The number of cholera cases decreased by 60% in 2018 compared to 2017. Cholera-endemic countries such as Haiti, Somalia, and the Democratic Republic of the Congo saw some of the highest reductions.

Cholera vaccination in Nigeria

“The decrease we are seeing in several major cholera-endemic countries demonstrates the increased engagement of countries in global efforts to slow and prevent cholera outbreaks and shows the vital role of mass cholera vaccination campaigns,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a press release. “The long-term solution for ending cholera lies in increasing access to clean drinking water and providing adequate sanitation and hygiene.”

There were 499,447 reported cases and 2990 deaths in 2018, significantly lower than the 1.2 million cases and 5654 deaths reported in 2017. The country most affected by the ongoing cholera pandemic continues to be Yemen, which reported 128,121 cases and 2485 deaths in 2018, according to data collected by WHO.

However, several cholera-endemic countries saw dramatic decreases in the number of cases – including Haiti, Somalia, DRC, Zambia, South Sudan, United Republic of Tanzania, Somalia, Bangladesh, and Nigeria – thanks to the implementation of new national action plans for cholera control.

“The global decrease in case numbers we are observing appears to be linked to large-scale vaccination campaigns and countries beginning to adopt the Global Roadmap to 2030 strategy in their national cholera action plans,” said Dr Dominique Legros, head of WHO’s cholera programme in Geneva.

“We must continue to strengthen our efforts to engage all cholera-endemic countries in this global strategy to eliminate cholera.”

Nearly 18 million doses of Oral Cholera Vaccine (OCV) were shipped to 11 countries in 2018, financed in part by Gavi, the Vaccine Alliance. However, experts at WHO say that vaccination must be supplemented with efforts to improve access to clean water and sanitation. Vibro cholerae, the bacterium that causes the acute diarrhoeal infection, breeds in contaminated food and water.

Mass vaccination and water and sanitation interventions are recommended as part of the Global Roadmap strategy, which provides a three-pillar framework for national action plans focusing on:

  • Early detection and rapid response to contain outbreaks
  • A multisectoral approach integrating strengthened surveillance, vaccination, community mobilization, and water, sanitation and hygiene to prevent cholera in hotspots in endemic countries
  • An effective mechanism of coordination for technical support, resource mobilization and partnership at the local and global levels.

Image Credits: WHO.

For the first time in two decades, tobacco use is projected to decline among men in 2020, according to a new World Health Organization report on trends in global tobacco use. However, the new report does not consider trends in e-cigarette use, where use may in fact be increasing.

“For many years now we had witnessed a steady rise in the number of males using deadly tobacco products. But now, for the first time, we are seeing a decline in male use, driven by governments being tougher on the tobacco industry,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus in a press release about the new report.

Based on data collected from 149 countries, global tobacco use has been steadily declining for the past 18 years, from 1.397 billion people in 2000 to 1.337 billion in 2018. But that downward trend had been primarily driven by declining use in women.  About 100 million fewer women used tobacco in 2018 as compared to 2000, and women’s use of tobacco is projected to decline further over the coming five years.

However, over the same 2000-2018 period, the number of men using tobacco actually increased by 40 million people, and males currently represent some 82% of tobacco users.

Yet over just the past year, prevalence of tobacco use in males has plateaued, and it is now projected to begin declining in 2020, the latest data shows. WHO estimates that there will be 2 million fewer male users in 2020 as compared to 2018, and 5 million fewer by 2025.

“Showing that tobacco use can be reversed gives the public health community confidence we can get back on track and meet the global targets of a 30% reduction [in smoking rates] by 2025 as compared to 2010,” Ruediger Krech, director of WHO’s Department of Health Promotion said at a press briefing.

Projections of a decline in male tobacco use for 2020 are not the same across all regions either, the WHO officials cautioned. While fewer men are expected to be seen smoking in the Americas, Europe, and Western Pacific regions, WHO’s South-East Asian region, which currently has the highest proportion of male smokers at 62.5%, is projected to see a slight increase in absolute numbers over the next five years. Numbers of male smokers are also predicted to increase in the WHO Eastern Mediterranean and African regions.

And around the world, 43.8 million children between 13-15 used tobacco in 2018. That number excludes the use of e-cigarettes and other such nicotine delivery devices, which some country specific surveys have found is on the rise in youth in countries such as the United States.

Krech credited the inroads made against tobacco use over the past two decades to increasingly strong policy measures such as: banning smoking in public places, tobacco taxation, and marketing restrictions like plain packaging of tobacco products, as well as bans on marketing aimed at teens and children.  But he said that such measures must be amplified in order to reach the global targets.

“The downwards trend in tobacco use offers a challenge to governments. We cannot be satisfied with a slow decline when over 1 billion people are still using tobacco,” said Krech. “We must dramatically accelerate tobacco control measures to protect current and future generations from tobacco.”

The Unknown Contribution of E-Cigarette Use

Another unknown involves the use of smokeless tobacco devices. Use of e-cigarettes, as welll as other electronic nicotine delivery and heated tobacco devices were all excluded from the analysis, raising questions about whether potential smokers might also be shifting away from traditional tobacco products over to such methods.

Originally marketed as smoking cessation devices, electronic nicotine delivery systems (ENDS) have gained increasing notoriety for allegedly hooking young people onto nicotine at earlier ages. According to the US National Youth Tobacco survey, one of the most comprehensive national surveys that collects data on nicotine consumption annually, the proportion of high-school students who have used an ENDS device at least once shot up to 27.5% in 2019, as compared to only 12% in 2017. Manufacturers have been accused of targeting their marketing directly towards young people, particularly by producing the nicotine liquid pods in a variety of flavors popular among teenagers.

“If there are flavors like chewing gum or strawberry, who is the target audience? Me or my grandchildren,” Krech remarked.

As for whether an increase in e-cigarette use has perhaps led to a decrease in use of other tobacco products, Krech said that WHO could not at this time “say whether that has an impact or not.”  However, he acknowledged that many tobacco smokers are so-called “dual-users” – using both combustible cigarettes and e-cigarettes.

Krech added that WHO is currently collecting data on e-cigarette use and tobacco vaping, and is planning to release a more comprehensive report on the subject in February 2020. Countries have only begun collecting nationally representative data on the use of ENDS in 2013, and currently data from 42 countries is available, with more reports coming in every day.

“There is no “safety” associated with e-cigarettes,” said Krech. “There are a lot of risks associated with e-cigarettes, and we’re going to be a bit more concrete about those risks [in the February report].”

Accelerate Actions to Decrease Tobacco Use

In terms of policy measures, the report finds a clear trend towards more stringent government policies and regulations aimed at reducing tobacco use and second-hand smoke exposures. As of 2018, 137 countries have put into place at least one of the six methods recommended by the WHO in line with guidelines of the Framework Convention on Tobacco Control (FCTC).

Some 116 of these 137 countries have seen their tobacco use rates decline since implementing the measures, which include stronger measures for monitoring tobacco use; protection against second-hand smoke exposures; quit smoking programmes; awareness raising about tobacco’s dangers; restrictions and bans on tobacco advertising, promotion, and sponsorship of activities; and increased taxes on tobacco products.

The report found that strong declines in average tobacco use prevalence were mostly seen in regions that implemented the policies. This was true for the WHO South-East Asia region, which saw reductions in tobacco use – mostly in smokeless tobacco – after all 11 countries of the region had implemented at least one policy.

“Continuing to reduce tobacco use will help save lives, nurture families, and strengthen communities,” said Krech. “We must dramatically accelerate tobacco control measures to protect current and future generations from tobacco.”

Civil society organizations agreed. Gan Quan, director of Tobacco Control at the International Union Against Tuberculosis and Lung Disease and a partner in tobacco industry watchdog STOP (Stopping Tobacco Organizations and Products), said in a statement, “The problem is that the tobacco industry continues to undermine such measures all over the world and to market their products aggressively.”

Quan added, “The data is clear: tobacco use falls when governments implement policies that are proven to encourage quitting and deter youth from starting to use tobacco.”

Image Credits: WHO, WHO global report on trends in the prevalence of tobacco use, MomentiMedia/Flickr.

After collecting a windfall of nearly US$14 billion in donor commitments in October, the Global Fund to Fight AIDS, TB and Malaria, on Wednesday published its blueprint to distribute most of the money to over 100 low- and middle-income countries worldwide, saying that allocations will increase by 23% over the next three years.

Nigeria, Mozambique and the Democratic Republic of Congo are set to receive the largest awards with over $US 890 million, $US 751 million and $US 644 mllion respectively. according to the  allocation plan published on the Global Fund website. Tanzania, Uganda, South Africa, Malawi, India and Zimbabwe would receive allocations of $US 500-US $600 million each,  followed by grants ranging from tens of million to several hundred million dollars each to other qualifying African, Asian and Latin American countries, as well as Russia and former Soviet Union states. The allocation amounts represent threshholds against which countries then apply for final funding in one or all of the disease categories.

The country allocations total some US$12.71 billion, the agency said in a press release, adding, “The funds will help save 16 million lives, cut the mortality rate for the three diseases in half and get the world back on track to end the epidemics of AIDS, tuberculosis and malaria by 2030.”  In addition, countries can also apply to a separate fund of US$890 million for so-called “catalytic investments” that aim to scale up specific aspects of HIV and TB prevention or treatment, as well as strengthening health services overall.

French President Emmanuel Macron (center), and Microsoft’s Bill Gates, (far right), stand triumphantly with other Global Fund partners and supporters at the end of the successful Replenishment Drive in October that collected nearly US$14 billion in commitments.

Most eligible countries will receive funding increases, the Global Fund said. Countries in Africa are receiving around US$2 billion more than in the previous period, and countries in West & Central Africa have the biggest increase – US$780 million. Worldwide, there are 32 countries with an increase of 40% or higher.

Allocations to individual countries are calculated using a formula that is predominantly based on each country’s disease burden and economy, and then further adjusted to account for “important contextual factors”, the press release stated.

The aim is to drive funding to: “higher burden, lower income countries, specifically accounting for HIV epidemics among key and vulnerable populations, the threat of multidrug-resistant TB, and for the risk of malaria resurgence.” On the other end of the spectrum, the Global Fund aims to provide “sustainable and paced reductions where funding is decreasing” in middle and upper middle income countries that have made significant inroads in reducing disease but still require support.

“World leaders came together at our Replenishment and made commitments to step up the fight to end these epidemics by 2030,” said Peter Sands, Executive Director of the Global Fund, in the press release. “Now the real work begins. Our allocations will allow partners to expand programs that work, and to find innovative solutions for new challenges. In addition to more money, we need better collaboration and more effective programs.”

The Global Fund’s 2020-2022 allocation methodology is geared toward increasing the overall impact of programs to prevent, treat and care for people affected by HIV, TB and malaria, and to build stronger health systems, the press release stated. “The allocations provide significantly more resources for the highest burden and lowest income countries, while maintaining current funding levels or moderating the pace of reductions in other contexts.”

The allocations include increased investments in Eastern and Southern Africa for HIV prevention among adolescent girls and young women; more funding for the countries with the highest burden of TB in Africa and Asia; continued investments in Eastern Europe to cover the costs of treatment for multidrug-resistant TB; more funding for African countries with a high burden of malaria, and increased focus in the Sahel region to boost vector control and seasonal prevention campaigns.

The full list of allocations is available on the Global Fund website, along with a detailed explanation of the allocation process. In the next step of the funding process, countries convene coordinating committees to prepare and submit funding requests to the Global Fund for review and approval of the grant allocations, which may be disbursed to government as well as non-governmental funding recipients and partners.

 

Image Credits: The Global Fund.

Novartis has relinquished a patent granted by the European Patent Office for Kymriah, a promising new gene therapy for certain forms of leukemia, claiming the patent was no longer essential to the development and marketing of the treatment. The decision followed the moves by the Swiss-based NGO, Public Eye and the French-based Doctors of the World/Médecins du Monde to contest the patent in the European Patent Office. Their opposition, filed in in July, claimed that the price of the innovative therapy was “exorbitant” – with one infusion of the therapy costing CHF 370,000 in Switzerland.

Frozen T-cells of cancer patients are genetically modified to attack cancer cells in novel CAR-T therapies.

Kymriah, one of the first CAR-T [Chimeric antigen receptors T cell] therapies to receive marketing approval in Europe, is specifically designed for treating relapsing or treatment-resistant forms of acute lymphoblastic leukemia (ALL). It was developed by the University of Pennsylvania and later licensed exclusively by Novartis. CAR-T cell therapies rely on an innovative process in which a patient’s own T cells, which are critical to the body’s immune system, are collected and genetically modified to target cancer cells more effectively, and then reinfused back into the patient to attack the cancer.

The Kymriah treatment is so far being used in a limited number of patients, for instance about 100 people a year in Switzerland.  However, the underlying technology of CAR-T therapy holds much promise for treating other kinds of cancer as well. This could mean a rapid increase in the demand for similar therapies in the near future. Thus, the decision on the “patentability of such procedures” is “crucial” for setting a precedent, Public Eye said in a July statement about the patent opposition.

In a letter to the European Patent Office dated 29 November, representatives for Novartis and the University of Pennsylvania, requested the revocation of the patent on the grounds that “the proprietor no longer approves the text on the basis of which the patent was granted, and will not be submitting an amended text.”

The unexpected move was welcomed by Public Eye and Médicines du Monde, who had prepared for a long fight after they officially filed an opposition with the European Patent Office in July on the grounds that the “subject-matter lacks novelty.” The NGOs said the patent would pave the way for the Swiss pharma company to claim broad, exclusive rights not only over Kymriah, as such, but over other CAR-T cell technologies on the European market. Surprisingly, the patent holders submitted a request to withdraw the patent before the opposition procedure had in fact begun.

In response to the recent patent revocation request, Public Eye said in a statement, “This volte-face confirms that the patent should never have been granted in the first place, given that the underlying technology is not novel. It also questions the validity of other patents on Kymriah and weakens the monopoly position of the Swiss giant in future price reviews.”

The NGO added that the revocation should benefit an initiative by a number of leading Swiss university hospitals, among others, “to develop similar but considerably cheaper cancer therapies.”

In the patent revocation letter, Novartis and the University of Pennsylvania’s representatives claimed that the opposition’s arguments were “without merit.”

“[We] strongly believe in the importance of intellectual property rights as an incentive for ground-breaking innovation such as Kymriah. However, the opposed patent is not critical to the continued developement and marketing of Kymriah and the decision has therefore been taken to withdraw the opposed patent,” a Novartis spokesperson was quoted as saying to the Swiss online journal, swissinfo.ch.

Last September, Novartis also dropped a second patent application for another aspect of the treatment. However, Novartis does hold a patent on Kymriah, as such, in Europe and elsewhere. Experts in intellectual property law say that this patent still protects Novartis against the production of identical versions of Kymriah by competitors.  However, withdrawal of the other two patents leaves open a wider door for competitors to lower costs with the advance of further CAR-T innovations.

Image Credits: Novartis, Novartis.

The number of new Ebola virus cases in the ongoing outbreak in the Democratic Republic of the Congo shot up to 27 confirmed cases in the last week, triple the number of 9 confirmed cases reported between 27 November to 3 December. The recent surge in cases comes in the wake of insecurity and a series of violent attacks on Ebola workers that froze the response.

“Since the beginning of the response, there is a factor that we cannot control – the context of the intervention, including insecurity,” Michel Yao, incident manager for the World Health Oganization’s Ebola Response in the DRC said at a press conference (translated from French). “In the zones [where cases are arising], there is one particular zone, Lwemba [in Beni Health Zone], that we have not been able to access for three weeks.”

Ebola vaccinators return to Biakato Mines following a deadly attack on healthcare workers in the area on 27 November.

According to the latest WHO Disease Outbreak Notice, most cases in the past week have arisen from Mabalako and Beni Health Zones, where the Ebola response seems to be mobilizing again after temporarily scaling back activities in the last two weeks of November due to violence and riots in those affected areas. Some 18 cases were reported from Mabalako, and 6 cases from Beni, and the remaining 3 cases originated from Mandima and Oicha. Six of the confirmed cases were health care workers – including 5 traditional practitioners – representing a spike in the number of health care workers infected in the outbreak.

Despite the surge, WHO says that the average proportion of contacts under surveillance in the last seven days has returned to normal levels, and the investigation of alerts has also been improving. To ensure continued care, WHO has mounted a limited daily helicopter “air bridge” operation to transport epidemiologists to investigate cases, but to also primarily send vaccinators to hard-to-reach communities. Dr Yao noted that the communities had come to the Ebola responders seeking help.

They “want the intervention”, he insisted, “but around we have armed groups that prevent us from reaching these communities…We’re mobilising communities all around to come and get vaccinated in a situation where there are (health) alerts but we can’t go to investigate because access is restricted.”

On Thursday, the first Ebola vaccinators returned to the Biakato Mines Area, where three Ebola responders were killed in late November, to continue fighting the outbreak.

So far, 17 of the new cases have been linked to one individual – who reportedly presented with EVD illness for the second time within a 6-month period. According to WHO, rare cases of relapses of Ebola, in which a person who has previously recovered from EVD gets symptoms again, have been recorded. However, DRC officials are also investigating the possibility of reinfection – a scenario in which an individual who has recovered from Ebola gets infected with EVD from another person – which has never been documented before.

Previous studies have shown that Ebola survivors can develop immunity to the disease which can last for over a decade, but experts have long been concerned about the possibility of relapse or reinfection. The possibility of relapse or reinfection could indicate a need to revisit the kind of care provided to survivors, and how Ebola survivors are involved in future response activities.

Image Credits: Twitter: @DamelSoceFall.

The World Health Organization issued new guidelines for the treatment of multi drug-resistant (MDR) tuberculosis on Wednesday, prioritizing for the first time an all-oral treatment regimen. The new treatment recommends replacing the painful injectable drugs that patients had to endure under previous treatment guidelines with a shorter course of oral bedaquiline – one of only three new drugs approved for treatment of TB within the last half century.

A healthcare worker counsels a patient with MDR-TB

The update was announced in a rapid communication released by WHO after an independent panel reviewed new evidence on treating multi-drug resistant (MDR) and rifampicin-resistant (RR) TB in November. Compelling data from the South African TB programme, collected in collaboration with research and technical partners such as The Union, showed that replacing injectable drugs with oral bedaquiline resulted in significantly better treatment outcomes for patients with MDR/RR-TB. Not only that, but more patients also completed the full 9-month treatment when provided all-oral regimen.

“The Union supports the move towards shorter all oral treatment regimens with better outcomes, lower toxicity and reduced side effects for people with drug-resistant TB,” said Grania Bridge, director of the Department of TB at The Union said in a press release. “As new all-oral regimens are developed, there is a clear need for more and better evidence to support their implementation around the world.”

Much of the new recommendations were based on evidence coming out of traditional clinical trials and operational research – which tests the regimens that pass through clinical trials under real-life conditions, where barriers to health care, stigma, and other factors can contribute to the likelihood of patients successfully completing a full course of treatment. This is especially important to observe for the long 9 to 11-month treatment regimens recommended for MDR/RR-TB.

“The WHO rapid communication emphasizes the importance of operational research in generating high quality programmatic data,” said Bridge, highlighting the need for countries and funders to “prioritise operational research to guide future treatment guidelines, as well as complement the data expected from clinical trials currently underway.”

In the update, WHO also issued guidance for the BPAL regimen – a breakthrough regimen for treating XDR TB that just received regulatory approval from the US Food and Drug Administration this August. In the rapid communication, WHO recognized that the BPAL regimen showed high treatment success when used in 108 XDR-TB patients in South Africa, but has refrained from recommending programmatic implementation of the regimen worldwide until more evidence has been generated. For the time being, WHO recommends collecting more evidence for the BPAL regimen under operational research conditions conforming to WHO standards.

WHO is set to release the next full update of consolidated guidelines on the treatment of all forms of drug-resistant TB in March 2020. The rapid communication was preemptively issued in order to prepare national TB programmes and other key stakeholders for what changes they can expect, in order to roll out the new guidelines as quickly as possible.

Image Credits: WHO PAHO.

On 22 November, the Norwegian government broke new ground for the non-communicable disease response. The Norwegian Ministry of Foreign Affairs launched the first international development strategy to focus on combatting NCDs in low- and middle-income countries (LMICs). The NCD Alliance, the Norwegian Cancer Society and other civil society partners around the world have heralded this as a major milestone. I had the pleasure of attending and speaking at the launch event of “Better Health, Better Lives” in Oslo. But why is this such a big deal and what are the broader implications?

A panel at the launch of Norway’s new NCD-focused development strategy. (left-right) Maria Neira, WHO; Omnia El Omrani, (IFMSA); Mamka Anyona, UNICEF; Tiy Chung, CCA Coalition; Andrea Winkler, Centre for Global Health, the University of Oslo; Katie Dain, NCD Alliance.

Let’s start with the numbers, as they speak volumes. NCDs including heart disease, stroke, diabetes, cancer and respiratory disease are now the cause of some 70% of total deaths worldwide. It is widely recognised that NCDs have a detrimental impact on many aspects of sustainable human development. Contrary to the perception of NCDs as a rich world problem, they impact most heavily on LMICs, where NCDs are responsible for over two-thirds of deaths and will cost $7 trillion in economic losses over the next two decades. However, the world’s biggest cause of premature death and disability are collectively the target of an astoundingly pitiful 1.7% of health-related development assistance (or $611 million).

Whilst bilateral donors (e.g. national governments or their development agencies) are the dominant source of funding in global health more broadly, providing 52% of overall development assistance for health, they have until now simply been absent in the field of NCDs. Between 2010-2015, non-governmental organisations (NGOs) collectively provided more than twice as much aid for NCDs than bilateral donors, and considerably more than multilateral organisations such as the World Bank and WHO.

The picture of resources available to tackle NCDs hasn’t changed markedly since 2015, despite the transition from the Millennium Development Goals (MDGs) to the era of the UN Sustainable Development Goals (SDGs), when NCDs were finally included as a priority for global health and sustainable development. After many years of campaigning, NCD advocates around the world could have hoped that this would be the moment that would trigger donor countries to incorporate NCDs into their development policies and strategies. But although many development agencies including from the UK, US, Sweden and Australia are supporting NCDs via different channels (for example, via health system strengthening efforts, integrating NCDs into existing global health programmes, or tobacco control programmes in LMICs), overall they have remained far too silent and passive on NCDs.

Consequently, LMICs have been left to respond to increasing burdens of NCDs within their own scarce resources. Governments are juggling a backlog of common infections, undernutrition and maternal mortality together with growing burdens of NCDs, pandemics and the alarming health effects of the climate emergency. Budgets and health systems are crippled and few poor countries provide care for NCDs in their health benefits packages. The result of this is a hugely unjust and unjustifiable burden: in lower-middle income countries, people are largely asked to pay for the care and treatment they need out of their own pockets. 56% of health spending is taken from the people who need treatment, rather than from government spending or other sources. For the many who cannot afford treatment, this means the agonizing choice between foregoing life-saving or life-improving care or tipping their family into poverty. This is a desperate reality particularly for the poorest, most marginalized populations, who are still all too often left behind.

These statistics and realities are why the Norwegian government’s international development strategy on NCDs is so important and such a welcome step. Norway is the first OECD country to translate the inclusion of NCDs within the SDGs into their development policy, and back it up with a clear and much-needed overseas development resources. Norway has announced a tripling of its assistance for NCDs, allocating over $20 million to support the strategy for 2020 and this commitment is expected to increase towards 2024. This is a relatively modest amount in the context of global health giving, but already catapults Norway to the ranks of the top three supporters for NCD prevention and control, well ahead of the US, UK, France, Germany and Canada.

The Norway example provides an important precedent as well as a model for other OECD countries to follow, not just for it being the first, but also the substance and approach taken. First, while the strategy is led by the Ministry of Foreign Affairs, the launch event in Oslo made clear that this was a product of cross-government collaboration, with both the Minister of International Development, Dag-Inge Ulstein and the Minster of Health, Bent Høie taking the stage together, sending a strong signal of whole-of-government leadership. Secondly, the strategy builds upon WHO’s normative work on NCDs by supporting low-income countries implement the “Best Buys” and embracing the broader “5×5” approach to NCDs with a welcome focus on mental health and air pollution. Thirdly, the pillars of the strategy build off Norway’s track record in NCDs and public health domestically and internationally, evident by the strong focus on proven prevention measures; tobacco control and the FCTC, regulation and taxation of unhealthy products, and attention to the commercial determinants of NCDs which is so urgently needed in many LMICs. Fourthly, it clearly articulates this new focus on NCDs as an opportunity to build on and augment (rather than divert) Norway’s global health and development priorities and investments to date, such as women and children’s health, climate and the environment, and humanitarian crises. And finally, both at the event and in the strategy, there is clear recognition for the integral role civil society and communities play in responding to NCDs.

Five ingredients of a strategy that has positioned Norway as a global leader in responding to NCDs in low-income countries and saving lives, and a model for other OECD countries to follow. Who will be the next to follow?

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Katie Dain is Chief Executive Officer of the NCD Alliance, a global network of civil society organisations dedicated to transforming the fight against non-communicable diseases (NCDs). Katie has worked with the NCD Alliance since its founding in 2009. Katie is widely recognised as a leading advocate and expert on NCDs. She is currently a member of the WHO Independent High-Level Commission on NCDs, co-chair of the WHO Civil Society Working Group on the UN High-Level Meeting on NCDs, and a member of The Lancet Commission on NCDIs of the Poorest Billion. 

 

 

 

 

Image Credits: Stine Loe Jenssen.

A new plan to dramatically accelerate global efforts to end tuberculosis, one of the world’s deadliest and oldest known infectious diseases, was launched Tuesday by the Stop TB Partnership in Jakarta.

The fully-costed plan is based on commitments made at a 2018 United Nations High-Level Meeting on Ending TB (UNHLM) to reduce TB deaths by 1.5 million people by 2022.  Two other initiatives – one to mobilize civil society support and another to launch a new regimen for treating drug-resistant TB in Indonesian children – were launched in tandem to increase efforts towards.

“I feel we are finally starting to get what we need to end TB. There is a long way to go; but we see light at the end of the tunnel,” said Stop TB Partnership’s Executive Director, Lucica Ditiu, in a press release.

According to the roadmap, funding for TB prevention, care, and R&D must be rapidly scaled up in order to reach global targets for reducing TB in line with 2022. Currently, funding for TB treatment and prevention stands at less than US $7 billion per annu; that must be doubled to at least US $14 billion per annum. R&D funding must be nearly tripled to over US $2.16 billion per annum.

“It is not just about launching the Global Plan, it is also about launching concrete tools and funding to implement it,” said Ditiu. “We have the largest-ever call for proposal from grassroot organizations as we must ensure that civil society and communities remain our full partners in ending TB. And we share with the world the pediatric formulations for children with drug resistant TB.”

Political leaders, Ministers of Health, TB survivors, donors, and TB experts from around the world gathered Tuesday for the official launch of the “Global Plan to End TB 2018 – 2022: The Paradigm Shift” in Indonesia, a country with one of the highest TB burdens in the world.

Globally, it is estimated that 10 million people developed TB disease in 2018, and around 3 million people who developed the disease were unable to get proper treatment for it.

In Pakistan, a healthcare worker listens to a child’s lungs for signs of pulmonary tuberculosis.

The new plan is an update and extension of the “Global Plan to End TB 2016-2020,” and follows on from last year’s first ever UNHLM on tuberculosis. While some heads of state from the G7 countries – the biggest donors to global health aid – and some high-burden TB countries were noticeably absent from the High Level Meeting, the event still  set a new tone for TB advocacy, and led to 129 countries signing onto the first ever Political Declaration on TB during the 73rd UN General Assembly – which outlines goals that are embedded in the Stop TB Partnership’s roadmap and budget.

If the plan is fully implemented by 2022, the Stop TB Partnership estimates that 40 million people will be treated for TB, including 3.5 million children and 1.5 million people with drug-resistant TB, and over 30 million people will receive TB preventive therapy. This will lead to 1.5 million fewer deaths due to TB and there will be a US $44 return on investment for every US $1 spent.

While the plan encourages upper-middle- and high-income countries to scale up domestic funding, it also notes that donors will need to step up external commitments to help support low- and lower-middle income countries. With the Global Fund to Fight AIDS, TB, and Malaria’s recent successful US $14.2 billion replenishment in October, the fight to end TB received a US$840 million annual boost for the next three years.

However, the Stop TB Partnership says that external funding will still need to be scaled up to fill the remaining funding shortfall of US $5.1 billion per year, warning that a five-year delay in increasing funding for TB R&D could lead to 13.8 million more people developing the disease and 2 million more people dying by TB.

Launch of a Multimillion Funding Facility for Civil Society 

Along with the updated global plan, the Stop TB Partnership is launching the “Challenge Facility for Civil Society 2019” – a fund of US $2.5 million in grants for civil society and community-based organizations (CBOs) who provide crucial advocacy and support to some of the hardest to reach populations impacted by TB.

According to the Stop TB Partnership, certain vulnerable populations face both an increased risk of contracting active TB and facing stigma due to where they live or work, leading to limited access to quality TB care. A number of community-based organizations and small non-governmental organizations have sprung up around the issue to help provide support to these affected communities.

The new funding facility will hold the largest-ever call for proposals for TB-affected community and civil society grassroots organizations. It will be supported by funding from USAID and the Global Fund, and the 12-months grants will range from US $25,000 to US $150,000.

Organizations from 14 high-burden countries – Bangladesh, Cambodia, DR Congo, India, Indonesia, Kenya, Mozambique, Myanmar, Nigeria, Pakistan, Philippines, South Africa, Tanzania, and Ukraine – are eligible to apply for funding. Organizations that operate regionally in anglophone Africa, francophone Africa, Asia, Latin America, the Caribbean, or Europe are also invited to apply.

Fighting Drug Resistant TB in Children – A New Initiative 

Tuesday also marked the official launch of the Stop TB Global Drug Facility’s Pediatric Drug-Resistant TB (DR-TB) initiative, launching child-friendly formulation of medicines used to treat drug-resistant TB (DR-TB) in Indonesia.

Of the estimated 1.1 million children under the age of 15 who became sick with TB around the world in 2018, an estimated 32,000 had MDR-TB. Of those, fewer than 5% are diagnosed and receive treatment. It’s estimated only 500 children under the age of five received treatment for DR-TB in 2018.

The Pediatric DR-TB Initiative will make child-friendly formulations of TB drugs like cycloserine (above) available to children who need them.

The dissolvable, flavored formulations of essential DR-TB drugs are already used in 56 other countries, including high-burden countries Nigeria and Haiti, and will replace the crushed-up tablets and intravenous injections currently used to treat drug-resistant TB in Indonesian children. The new treatment regimens for children are also shorter, and cause less dangerous side effects than traditional treatments for drug-resistant TB.

“What you often don’t see when looking at the crushing problems posed by TB—either at home or around the world—is how the disease affects children,” said Nigeria’s Minister of State for Health and Stop TB Partnership Board Member Osagie Emmanuel Ehanire.

“No child should have to suffer from DR-TB and we are committed to reaching these young children and treating them with these new medicines.”

The Stop TB Partnership’s Global Drug Facility (GDF) piloted the pediatric drug procurement initiative last year, with help from the Sentinel Project, in early adopter countries in order to pool demand from eligible countries and facilitate access to the child-friendly medicines. Through the pooled-demand mechanism, the GDF has negotiated price reductions of up to 85% for certain medicines in the child-friendly regimen, and has facilitated the procurement of the treatments in 16 countries in 2018 and an additional 40 countries in 2019.

So far, 1,100 treatments for children with drug-resistant TB have been procured, with the goal to reach the UNHLM target of treating 115,000 children with drug-resistant TB by the year 2022.

Image Credits: Stop TB Partnership, Maggie Steber/Stop TB's Global Drug Facility.

Madrid, Spain – India’s Environment Secretary has said that he does not deny the link between air pollution and its health impacts – and affirmed that India needs to act on the issue because “even a single death” from poor air quality would be too much.

“Nobody denies that poor air quality causes morbidity and may also cause mortality. Certainly …it must be causing mortality,” said CK Mishra, Secretary of the Ministry of Environment, Forestry and Climate Change, in an interview with Health Policy Watch and two Indian media reprsentatives at the COP 25 Climate Conference, where Mishra was leading the Indian delegation in negotiations last week.

 

Indian students at a recent protest over Delhi’s poor air quality.

“I mean it may not be 7.5 [million deaths],” Mishra added, an apparent reference to  WHO estimates that there are 7 million deaths globally every year from air pollution, “It could be 2 it could be 5. …But the fact remains that there are numbers to be attended to.

“As far as the ministry is concerned, we are very conscious of the fact that it is leading to loss of human life and we need to correct this situation.”

Mishra made his remarks prior to Friday´s controversial and widely-quoted comments by Environment Minister Prakash Javadekar who declared before the Indian parliament that “No Indian study has shown pollution shortens life. Let us not create fear psychosis among people.”

But in the halls of the Madrid Climate Conference, where the Environment Ministry´s top civil servant was leading the Indian delegation in negotiations, Mishra sought to convey a more nuanced view of the Indian position to reporters.

“It’s common sense,” he said. “If you are breathing  bad air, it cannot cause good to your system….Irrespective of the reliability of the number… a number indicates a job to be done….”

CK Mishra

While Mishra said that he was not trying to refute the link between air pollution and ill health – or even with mortality, he did say that more Indian-based studies would help nail down the exact numbers of people affected more clearly.

“We are not questioning the numbers. We are saying, let us get to know very closely how we get to that number. That also helps us find the causes.”

Javadekar’s statement roundly criticized 

Javadekar´s statement refuting the link between air pollution and health impacts was hotly contested by top WHO officials as well as some leading Indian medical experts. WHO has said that the evidence about reduced life expectancy among populations chronically exposed to air pollution is well-established globally, with evidence that recognizes no borders.

“No study shows Indians immune from air pollution: WHO responds to Prakash Javadekar,” said WHO´s Maria Neira, in a tweeted response on Friday. Neira, who leads the agency´s work on health, climate and environment, has become a vocal public advocate for national government action; but it is extremely rare for a WHO official to call out a single national government, or government official, by name.

“Air pollution is one of the biggest risk factors for health, especially impacting children and older people.  Reducing indoor and outdoor air pollution should be a high priority for governments and citizens,” said WHO’s Chief Scientist Soumya Swaminathan, herself a former head of the Indian Council of Medical Research (ICMR), in another tweet. While Swaminathan´s comments were not aimed directly at the Indian Minister, they highlighted a new study published just last week on the immediate health gains that have been realized from reducing air pollution levels in cities and regions around the world.

Indian researchers have indeed confirmed the fundamental linkage between  air pollution and ill health, Mishra acknowedged, referring to studies by the All India Institute of Medical Sciences [AIIMS] undertaken when he was Secretary of Ministry of Health and Family Welfare.

“AIIMS did some studies for us…and the established fact is vulnerable people are severely impacted by air pollution. Ok? The not so established fact is cause of death which is an academic exercise. ..this is an exercise that the Health Ministry is doing.

“As far as Environment Ministry is concerned, the concern is not numbers. The concern is why should even a single death happen because of air quality. That is the point I am making.”

He said, however, that studies ongoing at national level under the auspices of the Ministry of Health in collaboration with the Environment Ministry, would help to confirm the numbers of people impacted in India more precisely.

“Lots of studies are going on. They will have to be collated. The health mission will also give us some indication – the mission in collaboration with the Health Ministry that we launched six months ago. So, we are waiting.”

Estimating deaths attributable to air pollution risks is inherently more complex than counting the numbers of people who died from a particular disease, Mishra pointed out, although he acknowledged that what matters more, is to get a grip on the problem.

In fact, a broad scientific consensus has emerged around the basic methods for calculating deaths from air pollution. Based upon those methods, Indian mortality estimates were released just last year in The Lancet in a study co-sponsored by the ICMR. That study found some 1.24 million people died prematurely in India in 2017 due to air pollution, including 670,000 deaths from outdoor exposures and 480,000 from household air pollution.

But Mishra still contends that the methods used to make such assessments are not yet formalized. “Is there a coherent system, which is internationally accepted, to put a number on mortality caused by air pollution is the question? If that is there, no issues,” he said.

“Diseases are recognizable, identifiable causes. X died of tuberculosis” Mishra noted. “Now that death of the tuberculosis patient could have been hastened because of bad air.  There is a cause-effect…[but as for the] exact estimates of the number of people who died from air pollution [that is] more difficult to calculate.

“Having said that, there is no harm in accepting them and working on them, instead of disputing them,” said Mishra referring to the prevailing expert estimates. His more nuanced views seemed to reflect growing recognition of the gravity of air pollution’s health impacts in some government circles, even if top politicians still seek to play it down.

India Will Improve Air Quality In Coming Years

In the interview, including journalists from The Telegraph India and India Climate Dialogue, Mishra also expressed confidence that within the coming few years, India will make big advances on air quality.

“I would like to dispel this belief that we have not seized this opportunity [to act]. India is very much there, and air pollution is a major concern. But let me tell you that it is not just Delhi or a couple of cities in India. This is a global issue and this issue arises from several things, including the fact that there are meteorological factors which are impacting it.

“Notwithstanding all that, the commitment is that over the next five years or so we will bring about a reduction of 30%, in terms of the particulate matter and the pollutants. We have already done about 15% reduction and we are steadily moving.

“We have a commitment to clean the air. Even if it causes no mortality no morbidity, we still need to do it….”

Mishra said, however, that WHO and other international agencies concerned with India´s air pollution problem should factor in the complexities that must be faced.

“One thing that I would like to emphasize is, that air quality and issues of air pollution, do not have a switch on-switch off solution or technology. It takes time. Efforts are on, resources are being put in, and I think every year it´s improving and by the end of another 4 years or so, we should have a much cleaner air – in the entire Indo-Gangetic plain which incidentally is the only problem area for India. It is a small portion of a big country like India.

“…And yes of course it is about morbidity. I do not know how much of a direct connect you have to mortality in terms of counting numbers. But anyway, be that as it may, it is a commitment of the Indian government. And the Swachh Bharat (Clean India) mission of the Prime Minister – the entire switching over to cleaner fuels… e-vehicles…they are all part of the strategy.”

As for the contribution of rice stub burning in Punjab and other neighboring states to Delhi´s chronic winter air pollution crises, a major focus of media attention this year, Mishra said the focus on crop burning may be “slightly disproportionate to the kind of problem that it poses.

“But be that as it may, there are two solutions we have come up with. Last year and this year, we have tried on what it is known as the in-situ solution of mulching the straw in the ground.

“At the same time, there are private sector players as well as public sector players, which are strongly looking at ex- situ solutions, which include using that straw and the biomass for power generation, for gasification, for bio-ethanol, and many other purposes. So that experiment is going on, and I think over the next couple of years, we are going to see a huge improvement, including some changes in crop patterns as well.

He also praised Delhi officials for playing a strong role to confront the air pollution emergency that has wracked the city over the past month, where levels of small particles at times rose higher than the measurement limits of monitoring equipment.

“The municipal bodies have to really, really come forward to take it up. The kind of work they [in Delhi] have done this year, if they continue to do it for the next two years, we will have much cleaner air. They have really, really responded well this year.”

In the broader climate arena, Mishra also said India intends to take a stronger leadership role in the stalled negotiations – even if that has not been explicitly stated.

“You don´t take a leadership role, by announcing that your leadership. You take a leadership role by your actions, by what are you doing. And the globe watches you very carefully. So when I say India is going to take a leadership role, it is two-fold. “A – India is slowly becoming the voice of many countries which have this problem and are trying to solve it and B – In our own field, in reduction of emissions, we want to lead the rest of the world.”

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Priti Patniak contributed to the research and reporting of this story.

 

 

 

 

 

 

Image Credits: E Fletcher/HP-Watch, @DYFIDELHI.