Dr Faustine Ndugulile (centre) flanked by outgoing WHO Africa

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The 50 cities evaluated in the City Heartbeat Index.

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

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

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

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

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

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

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

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

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

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

The burden of CVD is driving action

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

Access to universal healthcare has also helped cities’ ranking.

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

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

Critical data is still missing

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

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

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

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

Cities prioritise some risk factors over others

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

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

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

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

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

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

Image Credits: City Heartbeat Index Report.

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

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

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

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

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

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

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

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

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

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

Gabon reports first case

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

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

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

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

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

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

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

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

Image Credits: Tessa Davis/Twitter .

Dr Tedros addressing the WHO Africa regional meeting on Monday.

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

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

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

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

Continent needs $135 million for mpox

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

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

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

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

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

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

Conference praises outgoing director

Dr Matshidiso Moeti, outgoing WHO Africa regional director

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Hotly contested leadership race

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

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

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

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

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

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

 

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

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

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

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

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

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

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

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

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

Famous for exposing ‘dieselgate’

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

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

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

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

CNG is not a ‘clean’ fuel

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

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

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

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

 

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

Commercial vehicles pollute more than private cars

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

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

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

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

Innovative remote sensing technology 

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

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

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

Current vehicle pollution-check system unreliable 

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

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

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

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

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

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

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

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

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

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

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

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

Image Credits: ICCT, Chetan Bhattacharji/HPW.

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

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

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

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

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

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

From Scientist to Public Enemy

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

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

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

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

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

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

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

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

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

Visit the podcast website.

Image Credits: TDR Global Health Matters Podcast.

Sudan cholera
A new cholera outbreak is threatening the millions of internally-displaced Sudanese. Over 600 cases have been reported in the past week.

United Nations officials are expressing concern that a new cholera outbreak in conflict-ridden Sudan, declared 10 days ago, could widen dramatically in the wake of increased rainfall and flooding. Some 658 cases of cholera have been reported since 12 August, with 28 deaths, the World Health Organization (WHO) revealed in its latest situation report, published Friday. 

The last outbreak of cholera in May saw more than 11,300 cases and at least 300 deaths.

Twelve of Sudan’s 18 states are struggling to simultaneously contain outbreaks of three or more diseases. The worsening humanitarian situation, fueled by 16 months of fighting between the Sudanese Armed Forces and the insurgent Rapid Support Forces (RSF), crippling humanitarian aid deliveries, have left embattled health workers coping with outbreaks of measles, malaria, and dengue, along with the deadly diarroheal disease.  

Now, with heavy rains deluging the country, cholera cases have “surged,” said UN High Commissioner for Refugees (UNHCR) Representative in Sudan Kristine Hambrouck at a press briefing in Geneva on Friday.

“Risks are compounded by the continuing conflict and dire humanitarian conditions, including overcrowding in camps and gathering sites for refugees and Sudanese displaced by the war, as well as limited medical supplies and health workers. This is in addition to overstretched health, water and sanitation and hygiene infrastructure – all of which have been heavily impacted by the war,” she said.

Since the start of the devastating civil war in April 2023, the violence between the RSF (RSF) and the Sudanese Armed Forces have displaced over 10.2 million people internally – and forced another 2.1 million people into neighboring countries – creating the largest refugee crises in the world along with widespread hunger as well as widening pockets of outright famine in the western Darfour region. 

With large scale displacement, violence, and attacks on humanitarian aid, Sudan’s health system has quickly deteriorated. The WHO reports that over two-thirds of the country’s healthcare centers are not operational, and the ones still functioning are “at risk of closure due to shortages of medical staff, supplies, safe water, and electricity.” Furthermore, targeted attacks on hospitals, like June’s siege on the western Sudanese city of El Fashir, and its only maternity hospital, have left only 2% of the population with adequate healthcare.

“A new wave” of cholera roars through eastern provinces after heavy rains

Cholera oral vaccine Sudan
Already WHO has used over 50,000 oral cholera vaccine doses, and hopes to vaccinate more children in the coming weeks.

Just a few months into the fighting, in June 2023, cholera broke out in a dozen Sudanese states. Since then, these states have reported more than 11,000 cases and 316 deaths. At the country level, cases peaked over the winter of 2023.  But the country’s eastern Red Sea state, at the epicenter of the outbreak, continued to see new cases. 

Just south of the capital state of Khartoum, the Sudan Federal Ministry of Health officially declared a new outbreak in Al Jazirah in the Kassala state earlier this month, raising concerns for outbreaks in an area where aid workers are repeatedly denied access. 

“Of particular concern is the spread of the disease in areas hosting refugees, mainly in Kassala, Gedaref and Jazirah states. In addition to hosting refugees from other countries, these states are also sheltering thousands of displaced Sudanese who have sought safety from ongoing hostilities,” said UNCHR in a statement.

In Kassala’s refugee camps, “people live on top of each other, they are hugely overcrowded,” said Hambrouck. “The water systems that were in place do not have the capacity to respond, it really needs massive investments.”

Yet the risk of cholera is not constrained to within Sudan’s borders. In the neighboring countries of Chad and South Sudan, UNCHR has reported an elevated risk of cholera outbreaks in refugee sites amid the onset of the rainy season. 

Sudan cholera and measles outbreak
Twelve of Sudan’s 18 states are experiencing multiple disease outbreaks, including cholera.

“We are also concerned for the health and protection of Sudanese refugees who fled the country,” said Hambrouk. “Our teams have reported an increase in malaria cases…amid alarming rates of malnutrition, and cases of measles, acute respiratory infections, acute watery diarrhea, and the risk of outbreaks of cholera.”

WHO scaling up cholera immunization campaign – but malaria and measles also threaten

Despite these challenges, an initial vaccination campaign  in Kassala state successfully protected more than 50,000 people from cholera, with hundreds of thousands more doses on the way. 

“The vaccination campaign already started and we used the 51,000 doses that were already in the country,” said Dr Shible Sahbani, WHO Representative in Sudan. Speaking from Port Sudan, he confirmed that the inoculation campaign concluded in Kassala state on Thursday. “We were aiming to reach the 97 per cent of the target population,” he said, adding that the UN health agency has also secured the approval to procure an additional 455,000 doses of cholera vaccine – “good news in the middle of this horrible crisis.”

Sudan WHO representative cholera
Dr Shible Sahbani, WHO Representative in Sudan speaking from Port Sudan, discusses a new cholera vaccination campaign.

Malaria continues to be a leading infectious cause of morbidity and mortality in Sudan. In the past decade, malaria cases increased by more than 40%, most likely due to frequent flooding, population movement, and the emergence of a new, and more invasive mosquito vector, anopheles stephensi. The WHO reports that between November 2023 and July 2024, over 1.67 million cases have been reported from 15 states. 

This comes just two years after the WHO congratulated Sudan on its steps in vector control – efforts that have now been derailed by the civil war. 

The WHO situation report also highlights a concerning numbers of measles cases – nearly 5,000 of a disease that is vaccine-preventable since late 2023. Low immunization rates and hard-to-access areas in places like Darfur and Kordofan states means that the risk of measles remains high, prompting the WHO and its partners to gear up for a large-scale campaign in the coming months.

Yet concerns over funding and humanitarian access may hamper the global health agency and its partners to implement a campaign at that scale. Of the $ 1.5 billion required by UNHCR and other partners for the Regional Refugee Response Plan (RRRP) to provide assistance in countries bordering Sudan, just 22% has been received. The inter-agency response inside Sudan is only 37% funded.

Even with funding, an “immediate ceasefire” and unimpeded and safe humanitarian access is needed to ensure aid can reach those who need it, said UNICEF spokesperson James Elder at the Geneva press briefing. Recent US-mediated peace talk efforts fell through after both warring parties failed to show up for talks last week in Geneva.

Image Credits: WHO, WHO, WHO, WHO.

A nurse prepares a trial participant for various tests as part of a trial of drug-resistant TB drugs.

The World Health Organization (WHO) this week recommended three new regimens for multidrug-resistant or rifampicin-resistant tuberculosis (MDR/RR-TB) tuberculosis (TB) that are far shorter than the current regimens and can be taken orally.

The new regimens can cure patients in six to nine months rather than the usual 18 months and dispense with the painful injections that people with DR TB have had to endure as part of their treatment.

Almost half a million people contract MDR-TB/RR-TB every year, and many die from it – in part because it is hard for them to adhere to treatment.

“The use of new and repurposed medicines like bedaquiline, pretomanid, linezolid, and delamanid and the shift away from older injectable-based regimens has led to incremental improvements in the treatment success rate for people with MDR/RR-TB,” according to the WHO.

“Globally in 2022, in MDR/RR-TB patients who started treatment in 2021, the treatment success rate was 63%, reflecting a steady improvement from 50% in 2012 .”

Bedaquiline and delamanid are the first new TB drugs in 50 years.

Tested on wide range of patients

The WHO recommendations are based on results from the BEAT-TB clinical trial conducted in South Africa and the endTB trial conducted in seven countries between 2017 and 2023 by Médecins Sans Frontières’ (MSF), Partners In Health (PIH) and Interactive Research and Development (IRD), and funded by Unitaid.

Trial participants included children, adolescents, pregnant and breastfeeding women. 

“Clinicians can now offer these advances to nearly all patients, thereby increasing chances of cure while reducing exposure to treatment toxicity and reducing the spread of drug-resistant forms of TB in the community”, says Professor Carole Mitnick, PID Director of Research for the endTB project, co-Principal Investigator of the study, and Professor of Global Health and Social Medicine at Harvard Medical School. 

“With treatment complexity, duration, and toxicity reduced – and options increased – prospects for eliminating the gap between need (approximately 500,000 patients/year) and percentage treated (no more than 35%/year) are vastly improved,” she added.

Drug cost barrier

“WHO’s recommendations are a major step forward for the health of millions of patients affected by this form of the disease, which is particularly difficult to treat,” said Dr Lorenzo Guglielmetti, MSF’s director of the endTB project and co-principal investigator of the clinical trial.

“MSF carried out the endTB clinical trial – along with another TB trial called TB PRACTECAL – because the pharmaceutical industry failed to do so. Both trials have found better treatments for people with TB and influenced WHO recommendations and guidelines,” said MSF in a media statement released on Thursday.

“After several decades of therapeutic status quo – and for the second time in two years, along with TB PRACTECAL – new treatments evaluated by independent actors, including NGOs, have been rapidly incorporated by WHO into its recommendations for combating the scourge of MDR-TB,” added Guglielmetti. 

“It’s important to remember that the pharmaceutical industry, despite significant public financing, has only brought new drugs to market. They have not informed the use of these drugs in regimens. It has been left to NGOs to conduct controlled trials to inform practical use of, and innovations with, novel products.”

However, the success of the new guidelines rests on a reduction in the price of delamanid, which MSF described as “excessively high”. 

Japanese pharmaceutical corporation Otsuka produces delamanid through an exclusive licence with Viatris.

“We call on Otsuka and Viatris to stop blocking price-lowering generics from entering the market and to immediately share delamanid with every company interested in making more affordable quality-assured generic versions of this lifesaving TB drug,” said Christophe Perrin, TB advocacy pharmacist at MSF’s Access Campaign. 

“Otsuka and Viatris must also urgently drop their prices for delamanid so that many more people with DR-TB can access this lifesaving drug as part of shorter, all-oral regimens.”

Image Credits: TB Alliance.

Access to the internet offers educational opportunities, but excessive social media use can harm children.

As evidence mounts of the health harms of excessive social media use on children, governments and academics are mulling how to regulate and contain these harms – notably anxiety, depression and low self-esteem.

US Surgeon General Dr Vivek Murthy recently appealed to his country’s Congress to compel social media sites to carry warning labels about the potential negative effects on the mental health of teens and children. This approach is akin to that used in many countries to warn of the harms of tobacco products and alcohol.

A study of over 6,500 US teens adjusted for baseline mental health status found that those who spent more than three hours a day on social media faced double the risk of experiencing poor mental health outcomes including symptoms of depression and anxiety.

Excessive time online also cuts children off from friends and family, makes them less likely to exercise and increases their exposure to online marketing of unhealthy goods such as alcohol, cigarettes and gambling – as well as sexual predators.

But there are also educational advantages to online access, which complicates regulation. In addition, many parts of the world are still grappling with how to extend internet access to their citizens.

Approximately one billion children and young people under the age of 26 have access to the internet at home – approximately one-third of this age group and skewed in favour of high-income countries and households, according to UNICEF.

UNICEF: Children and young people with access to the internet at home

Public health approach

A viewpoint published in last week’s Lancet appeals for “a public health approach” to protect children from digital harms. 

“To build healthy digital environments for children now and future generations, we recommend a precautionary approach to governance that prioritises children’s health and wellbeing, recognises their desire to enjoy the benefits of the digital world, and allows children to have a role in shaping their digital futures,” urge the authors, Louise Holly, Prof Sandro Demaio and Prof Ilona Kickbusch.

“New algorithmic features are emerging at a rapid pace to capture children’s attention and increase platform use. Legislation is failing to keep up with these developments and children remain unprotected,” they note.

The authors suggest three broad areas for intervention: delaying the age at which children  use digital media and devices; health warnings on device packaging, digital apps, and websites and health promotion campaigns to raise awareness of the benefits of delaying digital technology use among young children. 

To achieve these, they suggest six strategies.

The first involves using the built-in technical features of smartphones and apps limit users’ time. 

“Regulations could require such time-limiting features to be strengthened to protect children and could also be set as a default on all devices, games, and apps so the onus is on users to reduce, rather than set or increase time limits,” they suggest.

The second involves increasing the cost of products such as games, apps and smartphones by taxation.

The introduction of “device-free spaces similar to smoke-free spaces” is their third suggestion.

The fourth strategy involves “comprehensive digital education”. In addition, UNESCO recommends that schools limit the amount of learning done on individual devices.

Fifth, they recommend changing the “norms around children using smartphones”, referring to how the French town of Seine-Port has banned the use of smartphones in public places after this was agreed via a referendum. 

Finally, they recommend creating offline alternatives for children such as  green spaces and sports facilities. Here they refer to Iceland’s “whole-of-society approach that includes increasing opportunities for children to engage in organised leisure activities” to reduce drug use.

Impact on girls

The US Surgeon General has also published an advisory on the impact of social media on young people highlighting its pernicious influence on girls.

“Social media may also perpetuate body dissatisfaction, disordered eating behaviors, social comparison, and low self-esteem, especially among adolescent girls,” it notes.

“One-third or more of girls aged 11-15 say they feel ‘addicted’ to certain social media platforms and over half of teenagers report that it would be hard to give up social media. “When asked about the impact of social media on their body image, 46% of adolescents aged 13-17 said social media makes them feel worse,” according to the advisory. 

“Additionally, 64% of adolescents are ‘often’ or ‘sometimes’ exposed to hate-based content through social media. Studies have also shown a relationship between social media use and poor sleep quality, reduced sleep duration, sleep difficulties, and depression among youth.”

Image Credits: UNICEF.

Deforestation drives vector-borne diseases
Oropouche virus, which causes similar symptoms to dengue, is now spreading in countries beyond Brazil’s heavily forested Amazon region. Cases have increased ten-fold since last year, prompting the CDC and PAHO to issue warnings.

A little known, but potentially lethal virus is spreading throughout Latin America and the Caribbean, prompting the US Centers for Disease Control (CDC) and other health agencies to issue warnings for travelers and clinicians.

Oropouche virus, an arbovirus like dengue, Zika, and chikungunya, is spread through certain midge or mosquito bites. Oropouche symptoms are similar to these other arboviruses with fever, rashes, muscle aches, and headaches common. Symptoms typically last 5 to 7 days, but more recently, the virus has been linked to severe fetal outcomes, including congenital abnormalities and death. 

While the virus was first detected in 1955 in the Caribbean nation of Trinidad and Tobago, the Americas saw few cases each year – and those that were reported were mostly concentrated in the  Amazon or other rainforests.  

Oropouche-carrying midge
Biting midges along with certain mosquitoes, are the primary vector for the disease.

Now, however, Oropouche cases have jumped dramatically. The Pan-American Health Organization (PAHO) has reported 8,078 confirmed cases since January – almost a ten-fold increase since last year – with Brazil’s endemic Amazon regions contributing most to the case count. Other countries, like Cuba and Bolivia, are reporting cases for the very first time.

Despite ongoing research, much about Oropouche virus remains unknown, including the factors behind this year’s unusually severe outbreak, which prompted The Lancet to label it a “mysterious threat.” Historically, no Oropouche-attributed deaths have occurred since the virus was discovered, yet this year has already seen the deaths of two otherwise healthy Brazilian women. 

PAHO notes that “although the disease has historically been described as mild, the geographic spread in transmission and the detection of more severe cases underscore the need for increased surveillance and characterization of possible more severe manifestations.”

Vertical transmission reported, travel-associated cases

Graph of Oropouche cases 2024
Brazil accounts for the majority of Oropouche virus cases, yet several countries are now seeing first-time transmission.

 

Brazil was the first country to report instances of vertical transmission – when a disease passes from mother to fetus – earlier this summer. The latest epidemiological alert notes four cases of infant microcephaly, and four suspected fetal deaths. 

The CDC has thus urged pregnant women to reconsider nonessential travel to Cuba and if unavoidable to strictly follow the CDC’s prevention recommendations, which include using insect repellent, and window and door screens. These recommendations also work to prevent dengue, which has so far caused over 10 million cases in the Americas, including the US territory of Puerto Rico. 

The CDC’s alert comes as a response to several travel-associated cases in the US and Europe, mostly from individuals returning from Cuba and Brazil. No local transmission has been reported in the US or Europe.  

Climate change, deforestation, mutations, possible culprits

Oropouche mosquito monitoring
PAHO staff explain mosquito sampling methodology to better understand the distribution of disease-carrying species.

The CDC report came just a few days prior to World Mosquito Day, in which the World Health Organization has called for member states to intensify their awareness of the dangers posed by mosquito-borne diseases. 

Climate change, deforestation, and unplanned urbanization are facilitating Oropouche’s march through Latin America and the Caribbean, PAHO noted in its analysis. As in many cases, these trends help facilitate the leap of vector-borne diseases that were previously prevalent mostly in remote rural areas to cities.

“Oropouche virus has infected people living in regions far from forested areas, thus indicating that an urban cycle can exist as well,” wrote the Lancet editorial team. The authors also speculate that genetic mutations could help explain the rapid increase in cases. Yet the virus’s spread follows a pattern similar to dengue, zika, and chikungunya – the mosquito-borne diseases that have smashed records this year. 

Like many neglected tropical diseases, the actual number of Oropouche cases may be much higher, said PAHO in a recent statement. 

And with Oropouche presenting symptoms similar to other arboviruses, PAHO is urging member states to strengthen epidemiological surveillance and laboratory diagnosis, particularly to identify fatal and severe cases and possible cases of vertical transmission. The organization also urges countries to “expand prevention campaigns and strengthen entomological surveillance and vector control actions to reduce mosquito and gnat populations.”

Image Credits: Earth.org, PAHO , PAHO/WHO.