritising CVD risk factors that have typically been overlooked such as high cholesterol,” said Sazonov.

Worsening climate impacts like heat were not a part of the report this year but Narula said that the indicators will evolve.

Image Credits: City Heartbeat Index Report.

Children are vulnerable to mpox due to contact with infected animals and poor immune systems.

The government of Japan is preparing to send donations of mpox vaccines to the Democratic Republic of Congo (DRC), the epicentre of the global outbreak, according to the Africa Centre for Disease Control and Prevention (Africa CDC).

The Japan-based KM Biologics makes LC16, the only mpox vaccine currently licensed for children. This is essential for Africa up to 60% of cases in the DRC and 43% in neighbouring Burundi are children under 10.

Most of the children infected in the eastern DRC are malnourished, which means that their immune systems are weak and susceptible to mpox infection.

Vaccine donations are also underway from the European Union (215,000 doses), the US (15,000) and Gavi (5,000), and the first vaccines expected to land on the continent next week, Africa CDC Director-General Dr Jean Kaseya told a media briefing on Tuesday. 

Bavarian Nordic’s Jynneos (also called MVA-BN), is the other vaccine expected. This is not yet licensed for use in children but the company said it had recently submitted clinical data to the European Medicines Agency “to potentially support the use of the mpox vaccine in adolescents (12–17-year-olds)”. 

This follows a clinical study involving over 300 adolescents completed with the US National Institute of Allergy and Infectious Diseases (NIAID).

“Furthermore, through a collaboration with the Coalition for Epidemic Preparedness Innovations (CEPI), the company will shortly initiate a clinical trial to assess the immunogenicity and safety of MVA-BN in children from 2-12 years of age, aiming to further extend the indication of the vaccine into younger populations,” the company added.

Bavarian Nordic confirmed that it was working on tech transfer to enable African manufacturers to make the vaccine, which Kaseya told the briefing would involve the end process of “fit and finish”.

The African Union has made $10 million available to address the outbreak, and this is being used to prepare countries to receive and distribute the vaccines and improve surveillance, said Kaseya.

Gabon reports first case

Meanwhile, Gabon is the latest country to report an mpox case as cases continue to rise on the continent – up almost 2000 to 22,863 cases since last week.

However, Kaseya said that the Africa CDC was concerned that this was an undercount given weaknesses in surveillance, with some countries only able to test around 18% of suspected cases.

To address this, Africa CDC is deploying 72 epidemiologists to the outbreak hotspots to enhance surveillance and data quality.

Kaseya also confirmed that the Africa CDC had met close to 200 partners to galvanise support for mpox response, and had been assured via a foreign ministers’ forum that Western countries would not impose a travel ban on people from outbreak areas.

Kaseya also said that Gavi and UNICEF had been given the go-ahead from the World Health Organization (WHO) to procure vaccines for the continent even though the outcome of the WHO’s emergency use listing (EUL) of the two mpox vaccines was only expected in mid-September.

The EUL procedure fast-tracks unlicensed medical products in public health emergencies. As the vaccines are already licensed in the US and European Union so the EUL is likely to be issued.

The WHO has been criticised for being too slow to evaluate potential mpox vaccines already approved by the US and Europe, thus leaving Africa dependent on donated vaccines.

“Currently, we are putting all African countries’ efforts in one basket. This is why we say we are finalizing the response plan, and we have a meeting in September where countries will also pledge funding [for the outbreak],” said Kaseya.

Image Credits: Tessa Davis/Twitter .

Dr Tedros addressing the WHO Africa regional meeting on Monday.

The World Health Organization (WHO) will decide on whether to issue an emergency use listing (EUL) for an mpox vaccine within three weeks after its manufacturer supplied the global body with all the required information last Friday, Director-General Dr Tedros Adhanom Ghebreyesus told the opening of the WHO Africa regional conference on Monday.

The WHO has been criticised for being too slow to evaluate potential mpox vaccines already approved by the US and Europe, thus leaving Africa dependent on donated vaccines.

Africa’s biggest vaccine procurers, Gavi and UNICEF, are unable to buy vaccines without either EUL or full WHO approval.

The EUL procedure fast-tracks unlicensed medical products in public health emergencies, and Bavarian Nordic’s Jynneos (also called MVA) and Emergent BioSolutions’s ACAM2000 vaccines have both been recommended for consideration by independent health experts. 

Continent needs $135 million for mpox

Tedros added that it will take around $135 million to bring the current mpox outbreaks in Africa under control, requiring “a complex, comprehensive and coordinated international response”. 

The WHO also published a Global Strategic Preparedness and Response Plan for mpox on Monday setting out steps to address the outbreak. 

“So far this year, more than 18,000 suspected cases of mpox, with 615 deaths have been reported in the Democratic Republic of Congo alone, already exceeding last year’s total, which was itself a record,” Tedros told the meeting, which is being held over five days in the Republic of Congo (Brazzaville).

“Of particular concern is the rapid spread of a new strain of the virus that causes mpox called clade 1b in the countries. In the past month, more than 220 cases of clade 1b have also been confirmed in four countries neighbouring DRC, which had not reported mpox before, Burundi, Kenya, Rwanda and Uganda.”

Tedros also commended the WHO Africa region for improvements in primary healthcare across the continent, as well as a 50% increase in funding for the WHO provided by member states.

“District Health Systems have been strengthened. Access to essential medicines is improving. The capacity of the health workforce is increasing, and community health communities are functioning effectively,” said Tedros.

Conference praises outgoing director

Dr Matshidiso Moeti, outgoing WHO Africa regional director

Botswana’s Dr Matshidiso Moeti, the outgoing WHO Africa regional director, told the conference that “economic difficulties, which include debt servicing, growing wealth inequalities and conflicts, are slowing down investment in priority health programmes”.

Poorer African countries are experiencing “deteriorating conditions below 2019, pre-pandemic levels”, making it “even more difficult to achieve the sustainable development goals health targets”.

“As a region, we must unite and encourage the rest of the world to join forces against the major threats of the 21st century, especially climate change, the next pandemic and non-communicable diseases,” Moeti urged.

“These threats, demand, international collaboration. They require government leadership and the public and private sectors to work together with fairness.”

Moeti added that the WHO country teams are “working on the frontline to help reinforce measures to spread to to curb the spread of mpox”, and in partnership with the African Union, “we continue to advocate for the necessary diagnostic therapeutic tools and vaccines”.

Moeti also raised the emigration of African health workers, and called for the implementation of the Africa Health Workforce Investment charter which was luanched in May.

“In Uganda, the immigration of doctors increased by 16% in three years, while in Zimbabwe, during the same period, over one in five doctors has left the country in May,” Moeti noted.

Moeti, who was appointed in 2015 and served two terms so is not available for re-election. She has overseen WHO’s operations through trying circumstances, including Ebola outbreaks and the COVID-19 pandemic.

“Never before has healthy life expectancy been so high in the African region. Never before have fewer young children died each year, or fewer women died of maternal causes. Never before have we responded to emergencies in so short a time. Never before have malaria vaccines been introduced into routine child immunization schedules in Africa, and this after centuries of waiting,” said Moeti, who described her term as the “highest honour of my life”.

Dr Matshidiso Moeti, the outgoing regional director, who served the continent for 10 years during some of its toughest challenges, gets a standing ovation at the WHO Africa regional conference.

Tedros described Moeti as “one of the most formidable health professionals I have ever had the privilege to call my colleague”.

“She is not afraid to tell you exactly what she thinks, but she does it because she cares. She cares deeply about the people of our continent and the people of the regional and country offices. She believes that the people of Africa deserve nothing but her best, and that’s what she has given for the past 10 years,” said Tedros.

“Under the leadership of Dr Moeti, WHO Africa region has been leading a transformation agenda to ensure that the organisation is accountable, effective, and driven by results,” said Botswanan health minister Dr Edwin Dikoloti.

“In this regard, we are pleased that many countries have now undertaken reforms to improve health financing and the delivery of quality essential health services.” 

Hotly contested leadership race

On Tuesday, the conference will elect a new regional director with five males candidates contesting for the position. 

Senegalese Dr Ibrahima Socé Fall, proposed by his home country, is currently the WHO director of Global Neglected Tropical Diseases (NTD). 

Dr N’da Konan Michel Yao, proposed by his home country of Côte d’Ivoire, has been WHO Director of Strategic Health Operations since August 2020, where he coordinates the body’s response to health, natural and humanitarian disasters.

Dr Richard Mihigo, proposed by Rwanda, is currently senior director of programmatic and strategic engagement with the African Union and Africa CDC. 

Dr Boureima Hama Sambo, proposed by Niger, is WHO’s Representative to the Democratic Republic of the Congo as Head of Mission. 

Dr Faustine Engelbert Ndugulile, proposed by Tanzania, was that country’s Minister for Communication and Information Technology between December 2020 and September 2021 and has also served as a deputy minister of health.

 

Air pollution remote sensor India
Remote sensing equipment and camera capturing real-world emissions data of vehicles as they drive by. The data is then matched with the transport department’s database using the registration number clicked by the camera.

New Delhi’s decades-old regime to control vehicular pollution, including a heavy reliance by commercial vehicles on compressed natural gas (CNG) fuel, has been challenged by a new study by the International Council on Clean Transportation (ICCT). 

The report upends the narrative the that CNG is a ‘clean’ fuel, pointing to its high level of health-damaging emissions of nitrogen oxide (NOx), which can damage children’s lung development and contribute to a range of chronic lung diseases.

The report is based on innovative remote sensing technology that monitored actual traffic flows. Its results challenge two critical policy interventions: the mandate for buses and taxis to use CNG, as well as a Pollution Under Control Certificate (PUCC) surveillance system.

Electric bus in India
ICCT calls for replacing CNG with zero-emission vehicles.

The PUCC requires every fossil-fuel powered vehicle to undergo regular emissions checks, with car owners facing fine if they do not have an up-to-date certificate. 

However, the ICCT report highlights how the PUCC inspections fail to capture emissions of the two biggest polluters – NOx and Particulate (PM2.5) – as well as failing to reflect the level of real-time emissions on city roads.

Its authors point out that both automobile tech and air pollution monitoring have become a lot more sophisticated and the PUCC tech has not kept up. 

Vehicle emissions, according to some estimates, contribute as much as 38% to Delhi’s pollution. 

Famous for exposing ‘dieselgate’

The ICCT is famous for exposing Volkswagen for falsifying real-time data on NOx vehicle diesel emissions in its reporting  to the US Environmental Protection Agency in 2015. The scandal, widely known as ‘Dieselgate’, led to a global reconsideration of diesel engines and their health impacts, in terms of excessive particulate emissions as well as NOx.

It conducted this India study on CNG vehicles with the support of the local transport and police departments in Delhi and Gurugram, on its southern border. The two cities are among the 20 most polluted globally. 

“For the first time in India, we have collected significant emissions data from motor vehicles on the road and it is crucial to remember that what impacts our air quality is not the laboratory emissions but the pollutants released by these vehicles when they are in operation. Therefore, it’s time to reimagine our emissions testing regime and aggressively push for the adoption of zero-emission vehicles,” said Amit Bhatt, India managing director of ICCT.

Dehli air pollution sources graph
Why road transport emissions are important to tackle air pollution in Delhi.

CNG is not a ‘clean’ fuel

According to the study, CNG vehicles emitted very high levels of nitrogen dioxide and other oxide of nitrogen  (NOx) emissions, challenging the narrative that CNG is a ‘clean’ alternative fuel.

NOx causes shortness of breath, irritation in the eyes, nose and throat in acute exposures. But there’s also substantial evidence of excess rates of asthma and impeded lung development amongst children growing up along busy highways where NOx emissions are high. Chronic NOx exposure can lead to the development of a range of lung diseases in the long term. For example, some light goods vehicles, commonly seen ferrying vegetables and other supplies in the city, emit up to 14.2 times their lab limits, and taxis are four times. 

“This shows that while the CNG transition has helped cut toxic particulate emissions from diesel vehicles during the early years, NOx emissions from on-road CNG vehicles without adequate controls can be high. This builds a case for the next big transition to electrification to make tailpipe emissions not cleaner but zero,” said Anumita Roychowdhury, executive director of the Centre for Science and Environment, one of India’s foremost air pollution experts.

The report found that tougher engine standards have helped reduce NOx emissions. The latest Indian standard, Bharat Stage 6 (BS6), which is comparable to a Euro 6 engine, shows a reduction in real-world NOx emissions from private cars of 81% and buses by nearly 95% as compared to Bharat Stage 4 (comparable to a Euro 4). Of the over 110,000 vehicles sampled by the ICCT study, 55.5% are BS 4, and 33.5% are of BS 6. (See figure below.)

 

Proportion of fleet at Bharat Stage 1 to Bharat Stage 6 , in ICCT study.

Commercial vehicles pollute more than private cars

One clear trend the study identifies  is that commercial vehicle emissions are higher than private vehicles. 

In the BS6 four-wheeler category, light goods vehicles (LGV) had five times higher NOx emissions, seven times higher carbon monoxide emissions, and five times higher hydrocarbon emissions than private cars.

Meanwhile, in comparison to taxis, light goods vehicles had double the NOx emissions, six times higher carbon monoxide emissions, and four times higher hydrocarbon emissions.

However, commercial taxis were consistently far more polluting than private cars within the passenger car segment, indicating poor maintenance. There were also multiple instances where three-wheelers, mostly running on CNG, had higher emissions than passenger cars.

Innovative remote sensing technology 

ICCT used a remote sensing technology to measure the emissions of vehicles on roads as they drove past the sensors. At each of the 20-odd sites, machines about the size of large microwave ovens were placed on either side of a road lane. It took a split second to capture the emissions data. Simultaneously, a camera snapped a picture of the vehicle and licence plate. The emission data was matched with the registered vehicles database. Over 110,000 vehicles were monitored across four months in early 2023.

Remote sensing equipment and camera capturing real-world emissions data of vehicles as they drive by. The data is then matched with the transport department’s database using the registration number clicked by the camera.

Now, the ICCT is calling for the remote sensing system to be implemented as a regular monitoring system. It points out how air pollution has shut down schools in Delhi and Gurugram and how harmful it is to human health and the local economy.

Current vehicle pollution-check system unreliable 

While the ICCT says the system can complement the over two-decade-old PUCC system, it could render the PUCC obsolete. The latter does not measure on-road emissions; it only measures when the vehicle is parked. 

The PUCC monitors CO and HC but not particulate matter or NOx, which are major contributors to pollution in this region. 

There also are concerns that the PUCC data can be manipulated, especially in states where it’s recorded manually. The low failure rates, the report says, suggest a need to reconsider the reliability and authenticity of the tests. All of this suggests a broken system.

ICCT’s presentation on the real-time sensing points out gaps in the current vehicle pollution control regime.

Swagata Dey, an air quality policy specialist at the Centre for the Study of Science, Technology and Policy (CSTEP), has spent years studying the PUCC system.

She says this is “not effective in controlling real-world emissions. So, in this case, the remote sensing technique is welcome, but we also have to find a way to scale up the process… Further, we have to ensure that results from such methods are acceptable in the court of law.  Without this [legal recognition of the remote sensing technology], vehicles cannot be asked to comply with this test for obtaining PUCC certification.”

The policy stage, however, has been long set for the wider adoption of a more accurate pollution monitoring regime. India’s Supreme Court, the National Green Tribunal, India’s top dedicated environment court and federal pollution control agency, have all called for implementation of more accurate vehicle surveillance for some years. 

ICCT’s table shows how the remote sensing tech compares with India’s emissions compliance test, the PUCC.

Kolkata authorities have been using remote sensing since 2009, the study’s authors point out, even initiating action against vehicle owners based on readings. 

Globally, the system has been used extensively in places like London, Paris, and Hong Kong. 

What the ICCT report offers is new scientific evidence to overhaul or even replace the PUCC regime. It also challenges the notion that CNG can serve as an alternative, clean fuel to diesel and petrol.

For about two decades both concepts have been the bedrock of policy action to reduce vehicular pollution, a significant contributor to India’s air pollution crisis.  Debunking these misconceptions, can jump-start the dialogue about truly sustainable solutions. 

Image Credits: ICCT, Chetan Bhattacharji/HPW.

How did vaccines, once hailed as essential tools for global peace, security and international cooperation, become something that some now fear could kill them?

This is the focus of the latest episode of the Global Health Matters podcast, hosted by Garry Aslnyan. In an interview with author Peter Hotez, the discussion delves into how misinformation and politics, particularly in the United States, have led to a deadly distrust of vaccines.

Hotez and his colleague, Maria Elena Bottazzi, were nominated for the Nobel Peace Prize for “their work to develop and distribute a low-cost COVID-19 vaccine to people of the world without patent limitation.” Hotez is a vaccine scientist, biochemist and paediatrician from Texas. He also wrote several vaccine-related books, including “The Deadly Rise of Anti-Science.”

Aslnyan said vaccines are “one of the most powerful biotechnologies ever invented. It has not only had an effect on life expectancy, as we know, but also, it’s a vital tool for peace, global security and international cooperation.” Yet — and this is the topic of the “Dialogues” podcast — when COVID-19 hit, the situation rapidly changed. By the summer of 2021, there were calls to be defiant against vaccines, Hotez told Aslnyan.

“What happened was that under the banner of health freedom, medical freedom, elected leaders from a political party were telling people, we’re railing against vaccine mandates pushing against the idea of vaccine mandates, but they took it a step further,” Hotez said. “They not only tried to discredit vaccine mandates, but they tried to discredit the effectiveness and safety of the COVID vaccines themselves, and by crossing that line, they basically convinced hundreds of thousands of Americans, millions of Americans, predominantly in conservative parts of the United States, Texas, Oklahoma, Arkansas where I am, not to take a COVID vaccine during the Delta wave.

“So, they were unvaccinated. The results were, again, predicted and predictable,” he continued. “My estimate is 40,000 people in my state of Texas needlessly died because they refused a COVID vaccine.”

From Scientist to Public Enemy

In his book, Hotez describes how he received “dark emails or tweets on a Sunday that ominously warn of patriots hunting me down.” He said, “I never imagined a segment of society turning against me or my scientific colleagues. It is still almost unbelievable how many Americans now view us as enemies.”

He noted that this phenomenon has spread beyond the United States, reaching Africa, Latin America, and Europe. The concern now is that it could also take root in low- and middle-income countries.

“This is a full-on negative global force. I worry now that it’s not stopping at COVID-19; it’s spilling over into childhood immunisations,” Hotez told Aslnyan.

Hotez said that he called out the far right for contributing to the unnecessary deaths of 200,000 Americans for political reasons, “it’s not misinformation or the infodemic as though it’s just some random junk on the internet; it’s organised, strategic, deliberate, well-financed, politically motivated and it’s killing people.”

This misinformation about vaccines has entered a new phase. Instead of acknowledging that people died because they didn’t get vaccinated, some now claim that the vaccine itself caused deaths. There is also the theory that scientists created the COVID-19 virus through gain-of-function research. Hotez emphasised that both of these ideas are baseless.

However, he said the public health community also had to take responsibility for where it failed, which was around communication about the vaccines.

“I could do a whole hour podcast with you on the ways in which we could have communicated better,” Hotez told Aslnyan, “but that, in my view, accounts for 10 to 20% of the problem at most because what was really going on were bad actors weaponising all of this.”

And, as he concludes with an excerpt from his book, “This will only get worse.”

Listen to the Global Health Matters podcast on Health Policy Watch.

Visit the podcast website.

Image Credits: TDR Global Health Matters Podcast.