WHO Report Shows Gains Are Levelling
After unprecedented global success in malaria control, progress has stalled, according to the World malaria report 2017. There were an estimated 5 million more malaria cases in 2016 than in 2015. Malaria deaths stood at around 445 000, a similar number to the previous year.
“In recent years, we have made major gains in the fight against malaria,” said Dr Tedros Adhanom Ghebreyesus, Director-General of WHO. “We are now at a turning point. Without urgent action, we risk going backwards, and missing the global malaria targets for 2020 and beyond.”
The WHO Global Technical Strategy for Malaria calls for reductions of at least 40% in malaria case incidence and mortality rates by the year 2020. According to WHO’s latest malaria report, the world is not on track to reach these critical milestones.
A major problem is insufficient funding at both domestic and international levels, resulting in major gaps in coverage of insecticide-treated nets, medicines, and other life-saving tools.
An estimated US$ 2.7 billion was invested in malaria control and elimination efforts globally in 2016. That is well below the US $6.5 billion annual investment required by 2020 to meet the 2030 targets of the WHO global malaria strategy.
In 2016, governments of endemic countries provided US$ 800 million, representing 31% of total funding. The United States of America was the largest international funder of malaria control programmes in 2016, providing US$1 billion (38% of all malaria funding), followed by other major donors, including the United Kingdom of Great Britain and Northern Ireland, France, Germany and Japan.
The global figures
The report shows that, in 2016, there were an estimated 216 million cases of malaria in 91 countries, up from 211 million cases in 2015. The estimated global tally of malaria deaths reached 445 000 in 2016 compared to 446 000 the previous year.
While the rate of new cases of malaria had fallen overall, since 2014 the trend has levelled off and even reversed in some regions. Malaria mortality rates followed a similar pattern.
The African Region continues to bear an estimated 90% of all malaria cases and deaths worldwide. Fifteen countries – all but one in sub-Saharan Africa – carry 80% of the global malaria burden.
“Clearly, if we are to get the global malaria response back on track, supporting the most heavily affected countries in the African Region must be the primary focus,” said Dr Tedros.
In most malaria-affected countries, sleeping under an insecticide-treated bednet (ITN) is the most common and most effective way to prevent infection. In 2016, an estimated 54% of people at risk of malaria in sub-Saharan Africa slept under an ITN compared to 30% in 2010. However, the rate of increase in ITN coverage has slowed since 2014, the report finds.
Spraying the inside walls of homes with insecticides is another effective way to prevent malaria. The report reveals a steep drop in the number of people protected from malaria by this method – from an estimated 180 million in 2010 to 100 million in 2016 – with the largest reductions seen in the African Region.
The African Region has seen a major increase in diagnostic testing in the public health sector: from 36% of suspected cases in 2010 to 87% in 2016. A majority of patients (70%) who sought treatment for malaria in the public health sector received artemisinin-based combination therapies (ACTs) – the most effective antimalarial medicines.
However, in many areas, access to the public health system remains low. National-level surveys in the African Region show that only about one third (34%) of children with a fever are taken to a medical provider in the public health sector.
Tackling malaria in complex settings
The report also outlines additional challenges in the global malaria response, including the risks posed by conflict and crises in malaria endemic zones. WHO is currently supporting malaria responses in Nigeria, South Sudan, Venezuela (Bolivarian Republic of) and Yemen, where ongoing humanitarian crises pose serious health risks. In Nigeria’s Borno State, for example, WHO supported the launch of a mass antimalarial drug administration campaign this year that reached an estimated 1.2 million children aged under 5 years in targeted areas. Early results point to a reduction in malaria cases and deaths in this state.
A wake-up call
“We are at a crossroads in the response to malaria,” said Dr Pedro Alonso, Director of the Global Malaria Programme, commenting on the findings of this year’s report. “We hope this report serves as a wake-up call for the global health community. Meeting the global malaria targets will only be possible through greater investment and expanded coverage of core tools that prevent, diagnose and treat malaria. Robust financing for the research and development of new tools is equally critical.”
Investments In Malaria Programmes And Research
Malaria control and elimination investments
In 2016, an estimated US$ 2.7 billion was invested in malaria control and elimination efforts globally by governments of malaria endemic countries and international partners.
The majority (74%) of investments in 2016 were spent in the WHO African Region, followed by the WHO regions of South-East Asia (7%), the Eastern Mediterranean and the Americas (each 6%), and the Western Pacific (4%).
Governments of endemic countries contributed 31% of total funding (US$ 800 million) in 2016.
The United States of America (USA) was the largest international source of malaria financing in 2016, providing US$ 1 billion (38%), followed by the United Kingdom of Great Britain and Northern Ireland (United Kingdom) and other international donors, including France, Germany and Japan.
More than half (57%) of resources in 2016 were channelled through the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund).
Although funding for malaria has remained relatively stable since 2010, the level of investment in 2016 is far from what is required to reach the first milestone of the GTS, which is a reduction of at least 40% in malaria case incidence and mortality rates globally when compared to 2015 levels.
To reach this milestone, the GTS estimated that annual funding would need to increase to US$ 6.5 billion per year by 2020. The US$ 2.7 billion invested in malaria in 2016 represents less than half (41%) of that amount.
Stepping up investments in malaria research and development is key to achieving the GTS targets. In 2015, US$ 572 million was spent in this area, representing 83% of the estimated annual need for research and development.
Deliveries of malaria commodities
Insecticide-treated mosquito nets
Between 2014 and 2016, a total of 582 million insecticide-treated mosquito nets (ITNs) were reported by manufacturers as having been delivered globally.
Of this amount, 505 million ITNs were delivered in sub-Saharan Africa, compared with 301 million bednets in the preceding 3-year period (2011–2013).
Data from national malaria control programmes (NMCPs) in Africa indicate that, between 2014 and 2016, 75% of ITNs were distributed through mass distribution campaigns.
Rapid diagnostic tests
An estimated 312 million rapid diagnostic tests (RDTs) were delivered globally in 2016. Of these, 269 million were delivered in the WHO African Region.
The number of RDTs distributed by NMCPs increased between 2010 and 2015, but fell from 247 million in 2015 to 221 million in 2016. The decrease was entirely in sub-Saharan Africa, where distributions dropped from 219 million to 177 million RDTs over the 2015–2016 period.
Artemisinin-based combination therapy
An estimated 409 million treatment courses of artemisinin-based combination therapy (ACT) were procured by countries in 2016, an increase from 311 million in 2015. Over 69% of these procurements were reported to have been made for the public sector.
The number of ACT treatments distributed by NMCPs to the public sector increased from 192 million in 2013 to 198 million in 2016. Most of the NMCP distributions of ACTs (99%) in 2016 occurred in the WHO African Region.
Across sub-Saharan Africa, household ownership of at least one ITN increased from 50% in 2010 to 80% in 2016. However, the proportion of households with sufficient nets (i.e. one net for every two people) remains inadequate, at 43% in 2016.
More people at risk of malaria in Africa are sleeping under an ITN. In 2016, 54% of the population was protected by this intervention, an increase from 30% in 2010.
Fewer people at risk of malaria are being protected by indoor residual spraying (IRS), a prevention method that involves spraying the inside walls of dwellings with insecticides. Globally, IRS protection declined from a peak of 5.8% in 2010 to 2.9% in 2016, with decreases seen across all WHO regions. In the WHO African Region, coverage dropped from 80 million people at risk in 2010 to 45 million in 2016.
The declines in IRS coverage are occurring as countries change or rotate insecticides to more expensive chemicals.
To protect women in areas of moderate and high malaria transmission in Africa, WHO recommends “intermittent preventive treatment in pregnancy” (IPTp) with the antimalarial drug sulfadoxinepyrimethamine. Among 23 African countries that reported on IPTp coverage levels in 2016, an estimated 19% of eligible pregnant women received the recommended 3 or more doses of IPTp, compared with 18% in 2015 and 13% in 2014.
In 2016, 15 million children in 12 countries in Africa’s Sahel subregion were protected through seasonal malaria chemoprevention (SMC) programmes. However, about 13 million children who could have benefited from this intervention were not covered, mainly due to a lack of funding. Since 2012, SMC has been recommended by WHO for children aged 3-59 months living in areas of highly seasonal malaria transmission in this subregion.
Diagnostic Testing And Treatment
Prompt diagnosis and treatment is the most effective means of preventing a mild case of malaria from developing into severe disease and death. Among national-level surveys completed in 18 countries in sub-Saharan Africa between 2014 and 2016 (representing 61% of the population at risk), a median of 47% (interquartile range [IQR]: 38–56%) of children with a fever (febrile) were taken to a trained medical provider for care. This includes public sector hospitals and clinics, formal private sector facilities and community health workers.
More febrile children sought care in the public sector (median: 34%, IQR: 28–44%) than in the private sector (median: 22%, IQR: 14–34%). However, the surveys from Africa also indicate that a high proportion of febrile children did not receive medical attention (median: 39%, IQR: 29–44%). Possible reasons include poor access to health-care providers or lack of awareness among caregivers.
Among 17 national-level surveys completed in sub-Saharan Africa between 2014 and 2016, the proportion of children with a fever who received a finger or a heel stick – suggesting that a malaria diagnostic test may have been performed – was greater in the public sector (median: 52%, IQR: 34–59%) than in both the formal and informal private sector.
Testing of suspected cases in the public health system increased in most WHO regions since 2010. The WHO African Region recorded the biggest rise, with diagnostic testing in the public health sector increasing from 36% of suspected cases in 2010 to 87% in 2016.
Among 18 household surveys conducted in sub-Saharan Africa between 2014 and 2016, the proportion of children aged under 5 years with a fever who received any antimalarial drug was 41% (IQR: 21–49%).
A majority of patients (70%) who sought treatment for malaria in the public health sector received ACTs, the most effective antimalarial drugs. Children are more likely to be given ACTs if medical care is sought at public health facilities than in the private sector.
To bridge the treatment gap among children, WHO recommends the uptake of integrated community case management (iCCM). This approach promotes integrated management of common life-threatening conditions in children – malaria, pneumonia and diarrhoea – at health facility and community levels. In 2016, 26 malaria-affected countries had iCCM policies in place, of which 24 had started implementing those policies. An evaluation from Uganda found that districts with iCCM experienced a 21% increase in care-seeking for fever compared with districts without an iCCM policy in place.
Outside the WHO African Region, only a handful of countries in each of the other regions reported having such policies in place, though data on the level of implementation are unavailable for most countries.
Malaria surveillance systems
Effective surveillance of malaria cases and deaths is essential for identifying the areas or population groups that are most affected by malaria, and for targeting resources for maximum impact. A strong surveillance system requires high levels of access to care and case detection, and complete reporting by all health sectors, whether public or private.
In 2016, 37 out of 46 countries in the WHO African Region indicated that at least 80% of public health facilities had reported data on malaria through their national health information system. Rates vary within other WHO regions. For example, in the WHO Eastern Mediterranean Region, only 3 out of 8 countries had 80% or more public health facilities reporting in 2016.
Among 55 countries where the burden of malaria was estimated, 31 countries have a malaria case reporting rate by surveillance systems of less than 50%. This includes the high-burden countries of India and Nigeria.
Global And Regional Malaria Trends In Numbers
In 2016, an estimated 216 million cases of malaria occurred worldwide (95% confidence interval [CI]: 196–263 million), compared with 237 million cases in 2010 (95% CI: 218–278 million) and 211 million cases in 2015 (95% CI: 192–257 million).
Most malaria cases in 2016 were in the WHO African Region (90%), followed by the WHO South-East Asia Region (3%) and the WHO Eastern Mediterranean Region (2%).
Of the 91 countries reporting indigenous malaria cases in 2016, 15 countries – all in sub-Saharan Africa, except India – carried 80% of the global malaria burden.
The incidence rate of malaria is estimated to have decreased by 18% globally, from 76 to 63 cases per 1000 population at risk, between 2010 and 2016. The WHO South-East Asia Region recorded the largest decline (48%) followed by the WHO Region of the Americas (22%) and the WHO African Region (20%).
Despite these reductions, between 2014 and 2016, substantial increases in case incidence occurred in the WHO Region of the Americas, and marginally in the WHO South-East Asia, Western Pacific and African regions.
Plasmodium falciparum is the most prevalent malaria parasite in sub-Saharan Africa, accounting for 99% of estimated malaria cases in 2016. Outside of Africa, P. vivax is the predominant parasite in the WHO Region of the Americas, representing 64% of malaria cases, and is above 30% in the WHO South- East Asia and 40% in the Eastern Mediterranean regions.
New data from improved surveillance systems in several countries in the WHO African Region indicate that the number of malaria cases presented in this year’s report are conservative estimates. WHO will review its malaria burden estimation methods for sub-Saharan Africa in 2018.
In 2016, there were an estimated 445 000 deaths from malaria globally, compared to 446 000 estimated deaths in 2015.
The WHO African Region accounted for 91% of all malaria deaths in 2016, followed by the WHO South- East Asia Region (6%).
Fifteen countries accounted for 80% of global malaria deaths in 2016; all of these countries are in sub-Saharan Africa, except for India.
All regions recorded reductions in mortality in 2016 when compared with 2010, with the exception of the WHO Eastern Mediterranean Region, where mortality rates remained virtually unchanged in the period. The largest decline occurred in the WHO regions of South-East Asia (44%), Africa (37%) and the Americas (27%).
However, between 2015 and 2016, mortality rates stalled in the WHO regions of South-East Asia, the Western Pacific and Africa, and increased in the Eastern Mediterranean and the Americas.
Globally, more countries are moving towards elimination: in 2016, 44 countries reported fewer than 10 000 malaria cases, up from 37 countries in 2010.
Kyrgyzstan and Sri Lanka were certified by WHO as malaria free in 2016.
In 2016, WHO identified 21 countries with the potential to eliminate malaria by the year 2020. WHO is working with the governments in these countries – known as “E-2020 countries” – to support their elimination acceleration goals.
Although some of E-2020 countries remain on track to achieve their elimination goals, 11 have reported increases in indigenous malaria cases since 2015, and 5 countries reported an increase of more than 100 cases in 2016 compared with 2015
Challenges To Achieving A Malaria-Free World
Some of the challenges impeding countries’ abilities to stay on track and advance towards elimination include lack of sustainable and predictable international and domestic funding, risks posed by conflict in malaria endemic zones, anomalous climate patterns, the emergence of parasite resistance to antimalarial medicines and mosquito resistance to insecticides.
WHO is supporting malaria emergency responses in Nigeria, South Sudan, Venezuela (Bolivarian Republic of) and Yemen, where ongoing humanitarian crises pose serious health risks. In Nigeria’s Borno State, WHO supported the launch of a mass antimalarial drug administration campaign that reached an estimated 1.2 million children aged under 5 years in targeted areas. Early results point to a reduction in malaria cases and deaths in this state.
In 34 out of 41 high-burden countries, which rely mainly on external funding for malaria programmes, the average level of funding available per person at risk in the past 3 years (2014–2016) reduced when compared with 2011–2013. Exceptions were Democratic Republic of the Congo, Guinea, Mauritania, Mozambique, Niger, Pakistan and Senegal, which recorded increases.
Among the 41 high-burden countries, overall, funding per person at risk of malaria remains below US$ 2.
Histidine-rich protein 2 deletions
In some settings, increasing levels of histidine-rich protein 2 gene (HRP2) deletions threaten the ability to diagnose and appropriately treat people infected with falciparum malaria. An absence of the HRP2 gene enables parasites to evade detection by HRP2-based RDTs, resulting in a false-negative test result. Although the prevalence of HRP2 gene deletions in most high-transmission countries remains low, further monitoring is required.
ACTs have been integral to the recent success of global malaria control, and protecting their efficacy for the treatment of malaria is a global health priority.
Although multidrug resistance, including artemisinin (partial) resistance and partner drug resistance, has been reported in five countries of the Greater Mekong subregion (GMS), there has been a massive reduction in malaria cases and deaths in this subregion. Monitoring the efficacy of antimalarial drugs has led to timely treatment policy updates across the GMS.
In Africa, artemisinin (partial) resistance has not been reported to date and first-line ACTs remain efficacious in all malaria endemic settings.
Of the 76 malaria endemic countries that provided data for 2010 to 2016, resistance to at least one insecticide in one malaria vector from one collection site was detected in 61 countries. In 50 countries, resistance to 2 or more insecticide classes was reported.
In 2016, resistance to one or more insecticides was present in all WHO regions, although the extent of monitoring varied.
Resistance to pyrethroids – the only insecticide class currently used in ITNs – is widespread. The proportion of malaria endemic countries that monitored and subsequently reported pyrethroid resistance increased from 71% in 2010 to 81% in 2016. The prevalence of confirmed resistance to pyrethroids differed between regions, and was highest in the WHO African and Eastern Mediterranean regions, where it was detected in malaria vectors in over two thirds of all sites monitored.
ITNs continue to be an effective tool for malaria prevention, even in areas where mosquitoes have developed resistance to pyrethroids. This was evidenced in a large multicountry evaluation coordinated by WHO between 2011 and 2016, which did not find an association between malaria disease burden and pyrethroid resistance across study locations in 5 countries.
How Do Microneedles Deliver Drugs?
Dr Ryan Donnelly, from the School of Pharmacy at Queen's University Belfast, demonstrates his microneedle technology that could revolutionize the way drugs are delivered -- from small molecules to vaccines and biological compounds.
The microneedle patches, which can range from the size of a phone sim card to the size of a mobile phone, are applied to the skin like a normal medical plaster. What makes Donnelly's system special compared to similar emerging 'needleless injection' platforms is that his array of just over 300 microneedles -- each just over half a millimeter high -- are made of biocompatible hydrogels that are not toxic to the human body, but can also take up biological fluids and so lead to new ways to monitor metabolites, such as blood sugar in diabetes, in the sick and healthy.
Microneedle Sensor Can Painlessly Monitor Health Biomarkers
A new pain-free microneedle has the potential to help athletes, soldiers and others ward off dehydration and severe exhaustion before it is too late.
A team of researchers from Sandia National Laboratory and the University of New Mexico (UNM) have developed microneedles that are painless and minimally invasive, and can be left in a subject’s arm for hours or even an entire day without causing irritation, allowing constant monitoring of important biomarkers.
The researchers have developed a small, wearable monitor that could help endurance athletes meet their training goals, by tracking dehydration or severe exhaustion, and also help soldiers track their physiological conditions on strenuous missions, alerting them before they become too exhausted.
The sensors could also be used in emergency rooms and critical care facilities to determine which salts are out of balance in cases of severe dehydration or track the response of a septic patients to a course of antibiotics.
“There are a lot of great uses for these microneedle sensors,” said Dr. Justin Baca, Ph.D., an assistant professor of emergency medicine at UNM who leads the human testing of the sensor, said in a statement. “It has the ability to help a lot in the medical sphere and in national security but it could also be something that’s useful to somebody who’s just trying to improve their performance as a cyclist.”
The new development could enable the continual sampling of important biomarkers in the interstitial fluid including electrolytes, salts like potassium and sodium, glucose and lactose that could help monitor and diagnose several diseases and disorders.
Microneedles can capture the clear fluid between cells in the middle layer of skin—below the top most layer of dead skin cells and above the layer of skin where veins and nerves reside.
During the experiment, a volunteer had five microneedles, clasped in a 3D printed holder, inserted into her forearm for 30 minutes with very little pain.
The researchers tested three different lengths of needles in the subject and determined that the best microneedles are 1.5-millimeters long.
“Now we have a pretty good sense of what the average length we should use for most people but some people’s skin is a little thicker or a little thinner in that area and the flow rate may be decreased,” Baca said.
Source: BBSRC and RDMag
Please meet Jane. She has a high-risk pregnancy. Within 24 weeks, she's on bed rest at the hospital, being monitored for her preterm contractions.
She doesn't look the happiest. That's in part because it requires technicians and experts to apply these clunky belts on her to monitor her uterine contractions. Another reason Jane is not so happy is because she's worried. In particular, she's worried about what happens after her 10-day stay on bed rest at the hospital. What happens when she's home? If she were to give birth this early it would be devastating. As an African-American woman, she's twice as likely to have a premature birth or to have a stillbirth. So Jane basically has one of two options: stay at the hospital on bed rest, a prisoner to the technology until she gives birth, and then spend the rest of her life paying for the bill; or head home after her 10-day stay and hope for the best. Neither of these two options seems appealing.
As I began to think about stories like this and hear about stories like this, I began to ask myself and imagine: Is there an alternative? Is there a way we could have the benefits of high-fidelity monitoring that we get with our trusted partners in the hospital while someone is at home living their daily life?
With that in mind, I encouraged people in my research group to partner with some clever material scientists, and all of us came together and brainstormed. And after a long process, we came up with a vision, an idea, of a wearable system that perhaps you could wear like a piece of jewelry or you could apply to yourself like a Band-Aid. And after many trials and tribulations and years of endeavors, we were able to come up with this flexible electronic patch that was manufactured using the same processes that they use to build computer chips, except the electronics are transferred from a semiconductor wafer onto a flexible material that can interface with the human body.
These systems are about the thickness of a human hair. They can measure the types of information that we want, things such as: bodily movement, bodily temperature, electrical rhythms of the body and so forth. We can also engineer these systems, so they can integrate energy sources, and can have wireless transmission capabilities.
So as we began to build these types of systems, we began to test them on ourselves in our research group. But in addition, we began to reach out to some of our clinical partners in San Diego, and test these on different patients in different clinical conditions, including moms-to-be like Jane.
Here is a picture of a pregnant woman in labor at our university hospital being monitored for her uterine contractions with the conventional belt. In addition, our flexible electronic patches are there. This picture demonstrates waveforms pertaining to the fetal heart rate, where the red corresponds to what was acquired with the conventional belts, and the blue corresponds to our estimates using our flexible electronic systems and our algorithms.
At this moment, we gave ourselves a big mental high five. Some of the things we had imagined were beginning to come to fruition, and we were actually seeing this in a clinical context.
But there was still a problem. The problem was, the way we manufactured these systems was very inefficient, had low yield and was very error-prone. In addition, as we talked to some of the nurses in the hospital, they encouraged us to make sure that our electronics worked with typical medical adhesives that are used in a hospital. We had an epiphany and said, "Wait a minute. Rather than just making them work with adhesives, let's integrate them into adhesives, and that could solve our manufacturing problem."
This picture that you see here is our ability to embed these censors inside of a piece of Scotch tape by simply peeling it off of a wafer. Ongoing work in our research group allows us to, in addition, embed integrated circuits into the flexible adhesives to do things like amplifying signals and digitizing them, processing them and encoding for wireless transmission. All of this integrated into the same medical adhesives that are used in the hospital.
So when we reached this point, we had some other challenges, from both an engineering as well as a usability perspective, to make sure that we could make it used practically.
In many digital health discussions, people believe in and embrace the idea that we can simply digitize the data, wirelessly transmit it, send it to the cloud, and in the cloud, we can extract meaningful information for interpretation. And indeed, you can do all of that, if you're not worried about some of the energy challenges. Think about Jane for a moment. She doesn't live in Palo Alto, nor does she live in Beverly Hills. What that means is, we have to be mindful about her data plan and how much it would cost for her to be sending out a continuous stream of data.
There's another challenge that not everyone in the medical profession is comfortable talking about. And that is, that Jane does not have the most trust in the medical establishment. She, people like her, her ancestors, have not had the best experiences at the hands of doctors and the hospital or insurance companies. That means that we have to be mindful of questions of privacy. Jane might not feel that happy about all that data being processed into the cloud. And Jane cannot be fooled; she reads the news. She knows that if the federal government can be hacked, if the Fortune 500 can be hacked, so can her doctor.
And so with that in mind, we had an epiphany. We cannot outsmart all the hackers in the world, but perhaps we can present them a smaller target. What if we could actually, rather than have those algorithms that do data interpretation run in the cloud, what if we have those algorithms run on those small integrated circuits embedded into those adhesives?
And so when we integrate these things together, what this means is that now we can think about the future where someone like Jane can still go about living her normal daily life, she can be monitored, it can be done in a way where she doesn't have to get another job to pay her data plan, and we can also address some of her concerns about privacy.
So at this point, we're feeling very good about ourselves. We've accomplished this, we've begun to address some of these questions about privacy and we feel like, pretty much the chapter is closed now. Everyone lived happily ever after, right? Well, not so fast.
One of the things we have to remember, as I mentioned earlier, is that Jane does not have the most trust in the medical establishment. We have to remember that there are increasing and widening health disparities, and there's inequity in terms of proper care management. And so what that means is that this simple picture of Jane and her data -- even with her being comfortable being wirelessly transmitted to the cloud, letting a doctor intervene if necessary -- is not the whole story.
So what we're beginning to do is to think about ways to have trusted parties serve as intermediaries between people like Jane and her health care providers. For example, we've begun to partner with churches and to think about nurses that are church members, that come from that trusted community, as patient advocates and health coaches to people like Jane.
Another thing we have going for us is that insurance companies, increasingly, are attracted to some of these ideas. They're increasingly realizing that perhaps it's better to pay one dollar now for a wearable device and a health coach, rather than paying 10 dollars later, when that baby is born prematurely and ends up in the neonatal intensive care unit -- one of the most expensive parts of a hospital.
This has been a long learning process for us. This iterative process of breaking through and attacking one problem and not feeling totally comfortable, and identifying the next problem, has helped us go along this path of actually trying to not only innovate with this technology but make sure it can be used for people who perhaps need it the most.
Another learning lesson we've taken from this process that is very humbling, is that as technology progresses and advances at an accelerating rate, we have to remember that human beings are using this technology, and we have to be mindful that these human beings -- they have a face, they have a name and a life. And in the case of Jane, hopefully, two.
Illness is universal — but access to care is not. Physician Raj Panjabi has a bold vision to bring health care to everyone, everywhere. With the 2017 TED Prize, Panjabi is building the Community Health Academy, a global platform that aims to modernize how community health workers learn vital skills, creating jobs along the way.
A billion people around the world lack access to health care because they live too far from a clinic. Through Last Mile Health, 2017 TED Prize winner Raj Panjabi aims to extend health services to all — by training members of the community.
Why you should listen
Raj Panjabi was nine years old when civil war broke out in his native country of Liberia. His family fled, eventually resettling in High Point, North Carolina. As a medical student in 2005, he returned to Liberia. He was shocked to find a health care system in total devastation. Only 50 doctors remained to treat a population of four million.
With a small team of Liberian civil war survivors, American health workers and $6,000 he'd received as a wedding gift, Panjabi co-founded Last Mile Health in 2007. Initially focused on care for HIV patients, Last Mile Health has grown into a robust organization that partners with the government of Liberia to recruit, train, equip and employ community health workers who provide a wide range of services to their neighbors in Liberia's most remote regions. In 2016, Last Mile Health workers treated 50,000 patients, including nearly 22,000 cases of malaria, pneumonia and diarrhea in children. While the organization focuses on integrated primary care, its network can be leveraged in a crisis. In the fight against Ebola, Last Mile Health supported government response by training 1,300 health workers in southeastern Liberia.
Panjabi is a physician in the Division of Global Health Equity at Harvard Medical School, Brigham and Women's Hospital and an advisor to the Clinton Global Initiative. He was ranked as one of "The World’s 50 Greatest Leaders" by Fortune in 2015 and named to TIME's list of the "100 Most Influential People in the World" in 2016. As the winner of the 2017 TED Prize, Raj is creating the Community Health Academy, a global platform to train, connect and empower community health workers. The academy will be prototyped in Liberia and a handful of key countries, and will go global from there.
Where did Zika come from, and what can we do about it? Molecular biologist Nina Fedoroff takes us around the world to understand Zika's origins and how it spread, proposing a controversial way to stop the virus — and other deadly diseases — by preventing infected mosquitoes from multiplying.
Our pertinent blogs
21 APRIL 2017 | GENEVA, AMSTERDAM - New WHO data reveal that an estimated 325 million people worldwide are living with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. The WHO Global hepatitis report, 2017 indicates that the large majority of these people lack access to life-saving testing and treatment. As a result, millions of people are at risk of a slow progression to chronic liver disease, cancer, and death.
"Viral hepatitis is now recognized as a major public health challenge that requires an urgent response," said Dr Margaret Chan, WHO Director-General. "Vaccines and medicines to tackle hepatitis exist, and WHO is committed to helping ensure these tools reach all those who need them."
Increasing mortality, new infections
Viral hepatitis caused 1.34 million deaths in 2015, a number comparable to deaths caused by tuberculosis and HIV. But while mortality from tuberculosis and HIV has been declining, deaths from hepatitis are on the increase.
Approximately 1.75 million people were newly infected with HCV in 2015, bringing the global total of people living with hepatitis C to 71 million.
Although overall deaths from hepatitis are increasing, new infections of HBV are falling, thanks to increased coverage of HBV vaccination among children. Globally, 84% of children born in 2015 received the 3 recommended doses of hepatitis B vaccine. Between the pre-vaccine era (which, according to the year of introduction can range from the 1980s to the early 2000s) and 2015, the proportion of children under 5 years of age with new infections fell from 4.7% to 1.3%. However, an estimated 257 million people, mostly adults born before the introduction of the HBV vaccine, were living with chronic hepatitis B infection in 2015.
Epidemics in regions and "hotspots"
Hepatitis B levels vary widely across WHO regions with the WHO African Region and WHO Western Pacific Region sharing the greatest burden.
Treatment access is low
There is currently no vaccine against HCV, and access to treatment for HBV and HCV is still low.
WHO's Global Health Sector Strategy on viral hepatitis aims to test 90% and treat 80% of people with HBV and HCV by 2030.
The report notes that just 9% of all HBV infections and 20% of all HCV infections were diagnosed in 2015. An even smaller fraction – 8% of those diagnosed with HBV infection (1.7 million people) were on treatment, and only 7% of those diagnosed with HCV infection (1.1 million people) had started curative treatment during that year.
HBV infection requires lifelong treatment, and WHO currently recommends the medicine tenofovir, already widely used in HIV treatment. Hepatitis C can be cured within a relatively short time using the highly effective direct-acting antivirals (DAAs).
"We are still at an early stage of the viral hepatitis response, but the way forward looks promising," said Dr Gottfried Hirnschall, Director of WHO's Department of HIV and the Global Hepatitis Programme. "More countries are making hepatitis services available for people in need – a diagnostic test costs less than US$ 1 and the cure for hepatitis C can be below US$ 200. But the data clearly highlight the urgency with which we must address the remaining gaps in testing and treatment."
WHO's Global hepatitis report, 2017 demonstrates that despite challenges, some countries are taking successful steps to scale-up hepatitis services.
China achieved high coverage (96%) for the timely birth dose of HBV vaccines, and reached the hepatitis B control goal of less than 1% prevalence in children under the age of 5 in 2015. Mongolia improved uptake of hepatitis treatment by including HBV and HCV medicines in its National Health Insurance scheme, which covers 98% of its population. In Egypt, generic competition has reduced the price of a 3-month cure for hepatitis C, from US$ 900 in 2015, to less than US$ 200 in 2016. Today in Pakistan, the same course costs as little as US$ 100.
Improving access to hepatitis C cure received a boost at the end of March 2017, when WHO prequalified the generic active pharmaceutical ingredient of sofosbuvir. This step will enable more countries to produce affordable hepatitis medicines
Baseline for elimination
WHO's Global hepatitis report, 2017 aims to provide a starting point for hepatitis elimination by indicating baseline statistics on HBV and HCV infections, including mortality, and coverage levels of key interventions. Hepatitis B and C – the 2 main types out of 5 different hepatitis infections – are responsible for 96% of overall hepatitis mortality.
Notes for editors
World Immunization Week (24–30 April): WHO recommends the use of vaccines against 26 diseases, which include 3 vaccine-preventable types of viral hepatitis (A,B and E) out of 5 types of viral hepatitis (A,B,C,D,E).
World Hepatitis Day 2017 and World Hepatitis Summit 2017: WHO and partners will organize 2 high-profile global initiatives to advocate for an urgent response to viral hepatitis. World Hepatitis Day 2017 will be commemorated on 28 July under the theme “Eliminate hepatitis”. The World Hepatitis Summit 2017, the principal convention of the global hepatitis community, is being co-organized by WHO, the Government of Brazil and the World Hepatitis Alliance. It will be held on 1–3 November 2017 in São Paulo, Brazil.
Source: World Health Organization
CDC Report’s Abstract (U.S. Department of Health and Human Services - Centers for Disease Control and Prevention)
Background: In collaboration with state, tribal, local, and territorial health departments, CDC established the U.S. Zika Pregnancy Registry (USZPR) in early 2016 to monitor pregnant women with laboratory evidence of possible recent Zika virus infection and their infants.
Methods: This report includes an analysis of completed pregnancies (which include live births and pregnancy losses, regardless of gestational age) in the 50 U.S. states and the District of Columbia (DC) with laboratory evidence of possible recent Zika virus infection reported to the USZPR from January 15 to December 27, 2016. Birth defects potentially associated with Zika virus infection during pregnancy include brain abnormalities and/or microcephaly, eye abnormalities, other consequences of central nervous system dysfunction, and neural tube defects and other early brain malformations.
Results: During the analysis period, 1,297 pregnant women in 44 states were reported to the USZPR. Zika virus–associated birth defects were reported for 51 (5%) of the 972 fetuses/infants from completed pregnancies with laboratory evidence of possible recent Zika virus infection (95% confidence interval [CI] = 4%–7%); the proportion was higher when restricted to pregnancies with laboratory-confirmed Zika virus infection (24/250 completed pregnancies [10%, 95% CI = 7%–14%]). Birth defects were reported in 15% (95% CI = 8%–26%) of fetuses/infants of completed pregnancies with confirmed Zika virus infection in the first trimester. Among 895 liveborn infants from pregnancies with possible recent Zika virus infection, postnatal neuroimaging was reported for 221 (25%), and Zika virus testing of at least one infant specimen was reported for 585 (65%).
Conclusions and Implications for Public Health Practice: These findings highlight why pregnant women should avoid Zika virus exposure. Because the full clinical spectrum of congenital Zika virus infection is not yet known, all infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy should receive postnatal neuroimaging and Zika virus testing in addition to a comprehensive newborn physical exam and hearing screen. Identification and follow-up care of infants born to women with laboratory evidence of possible recent Zika virus infection during pregnancy and infants with possible congenital Zika virus infection can ensure that appropriate clinical services are available.
Pregnant women infected with Zika risk giving birth to babies with an abnormally small head and brain. Credit: Flickr, bra_j
Zika is spread mostly by the bite of an infected Aedes species mosquito (Ae. aegypti and Ae. albopictus). There is no vaccine for Zika virus disease yet, which causes symptoms like mild fever, skin rash, conjunctivitis, muscle and joint pain, malaise, or headache. The symptoms subside after 3-7 days but the biggest threat Zika possess is to pregnant women. It’s well established now that pregnant women infected with Zika risk giving birth to babies with microcephaly, a condition that causes babies to be born with abnormally small heads and brains, and Guillain-Barré syndrome.
“Zika virus can be scary and potentially devastating to families. Zika continues to be a threat to pregnant women across the U.S.,” said CDC Acting Director Anne Schuchat, M.D. “With warm weather and a new mosquito season approaching, prevention is crucial to protect the health of mothers and babies. Healthcare providers can play a key role in prevention efforts.”
The CDC report confirms previous studies which found women infected in the first trimester of their pregnancy are the most vulnerable. Some 15% of American women known to be infected with Zika during their first trimester had babies with birth defects. Overall, 10% of infected pregnant American women gave birth to babies with brain damage or other birth defects, so getting infected later in pregnancy can also be risky.
In total, the report covered 1,297 pregnancies which were tracked from Jan. 15 through Dec. 27, 2017. Of these pregnancies, 972 were confirmed to be Zika infected by lab evidence, which resulted in 895 live births and 77 losses (abortions, miscarriages, stillbirths). Every 50 state and Washington, D.C, had at least once case of Zika-infected pregnancy.
Overall, 51 babies were born with birth defects. For the 250 cases or so where the presence of the Zika virus was confirmed, 24 pregnancies or 10 percent resulted in birth defects, most of which involved microcephaly. In eight cases, the damage included other brain malformations and dysfunctions in the central nervous system.
The report comes with a couple of caveats. Only 25 percent of the babies included in the study had their brains scanned, despite the CDC’s recommendation that all babies born to women with potential Zika infections should have their brains scanned. This limitation means we’re likely underestimating the birth defects that follow Zika in pregnancy. For instance, some babies that look fine at birth, i.e. with a normally sized head, might later be diagnosed with some congenital Zika syndrome.
“CDC recommends that pregnant women avoid travel to areas with risk of Zika and unprotected sex with a partner who has traveled to an area with Zika to prevent Zika-related birth defects in their babies,” said Peggy Honein, Ph.D., the Zika Response’s Pregnancy and Birth Defects Task Force co-lead. “CDC continues to work closely with health departments on the U.S. Zika Pregnancy Registry to follow up infants with possible congenital Zika virus infection and better understand the full range of disabilities that can result from this infection.”
Key findings from the CDC's report
Source: ZME Science and CDC
The five strains of viral hepatitis (A, B, C, D and E) affect 400 million people around the world. Hepatitis B and C are the most deadly; these infections are blood borne, transmitted mainly through unsafe medical practices or injection drug use.
Viral hepatitis is a global epidemic with distinct regional patterns. In Europe, hepatitis C is mostly associated with injecting drugs but on the African continent, it is a generalised epidemic and a major public health issue.
The case of viral hepatitis sheds light on the key challenges faced by health systems in Africa in relation to the prevention of infection, barriers to accessing care and treatments and social and economic equity.
A deadly epidemic
It is estimated that 100 million people are affected by chronic hepatitis B in Africa, most of whom don’t know they have the infection; 19 million adults have hepatitis C.
Despite a lack of accurate epidemiological data at national levels, various estimations put hepatitis B prevalence at around 8-10% of the population in many countries. It is a generalised epidemic, not confined to specific segments of the population or high-risk groups.
This epidemic is even more worrying when we consider how hard it is to get treated – only 1% of chronic carriers can access treatment. When patients test positive for hepatitis they must undergo a series of biological and molecular tests that are, at the moment, unacceptably expensive in Africa.
It costs between €200 and €400 to have a complete pre-therapeutic assessment for hepatitis B or C in Cameroon and around €210 for an assessment for hepatitis B in Burkina-Faso.
After these tests, very few patients make it to the antiretroviral treatments. which are available for HIV patients but not for those affected by hepatitis B. In the case of hepatitis C, a single injection of pegylated interferon can cost as much as €230 in Côte d’Ivoire or Cameroon, and patients need 46 injections minimum.
If a hepatitis patient cannot access regular treatment, they end up hospitalised, affecting entire families both emotionally and financially. The people who die young of the diseases represent the workforce in many countries. As in the early years of AIDS, the shape of Africa’s future is affected by these infections.
A history of neglect
And just as the AIDS epidemic embodied colonial violence and weak health systems, so does viral hepatitis.
In Cameroon, the hepatitis C virus was transmitted through colonial medical campaigns in the late 1950s to 1960s. In Ebolowa, it is associated with intravenous treatment of malaria that today’s older people received when they were young; hepatitis C therefore affects more than 50% of people older than 50 in certain regions.
Transmission of hepatitis C might not be acute today, but certain medical procedures do carry the risk of infection. In Cameroon, those who undergo repeated blood transfusions are at greater risk of contracting HCV, just as health workers, exposed in the workplace.
Viral hepatitis also sheds light on global healthcare priorities. The hepatitis B vaccines arrived late to the African continent: though the extent of hepatitis B and liver cancer were known in the late 1970s in Senegal and stimulated the development of a vaccine, once manufactured this vaccine was not made accessible in Africa until mid-1990s. Even today, populations are not fully covered by vaccination.
In the 1980s the HIV epidemic obscured the extent of hepatitis. Today, the free antiretroviral drugs provided through the support of Global Fund against HIV, TB and malaria are perceived as unfair by many of those affected by hepatitis.
In the fight against hepatitis, many lessons can be drawn from HIV, as well as from the recent Ebola outbreak*.
Massive international interventions cannot just target access to drugs and biomedical interventions. Chances of surviving Ebola were considerably increased when patients could access basic measures, including intensive care and rehydration.
And instead of trying to change people’s behaviour, history shows it is wiser to understand the social, economic and political context of epidemics and to trust local knowledge and experience. In his recent book on Ebola, anthropologist Paul Richards asserts that the epidemic ended not just because of international support, but also thanks to community work, even despite the lack of effective treatment.
Communities responded, and they produced their own science of the disease. They mobilised techniques to protect themselves, for instance by using plastic bags or other materials while attending to their sick loved ones.
Today, in places like Cameroon, many physicians, patients and families have similarly developed ways to cope with hepatitis, jaundice or liver pathologies. Their insight and experience should be at the centre of future policies.
Many professionals deplore the lack of universal protection from hepatitis transmission and the risk of infection in hospitals is high. Health workers are not immunised correctly, and they lack critical equipment such as gloves and sterilising material.
Another efficient way to prevent transmission is to vaccinate for hepatitis at birth instead of starting at six weeks.
There is also an urgent need to address pain management and palliative care as the complications of hepatitis (liver cancer and cirrhosis) can be very debilitating and inhumane experiences, often leading to death.
Across the African continent, hepatitis does not today receive the same kind of attention from NGOs and civil society as HIV did in the 2000s.
But other forms of mobilisation are emerging among clinicians, as national professional associations combine scientific and medical work and advocate to their respective governments for sustained pan-African collaboration.
Clinicians in Africa and in Europe are also joining forces through scientific and medical cooperation and are calling for action to fight these unacceptable global inequalities. Their insights should be combined with strong social support for patients and their families.
The viral hepatitis response also requires urgent infrastructure interventions to ensure access to clean water, hospital hygiene and blood safety.
The WHO Regional Committee for Africa promotes a public health approach that includes vaccination at birth, integration of testing services and linkage to care.
If making drugs available is a priority, it is also imperative to avoid catastrophic health expenses and include diagnostic tests, treatments and follow-up tests in national projects for universal health coverage.
Fanny Chabrol, Postdoctoral fellow in Global health, Institut national de la santé et de la recherche médicale (Inserm)
Viral hepatitis infection is widely spread, affecting 400 million people worldwide – over 10 times the number of people infected with HIV. Globally, about 1.4 million people die each year from hepatitis. It is estimated that only 5% of people with chronic hepatitis know of their infection, and less than 1% have access to treatment.
Yet, hepatitis is fully preventable and treatable: there are effective vaccines and treatments for hepatitis B, and over 90% of people with hepatitis C can be cured with treatment. The vision of eliminating hepatitis as a public health threat by 2030 can be achieved, if people and countries affected by this disease were better equipped and enabled to "know hepatitis" and "act now".
Know hepatitis - Are you at risk?
Know hepatitis - Demand treatment