Milestones :: Perspectives

Milestones :: Perspectives

Twelfth meeting of the Emergency Committee under the International Health Regulations (2015) regarding the international spread of poliovirus
[Excerpts; text bolding by Editor]
13 February 2017 – The twelfth meeting of the Emergency Committee (EC) under the International Health Regulations (2005) (IHR) regarding the international spread of poliovirus was convened via teleconference by the Director General on 7 February 2017…

Conclusion
The Committee unanimously agreed that the international spread of poliovirus remains a Public Health Emergency of International Concern (PHEIC), and recommended the extension of the Temporary Recommendations for a further three months. The Committee considered the following factors in reaching this conclusion:
:: The outbreak of WPV1 and cVDPV in Nigeria highlighting that there are high-risk areas where surveillance is compromised by inaccessibility, resulting in ongoing circulation of WPV for several years without detection. The risk of transmission in the Lake Chad sub-region appears high.
:: The continued international spread of WPV1 between Pakistan and Afghanistan.
:: The persistent, wide geographical distribution of positive WPV1 in environmental samples and AFP cases in Pakistan, while acknowledging the intensification of environmental surveillance inevitably increasing detection rates.
:: The current special and extraordinary context of being closer to polio eradication than ever before in history, with the lowest number of WPV1 cases ever recorded occurring in 2016.
:: The risk and consequent costs of failure to eradicate globally one of the world’s most serious vaccine preventable diseases. Even though global transmission has fallen dramatically and with it the likelihood of international spread, the consequences and impact of international spread should it occur would be grave.
:: The possibility of global complacency developing as the numbers of polio cases continues to fall and eradication becomes a possibility.
:: The serious consequences of further international spread for the increasing number of countries in which immunization systems have been weakened or disrupted by conflict and complex emergencies. Populations in these fragile states are vulnerable to outbreaks of polio. Outbreaks in fragile states are exceedingly difficult to control and threaten the completion of global polio eradication during its end stage.
:: The continued necessity for a coordinated international response to improve immunization and surveillance for WPV1, to stop international spread and reduce the risk of new spread.
:: The importance of a regional approach and strong crossborder cooperation, as much international spread of polio occurs over land borders, while also recognizing that the risk of distant international spread remains from zones with active poliovirus transmission.

:: Additionally with respect to cVDPV:
:: cVDPVs also pose a risk for international spread, which without an urgent response with appropriate measures threatens vulnerable populations as noted above;
:: The ongoing circulation of cVDPV2 in Nigeria and Pakistan, demonstrates significant gaps in population immunity at a critical time in the polio endgame;
:: The ongoing urgency to prevent type 2 cVDPVs following the globally synchronized withdrawal of the type 2 component of the oral poliovirus vaccine in April 2016;
:: The ongoing challenges of improving routine immunization in areas affected by insecurity and other emergencies, including the post Ebola context;
:: The global shortage of IPV which poses an additional threat from cVDPVs

…The Committee strongly urged global partners in polio eradication to provide optimal support to all infected and vulnerable countries at this critical time in the polio eradication programme for implementation of the Temporary Recommendations under the IHR, as well as providing ongoing support to all countries that were previously subject to Temporary Recommendations (Somalia, Ethiopia, Syria, Iraq and Israel).

The committee requested the secretariat to provide data on routine immunization in countries subject to Temporary Recommendations. Recognizing that cVDPV illustrates serious gaps in routine immunization programmes in otherwise polio free countries, the Committee recommended that the international partners in routine immunization, for example Gavi, should assist affected countries to improve the national immunization programme.

The Committee noted the Secretariat’s report on the identification of Sabin 2 virus detected in environmental samples in several countries, and in some of these cases probably due to the ongoing use of tOPV in the private sector. The Committee requested a full report on this at the next meeting.

The Committee noted a more detailed analysis of the public health benefits and costs of implementing temporary recommendations was completed and warranted further discussion and review.

The Committee urged all countries to avoid complacency which could easily lead to a polio resurgence. Surveillance particularly needs careful attention to quickly detect any resurgent transmission.

Based on the advice concerning WPV1 and cVDPV, and the reports made by Afghanistan, Pakistan, Nigeria, and the Central African Republic, the Director General accepted the Committee’s assessment and on 13 February 2017 determined that the events relating to poliovirus continue to constitute a PHEIC, with respect to WPV1 and cVDPV. The Director General endorsed the Committee’s recommendations for countries falling into the definition of ‘States currently exporting WPV1 or cVDPV’, for ‘States infected with WPV1 or cVDPV but not currently exporting’ and for ‘States no longer infected by WPV1, but which remain vulnerable to international spread, and states that are vulnerable to the emergence and circulation of VDPV’ and extended the Temporary Recommendations as revised by the Committee under the IHR to reduce the international spread of poliovirus, effective 13 February 2017.

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Grand challenges for the next decade in global health policy and programmes
Dr Margaret Chan
Director-General of the World Health Organization
Keynote address at a celebration of the 10th anniversary of the University of Washington’s Department of Global Health
Seattle, Washington, USA
8 February 2017
[Editor’s text bolding]
Honourable ministers, distinguished fellow speakers, faculty and staff at the University of Washington, colleagues in public health, ladies and gentlemen,

For global health, this is a jubilee year for the University of Washington’s Department of Global Health and at least seven other Washington-based health organizations.

I congratulate the Department of Global Health on its tenth anniversary celebration. With well over 600 current research projects in nearly 130 countries, your contribution to global health is broad and your productivity is astonishing.

Many of these projects are operating at the cutting edge of innovation and several are being conducted in close collaboration with WHO. Several are dear to my heart, especially in the era of sustainable development…

I have been asked to speak about grand challenges for health policy and programmes in the coming decade.

Your interdisciplinary panels will be exploring four of these challenges: preparedness for outbreaks of emerging and re-emerging diseases, the control of noncommunicable diseases, the health impact of environmental degradation and climate change, and the need for innovative approaches to education and training. I would add antimicrobial resistance, and its nightmare bacteria, to that list.

In our world of radically increased interdependence, the forces that have shaped these challenges are universal, and they are not easily reversed. The world has changed dramatically since the start of this century, when the Millennium Development Goals were put forward as the overarching framework for development cooperation.

World leaders at the Millennium Summit sought to create what they called “a more peaceful, prosperous, and just world”. That did not happen as planned.

To understand the newer challenges now embodied in the 2030 Agenda for Sustainable Development, we need to look at the larger sea in which these trends were set afloat.

Since 2001, terrorist attacks that deliberately target civilians have become more deadly, daring, and common. Armed conflicts are now the largest and longest experienced since the end of World War II. The refugee crisis in Europe taught the world that wars in faraway places will not stay remote.

International humanitarian law is now largely ignored, with the deliberate bombing of health care facilities and the use of siege and starvation as weapons of war.

Warnings about the consequences of climate change are increasingly shrill. Records for extreme weather events are being broken a record number of times. The past three years have been the hottest ever.

The phrase “mega-disaster” entered the humanitarian vocabulary following devastating earthquakes, tsunamis, tropical cyclones, droughts, and floods.

The world population is now bigger, more urban, and a lot older, adding dementia to the list of top health priorities. Everywhere in the world, people are living longer sicker lives, increasing the burden on health services, budgets, and the workforce.

Hunger has persisted, but most of the world got fat. The world has 800 million chronically hungry people, but it also has countries where more than 70% of the adult population is obese or overweight.

The globalized marketing of unhealthy products opened wide the entry point for the rise of lifestyle-related chronic conditions. Noncommunicable diseases have overtaken infectious diseases as the biggest killers worldwide.

This is a unique time in history, where economic progress, improved living conditions, and greater purchasing power are actually increasing diseases instead of reducing them.

Social media have become a new voice with considerable force, yet few safeguards governing the accuracy of its content. The proliferation of front groups and lobbies, protecting commodities that harm health, has created arguments that further muddle public thinking and challenge the authority of evidence.

The Oxford Dictionary of the English Language chose “post-truth” as its word of the year for 2016. In a post-truth, post-fact world, views that appeal to emotions and personal beliefs are more influential than objective evidence-based facts.

What does this mean for public trust in the evidence produced by science, medicine, and public health?

The 21st century has been rocked by the emergence of four new human pathogens: SARS, the H5N1 and H7N9 influenza viruses, and the MERS coronavirus. Other older diseases have remerged in ominous ways, including Ebola, yellow fever, and Zika virus disease.

As the century progressed, more and more first- and second-line antimicrobials failed. The pipeline of replacement products has nearly run dry, raising the spectre of a post-antibiotic era in which common infections will once again kill.

The world is also much richer than at the start of this century. Countries like China and India lifted millions of their citizens out of poverty, but in many countries, the benefits of growing wealth have gone to the privileged few.

The number of rich countries full of poor people has grown, changing the poverty map. Today, 70% of the world’s poor live in middle-income countries.

The consequences of the world’s extreme social inequalities are profound. Last month’s World Economic Forum identified growing inequalities in income and wealth as the single most significant trend that will shape global development over the next ten years.

In essence, the SDGs are a corrective strategy that looks at the root causes of inequality and aims to transform them. The international systems that govern finance, business relations, trade, and foreign affairs need a corrective strategy.

As some critics argue, the long-standing social contract that obliges the privileged few to care for those less fortunate has been broken in a world that has lost its moral compass.

Ladies and gentlemen,
As we collectively address these challenges, I ask you to keep in mind four overarching priorities that should guide health policies and programmes.

First, tackle inequality. Second, improve information. Third, stimulate innovation. Fourth, and above all, show impeccable integrity.

For inequality, the 2030 Agenda for Sustainable Development has the focus right. Leave no one behind. This is not easy, especially in these uncertain times.

Decades of experience tell us that this world will not become a fair place for health all by itself. Health systems will not automatically gravitate towards greater equality or naturally evolve towards universal coverage.

Economic decisions within a country will not automatically protect the poor or promote their health. Globalization will not self-regulate in ways that ensure the fair distribution of benefits. International trade agreements will not, by themselves, guarantee food security, or job security, or health security, or access to affordable medicines.

All of these outcomes require deliberate policy decisions.

I call on you to promote the SDG target for universal health coverage as the ultimate expression of fairness. It is one of the most powerful social equalizers among all policy options.

For information, some 85 countries, representing 65% of the world’s population, do not have reliable cause-of-death statistics. This means that causes of death are neither known nor recorded, and health programmes are left to base their strategies on crude and imprecise estimates. Until more countries have good systems for civil registration and vital statistics, health programmes will be working in the dark, throwing money into a black hole.

This is totally unacceptable in the current climate that places a premium on transparency, accountability, and independent monitoring of results. I am aware of the many current projects, undertaken by the Global Health Department and its partners, which are using the latest information technologies to address precisely this problem.

For innovation, we know that the supremely ambitious health targets set out in the SDGs cannot be met without powerful new medical tools. We know that new vaccines can prevent infections that currently contribute to the overuse of antibiotics.

We know that at least 11 epidemic-prone human pathogens, including the Zika, Lassa fever, and Nipah viruses, have no vaccine to protect populations during outbreaks.

We know that R&D incentives preferentially encourage the development of new products for markets that can pay.

One strategy that has worked well at WHO is to let the people, working in the field and seeing practical constraints on a daily basis, design the profile of an ideal new product, right down to its price. This was the strategy used so successfully in the Meningitis Vaccine Project, funded by the Bill and Melinda Gates Foundation, and coordinated by WHO and PATH. I encourage others to use a similar approach.

Finally, we must all work according to the highest standards of scientific integrity. Like others, I see a number of disturbing trends. Let me respond to just one.

Regulatory agencies everywhere must resist the push to replace randomized clinical trials, long the gold standard for approving new drugs, with research summaries provided by pharmaceutical companies.

As some argue, making this change would speed up regulatory approval, lower the costs to industry, and get more products on the market sooner. This kind of thinking is extremely dangerous.

We must not let anything, including economic arguments or industry pressure, lower our scientific standards or compromise our integrity. This is an absolute duty.

Don’t let politicians, the public, or industry forget the lessons from the thalidomide disaster.
Thank you.

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Editor’s Note:
While we have been monitoring the growing anti-vaccine/vaccine hesitancy “movement” globally, we have not formally designated space in this digest for such content. However, early signals from the new U.S. administration around vaccines and vaccine safety suggest we begin. Below is an announcement we felt warranted inclusion, however incredulous we are about its grounding.

Feb 15, 2017, 11:00 ET
Robert F. Kennedy, Jr. announces the World Mercury Project’s $100,000 challenge with goal of stopping use of highly toxic mercury in vaccines.
…Kennedy announced the “World Mercury Project Challenge” to American journalists and others “who have been assuring the public about the safety of mercury in vaccines.”
Kennedy explained that the WMP will pay $100,000 to the first journalist, or other individual, who can find a peer-reviewed scientific study demonstrating that thimerosal is safe in the amounts contained in vaccines currently being administered to American children and pregnant women….
…Actor Robert De Niro…who also spoke at the press conference, is a supporter of the WMP, whose vision is a world where mercury is no longer a threat to the health of our planet and people. The group focuses on making sound science the driver of public policy…