Omicron and Promises of Global Solidarity – A Chance to do Better in 2022

Happy Twenty twenty too?

In many ways the 2nd year of the COVID19 pandemic was supposed to be better – we had vaccines, new antiviral drugs in the pipeline, monoclonal antibodies and it felt like things would finally get back to normal. The arrival of Omicron in late November 2021 dealt a big blow to these hopes sweeping across the world with lightning speed, leaving chaos and uncertainty in its wake. The new variant of concern (VOC) first identified by scientists in Botswana and South Africa has seen some European countries reinstate lockdown measures, and the United States grapple with upscaling access to rapid diagnostic testing and increasing vaccine uptake.

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.

Promises Not Kept – Vaccine Equity 

Image credit: istock/Sorbetto

There are 28 vaccines against SARSCoV2 authorized and in use globally. 3.77 billion people have received at least two doses of vaccine. A veritable feat considering that the first vaccines were authorized barely 12 months ago. The rollout of vaccines has been plagued by waning effectiveness against infection, emergence of immune escape variants of the virus, vaccine hesitancy and the failure to deliver on the promise of vaccinating the world. 3.3 billion people mostly in low-income countries are yet to receive a first dose of any vaccine. The main driver of global vaccine inequity the has been the hoarding of available vaccine doses by rich countries purchasing more than needed for their populations. The prospect of intellectual property waivers to ease technology transfer and increase vaccine production in (LMIC) has faded. Key players like Germany have opposed the strategy and stifled negotiations. 

Source: https://pandem-ic.com/a-new-way-to-compare-vaccination-progress/

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.

World-wide rollout of boosters has widened the vaccine equity gap

Innovations Not Shared – Monoclonal antibodies, Immunomodulators and Antivirals 

When it comes to therapeutics, we are in a better place starting the new year than 12 months ago. Unfortunately, the scientific progress in the treatment of COVID19 has also been plagued by inequity. Monoclonal antibodies have been a live-saving intervention for millions of people in wealthy countries but beyond reach for poorer countries due to their high cost and the challenges of delivery. Immunomodulatory therapies haven’t fared any better. Dexamethasone is still the sole option in many resource-limited settings despite multiple mortality reducing options.

https://www.drugtargetreview.com/news/60206/celltrion-selects-14-lead-monoclonal-antibodies-for-covid-19-treatment/

The end of 2021 brought renewed hope with the authorization of oral antiviral drugs from Pfizer and Merck. High demand and limited supply mean that these drugs may only trickle down to LMICs several months from now. Ideally, countries with fragile health systems, unable to provide a high level of care for severe COVID19 should be prioritized for oral therapies which slow disease progression and keep patients out of hospital. This is unlikely to happen as has been the case with vaccines. Pharmaceutical companies have signed contracts to manufacture lower priced generic versions of these antiviral treatments. However, ramping up supply will take time and limited doses have been secured through advance purchase contracts by high income countries.

Source: https://www.newscientist.com/article/2302731-uk-has-begun-using-drugs-for-covid-19-cases-before-they-become-severe/

Africa’s Third Pandemic Year 

Africa bears the biggest burden of the inequity in accessing vaccines and therapeutic resources for COVID19. Only 9% of the continent’s population is vaccinated. This falls short of the 40% goal set by the WHO at the beginning of 2021. Limited health infrastructure, unsteady vaccine supply, transportation and storage challenges have all contributed to low rates of vaccination. 

Source: https://www.nature.com/articles/d41591-021-00037-1

Vaccine doses delivered with short expiration windows have led to only about 63% of the vaccines delivered to the continent being utilized. Furthermore, misinformation has fueled a loss of confidence in science and vaccines resulting in low uptake by the population even in countries where vaccines are available. The emergence of a vaccine tier system has not helped. A significant proportion of vaccines donated through COVAX are vectored vaccines from AstraZeneca and Johnson and Johnson, both of which have been plagued by rare blood clotting adverse effects. These vaccines have essentially been phased out of use in Europe and North America with mRNA vaccines being the preferred option. Many on the continent have viewed with skepticism and suspicion being offered vaccines which albeit effective are no longer used in the high-income countries donating them.

Source:https://africacdc.org/news-item/majority-of-africans-would-take-a-safe-and-effective-covid-19-vaccine/

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. 

Source :https://www.eurosport.com/football/africa-cup-of-nations/2022/africa-cup-of-nations-2022-opinion-the-solution-to-the-continued-disrespect-just-support-your-clubs-_sto8688253/story.shtml

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

Written by Boghuma K. Titanji

Malaria’s Big Year: New Horizons for Vaccines and Prophylaxis

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.

Despite its modest effectiveness, Mosquirix has been rolled out as part of ongoing studies in thousands of children in Malawi, Kenya and Ghana. Modeling studies indicate that if Mosquirix use is targeted to areas with the highest malaria burden, it could prevent thousands of childhood deaths. The slow process of developing effective Malaria vaccines is due in part to insufficient funding for Malaria research but also the complex life-cycle of the causal parasite (Plasmodium spp), which is versatile and difficult to target.

Source: Shutterstock
New Vaccines, New Hope

This summer a new Malaria vaccine candidate showed promising results in a study in children ages 5-17months. The new vaccine R21 is an updated/modified version of Mosquirix which uses a new adjuvant and generates a stronger immune response. In the phase 2 clinical trial of 450 children in Burkina-Faso, R21 effectively prevented Malaria by up to 77% over a one year period. This level of efficacy meets the preset target of 75% set by the World Health Organization (WHO). A large phase 3 trial will include 4800 children with the hope of confirming these exciting results. The new vaccine is manufactured by the Serum Institute of India, which has pledged to produce 200 million doses of the vaccine every year if it gains approval.

Source: https://www.bbc.com/news/health-56858158
new innovations,NeW CHALLENGES

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

The volunteers who received the vaccine were infected with malaria 3 months after vaccination to assess the efficacy of the vaccine. 87.5% of those who received the vaccine were protected from Malaria after being exposed to the same malaria strain as the one used in the vaccine. While 77.8% of those infected with a different strain of the parasite were protected. The study is proof of concept that high levels of vaccine efficacy can be achieved with a live-parasite vaccine. It also advances our understanding of what it takes to develop protective immunity to the parasite.

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.

Monoclonal Antibodies take on Malaria
Source: https://www.technologynetworks.com/biopharma/news/monoclonal-antibody-prevents-malaria-in-clinical-trial-351947

Current prophylaxis against Malaria relies almost completely on the use of antimalarial drugs. In a new clinical study led by the National Institutes of Health in the USA, a neutralizing monoclonal antibody (nMAb) was effective in preventing Malaria for up to 9 months in healthy volunteers. nMAbs are laboratory-made proteins, that can attach to harmful pathogens like bacteria, viruses and parasites and target them for destruction by the immune system.

In this study a nMAb called CIS43L3 derived from a naturally occurring neutralizing antibody called CIS43, was delivered through intravenous (IV) infusion or subcutaneous injection to 21 healthy volunteers who had never had Malaria before. CIS43 is an antibody that attaches to a unique site (crucial for facilitating infection), found on all species of malaria sporozoites worldwide. The volunteers were followed for 6 months to assess the safety and tolerability of the intervention and to determine how long CIS43L3 persisted in the blood. The IV infusions and subcutaneous injections of CIS43L3 were safe and well tolerated during the study period with minimal adverse effects.

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.

Combining old strategies with new ones

Reaching the goal of eliminating Malaria needs more than one intervention. A recent clinical study including 6861 children, showed that combining the Mosquirix vaccine with antimalarial drugs for preventing Malaria provided 72.9% protective efficacy against severe disease and death. The effect of combining two interventions was superior to either intervention alone. Seasonal prevention of Malaria through monthly doses of antimalarial drugs is highly effective in preventing Malaria during high transmission seasons. However, this intervention has been insufficient to reduce the burden of Malaria in the most affected areas. Combining novel vaccines with older interventions could maximize benefits for preventing severe disease and improve on existing interventions for Malaria control.

Source: istockphoto.com
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.

Image Source: https://www.health.harvard.edu/blog/

Written by Dr. Boghuma K. Titanji

COVID19 Vaccines – Not For Wealthy Countries Only

New Year, Same Pandemic

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.

Road ahead
Source https://www.statnews.com/feature/coronavirus/the-road-ahead-the-next-12-months-and-beyond/

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 !!!

Source : https://www.economist.com/leaders/2020/11/14/the-promise-of-the-new-covid-19-vaccine-is-immense

Effective Vaccines, Amplified Inequity

It is a feat of science that in just over a year since SARSCoV2 was identified, we now have 10 effective vaccines being deployed around the globe. Inequity has sadly been a central feature of this pandemic affecting access to protective equipment, diagnostics and treatment and now vaccines. At the current global vaccination rate of 4,607,324 doses a day it would take an estimated 6.8 years to vaccinate 75% of the world’s population. The world’s poorest and most vulnerable find themselves at the tail end of the global queue for COVID19 vaccination. 124 million vaccine doses have been delivered in 73 countries of which 4,935,611 doses (4%) in South America and a paltry 446,904 doses (0.37%) in Africa. The 20 wealthiest countries have the lion’s share representing 80% of the vaccine doses delivered so far.

Source: Bloomberg COVID19 vaccine tracker

COVAX – Bringing the World Together

The COVAX initiative co-led by WHO, GAVI and CEPI provides a risk-sharing mechanism for pooling resources to procure and equitably distribute COVID19 vaccines to countries regardless of wealth. It aims to deliver enough vaccine doses to allow participating countries to immunize 20% of their populations by the end of 2021. This goal is ambitious but the urgency of the moment demands it. To achieve this target, COVAX will have to raise an additional $6.8 billion in 2021 – $800 million for research and development, $4.6 billion for acquiring doses and $1.4 billion for delivery support. Its success largely depends on effective fundraising and donors making good on their pledges. The recent news that COVAX will ship 90 million doses of vaccine to Africa starting in February of 2021 is a welcome start. Put in perspective, these doses will cover about 3% of the continent’s 1.3 billion strong population. COVAX is doing a lot but it cannot do it all alone. Important regional and national efforts to bolster vaccine access for poor countries have to contend with a tense and competitive vaccine market as well as vaccine nationalism.

Image result for vaccine nationalism
Source: Getty Images

Vaccine Nationalism – An Existential Threat

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.

Data as of Nov. 30. Potential dose purchases include deals that are under negotiation and options for additional doses as part of existing confirmed deals.
Source: Launch and Scale Speedometer, Duke Global Health Innovation Center
Credit: Connie Hanzhang Jin/NPR

The Case for Acting Now and Acting Fast

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.

Image result for inequity
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.

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Source: Franesco Ciccolella
Emerging variants and the race to vaccinate

Emerging variants of SARSCoV2 present a new challenge and have brought a sense of enhanced urgency to accelerate the distribution of vaccines. Some of the more concerning variants have accumulated changes in the genome of the virus which make them more transmissible and easier to spread. In addition there is growing evidence that some of the changes in the virus genome could compromise the efficacy of first generation vaccines and antibody-based therapies. Many countries in sub-saharan Africa are seeing a surge of cases and deaths fueled by the spread of these new variants. Between December 29th 2020 and January 25th, 2021, new infections on the continent rose by 50% when compared to the preceding four weeks. The region had successfully weathered relatively milder first waves of the pandemic compared to other regions, by relying mainly on rigorous public health mitigation.

Image result for pandemic fatigue

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
Image result for vaccine hesitancy

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?
Image result for horizon

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.

Written by Boghuma. K. Titanji

Surge or Smolder? – Will Africa See A Second Wave of COVID-19

Winter is coming… 

As we head into the winter months in the northern hemisphere, the COVID-19 pandemic continues to dominate international news headlines. After a brief dip in case numbers in parts of Europe and the United States this summer, the turn of the weather heading into the colder months has brought with it a new surge of infections plunging many countries into their second and third waves. France and Germany have imposed lockdowns and curfews in an attempt to curb outbreaks spiraling out of control within their borders. Belgium is facing severe shortages of healthcare staff in its hospitals with intensive care beds set to run out in a few weeks. The United States, facing a dearth of coordinated national leadership, continues to see uncontrolled outbreaks in many states

Disaster avoided? 

Avoiding a cascade of negative events

Sub-Saharan Africa on the other hand has to a large degree defied the predicted apocalypse that followed the first reported case of COVID-19 on the continent back in February. News headlines early on were quick to highlight the continent’s weak health systems, fragile infrastructure and limited access to medical supplies and advanced medical equipment. Melinda Gates with great foreboding in April, made a dire prediction in an interview of “dead bodies on African streets soon”. These predictions fortunately have not come to pass as the African continent has consistently recorded the lowest numbers of cases and deaths from COVID-19 globally. As of October, 29th 1,750,331cases and 42,175 deaths (0.1% of deaths globally) from COVID-19 had been reported on the African continent which is home to 13% of the world’s population

https://www.bbc.com/news/world-africa-54418613

Big wins but more to do

Due credit has been given to a robust public health response by local governments with the support of WHO and Africa CDC . These organizations worked in tandem to improve testing capacity and implement measures which helped slow the initial spread of the virus on the continent. These measures were largely supported by populations accustomed to dealing with outbreaks of infectious diseases and tapped into good community health systems strengthened by previous epidemics.


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)

Ongoing speculation on the protective benefits of a warmer climate, a more youthful population and lower prevalence of risk factors for severe COVID-19 prevail. These theories bring with them the risk of complacency and premature victory laps in the wake of successes recorded in the first wave. The surge in COVID-19 cases across Europe and the Americas is slowly beginning to reflect as an upward trend in new cases in Africa. Whether this will result in a true second wave or a quiet smolder remains to be seen. Regardless of what happens in the coming months, the pandemic is far from over and the efforts to contain it must not relent.

Consolidating an initial good response 

Maintaining a good response

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.

Social distancing, mask mandates and lockdowns

Social distancing

Many African governments took an almost draconian approach in enforcing adherence to strict lockdowns, travel restrictions and mask mandates. In Kenya aggressive policing to uphold COVID19 curfews led to several weeks of violence and up to 15 deaths. In Senegal where civil uprisings are rare, the initial lockdowns in March sparked violent clashes between the population and the police. These lockdowns have quickly translated to significant losses in income for small businesses and daily wage earners, plunging many deeper into poverty. In recent months a lot of these measures have been loosened in an attempt to ease the economic toll of the pandemic on the population. Without robust and sustained government financial support moving forward, it is hard to imagine any appetite on the part of local populations to return to these strict measures even as fears of a second wave of infections loom. Some African government have provided stimulus packages for economic relief to their populations but these have been modest and do not meet the widespread need.

Source: https://www.bbc.com/news/world-africa-52426040

Social distancing and isolation of those who test positive haven’t been without challenges especially in large and densely populated cities . Government structures dedicated for quarantining purposes have been largely under-utilized due to the stigma associated with carrying a diagnosis of COVID-19. The models adopted in western cities such as working from home, online shopping, and grocery shopping on a schedule to limit person to person interactions is simply not feasible or adaptable to many African countries.

Lagos Market – https://guardian.ng/news/lagos-orders-markets-to-open-on-selective-dates-over-covid-19/

A large share of Africa’s urban population lives in crowded informal settlements, with small one- or two-bedroom houses. Differences across the continent are large, but on average, 45% of households share toilets with their neighbors and for 17%, their only access to water is from a communal tap“. There is a need to develop innovative strategies for infection control which take into account unique characteristics of the environment and provide the population with the means to comply to these measures without jeopardizing their livelihoods.

Therapeutics

Remdesivir vials

Remdesivir, has become the first antiviral drug approved for the treatment of COVID-19 in the United States.  This drug largely owes the initial phases of its clinical development to studies done in patients in the Democratic Republic of Congo (DRC) during the 2018 outbreak Ebola Virus Disease (EVD). While debates on the true efficacy of Remdesivir for COVID-19 continue to polarize, it is unlikely that the severely limited worldwide supply will trickle into enough African hospitals to create any meaningful impact on patient outcomes. 

Monoclonal antibodies may be useful for treatment of early COVID-19 and for prophylaxis

Monoclonal antibodies, another treatment strategy are likely to gain emergency use authorization for treatment on non-hospitalized patients with COVID-19 in the USA, in coming weeks. This therapeutic approach gained significant popularity during the last outbreak of the EVD in the DRC with two monoclonal antibody therapies showing statistically significant mortality benefit in clinical trials of acute EVD. The benefits so far  reported from trials of monoclonal antibody therapies in COVID-19 are  modest and these treatments carry a prohibitive price tag limiting their availability for now to very wealthy countries.

Dexamethasone – A Steroid that is on the WHO essential medication list

The RECOVERY trial, from the UK, demonstrated the benefit of a cheap steroid Dexamethasone in reducing mortality from severe COVID-19. Dexamethasone is on the WHO essential medication list which means that it can be accessed even in the most remote health settings. Dexamethasone has quickly become an important tool for treating COVID-19 patients globally. Widespread use of steroids isn’t without risks especially in areas with concomitant high prevalence of other infectious diseases which can be made worse by steroid use e.g. Tuberculosis, viral Hepatitis and certain parasitic infections etc. There is need for local prospective studies to better define the role of steroid therapy in treating COVID-19 in Africa taking into account unique risks they portend in this setting.

Vaccines

COVID-19 vaccines are in development

A lot hope for returning to a normal life now hinges on an effective COVID-19 vaccine. Several promising candidates have been fast tracked through phase1,2, 3 clinical studies. If these vaccines clear the threshold for efficacy, the bigger task ahead will be their distribution to the world’s 7.8 billion inhabitants.

Wealthy countries have positioned themselves ahead of the line by making deals worth billions to secure vaccine doses from leading manufacturers. The COVID-19 Vaccine global access (COVAX) initiative led by the WHO, the Coalition for Epidemic Preparedness (CEPI) and the Global Vaccine Alliance (GAVI) is working to ensure equitable access and distribution of vaccines between wealthy countries and middle- and lower-income countries. While this initiative is welcome and laudable, history from recent outbreaks gives Africa many reasons to worry.

In 2004, during the outbreak of the avian flu (H5N1), negotiations led by the WHO to share stockpiles of vaccines rapidly broke down. This scenario was again replayed in the 2009 H1N1 outbreak during which wealthy countries again reneged on their promises to share vaccine stockpiles and hoarded doses for themselves. In the mid-nineties antiretroviral therapies for treating HIV were priced out of the reach of many African countries and created delayed access to life-saving treatment for many people living with HIV. It is estimated that between 1997-2007 at least 12 million Africans died from HIV due to inability to access life-saving treatment. In the early months of the COVID-19 pandemic, many African countries were frozen out of the global market and struggled to secure personal protective equipment and testing supplies crucial for the pandemic response. The Africa CDC estimates the cost of building infrastructure and delivery systems to distribute a COVID-19 vaccine on the continent between $7 billion and $10 billion, a target which is a long way from being met.

Source : https://www.nature.com/articles/d41586-020-02774-8

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

*Click on undefined text to link to relevant reference

  • * Text in “” represent direct quote from another article

A Pandemic Summer – COVID-19, What Lies Ahead for Africa?

COVID-19 here, COVID-19 there, COVID-19 everywhere …

Until a few months ago, not a single person appeared to be infected with COVID-19 in sub-Saharan Africa. For a brief moment there was hope that maybe the continent would be spared the worst in the global pandemic. That hope was short-lived with Africa now seeing rapidly growing numbers of cases and deaths from COVID-19. There are currently about 382,000 confirmed cases and 7000 deaths in Africa from COVID-19. These numbers significantly underestimate the spread of SARSCoV2 on the continent due to severe limitations in testing capacity faced my many African countries. As an example, by the end of April 2020, Nigeria the most populous country in Africa with 200 million inhabitants, had only tested about 12000 people, 0.006% of its population for COVID-19.

COVID-19 Testing

Testing and Pandemic Preparedness – An Uphill Battle for Poor Countries 

Poor countries faced incredibly unfair market forces in their efforts to ramp up preparedness and testing .With the chaos of the pandemic even the world’s wealthiest countries initially struggled to expand testing and secure medical supplies for their own health systems. This led to widespread panic and protectionism with countries hoarding supplies for their own.

PPE

At least 60 countries so far have imposed bans and restrictions on the export of medical equipment and testing supplies. Even in situations where there aren’t restrictions in place, African countries are easily outbid by their wealthier counterparts. This has resulted in ongoing shortages in personal protective equipment, testing and medical supplies.

Unfair market forces

Good Old Public Health – Doing much with very little

Despite the many challenges to an effective response, many countries in sub-Saharan Africa are showing exemplary leadership in containing spread of COVID-19. The continent is no stranger to infectious disease outbreaks and has seen improvements in its response capacity following recent outbreaks of Ebola in West Africa and the DRC.

TETRIS – TEst, TRace ISolate

In the Democratic Republic of Congo which was in the middle of an Ebola outbreak at the beginning of the pandemic, existing protocols were quickly adapted for COVID-19 containment. Rwanda, Ethiopia and Uganda instituted and enforced early lockdowns, contact tracing and quarantines which helped to slow the spread of the virus within their borders. Kenya boosted local production of masks and other protective equipment by transforming a textile factory into a mask assembly line literally overnight. South Africa is drawing on its robust HIV-research network and leading as a site for therapeutic and vaccine trials. These good responses have defied predictions of doom for the continent which were widespread at the beginning of the pandemic.

Pandemics are Marathons not Sprints

The long road ahead

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

Only 4% (103) of the ongoing 2478 registered clinical trials for COVID-19 are currently recruiting participants in Africa. Of this number 39 are trials COVID-19 treatments and one is a phase I vaccine trial. The current distribution of COVID-19 clinical trials in Africa is concentrated in countries which had existing robust clinical trial networks prior to the pandemic. An approach that relies solely on individual countries to lead their own initiatives may be too slow to bridge the clinical trial gap in the short-term.

A better strategy to broadly benefit countries with weaker research infrastructure, should involve building collaborative networks between countries to design clinical trials, harmonizing management guidelines and coordinating sample collection, tracking and contemporaneous sharing of results. The recently established COVID-19 clinical research coalition is an important step in the right direction but has not yet translated to improved access to clinical trials in Africa.

Intravenous therapy

Delivering the level of sophisticated care needed to those who get severe COVID-19, is challenging in resource-limited settings. Important consideration must be given to how scalable and deliverable the treatment options under study will be for African countries. For example, Remdesivir, the first antiviral drug with moderate efficacy in patients with severe COVID-19, requires 10-days of intravenous administration which is challenging to deliver in any rural setting in Africa.  

Thriving market for street drugs in W.Africa

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.

Written by : Boghuma K. Titanji

Will We See Wide Spread of COVID19 in Africa?

Pandemic and Pandemonium 

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Countries with COVID19 cases around the globe

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 

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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

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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

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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.

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The influenza surveillance data for countries in sub-Saharan Africa, albeit limited, consistently show lower detection of circulating Influenza A and B. This may be in part be due to the fact that the climate is less favorable to the sustained transmission and persistence of viruses which predominantly spread through droplets. Other human coronaviruses have behaved similarly, showing seasonality and a predominance in the winter months but only time will tell whether SARS-CoV will follow this pattern.

Age Really Matters 

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So far what we have seen in the COVID19 pandemic are very high rates of severe illness and death in patients older than 60 years and with underlying chronic medical conditions. The young and healthy have generally done well, with zero deaths in the 0-10-year age group and < 2% of deaths in people under the age of 30.  Africa is the second largest and second most populated continent on the planet after Asia. Its population as a whole is very young with 60% of the entire continent aged below 25! This makes it by far the youngest continent in the world. In Italy which has the worst COVID19 outbreak outside of Asia, the median age is 47.3 years. Compare this to the 17.9 median age of Africa’s most populated nation Nigeria and the difference is striking.

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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?

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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? 

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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.

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Good examples of this phenomenon are reduced severity of diarrhea from rotavirus infections in children who also concomitantly have infection with the intestinal parasite Giardia lambliaA similar effect of decreased severity of Chikungunya virus infections has been noted with concomitant plasmodium infection. The immune mechanisms which explain these observations are complex and incompletely understood and also well beyond the scope of our current discussion (further reading in this link). Whether the phenomenon of parasitic antagonism will have an impact on severity COVID19 in Africa remains to be determined, but is certainly an interesting thought.

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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.

Getting better but not there yet

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Earlier this week I took care of my first patient with confirmed COVID19. I know there will be many more in coming days and weeks. Things now feel very real with China and Italy clearly illustrating how much pressure a flood of cases can inflict and even break the most robust healthcare systems. The fragile healthcare systems in Africa do not stand a a fighting chance to cope with the clinical care of a large volume of patients. The lack of ventilators, limited numbers of ICU beds, and severe short-staffing in medical personnel are not challenges which can be overcome overnight.  This makes aggressive public health measures to prevent community spread from establishing itself absolutely key. Basic hygiene remains a big challenge in many parts of the continent where access to soap and clean water are not always a given.

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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.

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One of the positives that emerged from the Ebola outbreak in W. Africa in 2016, is countries stepping up their public health response preparedness by improving laboratory capacity, strengthening public health institutions and increasing outbreak surveillance systems. There’s still a lot that needs to be done but these changes represent the first steps in the right direction. As we nervously continue to watch the numbers of COVID19 cases, we can only hope that Africa will be spared the worst. This year, the continent has already dealt with several outbreaks including measles, cholera, monkey pox, Lassa fever and Ebola with several still ongoing.

#ThisTooShallPass

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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. 

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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.

Written by : Boghuma . K. Titanji

*For reliable information on what to do to protect yourself and those around you at this time the IDSA website offers excellent resources.

Perspectives – Travel Bans, Stigma and an Impending Pandemic

It’s 6:30 am on a Saturday morning and as has become my daily routine, I grab my phone and search the internet looking for updates on the 2019 novel Corona virus outbreak (nCoV-2019). Today it is dominated by the news of the United States imposing a limited ban on travel from China and on foreign nationals who have visited the country within the past 14 days. A few other countries including the Bahamas, Mongolia and Singapore have adopted this approach, also imposing limited and full travel bans from China. 

A New Decade, A New Pandemic?

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A silent moment of reflection brings back flashbacks from another time and another outbreak. In 2013-2014 during the peak of the Ebola outbreak in West Africa, as West African living in London, I experienced first-hand the impact of a travel ban. Such bans quickly breed stigma and xenophobia towards large groups of people and also negatively impact the outbreak response. Since the first cases of an unusual respiratory illness were reported in November 2019, what’s now being dubbed novel Corona-virus 2019 (nCoV-2019) has recorded almost 12,000 cases and caused over 200 deaths. 98% of the cases so far have been in mainland China with exported cases reported in 26 countries around the world – a number that most certainly will continue to grow. 

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The scientific and medical communities have presented an incredibly united front with a pace of discovery and information sharing exceeding anything we have seen before. We now have a better understanding of how the virus is transmitted, the symptoms exhibited by those who become ill from it and drug trials are underway studying possible treatments. The nCoV-2019 outbreak highlights how interconnected our world truly is but also exposes the stark inequalities that make it wholly unprepared to fully combat a true pandemic.

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Wealthy and powerful nations have rushed to extract their nationals from Wuhan province in China, and flaunted elaborate and “full proof” plans for quarantine at home. Resource limited countries meanwhile, nervously await that first returning traveler with a nCoV-2019 diagnosis and plan as best as they can on how they will respond when that time ultimately arrives.

Travel bans – Deceptive, ineffective and morally wrong 

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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.

An unleveled playing FIELD
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One of the key principles of the International Health Regulations (IHR), a legally binding instrument of international law with 196 signatory countries, is the emphasis on avoiding “unnecessary interference with international traffic and trade”. In practice this means that individual states may not impose travel bans in the absence of a WHO recommendation or scientific evidence. The United States as the world’s leading super power, through the current ban has the ability to severely erode these regulations and global collaboration in the face of the ongoing nCoV-2019.

A set of rules that seemingly only applies to weaker and resource challenged countries disincentivizes future sharing of surveillance data to predict and curb future outbreaks. Lower income countries are likely to question the benefits of sharing surveillance data and being transparent on how they report on outbreaks when more powerful signatories to the IHR openly violate their own commitments to the same regulatory documents.

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The toll of Ebola on West Africa

The West Africa Ebola outbreak lasted 2.5 years and affected 30000 people. Almost 7-years later countries most directly impacted (99% of cases were in Guinea, Sierra Leone and Liberia) have not fully recovered from the effects of the airline freezes and travel bans imposed during that time. The resulting “loss” of direct travel and tourism GDP is equivalent to 0.9% and 1.6% of the whole economy in Guinea and Sierra Leone respectively. These are losses that the most fragile economies and healthcare systems in the world absolutely cannot afford and leaves then highly vulnerable to outbreaks like nCoV-2019. Canada a country with a strong economy, suffered indirect and direct losses estimated at 2-billion dollars in 2002-2003 during the outbreak of the Severe Acute Respiratory Syndrome (SARS) as a result of a WHO-imposed travel ban. These lessons from the recent past should help shape a global response that supersedes the short sighted interests of individual nations.

Blame it on bat soup? – Challenging Stigma and Xenophobia in the face of an outbreak

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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.

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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

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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.

Written by : Boghuma. K. Titanji

For reliably sourced information and updates on the outbreak I recommend visiting the Infectious Disease Society of America (IDSA)website at – https://www.idsociety.org/public-health/novel-Coronavirus/

The Short End of the Stick – We Can’t get to Zero if Women are Left Behind

Descovy for PrEP …excluding cisgender women 

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Earlier this month the US Food and Drug Administration (FDA) released a statement approving the use of Descovy for pre-exposure prophylaxis (PreP) to prevent infection with HIV. This announcement shockingly excluded cisgender women. Descovy is only the second drug approved for HIV prevention alongside its better-known counterpart Truvada which has been approved for this purpose since 2012. The news was received with shock by HIV/AIDS advocates and the medical community at large. The drug’s maker Gilead, only tested its efficacy in men and transgender women, and as such the US F.D.A claimed that a recommendation could not be made for its use in cisgender women/individuals engaging in receptive vaginal sex. 

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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.

Unique Challenges and Pattern of Neglect

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Women represent half of the adults living with HIV worldwide and 70% of PLWH in sub-Saharan Africa. HIV and AIDS remain the leading cause of death in women of reproductive age and infection rates in young women aged 15-24 are twice as high as in young men of the same age group.  Despite these stark numbers, women are severely under-represented in clinical trials on HIV treatment and prevention – accounting only for about 19% of participants

https://viivhealthcare.com/en-gb/our-stories/innovation-hiv-science/understanding-hiv-in-women-spotlight-on-the-gender-gap-in-hiv-research/

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. 

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This has resulted in limited information on the safety of most HIV drugs in pregnancy and a limited understanding of how gender specific physiologic and genetic factors may affect the body’s immune response to the virus. The most significant implication of this in my view is we may be failing to offer women the best data proven interventions for HIV prevention and treatment targeted to their unique needs.

Equity and Access

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In addition to the unique challenges of HIV research in women, there are also significant barriers and challenges to accessing those interventions which have proven to be beneficial. A good illustration of this are the challenges faced by the roll-out of the potent antiretroviral agent Dolutegravir, for women of childbearing age in sub-Saharan Africa. 

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Compared to older antiretroviral drugs, Dolutegravir controls HIV more rapidly and is associated with fewer side effects. In 2017 a generic one pill a day antiretroviral cocktail of three drugs including Dolutegravir became available for just 75$ for a year’s worth of treatment. This development meant that millions of PLWH in Sub-Saharan could finally have access to a state of the art first line treatment for HIV at a cost that was more affordable than the older less well tolerated drugs. 

Dolutegravir and the Right to Choose

In May of 2018, just as governments in the region were planning on including Dolutegravir into national treatment guidelines, a study in Botswana reported some concerning findings. Among 596 children born to women with HIV who received Dolutegravir during the first trimester of pregnancy, they noted an increased number of children born with neural tube defects (0.7%) compared to women who received older antiretroviral drugs (0.1%). A larger study presented at the IAS (International AIDS society) meeting in June 2019 estimated an associated risk for neural tube defects of about 0.4% with Dolutegravir but conceded that more data is needed. 

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Dolutegravir may lead to higher rates of neural tube defects if taken in first trimester of pregnancy

These concerns surrounding the use of Dolutegravir in pregnancy slowed its rollout with many governments debating whether women of reproductive age living with HIV should be given access to this drug. This led to a powerful consensus statement by female HIV activists in the region  stating “Each woman, is not just a vessel for a baby, but an individual in her own right, who deserves access to the very best evidence-based treatment available and the right to be adequately informed to make a choice that she feels is best for her.”

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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. 

On the issue of PrEP Access and Women

Pre-exposure prophylaxis with a combination of two antiretroviral drugs in a single pill, is the only effective strategy proven to prevent HIV infection. The roll-out of this intervention is unfortunately another area in which women have experienced unequal attention. In the United States besides black, hispanic and white MSM (men who have sex with men), black women are the largest group at risk for HIV infection. In 2017, 4008 new HIV infections in the United States occurred in black women yet many have never heard of PrEP or how to access it. 

https://www.avac.org/infographic/investment-women-focused-prep-rd-2017

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.

Young women in sub-Saharan Africa represent 3 million of the 4 million PLWH aged 15-26 years in the region. Ongoing studies on PrEP usage in this vulnerable group indicate that while many (95%) are willing to take PrEP, sustained adherence to the intervention is a challenge. Only 9% of young women are shown to have drug levels in their blood associated with high adherence at 12 months after being enrolled into PreP programs. This suggest that young women in Sub-Sharan Africa may have unique PrEP adherence support needs which would need to be studied and addressed in order to fully utilize this prevention strategy. 

Leave no Woman Behind 

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Leave no Woman Behind

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.

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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.

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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.

*Access outbound links to references by clicking on the underlined text.

Written by: Boghuma K Titanji

It’s Not All Doom and Gloom – Fighting Infant Mortality in Africa.

Her name was Amina 

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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. 

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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.

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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.

Bioko and Malawi – A time of hope and promise 

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In April of this year, the announcement of the upcoming malaria trial set to begin in 2020 in Bioko, Equatorial Guinea raised a lot of hope in the infectious disease community for several reasons.  This is not the first malaria vaccine trial in the region but for the very first time we have a malaria vaccine which going into a large clinical trial, has proven to be up to 100% efficacious in laboratory studies and in small numbers of healthy volunteers. Previous malaria vaccine trials have had mixed degrees of success, with some showing only partial efficacy and presenting serious challenges for effective widespread delivery. 

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Female Anopheles Mosquito

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.

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Malaria Vaccine Trial Underway in Malawi

The fact that the WHO will move forward with its development and distribution highlights the urgency with which effective solutions to fight malaria and other causes of infant mortality are needed. Malaria still causes 450,000 deaths every year with most of these being children under the age of five in sub-Saharan Africa and even a 30-40% reduction in severe disease is worth a shot. The WHO hopes that the expanded trials of the vaccine will provide information on its real-life efficacy and guidance on making recommendations for its broader use across the region, results that we all eagerly await.

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The vaccine, named PfSPZ which will be tested in Bioko – Equatorial Guinea, was developed by Sanaria® a biotech company based in Maryland. It is slightly different from other malaria vaccine candidates which have used protein components of the parasite to generate an immune response. PfSPZ uses weakened whole malaria parasites, that do not cause infection but are able to generate a robust protective immune response against live malaria infection. In this initial phase of large-scale testing, 2100 people between the ages of 2-50 years will receive the vaccine providing information on its safety and efficacy in a malaria endemic region.

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

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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? 

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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. 

These results were a follow-up on an initial study published 10 years ago which incidentally found that administering a single dose of Azithromycin to children aged 1 to 9 years as a measure to prevent Trachoma, resulted in a 50 percent decrease in childhood mortality in children who received the intervention. Trachoma is the leading cause of preventable blindness in the world and Azithromycin is active against the infection that can lead to irreversible damage to the eyes. This initial trial was carried out in Ethiopia, a country with an estimated infant mortality of 58 per 1000 live births and which also has a high prevalence of Trachoma. Being able to reduce infant mortality by such significant numbers through a simple intervention set the stage to test the intervention on larger numbers of children in the region.

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Mass distribution of Azithromycin for Trachoma

With funding secured through the Gates foundation the intervention was expanded to 200,000 children in Niger, Tanzania and Malawi with slightly less impressive reductions in childhood mortality of 14-18% noted. How the intervention works to reduce mortality is not completely understood but the researchers propose that the antibiotic likely provides some protection against common respiratory and gastro-intestinal pathogens which cause disease in young children in developing countries. Legitimate concerns over the risk of increasing antibiotic resistance overtime if this intervention were to be used more broadly cast a shadow over these encouraging results. The fear was that widespread distribution of an antibiotic will select for drug resistant pathogens and limit effective treatment options for serious infections in the future

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The latest studies published in the New England Journal of Medicine by the same research group allay some of these fears but also confirm some of the concerns previously mentioned. They have been able to show at the three-year follow-up mark in Niger, that childhood mortality in children receiving Azithromycin twice a year remains the same, suggesting that the intervention does not lose its efficacy overtime. Concomitantly a separate sub-study by the same group also noted an increase prevalence of pneumococcus (a bacteria which causes pneumonia and sinus infections), resistant to antibiotics in the same class as the intervention drug Azithromycin. Whether this raised prevalence of drug resistant Pneumococcus should completely nullify the clear benefits of the intervention is not an easy question to answer.

Childhood Mortality in the Developing World – No easy solutions!

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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.

Written by: Boghuma K Titanji

Swipe Right or Nah? – Dating Apps and the STI “Pubic” Health Crisis

“I sleep with my hands in my pants”

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Courtesy : https://melmagazine.com/en-us/story/hands-down-pants-helps-you-fall-asleep

On what seems like an ordinary Saturday call, I get a late afternoon page from the ED. It’s a young man presenting with “weird” lesions on his scalp. The emergency doctor wants to treat for syphilis but is not sure quite sure of the diagnosis and calls the ID consult team for help. I go to see the patient, a pleasant otherwise healthy 20-year-old man. He is visibly worried about the multiple unusual lesions on his scalp which appeared about a week ago. The lesions have a classic wet wart-like look of Condyloma lata, a classic genital rash seen in secondary syphilis. But why did they appear on his scalp?

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Treponema Pallidum – bacteria that causes Syphilis

With the initial pleasantries of the history taking out of the way I take a deep dive into the sexual history. It turns out the patient has had some recent unprotected casual sexual encounters with partners he met online, and is clearly at risk for sexually transmitted infections. A thorough physical exam reveals a similar rash on the patient’s genital area. My immediate thought is the lesions on his scalp are likely the result of   self-inoculation from groin lesions. Like any ID physician would, I ask even more strange questions and get the answer that confirms our hypothesis, “I sleep with my hands in my pants, it’s just something I’ve always done”. 

Mystery solved! I recommend empiric penicillin for presumptive treatment of secondary syphilis, which will be confirmed on his blood test results a few days later. I provide a well-rehearsed spiel on safer sex practices. The patient visibly shaken by an STI diagnosis, in the moment, is self-berating over recent choices he has made “hooking-up” casually with strangers from the dating apps in his phone. I nod in empathy with his moment of tinder regret and provide reassurance that his infection is curable and he will be fine. Months from now this whole episode will be a distant memory, but will he have the courage to swipe right again? Is the blame he is placing on dating apps really justified?

The Rise of STIs- Are Dating apps really to blame?

In 2018, the CDC released alarming updates on the rise of STIs in the United States. An estimated 2.3 million new cases were reported that year. Over a 4-year period between 2013 – 2017, the rates of syphilis have doubled, gonorrhea is up 67% and Chlamydia infections are at record breaking highs. Similar increases in cases have also been noted in Canada and many other countries around the world. This has prompted many to wonder what’s driving this growing public health crisis.

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Figuring this out has not been easy, as is often the case with studying human sexual behavior. For example, in a food borne outbreak of infection, investigations usually involve benign questions and contact tracing to identify the culprit contaminated food. On the other hand, accurate and truthful reporting on sexual exposures and practices is often confounded by reticent and heavily biased self-reporting. The reason is simple, no one wants to talk about their sex life like that! This maybe is the reason why some have suggested a theory that shifts the focus away from individuals and the judgement it implies, to the dating apps uploaded to the millions of smartphones in our pockets. Does the evidence really bear this out as true, or are we picking on an innocent bystander and ignoring more important drivers? 

Love me Tinder, Love me true

The past 15 years have seen an explosion in the popularity of dating apps with an estimated 15-20% of adults in the United States found to be active users in 2017. These apps were mostly designed to facilitate connections and potential dates between individuals with shared interests and characteristics. They work, are easy to use and have led to many long-lasting connections and relationships. It is no secret however that the ease of locating potential partners with a swipe of the touch screen, also makes these apps ideal for locating partners for casual sex. Whether this use of online dating apps translates to higher rates STI transmission may be too simplistic an explanation for a complex issue.

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The Nationwide Survey of Sexual Attitudes and Lifestyles carried out in the United Kingdom is the largest study to date that has attempted to explore adult sexual behavior in the digital age and its possible association with higher rates of STI diagnosis we are seeing currently. The study surveyed 15,162 individuals between ages 16-74 over a two-year period from 2010-2012. Finding sexual partners online was reported in about 17.6% of men and 10.1 % of women and was associated with higher number of new sexual partners and more unprotected sex acts. Surprisingly this was found to be associated to with only slightly increased rates of STI diagnoses and HIV testing in men but not in women who had a same chance of getting STIs regardless of their use of online dating technology

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Smartphone Dating Apps

For many, this may sound like an open and shut case – the multiplicity of dating apps leads to more hookups, high risk sexual behavior and ultimately higher rates of sexually transmitted infections, right?  Well not so fast, although the UK study certainly suggested that the cultural phenomenon of online dating may be contributing to some of the rise in STI infections, association does not necessarily imply causation. Also, the numbers are too small to lay all the blame on the shoulders of online dating suggesting that there are likely other factors at play and only dating apps are just the tip of the iceberg. 

Don’t blame it all on the Apps 

There is some suggestion that the higher rates of STIs are the direct result of more sensitive and sophisticated testing. We are simply finding more because we are testing more and better. This is true but we cannot ignore some of the more uncomfortable drivers that are probably contributing more to this problem than higher testing rates.

Funding cuts to effective prevention programs

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In 2016 in the United States, the budget for abstinence only sex education was increased to 85 million a year. This program has been shown time and again to be highly ineffective in reducing the rates of teenage pregnancy and STIs. Furthermore, an estimated 87% of sexual health programs across High schools nationwide allow parents and guardians to opt of having their teenage children participate in this curriculum.  This had led to a generation of young adults who do not fully understand how the sexual landscape has changed and the basics of effective prevention and sexual practices.

Planned Parenthood is constantly on threat of funding cuts

Programs that have been actually shown to be effective such as comprehensive sexual education and contraception through organizations like planned parenthood have been indexed as drivers of “society’s moral decline” and are experiencing severe cuts to funding. Pre-exposure prophylaxis (PrEP) for HIV prevention though highly effective, continues to struggle for funding in several states. 

Ignoring the baby boomers

The focus placed heavily on millennials when it comes to sex and STIs ignores a major group – the baby boomers. Sub-group analysis of the rise in STIs shows rates which are just as alarming in those ages 60 and above. In some studies, seniors have been shown to have the lowest condom usage rates of any population.

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Baby boomers have sex too!

With unwanted pregnancy no longer a concern and the advent of Viagra, baby boomers are even more liberated than ever. They often do not have the updated knowledge on navigating the risks that come with the territory of an active sex life. On the side of healthcare providers, there are intrinsic biases that make us assume that that older patients are not being sexually active, and we often do ask them about their sexual health or offer the same prevention and testing options as we do routinely for younger patients. 

Swiping happily ever after 

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Ultimately digital dating technology is here to stay and a reality of the present times. The narrative of “swiping right for syphilis” is stigmatizing and unhelpful when it comes to a public health approach at curbing the rise of STIs. Do dating apps make it easier to find partners? – of course they do. Are people having more sex as a result? – they probably are. Their existence however, should not stop us from addressing the more urgent issues of better funding for effective prevention strategies and as a society, learning to speak more candidly about sex and safer sexual practices across all generations. Here’s to swiping right, and remaining cautious while casual.

Written by Boghuma K Titanji