WHO

Is the US prepared for the next pandemic?

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In September 2021, the Biden administration introduced the American Pandemic Preparedness Plan, a proposal to transform the country’s capabilities to respond to future pandemics.

In it, the administration likened the danger posed by biological threats to the dangers posed by traditional weapons, terrorism and cyberattacks, and called for an effort to address pandemic preparedness on the level of the Apollo program that sent humans to the moon.

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Statistically speaking, influenza is the most likely cause of the next pandemic, according to Jennifer B. Nuzzo, DrPH.Image: Kenneth Zirkel/Brown University

Noting that the next pandemic “will likely be substantially different” from COVID-19, the new plan — also known as AP3 — outlined dozens of goals, including upgrading the country’s medical defenses by improving vaccines, therapeutics and diagnostics and strengthening relevant stockpiles and supply chains. It also called for improving public health systems in the United States and internationally.

“It really outlined this very bold agenda of not just research, but the whole gamut of what is needed to prepare for and respond to potential pandemic threats,” Jane Knisely, PhD, pandemic preparedness strategy coordinator at the National Institute of Allergy and Infectious Diseases’ Division of Microbiology and Infectious Diseases, said in an interview. “Unfortunately, it was not resourced.”

The plan is one of several proposed initiatives intended to strengthen the country’s preparedness for future pandemics. Another initiative, the National Biodefense Strategy and Implementation Plan, builds off AP3 and includes what a senior Biden administration official called “a series of moonshot efforts … that will help us accelerate the speed of our response and prepare for these unknown threats.”

“These science and technology goals lay out timelines that are not possible today, but these capabilities can be achieved and are within our reach with the right resources over the next 5 to 10 years,” the official said in a call with reporters to preview the strategy.

Biden launched the effort in a national security memo addressed to the heads of 20 government agencies, in which he wrote that “countering biological threats, advancing pandemic preparedness, and achieving global health security are top national and international security priorities for the United States.”

The administration said in October 2022 that it was already implementing parts of the plan with existing funding but would need Congress to allocate additional resources to fully achieve its objectives. Indeed, over the last 2 years, the administration has asked Congress for funding for these plans, including a 2024 budget request for $20 billion in new mandatory funding over 5 years to be allocated to various HHS public health agencies for pandemic preparedness and biodefense. The budget request includes $10.5 billion to improve public health infrastructure at the CDC and state and local levels, and to bolster surveillance, laboratory capacity and the public health workforce.

“The funding bills for fiscal year 2024 have not been passed yet. We’re still operating under a continuing resolution,” Amanda Jezek, senior vice president for public policy and government relations at the Infectious Diseases Society of America, noted in an interview. “So, we’re not quite where we need to be yet.”

This past summer, Biden picked surgeon and retired Air Force Maj. Gen. Paul Friedrichs, MD, to be the first director of a new permanent office in the executive branch that will oversee the country’s pandemic preparedness and response.

The Office of Pandemic Preparedness and Response Policy — which replaced the White House committees in charge of the COVID-19 and mpox responses — was established when Congress enacted portions of the PREVENT Pandemics Act as part of the 2023 budget. The office will coordinate the White House’s domestic response to pandemic threats, lead efforts at the federal level to develop new vaccines and technologies, and develop and provide periodic reports to Congress on the country’s level of preparedness.

Additional policies from the PREVENT Pandemics Act also passed as part of the 2023 budget — including one that makes CDC director a Senate-confirmable job, effective Jan. 20, 2025 — but Congress has so far not reauthorized the Pandemic and All Hazards Preparedness Act (PAHPA), a 2006 law that established an Assistant Secretary for Preparedness and Response position at HHS and supported the agency’s preparedness and response efforts.

Funding for PAHPA expired at the end of September, less than 2 months after a group of 19 Congressional Republicans said in a letter that the legislation should not be considered for a vote “without desperately needed reforms to protect the American people from tyrannical, incompetent and largely unchecked public health bureaucrats.” Among their list of demanded reforms, the lawmakers said PAHPA funding should return to pre-COVID-19 levels, that the U.S. should assert its authority over WHO, limit or ban Chinese-manufactured goods from the Strategic National Stockpile and restrict the government’s ability to issue vaccine mandates.

It has been 4 years since WHO declared COVID-19 a global public health emergency. The pandemic has many legacies, some of which we have covered in the first three parts of our ongoing “Life during COVID” series. For this fourth part, we checked in with experts to get their feedback on the country’s preparedness for the next pandemic.

[Editor’s note: Some responses have been edited for length and clarity, and some were broken up and organized based on topic.]

Is the US in a better or worse position to respond to the next pandemic compared with prior to COVID-19?

Jezek: It’s a mix of both. In some ways, I think we’re better prepared, and in some ways, we may be worse. We learned a lot from COVID-19. That is sort of the big advantage that we have now — we’ve had an opportunity to see what works well and what doesn’t, where our strengths and gaps are. That presents a real opportunity to apply those lessons and make the investments that we’ve seen are necessary.

Jennifer B. Nuzzo, DrPH, director of the Pandemic Center at Brown University School of Public Health:Here’s what I haven’t seen that I would like to see … I would like to see a bipartisan commitment to have a serious assessment of what went wrong during the pandemic. We need to get to the bottom of this in the same way that we wanted to get to the bottom of what went wrong during 9/11. A number of the United States’ challenges were probably as much about government effectiveness as they were about lack of resources, money, etc. We need to really, truly have an audit. Not necessarily in a punitive way, but a true audit.

Jay K. Varma, MD, executive vice president and chief medical officer at SIGA Technologies and former director of the Cornell Center for Pandemic Prevention and Response: Following 9/11, there was widespread political commitment and funding to strengthen intelligence and security, both domestically and globally, against violent threats. After COVID-19, we should have seen a stronger commitment to making similar investments in intelligence and security against biological threats, but they have not happened. That lack of action is concerning.

Amira A. Roess, PhD, MPH, professor of global health and epidemiology at the George Mason University College of Public Health: In most other aspects of life, when you know where your weaknesses are, you generally tend to address them. We haven’t done that, and when we faced another infectious disease outbreak last year, we didn’t do very well. We were lucky because the circulating mpox variant was the weaker one. We faced the same issues that we faced with the COVID-19 pandemic, including delays in recognizing the infection, delays in reaching people at risk, supply chain-related delays in getting vaccines and treatments to those affected. We had to rely heavily on nonprofit organizations and other nongovernmental organizations to respond to mpox. All of that highlights that our core public health infrastructure is still fractured and underfunded. Morale in many local public health agencies is low, and we continue to fail to provide adequate funding to support public health agencies.

Nuzzo: We are seeing a rollback in vaccination requirements across the country. So, at the kind of national policy level, I think we are less prepared.

[Editor’s note: CDC data published in November showed that kindergarten vaccination rates remained below pre-pandemic levelslast school year and vaccine exemptions reached an all-time high, driven by nonmedical exemptions.]

Varma: The size and strength of the anti-vaccine movement is troubling. If more parents decline to vaccinate their children and more states relax vaccine requirements, we could see a resurgence of old diseases. One shocking example is the report of a case of polio in New York state. More vaccine-preventable infections means more ill health and more opportunities for viruses to mutate and put more people at risk.

Susan C. Kim, JD, MPH, MBA, principal deputy assistant secretary of the Office of Global Affairs at HHS: Misinformation and disinformation have become more prevalent and are undermining confidence in science and public health and weakening trust in governmental and other institutions. Addressing misinformation will require a true global collaborative effort to build trust in science.

Nuzzo: At the same time, we also have some advantages in that the pandemic brought us some remarkable scientific achievements. In less than a year, we developed multiple safe and effective vaccines and rapid tests so that now people have the power to test themselves for COVID in their homes completely confidentially.

Varma: The most important improvement is in awareness. Before COVID-19, most elected officials and citizens did not view pandemic preparedness as something that needed attention and action. Now there is much more widespread awareness that a large infectious disease outbreak — whether natural, accidental or deliberate — could greatly damage American health and our social and business systems.

Nuzzo: We have a public that just went through this and understands now what an infectious disease is and what steps they can take to protect themselves. We have businesses that have seen firsthand how disruptive this is to their livelihoods and the safety of their workers and their customers. Those are important assets that should not be squandered. I would point to that as a source of optimism.

Jezek: The systems that we’ve built are another big advantage. All of the clinical trial infrastructure that was stood up during COVID-19, how rapidly we were able to develop novel vaccines and therapeutics — that is a huge advantage. I think it’s important to keep that going.

Roess: We’re better off in that we know how to distribute masks and other supplies in general. Medically vulnerable populations know a little bit more about how to protect themselves from infectious diseases. Some employers continue to use COVID-era protocols to scale back activities or modify operations to protect employees and those who come into contact with them when facing flu, RSV, COVID and other infectious diseases.

Jezek:In terms of where we are weaker, I think that there are serious trust issues with public health and with government, and we need to focus on rebuilding that trust.

Knisely: It’s very clear that the COVID pandemic exacerbated this polarization and distrust in science and a lack of understanding of the scientific process. Political polarization of science is extremely troubling.

Varma:Several states have also removed the authority of public health agencies to quarantine and isolate people with infectious diseases or to make other important public health decisions. This will weaken the ability of state and local governments to respond during a future pandemic. Many public health and health care workers have chosen to leave the field and are not being replaced. Many local health agencies have 20% to 30% vacancy rates. We need trained health care professionals to help us fight the next infectious disease threat. Without them, there will be even more illness and death.

What is the biggest lesson COVID-19 taught us?

Varma: That advanced health care services do not automatically protect a population against a pandemic. We need to invest in public health agencies and social support services to defend ourselves against pandemics.

Jezek: To me, the biggest lesson is that, with a novel virus, information is going to change over time. The public and the medical community and public health and government need to be transparent about that and need to be nimble, to be able to change course as the trajectory of a pandemic changes and as we learn more.

Knisely: From a biomedical research standpoint, I think there are three things. One, we can develop safe and effective vaccines in a fraction of the time that it typically takes. We just need to have investments in what we call plug-and-play vaccine platforms. Messenger RNA is a great example of that. Second, we need close collaborations with academic researchers, large and small companies, and regulators, which happened during COVID. That there were folks at the FDA who worked very closely with study teams on the vaccine and drug trials to navigate a path forward, and do it very quickly, was really essential. The other thing that was really critical that we need to sustain support for is having pre-existing preclinical and clinical trial infrastructure that can rapidly pivot to conduct the research that is needed.

Roess: The biggest lesson might be that we prioritize political affiliation over human lives. Before the pandemic, we knew how to respond to outbreaks and what measures can be effective to prevent transmission, but we were ill equipped to deal with combating anti-public health rhetoric, and we still are. The pandemic highlights our lack of support for public health infrastructure, education and minoritized communities. Unlike other high-income countries, we don’t think these are important things to support and the results are demonstrated every day.

What lessons have we not learned?

Varma: I think that many elected officials and the general public believe that the key to stopping a pandemic is advanced technology. While tests, treatments and vaccines are critical, we actually relearned a lesson that has been evident as far back as the 1918 influenza pandemic: Advanced health care technologies work best only when they are layered on top of a strong foundation of social and health care support for all people, so there is access to care for everyone who needs it, as well as housing, paid sick leave, child care services and workplace safety programs.

Knisely: The cycle of panic and neglect is the big one. This needs sustained funding and attention. It’s not something where you can just come in and mount an effective response after years of neglect. Public health has been chronically underfunded. Sadly, I don’t think we have learned that lesson.

Roess: We seem to play the short game. We’ve known that we’ve been underfunding public health infrastructure and yet have not done anything meaningful for decades to address shortages in public health workers and our limited infrastructure to prevent outbreaks.

Is pandemic preparedness taken seriously in the US?

Jezek: It is by many. If we’re thinking specifically about the federal government, the ability to take something seriously is not always matched with the necessary funding to really put in place the kind of infrastructure that’s required.

Roess: Our ever-decreasing attention span suggests that as a populous, we have a hard time taking much seriously for a long period of time. What’s taken decades to dismantle will take a serious and thoughtful investment to rebuild, and I don’t think our leaders will prioritize this.

Knisely: The current administration certainly has prioritized pandemic preparedness in multiple ways, and there are many members in Congress who take it very seriously.

Kim: The United States is the world’s leading funder of global health and pandemic preparedness. Since 2021, we’ve committed nearly $48 billion to global health, including nearly $16 billion globally to end the acute phase of the COVID-19 pandemic. We provided hundreds of millions of vaccine doses to over 100 countries, as well as therapeutics.

Are there other countries that are better prepared for a pandemic?

Varma: There are so many factors involved in assessing pandemic response that it is difficult to call out one country as being much better prepared. The countries that did best in responding to the COVID-19 pandemic had a strong foundation of social and health support for all people, including universal health care, housing and sick leave, as well as two important social factors: trust in government and trust in each other — social cohesion. This is what the U.S. should strive to achieve.

Nuzzo: The U.S. definitely underperformed, given its pre-pandemic advantages. We’re arguably one of the better prepared countries in the world. I run the Global Health Security Index, which measures countries’ capacities to be able to respond to pandemics, and the U.S. has more capacity than others. I think what we saw during COVID was that we really didn’t take advantage of what we had, and in some instances, we chose not to use what we had. What that meant was that the U.S. had more pandemic-related mortality than what other highly prepared countries had. To me, that seems like there were some real failures in our response. No country was fully prepared for pandemics at the start of COVID, and still no country is fully prepared for pandemics.

Jezek: I do think that the U.S. has some unique challenges in that we are very large and very diverse, and we have a wide array of beliefs and attitudes about public health and preparedness. All of that presents both opportunities and challenges. Something else that is unique among the U.S. and other high-income countries is that we have a responsibility not only within our borders but to support preparedness in the rest of the world, particularly among low- and middle-income countries. It’s important that we invest in preparedness throughout the world because we know that infections that originate anywhere across the globe are just a plane ride away from the U.S. In terms of thinking about preparedness within the U.S., we have to think globally.

What’s the most likely cause of the next pandemic?

Nuzzo: Statistically, it’s an influenza virus, only because we tend to have three per century and the last one was in 2009. But coronaviruses are like, “Hold my beer.” They’re trying to give flu a run for its money.

Knisely: We know influenza can cause pandemics.It evolves rapidly. It’s zoonotic in origin. Many different species can harbor influenza. The viruses can reassort their genes. So, we are always investing in understanding influenza transmission and evolution and developing countermeasures.

Kim: Many pandemics in history, including the recent COVID-19 pandemic, have originated from zoonotic diseases … which are very common, both in the United States and around the world. Scientists estimate that more than six out of every 10 known infectious diseases in people can be spread from animals, and three out of every four new or emerging infectious diseases in people come from animals. As such, a One Health approach — which recognizes the interconnectedness of human health, animal health and environmental health — is a critical component of pandemic prevention, preparedness and response efforts.

Varma: We can say with certainty that we are entering a new age of pandemics where the risk is higher and potentially more deadly. I am particularly worried about diseases transmitted by mosquitos, ticks and other insects. Climate change is rapidly altering the landscape of diseases — those that were once considered “tropical” and can now be found in places where they were not seen previously. This is true with dengue virus, chikungunya virus, and even malaria.

Nuzzo: It also depends on what you call a pandemic. I haven’t really used the word pandemic to describe the Zika virus situation, but it circulated in multiple regions of the world and caused serious health effects. A pandemic is not a really clear scientific term. It’s something we use to describe geographic spread. It doesn’t describe severity. Zika was an enormous health challenge but I’m thinking more of a no-notice, destabilizing type of event, and which pathogen is most likely to cause it. It’s probably a respiratory virus.

Varma: We also cannot underestimate the risk associated with either accidental or deliberate bioterrorism-related epidemics. As the world conducts more research on viruses, there is an increasing risk that a rogue actor could synthesize a new virus or a previously eradicated one, like smallpox, and release it accidentally or deliberately. As the world conducts more research and conflict between countries grow, there is an increasing risk that the next epidemic could be made by man, rather than by nature.

Knisely: At NIAID, we have a pandemic preparedness plan with two different approaches when we’re thinking about this question. The first we call priority pathogens — things that are always lurking in the background, posing a threat, like influenza. Similarly, coronaviruses are clearly a threat. We’ve had three major ones emerge in the last 20 years. What those share in common is that they are RNA viruses capable of rapid evolution and respiratory transmission. They’re at the top of a lot of people’s list. We’re trying to cover the bases so that we can be prepared, no matter what emerges.

Five billion people unprotected from trans fat leading to heart disease

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Five billion people globally remain unprotected from harmful trans fat, a new status report from WHO has found, increasing their risk of heart disease and death.

Since WHO first called for the global elimination of industrially produced trans fat in 2018 – with an elimination target set for 2023 – population coverage of best-practice policies has increased almost six-fold. Forty-three countries have now implemented best-practice policies for tackling trans fat in food, with 2.8 billion people protected globally.

Despite substantial progress, however, this still leaves 5 billion worldwide at risk from trans fat’s devastating health impacts with the global goal for its total elimination in 2023 remaining unattainable at this time.

Industrially produced trans fat (also called industrially produced trans-fatty acids) is commonly found in packaged foods, baked goods, cooking oils and spreads. Trans fat intake is responsible for up to 500 000 premature deaths from coronary heart disease each year around the world.

“Trans fat has no known benefit, and huge health risks that incur huge costs for health systems,” said WHO Director-General, Dr Tedros Adhanom Ghebreyesus. “By contrast, eliminating trans fat is cost effective and has enormous benefits for health. Put simply, trans fat is a toxic chemical that kills, and should have no place in food. It’s time to get rid of it once and for all.”

Currently, 9 of the 16 countries with the highest estimated proportion of coronary heart disease deaths caused by trans fat intake do not have a best-practice policy. They are Australia, Azerbaijan, Bhutan, Ecuador, Egypt, Iran (Islamic Republic of), Nepal, Pakistan and Republic of Korea.

Best-practices in trans fat elimination policies follow specific criteria established by WHO and limit industrially produced trans fat in all settings. There are two best-practice policy alternatives: 1) mandatory national limit of 2 grams of industrially produced trans fat per 100 grams of total fat in all foods; and 2) mandatory national ban on the production or use of partially hydrogenated oils (a major source of trans fat) as an ingredient in all foods.

“Progress in eliminating trans fat is at risk of stalling, and trans fat continues to kill people,” said Dr Tom Frieden, President and CEO of Resolve to Save Lives. “Every government can stop these preventable deaths by passing a best-practice policy now. The days of trans fat killing people are numbered – but governments must act to end this preventable tragedy.”

While most trans fat elimination policies to date have been implemented in higher-income countries (largely in the Americas and in Europe), an increasing number of middle-income countries are implementing or adopting these policies, including Argentina, Bangladesh, India, Paraguay, Philippines and Ukraine. Best-practice policies are also being considered in Mexico, Nigeria and Sri Lanka in 2023. If passed, Nigeria would be the second and most populous country in Africa to put a best-practice trans fat elimination policy in place. No low-income countries have yet adopted a best-practice policy to eliminate trans fat.

In 2023, WHO recommends that countries focus on these four areas: adopting best-practice policy, monitoring and surveillance, healthy oil replacements and advocacy. WHO guidance has been developed to help countries make rapid advances in these areas.

WHO also encourages food manufacturers to eliminate industrially produced trans fat from their products, aligning to the commitment made by the International Food and Beverage Alliance (IFBA). Major suppliers of oils and fats are asked to remove industrially produced trans fat from the products sold to food manufacturers globally.

The report, called Countdown to 2023 WHO Report on global trans fat elimination 2022, is an annual status report published by WHO in collaboration with Resolve to Save Lives, to track progress towards the goal of trans fat elimination in 2023.

Source: WHO

Cholera – Global situation: Disease Outbreak News and press briefing

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Cholera – Global situation

GLOBAL OVERVIEW

Current Situation                                                                                    

Since 2021, there has been an increase in cholera cases and their geographical distribution globally. In 2021, 23 countries reported cholera outbreaks, mainly in the WHO Regions of Africa and the Eastern Mediterranean. This trend has continued into 2022 with over 29 countries (Figure 1) reporting cholera cases or outbreaks. As of 30 November 2022, 16 of these have been reporting protracted outbreaks. Many of those countries reported higher case numbers and case fatality ratio (CFR) than in previous years. The average cholera CFR reported globally in 2021 was 1.9% (2.9% in Africa), well above acceptable (<1%) and the highest recorded in over a decade.

This year the number of cholera cases and cholera-associated deaths have surged globally following years of decline. Of particular concern are the outbreaks in 13 countries, which did not report cholera cases in 2021. Of these, some had not reported any cholera outbreaks for many years (between three and 30), and several are not considered cholera-endemic countries.i,ii The current situation represents a resurgence of the ongoing seventh pandemic of cholera which began in 1961.

The simultaneous progression of several cholera outbreaks, compounded in countries facing complex humanitarian crises with fragile health systems and aggravated by climate change, poses challenges to outbreak response and risks further spreading to other countries. The overall capacity to respond to the multiple and simultaneous outbreaks is strained due to the global lack of resources, including the oral cholera vaccine, as well as overstretched public health and medical personnel, who are often dealing with multiple disease outbreaks at the same time.  

Epidemiology

Cholera is an acute diarrheal infection characterized, in its severe form, by extreme watery diarrhea and potentially fatal dehydration. It is caused by the ingestion of food or water contaminated with the bacterium Vibrio cholerae. It has a short incubation period, ranging between two hours and five days. Most people will develop no or only mild symptoms; less than 20% of ill persons develop acute watery diarrhoea with moderate or severe dehydration and are at risk for rapid loss of body fluids, dehydration, and death. Despite being easily treatable with rehydration solution, cholera remains a global threat due to its high morbidity and mortality in vulnerable populations with a lack of access to adequate health care.

Seven distinct pandemics of cholera have been recorded during the past two centuries. The seventh pandemic, which is still ongoing today, is considered to have occurred principally between 1961 to 1974. During this period, following (re)introduction, many countries transitioned to becoming cholera-endemic. While global incidence greatly decreased in the late 1990s, cholera remained prevalent in parts of Africa and Asia.

The global burden of cholera is largely unknown because the majority of cases are not reported, however, previous studies estimate 2.9 million cases, and 95,000 deaths occur annually.

Figure-1: Incidence of cholera casesiii(including estimated cases of acute watery diarrhoea (AWD)iv)  per 100,000 population reported to WHO from 1 January to 30 November 2022v Note: countries in white did not report any cholera cases in 2022 

Figure-2: Cholera cases* reported to WHO by year and continent, global CFR, 1989-2021**

* In 2017 and 2019, Yemen accounted for 84% and 93% of all cholera cases respectively (Weekly Epidemiological Report 2018, 2020).

**The data for 2022 is not included in the epidemic curve due to (i) incompleteness (data available until 30 November 2022), (ii) provisional estimates. Official reporting of case counts per country to WHO is expected at the end of the year.

To note: data on cholera are often incomplete and underreporting is common. Several countries do not have reporting systems for cholera. This is why complete lists of countries with outbreaks, nor accurate case and death counts cannot be provided.

DRIVERS OF THE CURRENT OUTBREAKS AND CHALLENGES IMPACTING THE RESPONSE

The main drivers and challenges for controlling and containing the current cholera outbreaks are outlined below. Yet, addressing the need for, and lack of funding to prevent outbreaks is critical. Large-scale investments in water and sanitation infrastructure have largely led to the elimination of cholera in Europe and the Americas. Significant investments should support water, sanitation, and hygiene (WASH) interventions for cholera prevention and control. Such interventions should consider the social context and be supported by the best available evidence and updated models of cholera transmission.1

  • Climate change – widespread floods and drought

Of the countries that have reported cholera outbreaks in 2022, many are experiencing natural disasters such as cyclones (Mozambique, Malawi), flooding (Pakistan, Nigeria), and drought (countries in the Horn of Africa). Major flooding and above-normal hurricane seasons increase outbreak severity and the propensity for regional spread.The upcoming rainy/cyclone season, which is predicted to be severe, has the potential to spread the disease across Southern Africa. The above-normal hurricane season in the Americas is affecting several countries in the Caribbean and Central America causing major flooding. Post-monsoon season (and post-floods) is usually associated with a cholera peak in South Asia. Additionally, many countries experienced droughts leading to cholera2 due to poor access to water, marginalization of refugees and nomadic populations, and expansion of informal urban settlements.

  • Humanitarian crises, political instability, and conflict

Increasing humanitarian crises due to conflict, political instability, and a lack of development are leaving an increasing number of people at risk for cholera across all WHO regions. Of the countries that have reported outbreaks, nine are experiencing conflict or political violence in affected areas (Afghanistan, Cameroon, the Democratic Republic of Congo, Haiti, the Islamic Republic of Iran, Nigeria, Somalia, the Syrian Arab Republic, and Yemen). In two of these countries (Ethiopia and Cameroon), the current outbreak is not affecting conflict areas, but there is a high risk of spreading into areas of ongoing conflict, which would complicate the response.

  • Multiple ongoing emergencies

Several countries with cholera outbreaks are also responding to multiple other disease outbreaks including mpox (monkeypox), dengue, chikungunya, measles, and the ongoing COVID-19 pandemic. This also strains the overall response capacity to cholera, particularly in countries with limited resources.

  • Sub-optimal / delayed surveillance.

The lack of data hinders response. There are several country- and surveillance-specific reasons for the lack of data: (1) Countries with inadequate surveillance systems overall; (2) Countries with robust surveillance systems, which only report cholera from sentinel sites or do not include cholera at all; (3) Lack of data sharing; (4) Breakdown of surveillance systems during humanitarian crises and political instability; (5) Insufficient capacity for lab confirmation and use of heterogenous case definitions (eg. cholera versus acute watery diarrhea).

  • Medical commodities supply chain

At the time of this report, the global supply of cholera kits is depleted, and suppliers are struggling to meet demand. Delays or shortages of medical supplies can lead to preventable and avoidable deaths. WHO is facilitating global coordination and alternate sources of supply are being sought, but these will not be available immediately.

  • Limited availability of healthcare resources

The number of outbreaks and geographic scope has stretched the capacity of healthcare services to implement a comprehensive multisectoral response. Parallel large-scale, high-risk outbreaks and other public health and humanitarian crises are further stretching resources and limiting the capacity to respond. In addition, the emigration of skilled medical personnel during a humanitarian crisis, interruption in routine health services such as vaccination leading to (re)-emergence of vaccine-preventable diseases, destruction or inaccessibility of healthcare infrastructure, and violence against health workers have hindered outbreak response activities.

  • Availability of oral cholera vaccine

The global stockpile of Oral Cholera Vaccine (OCV) is currently insufficient to meet all requests for two doses of preventive vaccination. As a result, on 20 October 2022, the International Coordinating Group (ICG) members (IFRC, MSF, UNICEF, and WHO) took the unprecedented decision to temporarily limit all reactive OCV campaigns to one single dose. The production of OCV is a continuous process with around 2.5 million doses produced monthly. As vaccine manufacturers are producing at their maximum current capacity, there is no short-term solution to increase production. While using a single dose instead of two doses will allow more people to be protected in the short term, this strategy has its limitations, and it is unclear how long immunity will last. To solve the problem in the long term there needs to be an increase in global vaccine production. Since the creation of the global stockpile in 2013, more than 50 million doses of OCV have been successfully used in various settings through mass campaigns.3

REGIONAL OVERVIEW

In the table below, some countries under monitoring are described. These include countries with recently reported outbreaks of cholera, countries where we have observed a continuous rise in cases with challenges to control the outbreak, countries with protracted outbreaks with challenges to control, countries with repeated outbreaks in 2022, countries with large vulnerable populations, and countries where insecurity and conflict hinder the response.

Public health response

WHO is working with partners at global, regional & country level to support Member States in the following cholera outbreak response activities:

Coordination

  • Providing a forum for technical expertise exchange through the Global Task Force on Cholera Control (GTFCC) coordination, and cooperation on cholera-related activities to strengthen the country’s capacity to prevent and control cholera.
  • Providing technical support to all ongoing outbreaks (laboratory, case management, OCV, WASH).
  • Collaborating with key partners (UNICEF, MSF) to coordinate supply and optimal access to supplies.
  • Leveraging resources to support global monitoring of the cholera pandemic, provide technical support to countries, enhance data collection and reporting, strengthen advocacy, and provide medical and non-medical items to countries in need, especially for case management and diagnosis.
  • Supporting the deployment of experts through GAVI, GOARN, and standby partners.

Surveillance

  • Strengthening surveillance including strengthening diagnostic algorithms, use of rapid diagnostic tests, collecting and transporting of samples, and strengthening laboratory capacity to culture V. cholerae.

Vaccine

  • Providing guidance to identify target populations for vaccination and requesting vaccine through the ICG mechanism, in the context of acutely limited supply.
  • Supporting advocacy to increase OCV production and engage new vaccine manufacturers.
  • Working with countries to identify the areas/hotspots where vaccination is most needed.6

Case management

  • Strengthening case management and improving access to treatment for patients by setting-up dedicated healthcare facilities (Cholera Treatment Centres (CTCs) and Cholera Treatment Units (CTUs)) and training health workers and provision of technical guidance

Infection Prevention and Control (IPC)

  • Conducting advocacy and resource mobilization activities to support cholera prevention and control at national, regional, and global levels.

Risk communication and community engagement (RCCE)

  • Working closely with Member States and partners to strengthen risk communication and community engagement plans and strategies, adapted to local beliefs and contexts, to encourage behavioural change and adoption of appropriate protective measures such as vaccination, and ensuring safe food, water, and hygiene practices.
  • Providing support to increasing risk perception and knowledge among communities about the disease, its symptoms, associated risks, precautions to take, and when to seek treatment when symptoms appear.

Water, Sanitation, and Hygiene (WASH)

  • Working closely with Member States and partners to strengthen water, hygiene, and sanitation systems through multi-sectoral mechanisms, including IPC and guidance on water quality monitoring.
  • Supporting countries for the implementation of effective cholera control strategies and monitoring of progress.

Operations, Support, and Logistics (OSL)

  • Working closely with suppliers to secure Cholera Kits, sourcing other WASH supplies, and establishing a pipeline for bulk items.

WHO risk assessment

On 26 October 2022, WHO assessed the risk of cholera at the global level as very high, remaining a global threat to public health and an indicator of inequity and lack of social development. There has been an increase in global reported cholera outbreaks with 29 countries, mainly in the WHO African and Eastern Mediterranean Regions, reporting outbreaks to WHO in 2022 with many of those reporting higher case numbers and case fatality ratios (CFR) than in previous years.

Several countries are in the midst of complex humanitarian crises with fragile health systems, inadequate access to clean water and sanitation, and insufficient capacity to respond to these outbreaks. Climate change and lack of development also contribute to outbreaks, and cross-border population movements. The latter, along with increased global travel following the COVID-19 pandemic, further increase the risk of international spread.

The number of outbreaks occurring simultaneously across all WHO Regions is straining the overall epidemic response capacity. Protracted outbreaks of cholera are draining public health response personnel and depleting resources.

Due to the global shortage of OCV, the ICG recently made the unprecedented decision to temporarily suspend the second dose strategy for the outbreak response. There are also significant delays and shortages of medical supplies that can lead to preventable and avoidable deaths.

WHO advice

WHO recommends improving access to proper and timely case management of cholera cases, improving access to safe drinking water and sanitation infrastructure, as well as improving infection prevention and control in healthcare facilities. These measures along with the promotion of preventive hygiene practices and food safety in affected communities are the most effective means of controlling cholera. Effective risk communication and community engagement strategies are needed to encourage behavioral change and adoption of appropriate preventive measures.

The OCV should be used in conjunction with improvements in water and sanitation to control cholera outbreaks and for prevention in targeted areas known to be at high risk for cholera.

WHO recommends Member States to strengthen and maintain surveillance for cholera, especially at the community level, for the early detection of suspected cases and to provide adequate treatment and prevent its spread. Early and adequate treatment limits the CFR of patients to less than 1%.

WHO does not recommend any travel or trade restrictions on Member States based on the currently available information. However, as the outbreak also affects border areas where there is a significant cross-border movement, WHO encourages Member States to ensure cooperation and regular information sharing across all levels of the organization so that any spread across the border is quickly assessed and contained.

LINK:  https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426

Further information

References

  1. D’Mello-Guyett, L., Gallandat, K., Van den Bergh, R., Taylor, D., Bulit, G., Legros, D., Maes, P., Checchi, F., Cumming, O., 2020. Prevention and control of cholera with household and community water, sanitation and hygiene (WASH) interventions: A scoping review of current international guidelines. PloS One 15, e0226549. https://doi.org/10.1371/journal.pone.0226549 
  2. Full article: Drought-related cholera outbreaks in Africa and the implications for climate change: a narrative review [WWW Document], n.d. URL https://www.tandfonline.com/doi/full/10.1080/20477724.2021.1981716 (accessed 12.12.22).
  3. Ali, M., Nelson, A.R., Lopez, A.L., Sack, D.A., 2015. Updated Global Burden of Cholera in Endemic Countries. PLoS Negl. Trop. Dis. 9, e0003832. https://doi.org/10.1371/journal.pntd.0003832 
  4. Cholera Haiti – Risk assessment – PAHO/WHO | Pan American Health Organization [WWW Document], n.d. URL https://www.paho.org/en/documents/cholera-haiti-risk-assessment (accessed 12.15.22).
  5. Cholera- Haiti [WWW Document], n.d. URL https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON427 (accessed 12.15.22).
  6. About the International Coordinating Group (ICG) on Vaccine Provision [WWW Document], n.d. URL https://www.who.int/groups/icg/about (accessed 12.12.22).

i A cholera-endemic area is one where confirmed cholera cases were detected during the last three years with evidence of local transmission (i.e., the cases are not imported from elsewhere). A cholera outbreak/epidemic can occur in both endemic countries and in countries where cholera does not regularly occur.

ii Lebanon and Syria were not identified as endemic. Source: Global Task Force on Cholera Control (GTFCC) Ending Cholera: a global roadmap to 2030 strategy.

iii This is provisional estimates for 2022

iv AWD: Acute watery diarrhoea is an illness characterized by three or more loose or watery (non-bloody) stools within a 24-hour period (GTFCC).

v WHO receives data from sentinel sites for Bangladesh. This data only specifies acute water diarrhoea (AWD) cases. True estimates are used for data from India.

Citable reference: World Health Organization (16 December 2022). Disease Outbreak News; Cholera – Global situation. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON426

Source:WHO

WHO Asks China to Share Requested Data to Probe Origins of Covid-19

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Three years after its emergence in China’s Wuhan, exactly how SARS-CoV-2 first emerged as a respiratory pathogen capable of sustained human-to-human transmission remains the subject of active debate.

This handout picture made available by the World Health Organization (WHO) shows WHO Director-General Tedros Adhanom Ghebreyesus delivering remarks following the speech of US President’s chief medical adviser during a World Health Organization (WHO) executive board meeting on January 21, 2021 in Geneva. – In a dramatic about-turn, the new US administration on January 21, 2021 thanked the World Health Organization for leading the global pandemic response and vowed to remain a member. “The United States also intends to fulfil its financial obligations to the organisation,” top US scientist Anthony Fauci, who has been named President Joe Biden’s chief medical adviser, told a meeting of the WHO’s executive board. (Photo by Christopher Black / World Health Organization / AFP) / RESTRICTED TO EDITORIAL USE – MANDATORY CREDIT “AFP PHOTO/ CHRIS BLACK/ WORLD HEALTH ORGANIZATION” – NO MARKETING – NO ADVERTISING CAMPAIGNS – DISTRIBUTED AS A SERVICE TO CLIENTS

Geneva: At a time when fear looms over China for a bigger COVID-19 outbreak during the January Lunar New Year travel rush, the World Health Organization (WHO) head Tedros Adhanom Ghebreyesus on Wednesday called on the Asian nation to share the requested data concerning Covid-19 in a bid to understand the origins of the deadly coronavirus.

Addressing a media briefing, the WHO chief said, “We continue to call on China to share the data and conduct the studies that we have requested, to better understand the origins of this virus. As I have said many times, all hypotheses remain on the table.”

Three years after its emergence in China’s Wuhan, exactly how SARS-CoV-2 first emerged as a respiratory pathogen capable of sustained human-to-human transmission remains the subject of active debate.

Experts have put forward two dominant theories on the origins of the virus. The first theory is that SARS-CoV-2 is the result of a natural zoonotic spillover. The second theory is that the virus infected humans as a consequence of a research-related incident.

According to Reuters, a WHO body meets every few months to decide whether the new coronavirus has killed over 6.6 million people, still presents a “public health emergency of international concern” (PHEIC).

The WHO chief said that he is “hopeful” that the COVID-19 pandemic will no longer be considered a global health emergency next year. “We’re hopeful that at some point next year, we will be able to say that COVID-19 is no longer a global health emergency,” the WHO chief told a media briefing, as quoted in a statement on the organization’s website.

He recalled that one year ago, the Omicron variant “had just been identified and was starting to take off.”
“At that time, COVID-19 was killing 50,000 people each week. Last week, less than 10,000 people lost their lives globally. That’s still 10,000 too many – and there is still a lot that all countries can do to save lives – but we have come a long way,” he added.

The WHO head said the criteria for declaring an end to the emergency will be discussed during the next meeting of the Emergency Committee in January. He added that the virus “will not go away,” but all countries “will need to learn to manage it alongside other respiratory illnesses including influenza and RSV, both of which are now circulating intensely in many countries.”

Increased incidence of scarlet fever and invasive Group A Streptococcus infection – multi-country

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Situation at a glance

As of 8 December 2022, at least five Member States in the European Region, reported to WHO an increase in cases of invasive group A streptococcus (iGAS) disease and in some cases also scarlet fever. An increase in iGAS-related deaths has also been reported in some of these countries. Children under 10 years of age represent the most affected age group.

Group A Streptococcal (GAS) infection commonly causes mild illnesses such as tonsillitis, pharyngitis, impetigo, cellulitis and scarlet fever. However, in rare instances, GAS infection can lead to invasive iGAS, which can cause life-threatening conditions.

The observed increase may reflect an early start to the GAS infection season coinciding with an increase in the circulation of respiratory viruses and possible viral coinfection which may increase the risk of invasive GAS disease. This is in the context of increased population mixing following a period of reduced circulation of GAS during the COVID-19 pandemic.

In light of the moderate increase in cases of iGAS, GAS endemicity, no new emm gene sequence type identified and no reports of increased antibiotic resistance, WHO assesses that the risk for the general population posed by iGAS infections is low at present.

Description of the situation

During 2022, France, Ireland, the Netherlands, Sweden, and the United Kingdom of Great Britain and Northern Ireland, have been observing an increase in cases of invasive group A streptococcus disease and scarlet fever, mostly affecting children under 10 years of age. The increase has been particularly marked during the second half of the year.

In France, since mid-November 2022, clinicians have reported to Santé Publique France (SpF) and the Regional Health Agencies (ARS), an unusual increase in the number of iGAS cases and the detection of iGAS clusters. Some pediatric cases have been fatal. On 8 December, SpF published a status update reporting an increase in the number of iGAS infections in France since the beginning of 2022 in different regions (Occitanie, Auvergne-Rhône-Alpes, Nouvelle-Aquitaine), mainly in children under 10 years of age. SpF also detected an increase in cases of scarlet fever reported in outpatient clinics in the country since September 2022.

On 6 December, the Irish Health Protection Surveillance Centre (HPSC) reported an increase in iGAS cases in Ireland since the beginning of October. In 2022, as of 8 December, 57 iGAS cases have been notified to HPSC, of which 15 were in children less than 10 years of age. Twenty-three of the 57 iGAS cases have been reported since October 2022, compared to the 11 cases reported for the same period of 2019 (pre-COVID-19 pandemic).

The Public Health Agency of the Netherlands (RIVM) observed an increase in iGAS infections among children from March 2022 onward. Data between March and July 2022 indicates increased numbers of iGAS cases caused by different known emm gene sequence types (the gene encoding the M virulence protein responsible for many Streptococcus pyogenes serotypes). This increase has thus far not subsided. Coinfections with varicella zoster and respiratory viruses were noted.

In Sweden, since October 2022, an increase in iGAS in children under 10 years of age has been noted as compared to COVID-19 pre-pandemic levels for the equivalent period. Out of the 93 cases reported from October to 7 December, 16 (17.2%) occurred among children under 10 years of age. Between October and December 2018, seven iGAS cases were reported in this age group and 10 cases in 2019. According to the Public Health Agency of Sweden, during the season 1 July 2021 through 30 June 2022, 220 cases of iGAS were reported, compared to 173 cases reported in the previous season 2020/21. The highest numbers of iGAS cases, since iGAS became notifiable in Sweden in 2004, were reported before the pandemic in 2018/19 with 794 cases (incidence 7.8 per 100 000) and in 2017/18 with 800 cases (incidence 7.9 per 100 000).

According to the UK Health Security Agency, following a higher-than-expected scarlet fever activity in the summer in England, with a decrease during August 2022, notifications from mid-September to early December have increased again, remaining above what is normally seen at this time of year. A total of 4622 notifications of scarlet fever were reported from weeks 37 to 46 of the current season (2022/23), with 851 notifications received in week 46. This compares with an average of 1294 (range 258 to 2008) for this same period (weeks 37 to 46) in the previous five years. As expected, several scarlet fever outbreaks in nurseries and schools are being reported, of which a number involve the co-circulation of respiratory viruses. Likewise, in the summer of 2022, the levels of iGAS notifications were higher than expected, and iGAS notifications are currently higher than have been recorded over the last five seasons in all age groups (average 248, range 142 to 357 notifications). As of 8 December, 509 notifications of iGAS disease were reported through laboratory surveillance in England, with a weekly high of 73 notifications in week 46 (week commencing on 14 November). So far this season and as of 8 December 2022, the United Kingdom reported 13 deaths within seven days of an iGAS diagnosis in children under 15 years in England. This compares with four deaths in the same period in the 2017 to 2018 (pre-COVID-19 pandemic) season. Antimicrobial susceptibility results from routine laboratory surveillance in the United Kingdom indicated no increased antibiotic resistance. Additionally, laboratory surveillance has not revealed newly emerging emm gene sequence types.

Epidemiology of Group A Streptococcus

Streptococcus pyogenes, also known as Group A Streptococcus, is a group of Gram-positive bacteria which can be carried in human throats or skin; it is responsible for more than 500 000 deaths annually worldwide.

Transmission occurs by close contact with an infected person and can be passed on through coughs, sneezes, or contact with a wound.

GAS infection commonly causes mild illnesses such as tonsillitis, pharyngitis, impetigo, cellulitis and scarlet fever. GAS infections are easily treated with antibiotics, and a person with a mild illness stops being contagious after 24 hours of treatment.

GAS is considered a common cause of bacterial pharyngitis in school-aged children and may also affect younger children. The incidence of GAS pharyngitis usually peaks during winter months and early spring. Outbreaks in kindergartens and schools are common. GAS pharyngitis is diagnosed by rapid antigen tests (Rapid Strep) or bacterial culture and is treated with antibiotics and supportive care. Good hand hygiene and general personal hygiene can help control transmission.

However, in rare instances, GAS infection can lead to invasive GAS, which can cause life-threatening conditions, such as necrotizing fasciitis, streptococcal toxic shock syndrome and other severe infections, as well as post-immune mediated diseases, such as poststreptococcal glomerulonephritis, acute rheumatic fever and rheumatic heart disease.

Public health response

Enhanced surveillance activities have been implemented in the countries reporting an increase in iGAS cases, together with public health messages addressing the general population and clinicians, in order to enhance early recognition, reporting and prompt treatment initiation of GAS cases. An alert has been issued to other countries to be vigilant for a similar rise in cases and to report any unexpected increased national or regional incidence of iGAS infections to WHO.

WHO continues to support countries in assessing and responding to the epidemiological situation across the region and to provide recommendations to the public.

WHO risk assessment

WHO currently assesses the risk for the general population posed by the reported increase in iGAS infections in some European countries as low, considering the moderate rise in iGAS cases, GAS endemicity, no newly emerging emm gene sequence types identified, and no observed increases in antibiotic resistance.

The risk will be continuously assessed based on available and shared information.

WHO advice

The reports of these events do not change the current WHO recommendations on public health measures and surveillance of iGAS.

General recommendations

  • WHO recommends continued close analysis of the epidemiological situation in countries throughout the European region, which will be critical to assess ongoing risk and to adjust risk management measures in a timely manner.
  • WHO recommends that all countries be vigilant for a similar rise in cases, particularly in light of the ongoing increase in respiratory virus circulation that is now occurring across Europe.
  • Given the potential for severe cases, it remains important that GAS-related infections, including scarlet fever, streptococcal toxic shock syndrome, are identified and treated promptly with antibiotics to reduce the risk of potential complications such as iGAS and reduce onward transmission.
  • Countries should report any unexpected increased national or regional incidence of iGAS infections to WHO through IHR or equivalent mechanisms either as notifications or consultations, as applicable and driven by the decision-making instrument in Annex 2 of the IHR (2005).

Clinical recommendations

  • WHO encourages countries to undertake public health communication activities and messaging to healthcare providers to ensure proper clinical assessment and diagnostic testing of patients with symptoms consistent with GAS infection, and prompt treatment of patients with GAS. In addition, healthcare providers should be reminded that for iGAS infection, early recognition and prompt initiation of specific and supportive therapy for patients can be life-saving.
  • Healthcare providers should maintain a high degree of clinical suspicion for GAS infection when assessing patients, particularly those with preceding viral infection (including chickenpox) and those who are close contacts of scarlet fever or iGAS patients. In case of hospital admission, droplet precautions should be implemented. Healthcare workers should always follow standard precautions and perform a risk assessment to evaluate the need for additional precautions.
  • Healthcare providers should also be reminded of the increased risk of invasive disease among household contacts of scarlet fever and iGAS cases. Close contacts of these cases should be managed according to national guidance. In addition, adequate hand and respiratory hygiene and adequate indoor ventilation should continue to be emphasized as important protective measures during this winter season.

Laboratory and Surveillance recommendations

  • Clusters of cases of iGAS should be reported to local, regional or national health authorities to prompt further investigation.
  • In addition, laboratories should be encouraged to submit invasive disease isolates and also non-invasive isolates from suspected clusters or outbreaks to national reference laboratories for further characterization and antibiotic susceptibility testing.

Travel

WHO does not recommend any restrictions on travel and/or trade for any affected countries based on available information about this event.

Further information

Citable reference: World Health Organization (15 December 2022). Disease Outbreak News; Increased incidence of scarlet fever and invasive Group A Streptococcus infection – multi-country. Available at: https://www.who.int/emergencies/disease-outbreak-news/item/2022-DON429

Source: WHO

Recommendations of IDF, WHO, and EASD regarding the use of sulfonylureas in diabetes.

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Sulfonylureas are commonly prescribed oral anti-hyperglycaemic agents for the management of diabetes.

According to the International Diabetes Federation (IDF) guidelines:

  • Sulfonylureas (except Glibenclamide/Glyburide) are recommended for patients who are not tolerant to Metformin.
  • Sulfonylureas (except Glibenclamide/Glyburide), Sodium–glucose co-transporter-2 inhibitors (SGLT2is), or Dipeptidyl peptidase 4 (DPP-4) inhibitors can be prescribed in combination with Metformin.
  • It is advised to educate patients regarding the prevention, recognition, and management of hypoglycaemia while initiating sulfonylureas.

As per the recommendations of the World Health Organisation (WHO):

  • When Metformin monotherapy fails to attain glycaemic control, or for patients with Metformin intolerance, sulfonylureas are recommended.
  • The usage of modern sulfonylureas, such as Gliclazide, is advised to ensure better safety.

According to the European Association for the Study of Diabetes (EASD) recommendations:

  • Compared to lifestyle interventions alone, the addition of sulfonylureas effectively mitigates the cardiovascular risk. Therefore, it is recommended in patients with type 2 diabetes mellitus (T2DM).
  • Relatively lesser adverse events, such as hypoglycaemia and cardiovascular toxicity, are associated with the use of newer sulfonylureas, such as Glimepiride.

Globally, only one in five meet WHO’s physical activity guidelines

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Fewer than 20% of adults and adolescents around the world meet WHO’s physical activity guidelines, according to researchers.

The guidelines from 2020 recommend that children and adolescents complete 60 minutes of moderate-to-vigorous aerobic physical activity every day, and muscle-strengthening activities (MSA) 3 days per week. For adults and older adults, the guidelines call for 150 to 300 minutes of moderate physical activity or 75 to 150 minutes of vigorous intensity per week and MSA 2 days per week.

Exercise cycle 2019
Globally, only one in five adults meet physical activity guidelines, according to researchers. Source: Adobe Stock

In a systematic review and meta-analysis, Antonio Garcia-Hermoso, PhD, head of the children and youth physical activity unit at Navarrabiomed, which is affiliated with the Public University of Navarra, and colleagues sought to estimate the proportion of the global population that was meeting WHO’s recommendations.

“Our study provides an accurate estimate of the prevalence of physical activity at the population level, which is an important modifiable chronic disease risk factor,” Garcia-Hermoso and colleagues wrote in the British Journal of Sports Medicine. “Adults engaging in aerobic and MSA at recommended levels showed important reductions in the risk of all-cause and cause-specific mortality in addition to a lower risk for multimorbidity (eg, cardiovascular risk and type 2 diabetes).”

The researchers searched five databases and identified 21 studies that included approximately 3.4 million people from 31 countries.

Overall, they found that the prevalence of adherence to the guidelines was 17.15% (95%, CI 15.44%-18.94%) among adults. The prevalence of adherence was slightly higher among teens, at 19.45% (95% CI, 16.34%-22.75%)

They additionally noted that adherence was lower among adults with low or medium education levels, those who were older, women, people who had underweight or obesity and those who self-rated their health as poor or moderate (P < 0.001), “although the prevalence remained very low in all cases.”

The researchers also analyzed prevalence by geographic location. Compared with those from Northern European countries like Iceland, Sweden, Denmark and the Netherlands, the United States and Southern and Central European countries like Malta, Cyprus, Croatia, Romania and Poland had lower prevalence of meeting guidelines.

Garcia-Hermoso and colleagues wrote that they were “unable to identify the key causes of the geographical differences” but offered a few possible explanations, like the different tools used to measure physical activity or “adoption of different exercise promotion policies between countries.”

“The Netherlands, one of the countries with higher prevalence, adopted the physical activity guidelines in 2017, and aimed for 75% of the Dutch population to adhere to them,” the researchers wrote. “The government launched several national policies or action plans for the promotion of physical activity for health through the collaboration between central government, the sports sector, municipalities, businesses, care providers and civil society organizations.”

Additionally, “wealth inequalities across countries, which likely impact an individual’s access to fitness facilities or the availability of free time to engage in aerobic and MSA, could also explain some of these differences.”

Garcia-Hermoso and colleagues concluded that “only one out of five adolescents and adults met the recommended combined aerobic and MSA guidelines,” and “large-scale public health interventions promoting both types of exercise are needed to reduce the associated burden of noncommunicable diseases.”

“These low prevalence levels are concerning from a public health perspective and emphasize the need to provide large-scale physical activity interventions that must be supported by long-term political commitment and paired with coordinated and sustained dissemination and communication strategies across sectors,” they wrote.

WHO to rename monkeypox as ‘MPOX’ over stigma, pressure from US: Report

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WHO makes new recommendations for Ebola treatments, calls for improved access

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The World Health Organization (WHO) has published its first guideline for Ebola virus disease therapeutics, with new strong recommendations for the use of two monoclonal antibodies. WHO calls on the global community to increase access to these lifesaving medicines.

Ebola is a severe and too often fatal illness caused by the Ebola virus. Previous Ebola outbreaks and responses have shown that early diagnosis and treatment with optimized supportive care – with fluid and electrolyte repletion and treatment of symptoms – significantly improve survival. Now, following a systematic review and meta-analysis of randomized clinical trials of therapeutics for the disease, WHO has made strong recommendations for two monoclonal antibody treatments: mAb114 (Ansuvimab; Ebanga) and REGN-EB3 (Inmazeb).

Developed according to WHO standards and methods for guidelines, and published simultaneously in English and French, the guidelines will support health care providers caring for patients with Ebola, and policymakers involved in outbreak preparedness and response. The clinical trials were conducted during Ebola outbreaks, with the largest trial conducted in the Democratic Republic of the Congo, demonstrating that the highest level of scientific rigour can be applied even during Ebola outbreaks in difficult contexts.

The new guidance complements clinical care guidance that outlines the optimized supportive care Ebola patients should receive, from the relevant tests to administer, to managing pain, nutrition and co-infections, and other approaches that put the patient on the best path to recovery.

“This therapeutic guide is a critical tool to fight Ebola,” said Dr Richard Kojan, co-chair of the Guideline Development Group of experts selected by WHO and President of ALIMA, The Alliance for International Medical Action. “It will help reassure the communities, health care workers and patients, that this life-threatening disease can be treated thanks to effective drugs. From now on, people infected with the Ebola virus will have a greater chance of recovering if they seek care as early as possible. As with other infectious diseases, timeliness is key, and people should not hesitate to consult health workers as quickly as possible to ensure they receive the best care possible.”

The two recommended therapeutics have demonstrated clear benefits and therefore can be used for all patients confirmed positive for Ebola virus disease, including older people, pregnant and breastfeeding women, children and newborns born to mothers with confirmed Ebola within the first 7 days after birth. Patients should receive recommended neutralizing monoclonal antibodies as soon as possible after laboratory confirmation of diagnosis.

There is also a recommendation on therapeutics that should not be used to treat patients: these include ZMapp and remdesivir.

All these recommendations only apply to Ebola virus disease caused by Ebola virus (EBOV; Zaire ebolavirus).

“Advances in supportive care and therapeutics over the past decade have revolutionized the treatment of Ebola. Ebola virus disease used to be perceived as a near certain killer. However, that is no longer the case,” said Dr Robert Fowler, University of Toronto, Canada, and co-chair of the guideline development group. “Provision of best supportive medical care to patients, combined with monoclonal antibody treatment – MAb114 or REGN-EB3 – now leads to recovery for the vast majority of people.”

Access to both these treatments remains challenging, especially in resource-poor areas. These drugs should be where patients need them the most: where there is an active Ebola outbreak, or where the threat of outbreaks is high or very likely. WHO is ready to support countries, manufacturers and partners to improve access to these treatments, and to support national and global efforts to increase affordability of biotherapeutics and their corresponding similar biotherapeutic products, WHO published the first invitation to manufacturers of therapeutics against Ebola virus disease to share their drugs for evaluation by the WHO Prequalification Unit, a crucial step to improve drug access for communities and countries affected by Ebola.

“We have seen incredible advances in both the quality and safety of clinical care during Ebola outbreaks,” said Dr Janet Diaz, lead of the clinical management unit in WHO’s Health Emergencies programme. “Doing the basics well, including early diagnosis, providing optimized supportive care with the evaluation of new therapeutics under clinical trials, has transformed what is possible during Ebola outbreaks. This is what has led to development of a new standard of care for patients. However, timely access to these lifesaving interventions has to be a priority.”

Although WHO was able to make strong recommendations for the use of two therapeutics, there is a need for further research and evaluation of clinical interventions, as many uncertainties remain. Further improvements could be made in supportive care, and in our understanding and characterization of Ebola virus disease and its longer-term consequences, and to ensure continued inclusion of vulnerable populations (pregnant women, newborns, children and older people) in future research.

A tragic milestone: One million people died of COVID-19 in 2022: WHO.

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