HIV medicine dolutegravir.

The World Health Organization (WHO) recently reported drug resistance to the world’s gold-standard antiretroviral medicine, dolutegravir  “exceeding levels observed in clinical trials” – with resistance ranging from 3.9% to 19.6%.

This was potentially very bad news as dolutegravir has been the recommended first- and second-line HIV treatment for all population groups since 2018 – but the WHO told Health Policy Watch this week that the drug resistance was largely related to patients not adhering to treatment properly rather than growing resistance to the medicine.

Dolutegravir is “more effective, easier to take, and has fewer side effects than other drugs currently in use” with “a high genetic barrier to developing drug resistance”, according to the WHO.

It is used in antiretroviral therapy (ART) in combination with tenofovir and lamivudine, and its use has led to “very high levels of viral load suppression at the population level, often in excess of 90% or even 95%”, according to WHO. 

Country reports on resistance

The reports on resistance come from country surveys in Uganda, Ukraine, Malawi and Mozambique, WHO told Health Policy Watch.

In Uganda, Ukraine and Malawi, the levels of resistance to dolutegravir ranged from 3.9% to 8.6% in adults, ranging from those who had never taken ART to those with some exposure to the drugs.

But in Mozambique, the survey involved people experienced with treatment who had transitioned to a dolutegravir-containing regimen while having high HIV viral loads. And in this instance, resistance reached 19.6%. 

“Overwhelmingly, data suggest that non-adherence to treatment is the primary reason for viral non-suppression in people taking dolutegrivar, not drug resistance,” said the WHO spokesperson.

“Levels of HIV drug resistance observed to the integrase inhibitor dolutegravir are much lower than resistance levels observed in populations failing non-nucleoside reverse transcriptase inhibitors (NNRTIs)-based antiretroviral therapy,” added WHO.

NNRTIs refer to a class of ARVs that block an HIV enzyme called reverse transcriptase, which prevents the virus from replicating. Efavirenz, the previous WHO-recommended first-line HIV treatment regimen, was an NNRTI.

“In populations not achieving viral suppression on NNRTI-based ART, we saw levels of resistance from 70-90%. The combination of higher levels of viral load suppression and the much lower levels of acquired drug resistance affirm the global guidelines’ change from NNRTI- to dolutegravir-based treatment,” the WHO added.

The WHO official noted that there was still “much to learn about dolutegravir resistance”, with “very early and limited data” suggesting that “very large proportions of people not achieving viral suppression” on the dolutegravir would do so with “enhanced adherence support”. 

Dolutegravir and TB medication 

Meanwhile, a new clinical trial has found that people newly diagnosed with HIV fared well when given preventative treatment for tuberculosis at the same time as dolutegravir.

These results were released at the recent Conference on Retroviruses and Opportunistic Infections in Denver, Colorado.

“Each year, there are an estimated 670,000 new TB cases among people living with HIV and an estimated 167,000 deaths from TB-related HIV,” according to a media release from the Aurum Institute, one of the research partners in the trial.

The trial – called DOLPHIN-TOO – focused on whether the efficacy of dolutegravir in people living with HIV who had never previously been treated with ARVs was affected by prophylactic TB treatment – either the standard isoniazid (6H) or the newer regimen comprising of a weekly dose of isoniazid and rifapentine for three months referred to as 3HP.

The results showed that, while people in the 3HP group did have lower levels of dolutegravir in their bloodstream than people in the 6H group, they were able to achieve an undetectable level of HIV virus in blood by eight weeks and maintain this for the length of the six-month study. 

Minimal side effects were seen, none were severe, and the majority were resolved with continuation of therapy. 

Previous research released at the Union World Conference on Lung Health in November of 2023, had provided information on the safety and efficacy of the use of 3HP and dolutegravir  together, but without data on the drug levels in the blood.

“This study points to the use of short course TB preventive treatment in people who are newly diagnosed with HIV and are at highest risk of active TB disease,” according to a media release from Aurum.  

Medication-related harm accounts for a half of preventable harm in medical care

As many as one in 20 patients experience avoidable side effects from medication that they use, with this figure rising to 7% in developing countries. 

The causes range from taking the medication at the wrong time, which could result in minor side effects, to taking an  inappropriate drug, which might result in unpredicted harm as serious as yet another disease or even death.

Such errors are not that scarce, concludes Dr Maria Panagioti, senior lecturer in primary care and Health Services Research at the University of Manchester and one of the authors of a new World Health Organization (WHO) systematic review “Global burden of preventable medication-related harm”. 

The global cost associated with administering unsafe care is estimated at $ 40 billion each year, WHO says.

“Without measurement, action to drive improvements are not possible, regardless of context,” said Dr Neelam Dhingra, head of  WHO’s Patient Safety Unit, during a webinar on the new guidance. 

While developing new treatments and better policies is important, much progress in healthcare can be achieved as a result of simply “doing no harm,” she said.

Errors occur, reduction targets are scarce

Only 18% of WHO member countries have a national target for reducing medication-related harm.

Seven years ago, WHO established a Medication Without Harm challenge in which it setting the goal of reducing harm by incorrect medication by half in five years. This was followed by a Global Patient Safety Action Plan, approved by the World Health Assembly in 2019. But much remains to be done.

“Assessing the burden of patient harm and also medication-related harm is a critical part of measuring patient safety,” Dhingra highlighted. “However, this truly remains a challenging agenda still.”

According to the new systematic review, half of all avoidable harm in medical care is related to medication, and a quarter of mediciation’s preventable harm can have severe or even life-threatening consequences.

Medication error is often avoidable. Yet, it is experienced by 5% of all patients.

Many mistakes occur in specific contexts, such as when patients are already taking many different kinds of medication (polypharmacy) that interact with one another, or patients who transition between caretakers, or in situations where high risk drugs are used.

Areas of improvement

The new WHO policy brief proposes key areas for addressing the risks including better communication and engagement of patients and patient organisations. With good public awareness of medication effects, it is easier for patients themselves to identify errors, such as the prescription of the wrong drug by a pharmacist.

Four domains and three key areas outlined in the WHO’s Global Patient Safety Action Plan

Healthcare workers should also receive training on medication harm, the brief notes. Better health worker conditions also reduce the risk of errors from factors such as fatigue and multi-tasking.

Identification of high risk drugs and additional care in their management is also critical. 

There is a “huge burden of preventable harm due to unsafe medication practices and medication errors,” Dhingra noted. ”Action is required at all levels, […] and we need to implement safe systems and practices for medic medications.”

Image Credits: WHO/Quinn Mattingly, WHO, WHO.

monkeypox
Patient participating in a clinical trial of Tpoxx, an antiviral treatment for the mpox virus, in the Democratic Republic of Congo.

A leading Geneva-based global health organization has decried the lack of tests available for mpox in the Democratic Republic of the Congo (DRC) – where an outbreak declared in 2023 continues unchecked – saying that children are the main victims. 

“The mpox situation in the DRC is deeply alarming and the lack of tests for both mpox and HIV means it’s unclear just how bad the mpox situation is and what the underlying comorbidities are,” said Dr Ayoade Alakija, Chair of the Board at FIND in a press release.

According to FIND, a global non-profit dedicated to accelerating access to diagnostics, only 16% of suspected mpox cases in DRC undergo a PCR test. Among suspected cases that are tested, six out of ten test results are positive, underlining the degree of under-estimation of confirmed mpox cases.

“Testing capacity for mpox and HIV in the DRC is severely limited, meaning that many likely cases of mpox in the country are treated as suspected cases only,” Dr Sergio Carmona, FIND CEO and chief medical officer said.

Left unchecked – virus risks further spread abroad

Alakija compared the current mpox outbreak in the DRC with the situation during the COVID-19 pandemic, when many African countries were left behind in terms of tests and treatments and vaccines.

Left unchecked, the deadly Clade I form of the mpox virus now circulating in the DRC risks spreading further in Africa and beyond, she warned. 

“The people that are being prioritized for tests, treatment and vaccination are not in the outbreak countries in Africa,” she noted, referring to the rollout of measures in high- and middle-income countries over the past two years to counter the much milder, Clade I, form of the mpox virus that exploded in 2022. 

“We can either mobilize resources and fight the deadly mpox outbreak now in the DRC, or we can let the virus continue to spread and fight it when it is imported into other countries,” Alakija  said.

DRC outbreak is the largest ever recorded

According to the US Centers for Disease Control (US CDC) the current DRC mpox outbreak is the largest ever recorded, with cases reported in 22 out of the DRCs 26 provinces. Some 12,569 suspected cases and 581 deaths have been reported since 1 January 2023.  

From the start of 2022 to January 2024, the DRC reported 21,630 suspected MPXV cases and 1,003 deaths. Around 85% of deaths in this period were children under 15 years of age, according to WHO data.  

Epidemic curve shown by month for cases reported to WHO from the African region. Recent cases mostly in DRC.

Potentially ‘distinct’ Clade I strain and new patterns of transmission 

Mpox is a viral infection, which belongs to the same virus family as smallpox. It was traditionally confined to remote, rural areas of central and western Africa, where transmission was sporadic and occurred primarily through human contact with rodents and other small mammals. 

The virus burst onto the global arena in 2022 when WHO declared a global health emergency after the milder, Clade II form of mpox, began to spread through dozens of countries worldwide, infecting thousands of people, mainly through sexual transmission, and particularly men having sex with men. 

The global health emergency was declared over in 2023 following the scale up of diagnostics and vaccination in middle- and high-income countries, aimed at high-risk groups. 

Over the past year, however, global health authorities have expressed rising alarm over the increased circulation of the more deadly Clade 1 of mpox throughout central and east Africa – including through patterns of sexual transmission, including heterosexual transmission, not previously seen. 

In the case of the eastern DRC, female sex workers found to be among the leading groups transmitting the disease, along with transmission through close familial or community contacts, according to a study published Tuesday on the pre-print health sciences platform, MedRxiv. The study looked at transmission patterns in the city of Kamituga, in DRC’s south Kivu province.  

The sustained community-level transmission of mpox now seen in Kamituga “is….  being driven by a distinct Clade I mpox strain, possibly a novel subgroup, as confirmed with qPCR,” the researchers from over a dozen countries found. 

Mpox has similar symptoms as smallpox, including painful blisters and rash, fever, chills and fatigue. In the case of the milder, Clade II form of the virus, most patients recover after a few weeks of supportive care, WHO says.

Image Credits: WHO.

COVID-19 screening in Bangkok, Thailand: Financing future pandemic preparedness and response is unclear.

Many practical questions about how the pandemic agreement will be implemented – including how to finance countries’ pandemic prevention, preparedness and response (PPPR) – seem likely to be ceded to the Conference of Parties (COP).

According to the latest pandemic agreement draft, a “Coordinating Financial Mechanism” will support the implementation of the pandemic agreement and the International Health Regulations (IHR) (see Article 20).

“There’s a key debate with Article 20 within the negotiations about whether the coordinating mechanism should be hosted by the Pandemic Fund, the World Health Organization (WHO), or whether a new entity should be created,” Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds, told a Geneva Global Health Hub (G2H2) media briefing on Tuesday.

“There’s seemingly little appetite for a new institution, and there is a strong narrative being promoted for the Pandemic Fund in order to decrease fragmentation,” added Wallace Brown, who is director-designate of new WHO Collaboration Centre for Health Systems and Health Security.

The Pandemic Fund’s Priya Basu has made a strong bid for her entity to become this mechanism, telling Devex this week that a new fund to support PPPR would mean “duplication”.

Professor Garrett Wallace Brown, chair of Global Health Policy at the University of Leeds

But Wallace Brown said that “final decisions about the details of the coordinating mechanism are being offloaded to the Conference of the Parties (COP), which I think is a wise decision given the circumstances”. 

“There are only nine negotiating days left and there are lots of details to work through. But I think it’s only wise if the COP is representative, inclusive, proportional to risk and deliberative, meaning a move away from business as usual.”

In conversation with delegates involved in the Intergovernmental Negotiating Body (INB) thrashing out the pandemic agreement, Wallace Brown said that “what they want to do is make the wording strong enough to show that there’s a commitment to a coordinating mechanism and a commitment to financing those”.

In addition, they were “being somewhat more clear about what types of financing and what types of mechanisms would be housed underneath that, but offshoring those details for 12 months – I’m suggesting 24 months – to try to work out exactly how that is done”. 

Domestic funds?

According to the draft, the financing mechanism would include a pooled fund for PPPR, and may include “contributions received as part of operations of the [Pathogen Access and Benefit-Sharing System], voluntary funds from both states and non-state actors and other contributions to be agreed upon by the Conference of the Parties”.

G2H2 co-chair Nicoletta Dentico

However, G2H2 co-chair Nicoletta Dentico warned that poorer countries were mired in debt and debt cancellation should be a consideration to help these countries.

“Fifty four low-income countries with severe debt problems had to spend more money on debt servicing than on the COVID disease in 2020,” said Dentico, who heads the global health justice program at Society for International Development (SID).

“Contrary to the WHO Framework Convention on Tobacco Control, the [pandemic agreement] text opened for the final negotiations stubbornly ignores the repeated calls for legal safeguards that are indispensable to immunise the treaty implementation and financing from vested corporate interests,” added Dentico.

Mariska Meurs from the Dutch health NGO WEMOS, warned that “domestic funding for pandemic prevention preparedness and response must not undermine other domestic public health priorities”. 

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation”.

“But undermining other domestic public health priorities is exactly what we’ve seen happening under COVID-19. We’ve witnessed the shifts in global and domestic funding and how funding for basic health care has gone down,” warned Meurs.

“The text, as it lies before us now, does not acknowledge or try to remedy this.”

Mariska Meurs from the Dutch health NGO WEMOS

“The draft pandemic treaty text worryingly includes ‘innovative financing mechanisms’, which often means using public funds not for heath, but to attract private-for-profit investors. Instead, the pandemic treaty should embrace the most obvious and fair avenues for funding pandemic prevention, preparedness and response: global tax justice and debt cancellation,” said Meurs.

Pandemic Fund ‘black box’

Low and middle-income countries are more in favour of the pandemic financing mechanism being housed in the WHO “because they see it as being more representative” than the Pandemic Fund, said Wallace Brown.

But donors “are less keen because they see it as a mechanism that would give them less control of how funds are spent”.

However, for the Pandemic Fund to become the PPPR mechanism would require “radical changes” not “minor tweaks as we’re currently being told”. 

Some of the problems with the fund, are that it only focuses on three elements of PPPR and this “creates vertical silos”, and there is no explicit guidance in the fund’s governance framework on “how equity will be addressed in either the fund process or with reference to prioritise beneficiaries of programmes”, according to Wallace Brown.

In addition, the first round of funding was eight times over-subscribed but the selection process “was not clear”.

“Applications that met the scorecard threshold for funding had to be rejected, and it remains unclear exactly how the governing board made their final decisions,” he added.

Describing his personal view on the way forward as “agnostic”, Wallace Brown said he had been studying the Pandemic Fund for a while and “think it’s a bit of a black box”. 

However, the WHO would need capacity building to become the mechanism 

“They do handle funds, they have the contingency fund for emergencies. They are able to make funding available to people and have processes for that, but they don’t have it at the same scale as a World Bank,” he said.

“Or there could even be a third entity. So at the moment, I’m remaining agnostic. I think there needs to be better analysis, better evidence to decide what works and what doesn’t work” – and these kinds of details “won’t be decided in nine days”.

Image Credits: Prachatai/Flickr.

Lab technician at a pharmaceutical company conducting a test.

The new draft of the pandemic agreement “is a step backwards rather than forwards”, according to Thomas Cueni, Director General of the International Federation of Pharmaceutical Manufacturers and Associations (IFPMA). 

“It is critical that any agreement takes steps to ensure equity in access to medicines and vaccines in future pandemics, whilst preserving the innovation ecosystem that delivered a vaccine just 326 days after the SARS-CoV2 genome sequence was first sequenced,” said Cueni.

 Article 12 of the current draft proposes that manufacturers pay an annual subscription fee to a yet-to-be-formed World Health Organization (WHO) Pathogen Access and Benefit-Sharing (PABS) System.

In exchange, they would get “rapid, systematic and timely access to biological materials of pathogens with pandemic potential and the genetic sequence data (GSD) for such pathogens”.

The article also proposes that manufacturers provide “real-time contributions of relevant diagnostics, therapeutics or vaccines” with 10% free and 10% at not-for-profit prices during public health emergencies of international concern or pandemics.

‘Uncertainties will cause delays’

But Cueni was dubious: “Stringent requirements for accessing pathogen data would severely impact responses to future pandemics and basic research and development (R&D).

“Conditions, uncertainties, and negotiations surrounding pathogen access will cause delays in the developing medical countermeasures, leading to significant public health consequences, including loss of lives and unnecessary economic pressures. In the COVID-19 pandemic context, even a one-month delay could have meant an extra 400,000 lives lost.”

The pharmaceutical industry has warned that a mandatory financial contribution could dis-incentivise companies from joining the PABS system.

“The pharmaceutical industry is determined to continue to play our part in these final stages – sharing our experience, evidence and expertise to help deliver an agreement that will better protect the world when the next pandemic hits,” Cueni said.

Thomas Cueni, Director General of the IFPMA.

This week, the biopharmaceutical industry published a statement on how companies can work between pandemics – as well as when a pandemic hits – to deliver equitable access to medical countermeasures on the basis of public health risks, needs and demands.”

The statement was signed by a broad range of trade associations aside from the IFPMA, including the Developing Countries Vaccine Manufacturers Network, DCVMN, Europe (EFPIA), the US (PhRMA) and Japan (JPMA), and the Biotechnology Innovation Organization (BIO).

The companies detail the commitments to pre- and during pandemic measures.  These include improving surveillance; research on pathogens of pandemic potential; voluntary licensing and technology transfer based on “mutually agreed terms to improve geographic diversity of manufacturing”; real-time allocation of part of production, and equity-based tiered pricing.

Companies are also engaged in ongoing activities to support health system preparedness, whether by building clinical trial and regulatory capacity and harmonization, health care worker and community health worker trainings, or the continual investment needed to establish and maintain new technologies and platforms.

“With a final draft of a pandemic agreement now published, negotiators should redouble their efforts to find consensus as there is still much work to be done before an agreement can be reached, added Cueni. 

Previously, Cueni warned that “It would be better to have no pandemic treaty than a bad pandemic treaty.”

Image Credits: AMR Industry Alliance, World Health Summit.

Accra has reduced traffic crashes by 20% over seven years

CAPE TOWN – From Accra to Kathmandu, a global partnership of 74 cities has had remarkable success in addressing some of the key drivers of sickness and death since it was launched seven years ago.

Ghana’s capital city, Accra, has cut traffic crashes by 20%. In India, Bengaluru is virtually smoke-free – not even hookahs are allowed. Nepal’s Kathmandu has installed air quality sensors to assess air pollution while a number of Latin American cities are supporting better nutrition of their school children. 

“The Partnership for Health Cities (PHC) was formed in 2017 to address non-communicable diseases (NCDs) and injuries, which are responsible for 80% of deaths globally,” said Bloomberg Philanthropies’ Kelly Larson, welcoming city representatives to the PHC’s summit in Cape Town this week.  

“This opportunity for us to come together is very unique because we are all facing the same challenges and you can learn so much from one another. We really do believe in the power of cities to make change. We are here to support you in your efforts to know that you are leading the way on this,” added Larson, whose organisation supports the partnership, along with the World Health Organization (WHO) and Vital Strategies.

The partnership started with 54 cities but now consists of 74 cities that collectively represent over 300 million people.

Each city in the PHC chooses to work in one of six key work areas: food policy, overdose prevention, tobacco control, road safety, safe and active mobility (such as promoting cycling) or data surveillance.

The cities are encouraged to root their work in public health policies and to win as much public support as possible for these. The PHC’s  Policy Accelerator supports cities to create and implement these policies.

“Cities are a place where people are particularly at risk. There is a huge concentration of people exposed to risk of NCD and injuries,” said the WHO’s Etienne Krug.

“But cities are a particularly good place to think about interventions for a number of reasons,” he added. “First of all, they enforce national laws but they can also enhance these with additional regulations. City leaders are geographically close to their populations. It is easier for multi-sectoral approaches than at national level.”

Bengaluru: A model smoke-free city

Bengaluru in India has become a model smoke-free city

India’s Dr Vishal Rao has been an advocate for smoke-free laws for a number of years in Bengaluru (Bangalore) and its state, Karnataka. This is hardly surprising as a head and neck surgical oncologist at a cancer hospital and has treated numerous tumours in the thyroid, parotid, and salivary glands caused by tobacco use.

“We first prioritised creating a policy framework around smoking, and have built this policy around the three R’s – making somebody responsible, have it reviewed and reported,” Rao told Health Policy Watch.

Dr Vishal Rao from Bengaluru

“We prioritised smoke free policy because we realised that Bengaluru is a cosmopolitan  economic hub with a very vibrant culture of pubs, clubs, cafes, bars and restaurants, all of which were rampantly violating the smoke free laws,” said Rao, who is also a member of the Karnataka government’s High Power Committee on Tobacco Control.

“Reducing and protecting the non-smokers required a comprehensive approach of policy intervention which is why the mayor and the [state] commissioner came out with the government order completely banning smoking in hotels, bars, restaurants, clubs, pubs and cafes unless they have a designated smoking room which is compliant with the law,” said Rao.

The requirements for these designated smoking rooms were so onerous – including no sales or services of any sort being allowed – that most places opted not to set them up.

A couple of weeks back, the state government also banned hookah bars – including hookah with tobacco, flavoured and herbal hookah – becoming the first state to do so. The pushback has been immediate, with the Hookah Association lodging around 12 litigation cases against the new laws, said Rao.

For Rao, the partnership is less about the grants cities get and more about sharing strategies, tactics and “allowing champions to emerge” to promote the various themes – his city won an award at last year’s summit for its efforts.

Accra: All the laws but little implementation

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs

Rita Agyen Takyi is an advisor to Accra’s mayor on international affairs and the city’s focal person on road safety, the issue her city has chosen.

“Ghana has all the laws. But we needed enforcement, implementation and public awareness,” Takyi told Health Policy Watch. Accra’s Bloomberg Road Safety initiative started in 2015 and it joined the partnership at its launch in 2017.

Over half the city’s road traffic deaths involved pedestrians, cyclists and motorcyclists. Public awareness campaigns have included encouraging the use of seat belts and helmets, speed limit signs and speed detectors for traffic police, direction signs painted on roads and fixed painted bollards to prevent motorcyclists from entering pedestrian crossings.

“We have reduced traffic crashes by 22% since 2021/22,” said Takyi, who also credits this success to Accra bringing different stakeholders “out of their silos” and into one forum with a common goal.

Latin American cities prioritise food policy

Five cities in Latin America have chosen to focus on food policy. Quito in Ecuador is concerned with the nutrition of children, the city’s Marysol Ruilova told the Cape Town summit.

Quito has developed a policy requiring only healthy foods to be advertised near and at schools, and is also providing clean free water in 20 pilot schools.

However, since the COVID-19 pandemic, there has been an increase in child malnutrition so the city has focused on school feeding schemes.

Cordoba is focusing on school nutrition, including promoting water

Similarly, Córdoba in Argentina is preparing to restrict the sale and advertising of unhealthy food and beverages in schools and requiring healthy alternatives, while 

Cali in Colombia is also ensuring that scholars have access to nutritious and wholesome meals during school hours.

Lima in  Peru is also working to create healthier school environments through enforcement of a new policy that restricts sales and advertising of unhealthy products. Montevideo in Uruguay is incentivizing food services to provide healthier meals to public sector workers, through its “Healthy Canteens” initiative.

Cape Town: Socio-economic determinants of health

Cape Town mayor Geordin Hill-Lewis addresses the opening of the summit.

Host city Cape Town has been involved in tobacco control and food policy-related initiatives while part of the PHP.

“Against the backdrop of incredibly challenging national economic circumstances and very deep and wide local poverty, our city is still demonstrating progress,” Mayor Geordin Hill-Lewis told the summit.“But you cannot build a prosperous city or achieve our dream of a city of hope without also focusing on public health in a serious way.”

One of the things that Cape Town is currently focusing on is identifying and addressing the socio-economic determinants of health in the city and addressing these through infrastructure planning, service provision and job creation.

“Cape Town has a very high burden of NCDs and other preventable deaths. And, while we have a good understanding of the various factors that contribute to that burden, this programme will provide crucial information that can help determine strategies going forward,” according to Councillor Patricia Van der Ross.

Image Credits: Partnership for Health Cities, Kerry Cullinan.

HPV vaccine
The WHO set an ambitious goal of having 90% of girls vaccinated against HPV by 2030

Eliminating cervical cancer is within reach, thanks to new commitments by governments, donors and other partners, including pledges of almost $600 million, made at the first-ever global forum on cervical cancer in Cartagena de Indias in Colombia.

Every two minutes, a woman dies from cervical cancer, although vaccination against human papillomavirus (HPV), the leading cause of cervical cancer, can prevent the vast majority of cases. 

Cervical cancer is the fourth most common cancer in women worldwide, but disproportionately affects women and their families in low and middle-income countries (LMICs). 

Less than 5% of women in many LMICs are ever screened for cervical cancer, and over 90% of the 348 000 cervical cancer deaths in 2022 took place in LMICs. 

Furthermore, only one in five adolescent girls were vaccinated against HPV in 2022. 

Country commitments

global cervical cancer mortality heat map
Low and middle income countries experience the highest burden of cervical cancer

However, a number of countries stepped up at the forum. These include the Democratic Republic of Congo (DRC), which has committed to introduce the HPV vaccine as early as possible, targeting girls aged 9 to 14 years.

Ethiopia aims to reach at least 95% of all 14-year-old girls with the HPV vaccine this year, and screen one million eligible women every year for cervical cancer and to treat 90% of those screened who present with positive precancerous lesions. 

Further, HPV single dose has been approved to be introduced this year and scaled up as part of the country’s Expanded Program on Immunization plans.

Africa’s most populous country, Nigeria, has committed to vaccinating 80% of girls 9 to 14 years old by 2026, including those who are no longer at school.

The nearly $600 million in new funding includes $180 million from the Bill and Melinda Gates Foundation, $10 million from UNICEF, and $400 million from the World Bank. 

Elimination of a cancer

Press conference at the global cervical cancer elimination forum
Experts gathered in Colombia to discuss global collaboration for cervical cancer elimination

“If these ambitions to expand vaccine coverage and strengthen screening and treatment programs are fully realized, the world could eliminate a cancer for the first time,” according to the World Health Organization (WHO).

In 2022, the WHO revised its HPV vaccination recommendation from two to one-dose of the HPV vaccine, making it much easier and cheaper for countries to reach those who need it.

The WHO Americas region made a similar recommendation 2023, and WHO’s African regional just followed suit with its own recommendation. 

“We have the knowledge and the tools to make cervical cancer history, but vaccination, screening and treatment programmes are still not reaching the scale required,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. 

“This first global forum is an important opportunity for governments and partners to invest in the global elimination strategy and addressing the inequities that deny women and girls access to the life-saving tools they need.” 

However, many LMICs face an uphill battle. Malawian Minister of Health Kandodo Chiponda described the challenges her country faces at the forum’s opening plenary. 

Some 60% of Malawi’s population of over 20 million is under 35, and cervical cancer is the highest cancer burden, with the incidence rate as high as 70 per 100,000. Mortality figures are 52 per 100,000, said Chiponda, who also announced the opening of the first ever cancer center in Malawi. 

Chiponda noted that women have limited time and resources to seek care, limited access to screening and diagnostic services, and are subject to misinformation about vaccinations. 

She emphasized the need for cross-sector collaborations and the strengthening of primary healthcare to reach women and girls in remote areas.

‘Miracle of modern medicine’

WHO director general
“Cervical cancer is a disease of inequity” – Dr. Tedros Adhanom Ghebreyesus, WHO Director-General

“The HPV vaccine is one of the most impactful vaccines on the planet and has already helped save thousands of lives,” said Aurélia Nguyen, Gavi’s chief programme officer. 

Despite the efficiency and safety of the HPV vaccine, high costs, supply chain issues, and difficulties in reaching remote populations keep the vaccine out of reach for many.

“More girls urgently deserve the same protection, which is why in partnership with countries, Gavi has set an ambitious goal to help vaccinate 86 million adolescent girls by 2025. With bold commitment and decisive action, we can look forward to a future where cervical cancer has been eliminated for good.” 

Describing HPV vaccines as “a miracle of modern medicine”, Dr Chris Elias, the Bill and Melinda Gates Foundation’s president of global development, said that there is “no reason why women should die from cervical cancer.”

“Now is the time for governments and partners around the world to increase HPV vaccine access and protect future generations from cervical cancer.” 

Image Credits: Unsplash, IARC/WHO, Global Cervical Cancer Elimination Forum, GCCEF/WHO.

The European Parliament is to vote on a regulation to allow compulsory licencing during crises.

The European Parliament has been challenged to amend a proposed law to enable  countries outside the European Union (EU) to benefit from medical products produced under compulsory licences during crises.

The proposed regulation aims to ensure that, “during specific crises or emergencies”, the EU can issue a compulsory licence to enable the production of certain products – such as vaccines and medicines during a pandemic.

A compulsory licence gives governments the power to allow a third party to use a patent without the authorisation of the patent-holder, subject to certain conditions. 

“Compulsory licensing can therefore complement current EU efforts to improve its resilience to crises,” according to the EU.

But the draft regulation currently prohibits the export of any products produced under compulsory licences outside the EU.

On Tuesday, a group of over 70 influential civil society organisations and academics wrote a letter to the European Parliament challenging them to “support crucial amendments allowing the export of medical tools to third countries in the proposed Union Compulsory License”.

“The COVID-19 pandemic has made clear that major health emergencies need to be addressed at local, national, regional and global level and showcased that the EU’s advanced industrial capacity can be used to help protect EU citizens while also aiding and supplying non-EU countries, aligning with the principle that “No one is safe until everyone is safe”,” the letter notes.

“It is therefore disheartening to note that, when preparing for the next crisis, the EU risks turning its back on the rest of the world, including non-EU countries in Europe, with this compulsory licence proposal,” it adds.

EU harmonisation

Impetus for the new regulation stems from the fact that there is “no EU-wide harmonisation of compulsory licensing for the domestic market”, according to the EU, which adds that the new regulation has two main objectives.

“First, it aims to enable the EU to rely on compulsory licensing in the context of the EU crisis instruments. Second, it introduces an efficient compulsory licensing scheme, with appropriate features, to allow a swift and appropriate response to crises, with a functioning internal market, guaranteeing the supply and the free movement of crisis-critical products subject to compulsory licencing in the internal market.”

The letter’s signatories, including Médecins Sans Frontières, Health Action International (HAI) and Oxfam, state that they support EU compulsory licences as they have “the potential to foster a more effective response to public health challenges”.

But by prohibiting exports, the current draft – which has been put forward for a plenary vote of the European Parliament – goes against flexibilities enshrined in the World Trade Organization (WTO) Agreement on Trade Related Aspects of Intellectual Property Rights (TRIPS Agreement), according to the letter.

“This limitation is problematic, especially considering the use of a Union compulsory license would likely be triggered by situations that would affect not only EU countries but also countries outside of the EU, either in the region or globally,” they add.

Pandemics ‘don’t respect borders’

Making exports available under an EU compulsory licence “is not just a matter of international solidarity but is also in the EU’s interest” as it could “help in controlling potential outbreaks and emergencies that could spill over into the EU, allowing EU-based manufacturers to respond promptly to the needs of non-EU countries”.

“This vote is important for a number of reasons,” according to HAI Senior Policy Advisor Jaume Vidal.

“Embracing TRIPS flexibilities is, of course, a welcome step, but the current proposal risks becoming an ‘EU First’ response when it comes to pandemics and health emergencies, reminiscent of the inequities seen during the COVID-19 pandemic.

“Secondly, at a time when countries are negotiating a pandemic accord, a restrictive use of the proposed Union compulsory license that would limit exports would be sending an ominous message to negotiators. Finally, in times of greatest need, the EU would do well to remember that pandemics don’t respect borders or blocs,  and that no one is safe, until everyone is safe.”

Image Credits: Thijs ter Haar.

The sixth UN Environment Assembly was held in Nairobi

The sixth United Nations Environment Assembly (UNAE-6) ended last Friday in Nairobi, Kenya with the adoption of a Ministerial Declaration affirming member states’ commitment to slowing climate change, protecting biodiversity, and creating a pollution-free world.

The assembly, which attracted over 5,600 delegates from 190 countries, also adopted 15 resolutions covering a range of issues including chemicals, waste, metals and minerals and protecting the environment during and after conflicts.

“As governments, we need to push for more and reinvent partnerships with key stakeholders to implement these mandates. We need to continue to partner with civil society, continue to guide and empower our creative youth, and also with the private sector and philanthropies,” said Leila Benali, UNEA-6 President and the Minister of Energy Transition and Sustainable Development of Morocco. 

Benali noted that the resolutions called for enlightened leadership and urged scaling up means of implementation, enhancing national capacity to implement action plans and policies, and strengthening the science-policy interface.

Evidence of the extent of environmental degradation and its impact on individuals keeps rising. Along with updated estimates of air pollution-related deaths at 8.3 million annually, a host of recent studies have also linked excessive levels of air pollution with health issues ranging from increased neo-natal mortality to Alzheimer’s.  Most recently, one Nature study linked spikes in air pollution with increased risk of deaths by suicide. 

Leila Benali, UNEA-6 President and the Minister of Energy Transition and Sustainable Development of Morocco.

A slew of UN reports released during the assembly last week also presented a grim picture of the immediate future. Data from the 2024 Global Resource Outlook warned that without urgent action to reduce global consumption and production, extraction of natural resources could rise by 60 % from 2020 levels. This would worsen climate and pollution impacts, with consequently greater  risks to biodiversity and human health, the report said. 

It also blamed the high levels of material consumption in upper-middle and high-income countries for the problem. The report said that the rich countries use six times more resources and generate 10 times  climate impacts than low-income ones. 

The Global Waste Management Outlook 2024 showed that without a seismic shift away from ‘take-make-dispose’ societies towards circular economy and zero-waste approaches, the world’s waste pile could grow by two-thirds by 2050, and its cost to health, economies and the environment could double.  It reiterated that only a drastic reduction in waste generation will secure a liveable and affordable future, and ways to convert waste into a reusable resource would have to be employed.

Another UNEP report on Used Heavy Duty Vehicles and the Environment launched during a Climate and Clean Air Conference held ahead of UNEA, sounded the alarm on the rise of emissions from these heavy polluters, and their negative climate and health impacts.

Resolutions on improving response

The assembly also held its first Multilateral Environmental Agreements (MEA) Day that was dedicated to the international agreements addressing the most pressing environmental issues. UNEA-6 welcomed youth to host their own environmental summit, which called for greater inter-generational equity.

“The President has gavelled resolutions that address desertification, land restoration and more. We also have a ministerial declaration that affirms the international community’s strong intent to slow climate change, restore nature and land, and create a pollution-free world,” Inger Andersen, UN Evironmental Programme Executive Director, said.

“UNEP will now take forward the responsibilities you have entrusted to us in these new resolutions. In addition to keeping the environment under review. In addition to fulfilling our obligation to serve as an authoritative advocate for action across the triple planetary crisis,” Andersen added.

“In our quest to confront the monumental environmental challenges of our time—climate change, biodiversity loss, and pollution—there is but one path forward: teamwork. We share one Earth, bask under the same sun, and we must recognize that there is no backup plan. There’s no other planet waiting for us to escape to,” said Abdullah Bin Ali Amri, Oman’s chair of the Environment Authority and president-elect of the next UNEA, which will be held in December 2025 in Nairobi.

A patient with age-related hearing loss (Presbycusis), receiving free treatment from the NGO, All Ears Cambodia.

Over 400 million people with hearing loss could benefit from hearing devices. However, less than 20% of those people actually get hearing aids. 

That’s one of the findings cited in new World Health Organisation guidelines on improving access to hearing care, published Friday, just ahead of World Hearing Day. 

“Unaddressed hearing loss is a global public health challenge and incurs an estimated cost of over US$ 1 trillion annually. Given the global shortage of ear and hearing care specialists, we have to rethink how we traditionally deliver services,” said Dr Bente Mikkelsen, director of the WHO’s Department for Noncommunicable Diseases.

By 2050, nearly 2.5 billion people are projected to experience a degree of hearing loss, as populations around the world age. More than 700 million will likely require hearing rehabilitation, estimates the WHO.

But nearly 80% of people with disabling hearing loss live in low-income countries – which historically have lacked capacity for providing assistive devices like hearing aids. 

Fighting misconceptions and lack of resources

But addressing hearing loss is not necessarily expensive. An investment of $1.4 per person annually would be sufficient to scale up ear and hearing care services worldwide, WHO said.

To overcome current limitations of capacity, the guidelines encourage more service delivery by non-specialists, based in primary health care settings. 

Debunking misconceptions and stigma around hearing loss is another key aim of the guidelines, created with the support of ATscale Global Partnership for Assistive Technology. 

“Common myths about hearing loss often prevent people from seeking the services they require, even where these services are available,” said Dr Shelly Chadha, technical lead for ear and hearing care at WHO. 

“Any effort to improve hearing care provision through health system strengthening must be accompanied by work to raise awareness within societies and address stigma related to ear and hearing care.”

Image Credits: WHO/Miguel Jeronimo.