Daniel Kass

Health is becoming more prominent in the climate debate in light of the mounting human toll from extreme weather – and that’s only the tip of the ’iceberg’, in terms of what lies in store, says Daniel Kass, senior vice president at Vital Strategies and former Deputy Commissioner of Health for New York City. But health alone is not enough to move the political needle. As the world leaders gather Monday for the UN Climate Summit, to face what UN Secretary General António Guterres, has described as the “Battle of our Lives”, health advocates need to band together with other constituencies in a united front. Kass talked with Health Policy Watch about the issues at stake in the lead-up to Monday’s Summit.

Health Policy Watch:  What do you expect to be the main health-related aspects of climate change that will be discussed at the UN Climate Summit?

Daniel Kass: The evidence about the health impacts is growing, and that will help to focus attention on health at the meeting. It is always easiest to discuss the direct effects of climate change – in particular, weather-related mortality and illness, for example heat stroke and heat-related mortality, coastal flooding and drowning.

But more emphasis needs to be placed on the indirect impacts, and rightfully so, as they are far greater, and more far-reaching. These include impacts that are already with us – heart disease, respiratory disease and deaths from global increases in air pollution; deaths from resurgent vector-borne diseases like malaria as well as from novel vector-borne infections like Zika virus, which tend to spread more widely to human settlements as a result of deforestation, urbanization and related habitat changes.

Still, with the rapid pace of change, there needs to be more discussion about still more indirect impacts. This would include consideration of issues such as:  catastrophic outcomes including malnutrition from disruptions in food supplies; health impacts of water stress/shortages and indirect impacts from increases in water-related conflict and migration; and the potential for social safety net collapse as more resources are diverted to coping with climate-related mitigation.

A woman carries supplies through a flooded street. Thousands of people were displaced by unprecendented flooding in Haiti in 2014. Photo: Logan Abassi UN/MINUSTAH

HP Watch: This is a formidable list.  What are the main challenges to addressing it more effectively?

DK: The current breakdown in global economic and political cooperation is a huge impediment to progress. It is extremely difficult to manage more sustainable production of energy; standards for industrial processes and global commodities like vehicles; and harmonized trade rules and manufacturing standards necessary to address climate-related emissions. Progress depends on finding common ground based upon mutual self-interest. Perhaps the catastrophic threats from climate change will unify the world. But rising nationalism and the political marketing of self-interest does not make me hopeful, in the near term.

HP Watch:  The recent IPCC report also highlighted threats to food security, including the need to reduce meat consumption to ensure a sustainable food supply for a growing population. Do you see this as broadening the health agenda? And what are the concrete implications for the health sector? After all, a recent WHO nutrition report ignored warnings of health risks associated with red meat consumption, including from its own cancer researchers.[1]

DK: Carbon emissions reductions from greater reliance on renewable energy will have enormous health and economic co-benefits. So too will shifts in land use, in particular from reducing the impact of meat production— mammalian in particular.

Diets lower in meat and higher in variety and with greater caloric and nutritional needs met by grains, fruits, and vegetables, bring health benefits at individual and population levels. Remember, as well, that most of the world already lives without ready access to meat – especially beef. While it’s important for health advocates to join the call for more rational and less carbon-intensive food production, it is also important that as population and net global wealth grows, this does not come with a proportional increase in meat consumption. The challenges for nutritionists, agronomists and others are different while they work toward the same aims.

Climate advocates in the West should not get caught in the trap that may be set by proponents of the status quo. Industry wants to frame this as a consumer freedom issue, and sometimes advocates direct their efforts at consumers rather than the corporate and governmental policy actors that bear primary responsibility for reversing trends in CO2 emissions. That’s just what the food, fossil fuel and land oligarchs want to happen.

HP Watch:  Reducing climate emissions from fossil fuel sources, which also cause health harmful air pollution, means scaling back industries such as coal, automobiles, etc., which are lobbying hard to maintain their economic foothold, and even expand in low- and middle-income countries. What forms of political action and policy measures will be necessary to ensure change? 

DK: All of the work that must be done is ultimately political. There is greater public acknowledgement that the status quo cannot be maintained, and there remains no rational economic argument for doing so (once the true health and planetary costs of pollution and climate emissions are accounted for). Broad categories of policies that must be expanded or initiated include:

  • Eliminating subsidies on dirty fuels; shifting incentives to support clean tech innovation and solutions;
  • Prohibiting the dumping of dirty, inefficient vehicles and the export of superannuated technologies like coal-to-electricity to developing countries;
  • Incentivizing healthy and sustainable shifts in consumer and individual behavioural choices, around food, transport, and diet, for example;
  • Reorienting regulations toward steep improvements to achieve specific benefits and outcomes, rather than modest incremental improvements on the status quo.

This will require redirecting development funding toward green industries, and imposing conditions with sanctions for failing to meet goals. The greatest spending must happen where the greatest emissions are, and those countries (middle- and high-income countries) will only do so if there is a strong political movement to demand it. There are very positive signs that this is occurring – enabling health and climate advocates to advance calls for policy change. And people are mobilizing around the difficult issues of societal reorganization. The world’s nations spend nearly USD $2 trillion each year on militaries. Investing in planetary survival has a far greater return on investment than war.

HP Watch: Can you speak to the role of cities in reducing climate change and its related health impacts? And do you see the Climate Summit as a key event in planning and preparing for such changes?

DK: There is good reason to think cities will be central to the Summit, and central to potential solutions. The challenges are profound: The world is increasingly urbanized, and this trend is projected to continue. Cities suffer a commensurate global health and economic burden from climate change and air pollution, and a large proportion of urban populations are extremely vulnerable to climate change, loss of habitable area from rising sea levels, drought and flooding, all made worse by the informality of new urban settlements in low-income countries.

Cities can lead the way in mitigation and adaptation, but they typically don’t have the fiscal, political or regulatory authority to do it alone. There is good reason to believe that greater urbanization will ultimately support mitigation. Cities in the industrialized world typically have lower per capita CO2 emissions compared to their suburbs because of their efficiency, density, verticality, and availability of mass transit. Some cities are rethinking the place of automobiles and moving to regulate their own purchase of energy from renewable sources. We need to ensure that we increase knowledge and promote uptake of successful strategies so that more cities follow suit.

HP Watch:  While awareness of the human health impacts of climate change is growing, it still doesn’t seem to be sufficient to drive the kind of dramatic commitments that the SG has in mind.  Will some countries deliver? And if not, what does the world do on the day after the Climate Summit? 

DK: I think of health impacts as a necessary but insufficient way to mobilize additional constituencies around the impacts of climate change. Research and modelling show that the burden of death and disease from more extreme weather, population displacement, more widespread and novel infectious and vector-borne diseases, stress, negative birth outcomes (and the list goes on and on) will overwhelm even wealthy countries’ health systems and exhaust governmental resources in lower income countries. And these impacts are already being felt. Some people, organizations and institutions are motivated by health concerns and they need to be mobilized. Others are mobilized by environmental concerns or economic risk, others by their faith. The threat of irreversible and dramatic climate change can unify these communities. And the desire to avoid dissent is a great motivator for governmental action.

Some countries are already delivering, both in terms of energy transformation and funding to support global work. Others are cynically running in the wrong direction. Local governments, which feel the impacts earliest, are responding globally, but require national and international commitments to make an impact. Following the Climate Summit, the world needs to study the results and ask whether their representatives are serious, whether they are prepared to take rapid action, whether they can be counted on. If the answers are “no,” they should do everything they can to ensure that their term in office is short-lived.

Note: Kass is senior vice president of environmental health at Vital Strategies, a global health organization that works with governments and civil society in 73 countries to help them make rapid progress against cancer, heart disease, obesity, tobacco use, epidemic diseases, drug overdose, road crashes and other leading causes of disease, injury and death. Previously, Kass was Deputy Commissioner for the Division of Environmental Health Service at the New York City Department of Health and Mental Hygiene.

Elaine Ruth Fletcher contributed to this article

 

This story was published as part of Covering Climate Now, a global collaboration of more than 250 news outlets to strengthen coverage of the climate story, co-founded by The Nation and Columbia Journalism Review.

 

[1] International Agency for Research on Cancer (IARC)

Image Credits: Logan Abassi UN/MINUSTAH.

NEW YORK – As heads of state and international organisations gather for the 74th United Nations General Assembly, Monda‎y’s High-Level Meeting on Universal Health Coverage (UHC) is one of the key events of this session. It aspires to elevate access to quality healthcare for the global population by 2030, and one billion more people by 2023.

The stated aim of the event, “Universal Health Coverage: Moving Together to Build a Healthier World,” is to “accelerate progress toward universal health coverage (UHC), including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all.”

A draft UHC political declaration (note: text starts on p.3) – stripped of controversial language over thorny issues like sexual and reproductive health, and finalized last week – is to be approved at the High Level Meeting. It commits governments to the stated UHC aim of covering one billion more people by 2023, and all people by 2030 (paragraph 24). It also commits governments to halt rising out-of-pocket health expenditures by providing greater financial risk protection (such as insurance) for healthcare procedures.

A nurse consults her patient with family planning needs. Sexual and reproductive health has been a controversial issue in the UHC debate. Photo: Dominic Chavez/World Bank

While the lofty vision of this far-reaching effort is further detailed in the 11-page declaration text, observers will look to leaders’ statements for signals of how concrete actions may follow.

Some two dozen heads of state are said to be planning to attend Monday’s UHC session at the General Assembly (GA), which began Wednesday and runs to 30 September.

The draft agenda for the one-day UHC meeting shows a mix of plenary segments with government statements, and two panels. There may be more than two dozen heads of state in attendance, according to sources.

In the draft version of the agenda, panel speakers included: the prime ministers of Bangladesh and Spain; the heads of the UN, WHO, World Bank, UNHCR, GAVI, Oxfam, and Medtronic; and well-known political figures such as former WHO Director General Gro Harlem Brundtland (the “Eminent High-Level Champion of UHC and member of the Elders”); Jeffrey Sachs founder of Columbia University’s Earth Institute; former New Zealand Prime Minister Helen Clark, now the Board Chair of the Partnership for Maternal, Newborn & Child Health; and Keizo Takemi, member of the Japanese House of Councillors and WHO UHC Goodwill Ambassador.

A series of side events are taking place around the High-Level Meeting, many of which are open to all. A list of side events UHC2030 is hosting or co-organizing during the General Assembly is here. A list of further events during the General Assembly is in the UNGA guide 2019.

The UN has, in recent years, stepped up its high-level political attention to health issues, with a landmark declaration on AIDS, and in last year’s GA session, high-level meetings on non-communicable diseases, and tuberculosis. Observers argue, however, that such meetings lead to optimistic language but not enough concrete progress. From a development perspective, achieving UHC will require governments to take the broad declaration and fit it to their specific national needs, while increasing outlays for stronger health systems.

“Next week’s High Level Meeting on Universal Health Coverage is a window of opportunity that we need to seize,” Francesca Colombo, head of OECD’s Health Division, told Health Policy Watch. While acknowledging that the declaration sets ambitious aims, she said that drawing attention to the UHC issue at the UN’s highest level was already a “tremendous achievement.”

However, she acknowledged that the declaration and the High Level Meeting were just the beginning of the journey. “It’s unfinished business.” she said. “Much more needs to be done to draw attention to health as a critical economic development issue.”

Political Declaration

The final political declaration contains 83 paragraphs that capture the remarkably broad scope of global and public health issues such as health systems, financing, emergencies, health workers, gender, children, aging, migrants and refugees, discrimination and violence, communicable and non-communicable diseases, digital health and data, access to health technologies, and partnerships.

The declaration contains calls to use all levels of policymaking, governments, regions and the multilateral system and existing agreements, and details dozens of specific topics, such as eye and oral care, mental health, protection in armed conflict and humanitarian issues, sanitation, safety, healthy diets, and neglected diseases. It has numerous references to improving women’s health and involving them more completely in health care, and it stresses that primary health care is essential for UHC.

A core focus of UHC efforts is on financing and budgets, but no specific commitments are made, despite the many mentions throughout. The declaration does, however, cite the WHO’s recommended target of public spending of 1 percent of GDP or more on health. It also cites WHO estimates that an additional US$ 3.9 trillion in global spending by 2030 could prevent 97 million premature deaths and add between 3.1 and 8.4 years of life expectancy in LMICs.

The declaration repeatedly cites the need for affordable health care and medicines, vaccines and diagnostics, and urges bolstered domestic budgets and global coordination through financial groups like the Global Fund for AIDS, Tuberculosis and Malaria. It also mentions a growing strategy of pooling resources allocated to health, and it gives a clear message about the importance of private sector funding and contributions.

The declaration also highlights statistics showing the magnitude of need for stronger health systems to fulfill the aims of UHC – such as the shortfall of 18 million health workers especially in low- and middle-income countries.

And it declares “that action to achieve universal health coverage by 2030 is inadequate and that the level of progress and investment to date is insufficient to meet target 3.8 of the [SDGs], and that the world has yet to fulfill its promise of implementing, at all levels, measures to address the health needs of all.”

SDG 3.8 states: “achieve universal health coverage (UHC), including financial risk protection, access to quality essential health care services, and access to safe, effective, quality, and affordable essential medicines and vaccines for all.”

The text’s preamble of 23 paragraphs describe problems and shortfalls in the global, regional and national efforts in health, stating that in many cases efforts are not on track to fulfill the SDGs by 2030 and must be stepped up. Paragraphs 24 to 81 are action items to be undertaken across every front, from national governments to the UN system.

The UHC declaration calls for another high-level meeting to be held at the UN in New York in 2023 to review implementation of this year’s declaration. Next year’s General Assembly will receive a progress report on implementation of the declaration, and a report on recommendations on implementation. Next year’s General Assembly will decide the modalities for the 2023 meeting.

The UHC political declaration text is accompanied by a letter from the President of the General Assembly, María Fernanda Espinosa Garcés and the two co-facilitators of the political declaration negotiations, Georgia’s Ambassador Kaha Imnadze and Thailand’s Ambassador Vitavas Srivihok.

Sexual and Reproductive Health Settled

In the final agreed text, negotiators resolved an issue over references to sexual and reproductive health rights, which had prevented consensus on an earlier draft negotiated over the summer.

Negotiators removed the controversial reference to sexual and reproductive health at the end of paragraph 29, according to the letter from the co-facilitators’, Imnadze and Srivihok. The paragraph previously stated:

  1. “Take measures to reduce maternal, neonatal, infant and child mortality and morbidity and increase access to quality health-care services for newborns, infants, children as well as all women before, during and after pregnancy and childbirth, including in the area of sexual and reproductive health;”

The final text of paragraph 29 now ends after the word “childbirth”.

However, the text retained intact the reference to sexual and reproductive health in paragraph 68, which also hearkens from the SDGs. That states:

  1. “Ensure, by 2030, 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, which is fundamental to the achievement of universal health coverage, while reaffirming the commitments to 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;”

Meanwhile, reference to sexual and reproductive health was also removed from a third paragraph, 69, on gender rights, which had previously stated:

  1. “Mainstream a gender perspective on a systems-wide basis when designing, implementing and monitoring health policies, taking into account the specific needs of all women and girls, with a view to achieving gender equality and the empowerment of women in health policies and health systems delivery and the realization of their human rights, consistent with national legislations and in conformity with universally recognized international human rights, acknowledging 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;”

It now reads:

  1. “Mainstream a gender perspective on a systems-wide basis when designing, implementing and monitoring health policies, taking into account the specific needs of all women and girls, with a view to achieving gender equality and the empowerment of women in health policies and health systems delivery;”

The co-facilitators also noted that negotiators moved paragraph 12 up to paragraph 6, with no change to the text, effectively raising its profile somewhat. That paragraph emphasises the importance of “national ownership and the primary role and responsibility of governments at all levels to determine their own path towards achieving universal health coverage….”

Measuring Impact

The overarching set of guideposts for the UHC declaration work is the 2030 Sustainable Development Goals (SDGs), which include many objectives related to health throughout the 17 SDGs, along with the dedicated “Good health and well-being” goal of SDG 3. The declaration is filled with undefined goals, but it also contains numerous references to measuring progress. It will remain to be seen whether the momentum, pressure and language of the commitments will be strong enough to bring about the much-hoped for UHC achievements.

 

Image Credits: Dominic Chavez/World Bank.

Kenya initiated a national pilot of the world’s first malaria vaccine today, joining Ghana and Malawi to introduce the landmark vaccine as a tool against a disease that remains a leading killer of children under the age of 5 years, particularly in Sub-Saharan Africa.

The vaccine, known as RTS,S, will be rolled out nationally in phases to children from 6 months of age in eight counties across the country, beginning in Homa Bay, in western Kenya, said a WHO press release. It is the first vaccine with the potential to significantly reduce malaria infection in children, including life-threatening severe malaria, which claims the life of one child every two minutes.

Malaria vaccine launched in Kenya. Photo: WHO Africa Region

“Africa has witnessed a recent surge in the number of malaria cases and deaths. This threatens the gains in the fight against malaria made in the past two decades,” said Dr Matshidiso Moeti, WHO Regional Director for Africa, speaking at the Kenya launch event. “The ongoing pilots will provide the key information and data to inform a WHO policy on the broader use of the vaccine in sub-Saharan Africa. If introduced widely, the vaccine has the potential to save tens of thousands of lives.”

WHO said that the aim is to vaccinate about 120,000 children per year in Kenya. The WHO-coordinated pilot is a collaboration with the ministries of health in Ghana, Kenya and Malawi, as well as international and local NGOs. PATH and GSK, the vaccine developer and manufacturer, are donating up to 10 million vaccine doses for the pilot. Financing for the pilot programme has been mobilized through a collaboration between Gavi, the Vaccine Alliance; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and UNITAID.

WHO said that the vaccine has a proven track record from Phase 3 clinical trials, which were conducted between 2009 and 2014 through a network of African research sites, including three sites in Kenya (Kombewa, Siaya and Kilifi) and enrolling more than 4,000 Kenyan children. Children receiving four doses of RTS,S experienced significant reductions in malaria and malaria-related complications in comparison to those who did not receive RTS,S. Health benefits of the vaccine were added to those already seen through the use of insecticide-treated bed nets; prompt diagnosis; and effective antimalarial treatment. The vaccine, where available, will be given in four doses: three doses between 6 months and 9 months of age, and the fourth dose at 24 months (age 2).

After thirty years under development, WHO said that the vaccine is soon to be added to the core package of WHO-recommended measures for malaria prevention. Other key measures include use of insecticide-treated bed nets, indoor spraying with insecticides and access to malaria testing and treatment.

Kenya is one of three countries selected from among 10 African country applicants for the RTS,S pilot. Key criteria for selection included well-functioning malaria and immunization programmes and areas with moderate to high malaria transmission.

For more about the initiative, see the WHO Press release

 

Image Credits: WHO Africa Region.

Digital health holds the potential to transform health systems so that they become more proactive and responsive to patients, advocates said at Wednesday’s launch of a two-day international conference that brought together members of the global healthcare and artificial intelligence (AI) communities in Switzerland’s pharmaceutical industry hub, Basel.

But using AI doesn’t inherently empower women or other vulnerable groups, some speakers and participants also pointed out. Policies have to be shaped to ensure that such technologies advance equity and access to health care.

The two-day Intelligent Health 2019 conference, organized by Novartis Foundation, brings together experts from some 67 countries, as well as representatives of the World Health Organisation, and other international agencies, along with tech giants such as Google and Microsoft.

“Digital tech can transform our health and care systems from being reactive to becoming proactive and even predictive. That’s the challenge the Novartis Foundation is now fully focused on,” said Dr. Ann Aerts, Head of the Novartis Foundation, speaking about the conference aims in a blog.

“Some of the biggest medical and health problems in the world today can be solved by harnessing the power of AI, big data and digital solutions. We have the potential to unite multi disciplinary groups ….from governments, corporates, healthcare providers and global clinician communities to radically transform the quality of lives globally” said Sarah Porter, CEO & Founder of Inspired Minds, a conference co-organizer.

However, like all innovations and technologies, AI is neutral, and humans have to ensure that it is used for everyone’s benefit, others emphasized.

“In order for AI tools to actually impact health outcomes positively, the algorithms need to be diverse and inclusive,” Stephanie Kukku, of UCL Hospital, London, was quoted as saying in a presentation.

Using AI doesn’t necessarily lead to the empowerment of patients, one participant pointed out in a tweet:  “We need to acknowledge the real barriers patients are facing to accessing quality care.”

 

 

Image Credits: A Health Blog.

Reducing pesticide self-poisonings is one of the most effective ways to reduce suicide deaths –the second leading cause of death among young people aged 15-29 years, after road injury, according to a new WHO report.

Release of the WHO report, Preventing suicide, a resource for pesticide registrars and regulators, coincided with World Suicide Prevention Day on Tuesday.

Photo: WHO

The report reflects the growing body of evidence that regulations to prohibit the use of highly hazardous pesticides can lead to reductions in national suicide rates. In Sri Lanka, a series of bans led to a 70% fall in suicides and an estimated 93 000 lives saved between 1995 and 2015. In the Republic of Korea – where the herbicide paraquat accounted for the majority of pesticide suicide deaths in the 2000s – a ban on paraquat in 2011-2012 was followed by a halving of suicide deaths from pesticide poisoning between 2011 and 2013.

Globally, there is one suicide death every 40 seconds. While 79% of the world’s suicides occurred in low- and middle-income countries, high-income countries have the highest rate, at 11.5 per 100 000, according to a WHO press release.

Globally, there are an estimated 10.5 deaths by suicide per 100 000 people a year. Rates varied widely, however, between countries, from 5 suicide deaths per 100 000, to more than 30 per 100 000. Nearly three times as many men as women die by suicide in high-income countries, in contrast to low- and middle-income countries, where the rate is more equal.

Image Credits: WHO.

New data revealing that survivors of Guinea’s 2013-16 Ebola outbreak were five times more likely to die within the first year after recovery, as compared to the general population, suggests a need to revisit WHO guidance on Ebola survivors’ monitoring and care, a top WHO official said on Friday.

The findings were part of a study published in Lancet Infectious Diseases earlier this week. The WHO-led study also found that people hospitalized with the Ebola virus for a longer period had higher overall mortality rates than those with shorter stays. Beyond a year, however, the study of some 1130 survivors found that mortality rates of survivors and the general population evened out. The study also pointed to kidney failure as the most common cause of death.

The findings have many implications for monitoring and treating survivors of the current outbreak in the Democratic Republic of the Congo, said Professor Judith Glynn, a senior author of the study from the London School of Hygiene & Tropical Medicine.

Siah Tamba puts on a light personal protective equipment (PPE). She is an Ebola survivor who now works at the Ebola treatment unit (ETU) in Sinje, Grand Cape Mount, Liberia, after losing her mother, sister, and daughter. The facility is operated by the International Organization for Migration (IOM) in partnership with Liberia's Ministry of Health and Social Welfare (MOHSW) and supported by USAID's Office of U.S Foreign Disaster Assistance. It opened with a capacity of 10 beds, but can rapidly scale to provide care to up to 50 people. The ETU is staffed with 23 medical professionals from Kenya, South Africa, Tanzania, Uganda and Ukraine, as well as 114 Liberians from Grand Cape Mount county, who were recruited and trained to offer clinical and non-clinical care within the facility. The staff received training from the World Health Organisation (WHO) and the MOHSW, and experienced hands-on training at the IOM-managed ETU in Tubmanburg, Bomi County, Liberia.
Ebola survivor dons protective gear to meet and support a patient currently undergoing treatment.

“Our results could help to guide current and future survivors’ programmes and the prioritisation of funds in resource-constrained settings. For example, those hospitalised with Ebola for longer may be at greater risk, and could be specifically targeted,” Glynn said in a statement.

“As the evidence increases on Ebola survivors it might be good to revisit the Ebola CRF,” tweeted Sylvie Briand, director of epidemic and pandemic diseases at WHO, referring to the protocols that guide monitoring, care and treatment.  Currently, interim WHO guidelines on caring for Ebola survivors do not call out kidney failure as a high risk.

While a range of chronic symptoms have been previously reported in Ebola survivors, this was the first study to systematically track and document mortality rates among Ebola patients after they successfully underwent treatment and were discharged.

The study followed up on survivors in Guinea, the first country hit by the 2013-2016 West African Ebola outbreak, for a year and nine months after they were discharged from treatment centers. In the first year (2015), some 55 people died, five times more than the 11 people who might have been expected to die based on mortality rates in the general population. But in the subsequent nine months of 2016, when the study continued, mortality did not differ between Ebola survivors and others.

Because few detailed medical records exist, researchers relied on interviews with family members as the main source of information. Based on reported symptoms, kidney failure was the suspected cause of death in 37 out of 55 cases. Researchers stressed that the lack of documentation available to rule out other causes was a limiting factor in their findings.

“The research suggests that we need to continue supporting those recovering from Ebola and provide health care to them long after they have recovered from Ebola virus disease,” Josie Golding a senior officer at Wellcome Trust told Health Policy Watch.

“And I think that we need to consider other variables that can impact patients recovering from Ebola. As observed in DRC, people affected by Ebola are often stigmatised. We must better understand how this can impact on the health of those survivors in terms of access to healthcare.”

Finally, Golding said, researchers need to explore the long-term impacts of vaccination and treatments that have been become available since the Guinea outbreak. “We need to understand how long people are protected from Ebola, or what the impact vaccination can have in pregnant women.”

Notably Guinea’s Ebola victims did not receive the new WHO-prequalified Ebola treatments that are now being used in the DRC.

Infections Now Top 3000 Since August 2018

As of 4 September another milestone in the DRC epidemic had been passed as WHO reported 3054 Ebola cases  (2945 confirmed and 109 probable) since the outbreak began in August 2018, with 2052 deaths and 914 survivors, for a survival rate of about 30%.

In the latest report posted by WHO Friday evening, 57 new cases had been reported over the past week, slightly less than the average of 77 new cases in the weeks of August. However, while transmission in hotspots such as the Beni Health Zone in the province of North Kivu show signs of easing, “new hotspots are emerging elsewhere,” warned the WHO report. The epicenter of the outbreak has extended across the provinces of North Kivu and Ituri. The areas stretch along DRC’s long and porous border with the neighboring countries of Rwanda, Uganda, Burundi and South Sudan, which have been on high alert for the past few months, with several cases of transmission spilling over into neighboring Uganda.

Funding Shortfalls, Insecurity Continue to Plague Response

Funding shortages continue to plague the response. WHO has asked for an infusion of US$287 million to fund the core public health response to the epidemic between July and December 2019, but so far only about 45 million of those funds have been received and pledges will only fund response until the end of September, said WHO, which has appealed to donors to urgently provide more support.  On Thursday, USAID pledged some US$21 million more to the Ebola effort, bringing the total USAID funding for the DRC outbreak to US$158 million.

In a visit earlier this week to DRC, UN Secretary General Antonio Guterres also appealed to donors to follow through on their commitments urgently; “Ebola cannot wait, if the response is interrupted by one week, we might lose the battle,” he said in an interview broadcast over Twitter.

Guterres also said that more needed to be done to contain the violence that has plagued disease control efforts, due to the activities of armed militias operating in the areas of North Kivu, one of the epicenters of the epidemic.

“Combating Ebola requires freedom of movement, access, security,” the UN leader also observed, during a visit to an Ebola Treatment Center in Mangina, a rural municipality in Beni territory, North-Kivu province, where the first cases of Ebola was been detected over a year ago.

He said that increase cooperation between UN peacekeepers and DRC armed forces was necessary to overcome threats of “terrorist acts”. But efforts should also be intensified to demobilize local armed groups and reintegrate them into the civilian population.

Elaine Ruth Fletcher contributed reporting to this story.

Image Credits: UNMEER/Martine Perret 2015.

Facebook has begun rolling out a new algorithm that directs users searching for vaccine information to the United States Centers for Disease Control (CDC) website, in the case of US-based searches, and for users elsewhere, the World Health Organization website, as a top search pick.

The move was welcomed by WHO, officials at CDC, and other health experts as an important step in combating a wave of misinformation about immunization from vaccine opponents, so-called “anti-vaxxers,” that has swept over social media. The media fog, has in turn, been blamed for alarming parents, and contributing to the recent upsurge in measles cases in the US as well as vaccine resistance elsewhere.

“We welcome Facebook’s efforts to mitigate the spread of misinformation about vaccines and connect people to sources of accurate information … social media response is an important dimension of our broader efforts to build trust and confidence in immunisation,” Dr Heidi Larson, who runs the Vaccine Confidence Project at the London School of Hygiene and Tropical Medicine, told The Guardian, which had reported in February on the fact that Facebook users were being steered through popularity algorithms to anti-vaccine sites.

Facebook announced the new policy yesterday in a company newsroom post that said, “We are working to tackle vaccine misinformation on Facebook.” The company said it would “reduce rankings” for groups and pages that spread misinformation, and it would explore ways to promote sites that “provide people more accurate information from expert organizations about vaccines at the top of results for related searches.”

WHO Director General Dr. Tedros Adhanom Ghebreyesus, said in a statement: “The World Health Organization and Facebook have been in discussions for several months to ensure people can access authoritative information on vaccines and reduce the spread of inaccuracies. Facebook will direct millions of its users to WHO’s accurate and reliable vaccine information in several languages, to ensure that vital health messages reach people who need them most.”

“Vaccine misinformation is a major threat to global health that could reverse decades of progress made in tackling preventable diseases”, the statement added, noting that many “debilitating and deadly” diseases such as diphtheria, hepatitis, polio and measles can be effectively prevented through vaccination.

Some users were quick to note the challenges inherent in the Facebook move, including for WHO, which needs to ensure that users around the world can easily get to the relevant content on the vaccine issue in different languages. “Facebook is doing the right thing and the ball is now in the court of @WHO headquarters,” tweeted one commentator complaining, “The WHO page that @Facebook redirects to is only in English and has a readability of grade 4. Has the text been pretested with vaccine-hesitant parents?”

This reporter, signing onto Facebook from Europe Thursday evening, and searching under the word “vaccine”, got to the detailed US CDC vaccine information site as a first pick and as a second pick, to the general WHO Facebook page, promoting a Walk the Talk-Health For All walk/run event planned in New York City later this month ahead of the upcoming United Nations General Assembly. A reporter testing the new Facebook algorithm from New York City also landed on the general WHO facebook page when searching for “vaccines.”

A WHO spokeswoman said she had no further details about the nature of the WHO arrangement with Facebook or how it had been reached.  However, the Facebook action followed moves earlier this year by YouTube to reduce the frequency with which users would click into anti-vaccine propaganda, as well as an announcement last week by the social media platform Pinterest that it would curb misinformation on its website.  A WHO statement last week lauded “Pinterest’s leadership in protecting public health” and called upon other social media platforms to follow its example.

 

Search results for “vaccines” on Facebook.

 

Amid stalled global progress on reducing malaria cases and deaths since 2015, the World Health Organization has called for renewed and accelerated research and development (R&D) of new tools for malaria prevention and treatment, improved use of data, and strengthened international, regional, and sub-national cooperation.

WHO’s Strategic Advisory Group on Malaria Eradication (SAGme) said in the executive summary of their 23 August report that while much progress was made between 2000 and 2015, “the world is not on track to meet the 2020 milestones,” which could undermine the goal of reducing malaria cases and deaths by 90 percent by 2030.

“To achieve a malaria-free world we must reinvigorate the drive to find the transformative strategies and tools that can be tailored to the local situation. Business as usual is not only slowing progress, but it is sending us backwards,” said Dr Marcel Tanner, Chair of SAGme, according to a WHO press release.

“Freeing the world of malaria would be one of the greatest achievements in public health,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General, in the release. “With new tools and approaches we can make this vision a reality.”

Photo: WHO/Griff Tapper

Research and development of new tools for prevention and treatment are among the top priorities outlined by the SAGme report. Current insecticide-treated mosquito nets and indoor residual spraying are referred to as “old and imperfect,” protecting populations at home but leaving them vulnerable outdoors. Expanded vaccine research and development will also be critical, it says.

Today, however, “less than 1% of funding for health R&D investment goes to developing tools to tackle malaria,” the release states.

“We need the commitment of political leaders to provide adequate funding from international and domestic sources to ensure access to affordable health care,” said Dr. Pedro Alonso, Director of the Global Malaria Programme at WHO, in a 22 August press briefing.

“The economic and societal benefits of malaria eradication would be massive,” he said.

WHO estimates the cost of scaling up malaria interventions through 2030 at US $34 billion, which would be comprised of a combination of international and domestic funding from affected countries. Such a scale-up, it says, would prevent an additional 2 billion malaria cases and 4 million deaths by 2030.

Through this investment of US $34 billion, the Strategic Advisory Group forecasts the economic gain for the highest burden countries to be estimated at US$ 283 billion in total GDP through 2030.

Challenges to Eradication

Outlined by the WHO in its 2018 World Malaria Report and reiterated by Friday’s SAGme report, the fight against malaria has stalled after fifteen years of progress between 2000 and 2015. With progress towards meeting the 2020 Global Technical Strategy for Malaria 2016–2030 (GTS) milestones “off track,” the WHO and the Strategic Advisory Group on Malaria Eradication call for action to remove barriers that may pose a risk to achieving a 90 percent malaria case and mortality reduction by 2030.

Availability of affordable, quality health services is recognised as a major challenge to malaria eradication. “To eliminate malaria and prevent the re-establishment of transmission, a country will require strong political commitment and investment in universal health coverage, with a well-functioning primary health care system at its base,” stated the executive summary.

“Health system quality is strongly correlated with malaria progress across the spectrum of malaria endemicity,” it said, and a strong governance framework will be needed “to bring together health systems infrastructure, service delivery, civil society and communities.”

A second key challenge is regarding data analysis and surveillance and response. “We need to further improve the quality and the use of data to detect changes in malaria transmission and adequately respond,” said Dr Alonso during Thursday’s press briefing.

Improved data will serve as “an active tool that helps the decision makers [on] how to proceed” SAGme Chair Dr Marcel Tanner said in the briefing. In addition to addressing current needs, improving data and surveillance will allow for rapid and effective action in the event of changes in malaria transmission resulting from global trends such as urbanization, climate change and population growth.

“Today, we can say it is feasible to reach eradication but we cannot lay an exact date [for it],” Dr Tanner said in the briefing. However, the report notes that there still remains the possibility of reaching a 90 percent malaria reduction rate by 2030, provided new tools and approaches are implemented.

Image Credits: WHO/Griff Tapper.

The World Health Organization concluded that the current risk to human health of microplastics in drinking-water is low, according to a report released today. However, it says that further research is needed to more accurately assess the effects of exposure to microplastics.

“We urgently need to know more about the health impact of microplastics because they are everywhere – including in our drinking-water,” said Dr Maria Neira, Director of the Department of Public Health, Environment and Social Determinants of Health at WHO, quoted in a press release. “Based on the limited information we have, microplastics in drinking-water don’t appear to pose a health risk at current levels. But we need to find out more. We also need to stop the rise in plastic pollution worldwide.”

The main message of the report is “to reassure drinking-water consumers around the world that based on this assessment, the risk [to human health] is low,” said Dr Bruce Gordon, Coordinator of the Department of Water and Sanitation at WHO, in a press conference on the release of the analysis.

Photo: WHO/European Pressphoto Agency (EPA)

“This report focused on drinking-water, and there’s [also] a need to consider the other environmental pathways,” noted Jennifer de France, Technical Expert at WHO’s Department of Water and Sanitation and co-author of the report, in the press conference.

The WHO is now calling for more data collection in three priority areas: the occurrence of microplastics in the water cycle, the physical impacts of smaller microplastic particles, and the risk from total exposure to microplastics.

In the meantime, WHO recommends that global stakeholders focus on the known health risks of microplastics in drinking-water and pre-emptively reduce plastic pollution to limit human exposure and protect the environment.

This report was produced in response to an analysis released in 2018 that detected the presence of microplastics in tap water and bottled water, leading to concerns about the potential health risks.

Review of existing research has found that microplastics above 150 micrometers are not readily absorbed by the human body; concentrations of chemical additives found in microplastics in drinking-water are currently too low to cause adverse effects; and harmful bacteria are not likely to colonize the small particles.

WHO has therefore concluded that microplastics in drinking-water currently do not represent a significant hazard to human health, and does not recommend routine monitoring of microplastics in drinking-water at this time.

Stimulating Research on Microplastics

However, WHO says that additional investigative research is warranted based on the poor quality of existing studies and the proliferation of plastics in the environment.

Although research published in the last two years showed improved scientific rigor, most of the studies reviewed for the report lacked sufficient quality controls. Thus, WHO recommends that results from existing studies should be interpreted with caution.

Additionally, the report is limited to examining microplastic exposure only in the context of drinking-water.

Microplastics have also been found in air and food. In response, WHO has initiated a review on the potential health effects from microplastics due to total environmental exposure.

The research pipeline for microplastics in drinking-water is growing. According to Gordon, there has been an exponential increase in the number of studies published in the past year.

Keeping the Focus on Known Risks

In addition to motivating new research, WHO is pushing to reduce plastic pollution and prioritise increasing access to existing water treatment technologies to protect against known hazardous chemicals and water-borne diseases.

“We know from WHO data and UNICEF data that over 2 billion people drink water that is faecally contaminated, and that causes almost 1 million deaths per year. That has got to be the focus of regulators around the world,” said Gordon.

Unsafe drinking and tap water is a leading cause of diarrheal diseases such as cholera. Taken together, diarrheal diseases are the second leading cause of death in children under 5, and kill more children annually than AIDS, malaria, and measles combined.

Safe water treatment systems also reduce exposure to microplastics. Proper wastewater treatment can remove more than 90 percent of microplastic particles. Drinking-water systems are optimised to remove particles of even smaller size, filtering out microplastics smaller than one micrometer.

Ensuring the quality of water treatment systems and using existing guidelines and knowledge on water safety will also improve the removal of microplastics from drinking-water as a by-product.

The WHO report on microplastics in drinking-water was released on the heels of a World Bank Report that called attention to the economic effects of worsening water quality in many developing nations.

According to the World Bank analysis, poor water quality limits economic growth in some countries by one-third.

Both reports recommend increasing efforts to reduce plastic pollution and invest in improving water treatment systems.

“We strongly are pushing or promoting around the world to reduce plastic pollution. And that is out of great concern for this occurrence we’re seeing; it’s everywhere. And that is irrespective of any human health assessment,” said Gordon.

Plastics in the Environment

Global plastic production has increased exponentially since the 1950’s.

In 2017, approximately 407 million tons of plastic were produced, with intentional microplastics estimated to represent less than 0.1% of total plastics production. Unintentional, or secondary microplastics, break off of larger plastic pieces with regular wear and tear, and represent a larger share of microplastics found in the environment.

Researchers estimate that by 2050, over 12 billion tons of plastic could end up in landfills or the environment.

Image Credits: WHO/European Pressphoto Agency (EPA).

The US Food and Drug Administration (FDA) last week approved a tuberculosis (TB) treatment regimen containing a new drug, pretomanid, offering a shorter, more effective course of treatment for highly drug-resistant strains of TB, the world’s leading cause of death by infectious disease.

Pretomanid is only the third TB drug to be approved in over 50 years, and amidst the excitement from achieving this milestone, activists are calling for the developer and newly licensed producer of pretomanid to ensure that those most in need of the treatment will be able to access it.

“This newly approved regimen containing pretomanid could be a lifesaver for people with XDR-TB [extensively drug-resistant TB], but it’s not time to celebrate yet,” said Sharonann Lynch, HIV & TB Policy Advisor for Médecins Sans Frontières’ (MSF/Doctors Without Borders) Access Campaign. “The approval of this new regimen by the US FDA is just the first step. We now need pretomanid to be registered and available at an affordable price in all countries, prioritising those with the highest TB burden.”

José Luis Castro, Executive Director of the International Union Against Tuberculosis and Lung Disease (The Union), commented: “The Union welcomes a new shorter all-oral regimen for XDR-TB… and we emphasise the need that it will be affordable and made available to National TB Programmes to adopt and scale up to offer effective treatment options to people with this severe form of TB.”

Drug-resistant tuberculosis patient in Mumbai, India. Photo: MSF/Atul Loke/Panos Pictures

Unlike the two other new drugs in the TB arsenal, bedaquiline and delamanid, pretomanid is the first FDA-approved TB drug to be developed and registered by a non-profit organisation, the TB Alliance.

In 2000, resistance to decades-old front-line TB drugs was becoming increasingly common, yet there were no new antibiotics in the TB development pipeline. In response to this global gap in research and development (R&D), the TB Alliance was formed as a product development partnership (PDP) dedicated to “the discovery, development, and delivery of better, faster-acting and affordable tuberculosis drugs that are available to those who need them.”

After almost 2 decades and 19 clinical trials in 14 countries, pretomanid is the first TB treatment the Alliance has successfully registered with the FDA.

Mylan, a US based pharmaceutical corporation, was granted the first license to produce, register, and supply pretomanid in April 2019. Mylan is expected to bring the drug to market by as early as January 2020, pending anticipated guidance from the World Health Organization on the new treatment regimen.

A Potentially Game-Changing New Treatment

Pretomanid is listed to be given in a 3-drug regimen known as BPaL (bedaquiline + pretomanid + high dose linezolid) based on results from the landmark Nix-TB trial in South Africa.

Although the trial only enrolled 109 participants, results showed unprecedented cure rates of 89 percent in patients with extensively drug resistant tuberculosis (XDR-TB), representing a significantly higher success rate than the historical 34 percent cure rate.

The newly approved regimen is also much shorter and easier to administer – the 6-month treatment course consists of only 5 daily pills, taken orally.

Dr. Madhukar Pai, a TB expert and advisor for TB Alliance, explained in a recent article that patients often struggle to complete their full courses of therapy for XDR-TB due to drug toxicity and the long length of treatment.

Existing treatment regimens for XDR-TB require 6-8 drugs, administered both orally and intravenously, taken for up to 2 years. The intravenous drugs can cause serious side effects such as vertigo, deafness, and visual or auditory hallucinations, and patients can be required to take up to 40 pills a day.

While there are still concerns about contraindications from the high doses of linezolid required in the new BPaL treatment course, this shorter, simpler regimen holds promise for significantly improving adherence to treatment, quality of life while on treatment, and chance of complete cure.

More studies to test whether BPaL’s treatment efficacy can be maintained at lower doses of linezolid are underway.

Questions Around Treatment Access Remain

A number of TB stakeholders are cautiously optimistic about BPaL’s approval, claiming that the drug regimen means little if it cannot be delivered to patients in need.

Historically, there have been challenges in bringing new TB tools to scale. One of the necessary drugs in the newly approved BPaL regimen, bedaquiline, was approved for use against MDR-TB in 2012, yet MSF estimates that only 20 percent of people who require the drug are able to access it.

Bedaquiline remains priced out of reach for many people in low- and middle-income countries, and a number of high-TB burden countries have not yet registered the drug to allow importation and distribution.

MSF has been advocating for Janssen Pharmaceuticals, the only producer of bedaquiline, to halve the price of the drug to US$ 1 a day. They have recommended that the price for a 6-month course of BPaL be no more than US$ 500 per person.

Mylan has yet to release its launch price for pretomanid in low- and middle-income countries, and they hold exclusive rights for producing the drug until November 2020.

However, Daniel Everitt, VP and senior medical officer at the TB Alliance, says: “In all of the lower-income countries, [TB Alliance] will be encouraging other manufacturers, generic manufacturers, to get into the market — to get competition to drive down the price as well.”

TB Alliance is also poised to receive a Priority Review Voucher (PRV) as a reward for developing pretomanid. PRVs can be sold to pharmaceutical companies for as much as US$ 350 million, and activists have urged TB Alliance to apply potential profits from sale of a PRV to efforts to increase access to pretomanid.

On the regulatory side, TB experts have been calling on the WHO and high-burden countries, such as India and Russia, to develop guidelines and policies to ensure access to BPaL once it is brought to market. India has expressed interest in starting its own pretomanid trials soon.

WHO is in the process of updating existing treatment guidelines for MDR-TB which is expected to incorporate evidence on the BPaL regimen.

WHO is currently inviting health professionals, TB patients, policy makers, and other TB stakeholders to submit comments to the MDR-TB Guideline Development Group between August 8 and August 20 2019. New treatment guidelines are set to be released in late 2019.

Current Status of XDR-TB

“By the end of 2016, XDR-TB had been reported by 123 WHO Member States. Information from countries with reliable data suggests that about 6.2% of MDR-TB cases worldwide have XDR-TB. In 2016, there were an estimated 490 000 new cases of MDR-TB worldwide,” the WHO reports.

XDR-TB is highly underreported, so the true burden of disease is likely higher than official figures indicate.

Image Credits: MSF/Atul Loke/Panos Pictures.