The 77th general assembly of the United Nations (UNGA77) recently ended in New York. While the agenda was packed as per usual, topics on global health threats like the COVID-19 pandemic noticeably took a back seat. This highlights the prevailing shift by governments globally to turn the page on the pandemic while it is still ongoing. Thanks to vaccines and new treatments, COVID-19 is a much different threat in 2022 than when it first emerged in 2019. However, the scale of its impact on almost every aspect of population health worldwide is undeniable, ongoing and will reverberate for many years to come.
In this context I moderated a virtual event at the Science Summit at the General Assembly about meeting the Sustainable Development Goals (SDGs) through inclusive research and development (R&D) and equitable access. You can see the entire meeting here, which was co-organized by the Drugs for Neglected Diseases initiative (DNDi), MMV, and TB Alliance. You can watch the full session at this link.
It is important to pair investments in research and development (R&D) for addressing global health threats with investments aimed at ensuring equitable and sustainable implementation and access for populations everywhere. To achieve the third sustainable development goal of health for all will require much more that reactive responses in a time of crisis. The satellite event of the UNGA77, the UN Science summit brought together key actors in the global health space to reflect on the challenges of attaining these goals. So, what will it take to disrupt the status quo, to restore the gains lost during the pandemic and to ensure that future approaches draw important lessons from past mistakes? Three key areas were highlighted:
Strengthening the funding landscape and keeping funders engaged
With the world-facing many colliding global health challenges as well as geopolitical crises across many regions, it is increasingly difficult to keep diseases of poverty and neglected on the political agenda. Global health actors must continuously engage with police makers and funding agencies to emphasize what is gained through investing in tackling disease. For example investing in emerging disease surveillance could avert future outbreaks which may affect a larger population and have a cascade of consequences well beyond the public health sector. This can be done by highlighting success stories where investments are creating a positive impact and modelling the projected effects of sustained funding on reducing the burden of disease.
Engaging community activists and incorporating their feedback into implementation strategies and planning
The biggest successes in tackling diseases of poverty and neglect happen when the most impacted communities are engaged in developing and implementing the solutions to tackle the issues that affect them. Without paying attention and providing a seat at the table to members of the community a lot of the approaches are likely to be unsuccessful. This requires building trust within communities, recognizing the power dynamic that exist between researchers and the communities they serve and why that could be harmful and learning to incorporate important feedback from the communities when these conversations are initiated.
Developing a system for measuring and reporting results
Reporting on what gets done and gaining a better understanding on what needs to be measured to ensure science is sufficiently funded and optimally used to deliver health for all is an area that continues to struggle. Without adequately measuring the impact of investments in R&D in global public health it is challenging to have a clear picture of what areas need strengthening. Developing transparent systems for reporting will also serve as a tool for keeping funders engaged as well as motivation to actors working in this space where often progress may seem slow.
At the start of this new year 2022, things feel a bit depressing. We all seem resigned to being the next person with a sore throat and that tell-tale dry cough anxiously watching the double lines to appear on a rapid test. Would this year be better? Will we finally learn the lessons the virus has desperately tried to teach us these past two years?
Rapid Antigen Test for SARSCoV2
It didn’t have to be this way. From the beginning of the pandemic the threat of new variants of SARSCoV2 had always loomed. This justified the urgency to share vaccines and other resources globally to stay ahead of the virus. “No one is safe until everyone is safe” became the mantra of global health equity advocates everywhere but ignored by those who had the power to do something about it. The legacy of the what was supposed the year of celebrating scientific innovations to end a global pandemic is one of stark division pitting the wealthiest against the most vulnerable.
All of these factors have been compounded by the need for vaccine booster doses which have increased the pressures on supply and further widened the vaccine accessibility gap. The future of vaccine equity remains uncertain in 2022. Will we see updated second generation vaccines as the older versions become less protective against new variants? Would updated vaccines be available to everyone or will poor countries be left be to rely on older less-effective vaccines? Can global leaders commit to breaking the damaging cycle of vaccine tiering and hoarding? The answers to these questions are known.
It is clear that repeating the mistakes of 2021 is reckless and unlikely to yield different results. Without expanding the capacity of vaccine production in LMICs, the flow of vaccines will remains skewed towards HICs. Distribution of third vaccine doses in the most vaccinated parts of the world currently exceeds first doses in LMICs. Complacency has set in and the chatter about 1st doses before 3rd doses has died down. This doesn’t make the millions of people yet to get their first shots magically disappear but guarantees the virus continued opportunities to spread.
Africa compared to other parts of the world has seen fewer cases and deaths directly from COVID19. Many view the pandemic as of a less pressing health concern than Malaria, HIV/AIDS, Tuberculosis and other poverty related issues. The impact of COVID19 has been devastating for every aspect of healthcare and the economy in Africa. However, it is challenging to articulate secondary benefits of vaccination in public health messaging without addressing immediate pressing concerns.
With new vaccines now authorized and COVAX finally able to increase its supply, it is likely that in 2022 supply will exceed demand and the bigger challenge will be getting the available doses in arms. This will require addressing logistic challenges and barriers to vaccine delivery but also tackling head on the real issues around vaccine hesitancy and acceptability. While the mantra of “vaccinate the world” is attractive, one size will not fit all. A more tailored approach with countries setting realistic targets for their populations is likely to be more acceptable.
The Show Must Go On – AFCON with Omicron surging
Africa has weathered previous waves of SARSCoV2 successfully but the combination of Omicron surging, low vaccination rates and the African Cup of Nations (the continent’s largest sporting event ) brings fresh concerns. For a continent that loves its football, cancelling the competition for a second time was not on the cards. Cameroon will host and many see the success of the Olympics as proof that this can be done safely. However, the conditions in Cameroon leading up to the AFCON are quite different.
Cameroon is among the lowest vaccinated countries in the world. Non-pharmacologic interventions are barely enforced and pandemic is high. The competition will proceed with stadia at full capacity unlike the Olympics where no spectators were allowed. The ministry of health has announced that proof of negative testing and vaccination for entry into stadia. These measures are encouraging but corruption and bribery are rife and it is doubtful how these measures would be enforced. Also vaccine hesitancy is prevalent and testing capacity is low.
As a Cameroonian and a football fan I am rooting for a successful celebration of African football. I hope the resulting surge of COVID19 cases is minimal. The economy of the country needs the boost and the continent needs joy and celebration that accompany the AFCON. However, this hope is tempered with perspective. With omicron we are dealing with the virus in its most infectious variant yet. While the show must go on, the consequences of a massive wave after the games could have significant regional impact.
Despite encouraging signals that omicron may cause less severe disease, a rapid rise in case numbers can be a major stress test for any health system. This has been demonstrated across Europe and North America. The youthfulness of the population in Cameroon (median age 17) and immunity accumulated from previous waves may mitigate the severity of a surge. Only time will tell the impact of the games of the trajectory of the pandemic in Cameroon and Africa. Another situation to watch closely at the start of this new year.
Image credit-Nimble
The Virus is Still Speaking – We Should Start Listening
For many the realization has set in that we have to learn to live with the virus. How we choose to do that matters. The start of new year is always an opportunity for a reset and learn from past failures. With COVID19 this means a renewed commitment to global solidarity, not only in words but in action. The approach of every country for itself saw us squander the potential of vaccines and therapeutic advances in 2021. The virus carried on, unperturbed leaving a string of new variants, long-term chronic symptoms and deaths in its wake.
Credit: Alamy
We get a chance in 2022 at a do over, this time with even more tools in the pandemic toolkit. That means living out the words “no one is safe, until everyone is safe” by holding world leaders accountable to end the pandemic. Every moment wasted in repeating old mistakes is another victory for the virus. The virus will keep speaking until we are ready to listen and respond accordingly. That’s our only hope to make this year a better one for us all.
Abbreviations: LMIC – low and middle income countries, HIC -High income country
A great year of Malaria research has been overshadowed by the global pandemic of COVID-19. Headlines on promising new vaccines and prevention strategies barely survive the 24-hour news cycle, quickly superseded by the latest COVID-19 related research. Malaria remains a leading cause of death in children under the age of 5 who account for 57% of the > 400,000 deaths/ year from Malaria. With global deaths on this scale, Malaria still very much qualifies as a pandemic but doesn’t get the attention it deserves. Sub-Saharan Africa carries 94% of the burden of disease, a major reason why Malaria has become the neglected pandemic of the poor. The positive results on new vaccines and novel approaches for prevention (monoclonal antibodies) bring much needed hope for eradicating this disease.
Source: WHO world Malaria report 2020
A slow ROAD to PROGRESS
It took a year to develop over ten effective vaccines to prevent COVID-19, a disease that did not exist before the end of 2019. Progress on developing a vaccine for Malaria, which has been around for decades, has been very slow. So far Malaria vaccine research have yielded only one partially effective Malaria vaccine (RTS,S or Mosquirix). This vaccine offers a modest 56% protection against Malaria in the first year and effectiveness drops to 36% over 4 years.
Another clinical study published this summer used a novel approach , combined a live-parasite vaccine with antimalarial drugs. In this study which included 42 volunteers, the investigators injected participants with sporozoites (the stage of the malaria parasite that is transmitted from the mosquito to humans). They also treated the vaccinated individuals with antimalarial drugs to kill the parasites if they reached the liver or bloodstream so as to prevent the infection of red blood cells and symptomatic malaria. How does this work?- Exposing volunteers to live sporozoites stimulates a protective immune response against future malaria challenge while the antimalarial drug given at the time of vaccination prevents symptomatic malaria from occurring as a result of vaccination.
Malaria sporozoites, the infectious form of the malaria parasite that is injected into people by mosquitoes – image source NIAID
This approach however presents many challenges. Malaria sporozoites cannot be grown in batches in a laboratory for large scale vaccine production and only multiply in the salivary glands of mosquitos. Making enough live-parasite vaccine for larger clinical trials requires isolating sporozoites from millions of mosquitos (through dissection). Also storage of the isolated parasites requires ultra-cold temperatures, which has implications for the vaccine cold chain. These hurdles will increase manufacturing and distribution costs of any potential approved vaccine based on this approach. In addition, the need for combining antimalarial drugs with vaccination could drive development of drug resistance to effective antimalarial drugs. These factors need careful consideration in moving this vaccine forward through larger clinical studies.
Colorized electron micrograph showing malaria parasite (right, blue) attaching to a human red blood cell. The inset shows a detail of the attachment point at higher magnification. NIAID
In the second part of the study, 9 participants who received the nMAb (CIS43L3) treatment and 6 controls (individuals who did not receive nMAbs) were voluntarily exposed to Malaria infection in a controlled setting and closely monitored for symptoms for 21 days. None of the participants treated with nMAbs developed Malaria meanwhile 5/6 individuals in the control group did.
This successful phase I study, supports the viability of monoclonal antibodies for Malaria prevention in travelers visiting endemic regions. It also opens a range of possibilities nMAbs as a prevention tool for controlling seasonal Malaria in Africa and for future elimination campaigns. Ongoing clinical studies will help to better define the role of this exciting new strategy.
Breaking the plateau – the final push to eliminating Malaria
In recent years the push to eliminate Malaria hit what felt like an unsurmountable plateau. Effective strategies including; vector control, mosquito nets and chemoprophylaxis prevented millions of deaths but have seen their sustained efficacy wane. Resistance to antimalarial drugs and insecticides is on the rise and population growth in endemic areas has led to more cases. Complacency in the lack of progress means accepting 400,000 plus deaths from Malaria every year, mainly in children. That is what makes the new promising avenues of Malaria research so exciting. Renewed enthusiasm for re-igniting a final push towards eliminating a neglected pandemic and saving lives. At a time when a new pandemic is causing much sadness, I am hopeful for a future without malaria and that is worth celebrating.
The turn of the year has come and gone but a lot of the news feels the same in year two of the COVID19 pandemic. Many countries are experiencing severe 2nd and 3rd waves of infection. Highly transmissible new variants of the virus cast a cloud on the excitement and hope brought by effective new vaccines. COVID19 has become a part of daily life as a mask weary society trudges along, numb to the rising global death count.
When does it end? How does in end? When can we get back to life as we once knew it? I get these questions often and wish I had good answers. Effective vaccines are a light at the end of the tunnel but in an unequal world, how close that light feels and how brightly it shines depends on where you find yourself. As a frontline health worker in the United States, I was privileged to be among the first to receive the Pfizer mRNA vaccine. My absolute joy and relief at being immunized are tempered by the uncertainty that surrounds when my parents, will be able to access these live-saving vaccines. Like many others living in resource poor countries, for my parents the projections for access to COVID19 vaccines are bleak. It is estimated that at least 85 poor countries will not have widespread access to COVID19 vaccination before 2023, year 4 of the pandemic !!!
So far in the pandemic, countries have prioritized their own populations instead of a more concerted global effort working together to defeat the virus. This has been reflected in international trade restrictions which in the early days of the pandemic severely hampered the ability of poorer countries to respond effectively. The ongoing dispute on vaccine access and rollout between the EU and the UK is just the latest illustration of this. With many vaccine manufacturers experiencing delays in production and failing to meet delivery targets, the shortfall led the EU to impose export restrictions on COVID19 vaccines produced within the bloc. Although the EU has since backtracked on the widely condemned decision, the words of the EU commission
“The protection and safety of our citizens is a priority and the challenges we now face left us with no choice but to act,”
raise alarm bells that more countries will impose vaccine export bans to protect their own supplies. Poorer countries already struggling for access to vaccines will bear the brunt of the fall out.
Similar scenarios have played out in very recent history. In 2009 during the H1N1 influenza outbreak which killed 284,000 people globally, a vaccine was developed in just 7 months. However almost all of the vaccine supplies were hoarded by wealthy countries leaving others with nothing. The same can be said about eradication programs for smallpox and polio, for which vaccines only became widely available to the world’s poorest when these diseases had been largely eradicated from richer parts of the world.
The cost of inaction on global vaccine inequity is the risk of seeing COVID19 become just another in a long list of diseases which primarily affect the poor. Unlike Malaria, Tuberculosis and HIV, the world will not be able to “move on” if the problem is not confronted simultaneously on all fronts. The estimated monthly financial cost of the pandemic to the global economy is a staggering $375 billion. Besides the moral imperative to act, the financial arguments are equally compelling.
VAXXING TO SAVE Economies
A recent study commissioned by the international chamber of commerce projects that in a worse case scenario in which wealthiest countries are fully vaccinated by the middle of this year and poor countries are completely left out, the global economy could see losses exceeding $9 trillion! In the more likely scenario in which most wealthy countries could vaccinate 70-80% of their populations by the end of the 2021, the projected losses will still fall in the $1.8-$3.8trillion range. A significant proportion of these losses will be borne by wealthy countries, especially those heavily reliant on trade. In an interconnected world with global supply chains, sharing vaccines is more than just charity. In essence, the economic recovery of the strongest and the weakest economies are intimately connected to controlling the spread of the virus globally.
The collision of COVID19 fatigue, substantial economic losses from lockdowns and more transmissible variants creates a perfect storm. Severe subsequent waves of the virus could quickly overwhelm fragile health systems and be the deadliest yet. South Africa, where the 501Y-V2 variant of the virus was first identified, is experiencing its worse pandemic surge with massive case spikes, overwhelmed hospitals and a rising death toll. For weak healthcare systems with limited human and material resources, providing vaccination to frontline workers at the minimum is vital to preserving a functioning healthcare system. This is especially important in lower income countries where the pandemic has already severely impacted gains in other priority areas of global health including; access to HIV treatment, Polio eradication, Tuberculosis Control and Malaria prevention.
COVID DENIALISM AND Vaccine hesitancy – The ElephantS in the room
Vaccine hesitancy and COVID19 denialism are important and concerning threats which must be confronted and addressed in tandem with ensuring access to vaccines for all. Effective vaccines will only help if these can be delivered to those who need them the most. The current situation in Tanzania, has garnered international attention with its government openly shunning mask mandates and lockdowns and now rejecting COVID19 vaccines. Burundi, has also opted out, stating its intention to focus efforts more towards mitigation than mass immunization. Brazil which has experienced one of the worse outbreaks of COVID19 was largely crippled in its response by leadership which also shunned containment measures and vaccination. Even in countries willing to accept vaccine doses, there is considerable hesitancy within the populations which could significantly compromise vaccine distribution. The same fervor that is being applied to sourcing vaccines, must also be directed at increasing uptake. Aggressive information and education campaigns as well as incentives which have proven useful for other epidemics must serve as lessons. Confronting government sponsored vaccine denialism is more challenging because every country has the autonomy to define its internal health policy, even if these policies are harmful to its own citizens.
Where DO We GO FROM HERE?
Despite the isolation of the pandemic, the world strangely feels more connected through our shared trauma from the losses we have experienced and the changes in our daily lives. Effective vaccines provide hope for better days ahead and our collective humanity demands that we ensure this hope is felt by all. No country is an island in a global pandemic and making it out together also means bringing along those who need a little extra help on the road.
AP PHOTO/BRIAN INGANGAChildren run down a street past an informational mural warning people about the dangers of the new coronavirus, in the Kibera slum, or informal settlement, of Nairobi, Kenya Wednesday, June 3, 2020. (AP Photo/Brian Inganga)
As SARSCoV-2 has spread globally over the past 10 months our knowledge of the virus and how to control it has also grown at an incredible pace. There has been progress in therapeutics and several vaccine candidates are in advanced stages of development, with hope of starting distribution by early 2021. The access to these advances is expected to vary by region with poorer countries unlikely to access advanced therapies and vaccines until much later. Tried and true public health approaches have to remain at the center of the pandemic response in low income countries, but pandemic fatigue and the economic implications of strict enforcement present considerable challenges to sustaining these efforts long-term.
On a more positive note COVID-19 vaccine trials are now recruiting participants in up to 6 African countries. A key piece to successful vaccine distribution and fighting growing vaccine hesitancy is demonstrating efficacy in local populations.
Far from Over
A street vendor wearing a face mask to protect herself against COVID-19 in Abidjan, Ivory Coast. Image: REUTERS/Luc Gnago
Whether we see subsequent waves or a more smoldering course of COVID-19 in Africa is anyone’s guess. Regardless of the scenario that emerges, the most vulnerable amongst us will suffer most and longest. As we continue to fight this pandemic a global response in its true sense must remain grounded in our shared humanity. Africa being relatively spared in the first wave of the pandemic is a deceptive narrative that threatens the longterm sustained response. A slow and prolonged outbreak in Africa may present an even bigger challenge as this is likely to extend the devastating impact on the economy, education and healthcare well beyond this pandemic.
Written by : Boghuma K. Titanji
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These positives are encouraging and should be celebrated but history also teaches us that pandemics are marathons and not sprints. The bubonic plague one of the deadliest pandemics in history lasted over five-years and killed 75-200 million people worldwide. In the modern era the HIV pandemic is closing in on its 40th anniversary in 2021 and caused 690,000 deaths in 2019. For Africa to continue to defy the odds of deaths and new infections from COVID-19, the ongoing efforts will need to be sustained for many months to come. This is a where the real challenge lies and fragile economies and health systems with limited resources may not last the long haul.
The Long Reach of the Enemy
Far-reaching consequences
COVID-19 is affecting every aspect of healthcare for many countries in sub-Saharan Africa. Significant resources have been diverted from important surveillance and treatment programs for other diseases to respond to the crisis. Screening, treatment and infection control programs for Tuberculosis, Malaria and HIV now face major disruptions. This is likely to result in excess deaths and modeling from the WHO projects half-a-million more deaths from HIV compared to last year and a doubling of deaths from malaria this year. These ripple effects disproportionately affect children and women, compounded by expanding food insecurity , outbreaks of childhood infections and the progressive collapse of vaccination programs.
Avoiding the Worst
Avoiding Disaster
It is hard to feel optimistic about the pandemic summer for Africa when the full spectrum of challenges is put in perspective. Averting these bad outcomes will need concerted international collaboration and less individualism, areas in which countries have struggled during this pandemic.
LeVELING the TREATMENT AND VACCINE TRIALS LANDSCAPE
COVID-19 clinical trials in Africa – Source:https://ClinicalTrials.gov
Evidence that Dexamethasone, a cheap and widely available drug, reduces mortality in patients with severe COVID-19, is welcome tool for clinicians in Africa. Its use will have to be balanced with the high prevalence of infectious diseases which can be made worse by steroids (TB, Hepatitis B, parasitic infection) and the potential for inappropriate use and harm given easy access as a street drug.
COMBATTING FEAR AND MISINFORMATION
THE OTHER PANDEMIC -MISINFORMATION
The surge of misinformation on social media platforms and conspiracy theories has eroded the trust of the population and poses a real threat to vaccine and treatment trials on the continent. African led research efforts will more readily bridge these trust and confidence gaps. Most importantly this will prime the population to be more receptive to vaccines and therapeutic strategies supported by local evidence. Assertions of traditional medicine remedies emerging locally, also need to be validated in well-structured clinical trials before they are widely distributed.
FINDING THE RIGHT BALANCE – FIGHTING OLD FOES and COVID-19
A DELICATE BALANCE
A huge dilemma is how to protect the population from COVID-19 while fighting existing older threats. To avoid catastrophic outcomes from Malaria, HIV, TB etc., countries in Africa will need to engage with their populations and adapt the existing models of care to the current challenges. An important step is increasing sensitization and education on the real risks of death from other causes which may surpass the risk from COVID-19 for the continent’s youthful population.
THERE IS ALWAYS HOPE
HOPE
The WHO recently declared the end of the 10th Ebola outbreak in DRC, and almost simultaneously South Sudan, Africa’s youngest country, was declared free of wild polio . These are veritable feats of public health and give me hope that the Africa will also survive the pandemic summer. To ensure another success story, the efforts in fighting COVID-19 need to be unified and global in a true sense. In a pandemic no one wins if the most vulnerable are not given a fair chance in the fight. History teaches us as much, maybe it is time we finally learn from past mistakes and avoid repeating them.
It’s only March and 2020 already feels like a really long year. Like many around the world, every waking moment is filled with news of COVID19. As the SARS-CoV2 virus steadily continues its march across countries and continents with no respect for borders, it leaves panic and fear in its wake. As an infectious disease physician and a virologist, I try to be the voice of calm, holding on to the science of what we know about epidemics and this pandemic so far – “this too shall pass” has become a mantra I repeat to myself and loved ones seeking reassurance. As a human with parents in the most vulnerable age bracket being rational is much harder.
Mama Said Not to Worry
You see my parents are not only over age 60, they also reside in sub-Saharan Africa which is home to the world’s most vulnerable health systems. I called my mother earlier this week to check in and reinforce the messaging on infection prevention strategies and social distancing. It is the peak of the dry season in Cameroon, and like in many parts of the continent this means sweltering heat and scorching temperatures through the day. My mother knows my choice of specialty has me at the frontlines of this pandemic in the USA where I work. She tries to be reassuring “Don’t worry about us Bo, we are being safe, I don’t think the virus can even survive this horrible heat” she says. We both laugh nervously at this and chat about how so far, Africa seems to be relatively spared from a severe outbreak. I tell her to continue being safe and promise to check in again later in the week.
Hoping for the best
Traveller getting temperature checked at major African airport
Africa so far has been relatively spared a severe outbreak on the scale of which we have seen in parts of Asia and now in parts of Europe and the United States. As of March 13th, there were 147 confirmed cases of COVID19 in 15 African countries (most of these imported from Europe and Asia) with 4 deaths and very limited evidence of widespread community dissemination. Many have pondered the reasons behind this. I do believe that there is some merit to what I am calling “Mama’s dry season theory” but I think this only partially explains why Africa hopefully might actually sit this one out (i.e. be spared a catastrophic outbreak).
Climate Matters
Will the climate play a role in curbing this pandemic?
Many have expressed the hope that as the temperatures rise in temperate regions this could actually limit the spread of the virus and eventually lead to a sharp decline in cases. The evidence from other respiratory viruses like influenza which peak in the winter and decline in summer suggest that this may actually hold true to a certain degree. With hotter temperatures infectious droplets which transport the virus particles are likely to dry up more quickly and not travel as far. Ultraviolet rays from more sunshine in spring and summer months will make it more difficult for the virus to survive for extended times in the environment. Also, people will spend more time outdoors thus limiting indoor crowding.
If and when community spread becomes established in sub-Saharan Africa, I believe that herd immunity will accumulate quickly in a youthful population which is more likely to have mild disease and a higher rates of recovery and survival. This will be crucial in providing some degree of protection to continent’s elderly (> 60 years old), who represent 35% of the population . Another factor worth mentioning is that many of the Africa’s elderly live out their latter years within the family unit and nursing homes for the elderly are not the norm as in most developed countries. This limits the threat of high lethality outbreaks in settings with concentrations of vulnerable persons.
Limited Mobility… A Saving Grace?
The African continent by its sheer size and limited access to good road and rail networks is not as well connected as Europe, the United States and or Asia. Air travel is only marginally better with very few flight options between countries and associated significant cost of air travel as a result. Even within the borders of individual countries, travel between regions in a country is often limited by challenging terrains and unsafe roads. These logistical challenges which severely limit movement within the continent, may in the face of this pandemic be a positive factor for slowing the spread of COVID19 between countries. Whether this will have a significant role in how widely the virus will spread within the continent is something that cannot be predicted at this time and only time will tell.
What about Immunity?
Another question which has frequently come up in conversations with friends and family is whether being black and of African descent is protective against infection with SARS-CoV2. The simple answer is no, it is not. While we have fewer cases in Africa so far due to the reasons detailed above there is no evidence at this time to suggest that race or ethnicity confers a special protective benefit against COVID19. With that being said, the high burden of parasitic infections in sub-Saharan Africa has been suggested as protective in reducing the severity of some viral infections.
Coronaviruses are widespread among mammals and birds and cause a variety of diseases. Human coronaviruses are major causes of the “common cold” and generally cause mild infections. Occasionally, animal coronaviruses successfully emerge and adapt to infect humans as we have seen with SARS, MERS and now SARS-CoV2. Whether frequent exposure to animal coronaviruses through manipulation for food or close contact with animals and birds will confer any meaningful cross-protection against COVID19 in Africa is unlikely, as this has not been observed in other parts of the world. Data from patients who survive infection with SARS-CoV and MERS-CoV suggest that those who recover from these infections develop some degree of humoral immunity which can last for 2-6 years and we hope this will be similar for SARS-CoV2.
The continent may draw some level of comfort from the points I have discussed above. However, we cannot afford to be complacent. Following common sense public health measures of social distancing and effective hand hygiene remain crucial in slowing/delaying community spread. Local governments will need to double their efforts to ensure that when they call for more hand washing and social distancing, they are also putting their populations in the position to adhere to these measures.
The current pandemic of COVID19 illustrates more than ever before, the need to respond and prepare for outbreaks as a global collective. We have to do better at ensuring that the weakest links in the chain can respond and stop any outbreak from becoming a pandemic. This will not happen if every country continues to only look within its borders and we wait for pandemics to happen before we react. The reactionary response is much more costly than planning ahead and hopefully the lessons will stick this time. Three and a half months ago Wuhan and Hubei provinces in China seemed like very far off places. I occasionally spared a thought for medical colleagues at the frontlines there fighting the spread of the virus and wondered what it was like to be in their shoes.
Today alongside valiant co-workers, I find myself on America’s frontline while worrying about my parents in Cameroon. Things now feel uncomfortably close to home on all fronts. Mama’s always right they say and I sure hope her “dry season theory” holds true . While we await the warmer temperatures let’s remember to be kind to one another, provide a word of encouragement if you see someone who is struggling at this time. We will need each other more than ever in the coming months but I promise you we will get through this. #ThisTooShallPass.
Travel bans – Deceptive, ineffective and morally wrong
The World Health Organization earlier this week declared the nCoV-2019 outbreak a global health emergency. A move that is designed to help a more coordinated international response to the outbreak. In that same announcement it also urged nations to not restrict travel or trade with China – a plea that may have fallen on deaf ears. At face value travel bans may seem like a reasonable approach, as governments and politicians face intense pressure to “do something”. In reality these bans are ineffective, cause significant downstream effects and impede on an effective response. There is an immediate and significant economic impact on the most affected regions, high cost associated with crafting and implementing travel restrictions and a direct effects on transparency in reporting on the outbreak as countries fear they may be the next victim of future bans.
Blame it on bat soup? – Challenging Stigma and Xenophobia in the face of an outbreak
As we grapple with this outbreak many Chinese people around the globe are having to deal with xenophobic and racist chatter about their eating habits. This is reminiscent of the several media reports on “rampant” bush meat consumption in Africa during the West African Ebola outbreak and how this may have triggered the start of that outbreak. As someone born and raised in the African country of Cameroon, a warm plate of bush meat stew accompanied with boiled ripe plantains evokes warm memories of home and a lifestyle that I grew up with. Not the guilt and shame that a false narrative would have me feel about how Africans and their love of bush meat may be fueling outbreaks of zoonotic diseases.
When faced with the unknown the instinctive human reaction is usually, seeking to assign blame and point to the other. While this may offer a sense of superiority to the one doing the finger pointing it is highly damaging to the targeted group and sows the seeds of stigma and xenophobia which often outlast any outbreak. The WHO in avoiding linking a city, region or country to the naming of the new virus has been prescient on the negative impact this would have had on the residents of Wuhan. nCoV-2019 may not roll off the tongue as easily as some would like but at least spares the residents of Wuhan a haunting label they may never be able to shake-off after the outbreak is long forgotten. At a time when the global community must unite to face a pandemic being sensitive and compassionate in how we react to this outbreak is crucial.
More Connected, More United
We are only seeing the tip of the iceberg, this outbreak could last several more months, with projections that thousands more will become infected . While the scientific community comes together to find effective treatments and a vaccine, governments must recognize that we are all in this together. Faced with an impending pandemic travel bans, stigma, xenophobia and racism have no place in the appropriate moral response. We are all in this together and how we react in the coming days and months must reflect this.
This announcement highlights a pattern in which women are excluded in important studies of new medications and interventions targeting HIV prevention and treatment. UNAIDS set at ambitious target to end the AIDS epidemic by 2020 called 90-90-90. This means 90% of all people living with HIV(PLWH) will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression. While many have lauded this aggressive push towards ending the epidemic, we are far from achieving this goal which will remain unattainable if women continue to be excluded in important studies on treatment, prevention and potential cure strategies for HIV.
This pattern unfortunately is not new because including women in HIV clinical trials presents unique challenges that researchers have historically not been equipped or prepared to fully address. Women of reproductive age can become pregnant which in itself becomes a barrier to entering certain clinical trials. Furthermore, women often bear most of the responsibilities of childcare and other family related commitments. Disadvantaged women living in poverty, adolescent women and women living sub-saharan Africa represent vulnerable groups disproportionately affected by these factors. This implies that they are more likely to miss follow-up visits required by clinical trials and to drop out of studies before completion even when they are included.
Women have the right to make decisions on the health and their bodies
A simple solution to ensuring that women can safely access and benefit from Dolutegravir while we await more definitive information on its safety in pregnancy, is providing women with HIV access to contraception and pregnancy termination services. This in itself is fraught with controversy and opens the broader conversation of how a woman’s right to choose what happens to her body and her health is inextricably linked to our ability to fully address the HIV epidemic in this demographic.
From a broader perspective about 1.1million Americans are at high risk for HIV and could benefit from PrEP according to the CDC . However only about 10,000 women of any race are using the pill to prevent HIV. Excluding women from access to the latest drug (Descovy) approved from PrEP only compounds these existing inequities.
I am currently taking care of Anna in a clinic in Atlanta. She is a 30-year-old black woman who was recently diagnosed with HIV and AIDS during her pregnancy earlier this year. Fortunately, her baby was born healthy but Anna is fighting for her life after presenting with very advanced disease and several complications. During her most recent visit to the clinic, I prepared a pill tray with the 15 pills a day she is expected to take to treat the multiple infections ravaging her body and to control the HIV.
Pill burden
Before coming to the clinic, Anna had never heard about PrEP and did not have access affordable birth control. She is often teary with worry that she will not survive this phase and may not live to see her children grow up. This is what being left behind looks like – missed opportunities for prevention, late diagnoses and complications of AIDS.
Female silhouette
Every minute around the world, more than two women will become newly infected with HIV and one of those will be under 18. This will only change if we are more deliberate in prioritizing HIV research that includes women. Getting to zero, means leaving no one behind. When it comes to women and HIV epidemic, we are doing just that.
*Names and specific patient identifiers were modified for this article to preserve patient anonymity.
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They say you never forget the first patient you lose. Mine was an 11 months old little girl, during my first rotation in pediatrics as a house officer. Her parents brought her to the pediatrics emergency department in Yaoundé – Cameroon, unresponsive with a high fever. She had been ill for two days and had failed to improve with several home remedies tried by her parents. I held her pale body in my arms as the skilled pediatrics nurse and pediatrics attending searched her limp arms and legs for venous access. The diagnosis – severe Malaria complicated by severe anemia. The time it took to get venous access and start an emergent blood transfusion probably wasn’t that long but, in the moment, felt like a thousand hours.
Despite the medical team successfully starting the blood transfusion and IV treatment with antimalaria medications, a few hours later Amina will go into cardiac arrest and lose her life. This moment has remained burned into my memory in vivid detail. Maybe it is the heart-breaking sobs of her mother begging us to save her child, or the defeated helpless figure of her quiet father in the back of the room or the anguish in Amina’s eyes as life slipped away from her. Maybe it is all of these elements together and my own helplessness in the moment which make this memory so powerful – I remember her name, her face, and all the emotions like it happened yesterday. I also remember it was the first of many times I allowed myself to cry with a patient’s family and share a powerful human moment while at work.
As I reflect on this poignant memory which in many ways influenced my decision to become an Infectious Diseases physician later in life, I also recognize how incredibly lucky I am to have made it into adulthood to be in the position to make that decision. You see, as someone born and raised in sub – Saharan Africa, the part of the world with the highest rates of infant mortality, surviving childhood is not to be taken for granted. It implies surviving several bouts of malaria and other preventable infectious disease conditions which claim the lives of hundreds of children daily in this part of the world. In 2017, the risk of a child dying before their first year was highest in the WHO Africa region (51 per 1000 life births), over 6 times higher than in the WHO European region (8 per 1000 life births). With these staggering figures, effective interventions to target infant mortality in the region can’t come quickly enough and for the first time in many years this summer holds a special hope.
For example, the WHO also in April of this year, announced its approval of widespread testing for GlaxoSmithKline’s Malaria vaccine Mosquirix® in 360,000 children in Malawi and two other African countries. GSK’s vaccine in smaller pilot studies, has only shown about 30-40% efficacy in preventing severe malaria and about 60% reduction in severe anemia – one of the major complications of the disease. It requires four injections before the age of two which presents a unique challenge in synchronizing delivery with national immunization schedules. Furthermore, it is unclear how long-lasting these limited levels of protection provided by the vaccine will be. These issues have raised skepticism on the WHO’s decision to move forward with widespread testing of this vaccine with many holding the view that resources would be better served towards expanding prevention strategies with better established track records.
The small study which demonstrated the efficacy of the PfSPZ vaccine enrolled 31 healthy adults ages 18-45. Participants received three intravenous doses of the vaccine at 8 weeks intervals and 19 weeks after the final vaccine dose were exposed to the same strain of malaria used to manufacture the vaccine and the vaccine was found to proffer high levels of protection lasting up to eight months.
The ultimate test for this vaccine will be how it performs in an area of high malaria endemicity against different strains of the parasite. Another challenge is the requirement for intravenous administration for up to three doses. Most childhood vaccines are easily administered by oral, intradermal and intramuscular routes and a vaccine requiring the additional skill of intravenous administration adds a layer of complexity to large scale distribution in resource limited settings. With that being said the future for malaria prevention in sub-Saharan Africa and the implications this will have for infant mortality in the region is promising with much to look forward to going into 2020. The only way to find a refine solutions that work will be through the information obtained from these essential trials.
Azithromycin for everyone?
Before I got the chance to fully digest my excitement over the upcoming Malaria trials, more news of another potentially cheap and simple intervention to reduce childhood mortality in sub-Saharan Africa landed earlier this month. Researchers from University of California San Francisco published the findings of their trial providing the longer-term assessment of the use of Azithromycin in reducing childhood mortality in Africa.
Childhood Mortality in the Developing World – No easy solutions!
When it comes to reducing childhood mortality in developing countries, there are no simple or straight forward answers but there is certainly promise and reason for optimism especially at this time. It is unlikely that we will find a perfect solution which does not present any challenge be it in terms of delivery, level of efficacy or perceived adverse secondary effects. What I do know is that at intervention even with only a 10% mortality benefit would have given Amina a better shot at making it to adulthood an achieving her full potential and for that reason I have hope in what the future holds.
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