Even as health workers scramble to contain raging COVID-19 epidemics across the globe, a host of services for other infectious diseases such as cholera, Ebola, measles, and polio are simultaneously being disrupted.
While SARS-CoV-2 has infected millions and claimed more than 250,000 lives, experts are warning that the impact of other diseases neglected due to the pandemic may be just as significant in the months and years to come.
Lockdowns and travel restrictions have resulted in the suspension of immunisation programmes, threatened vaccine stockpiles, and impeded the ability of health personnel to respond to other emergencies.
Everyone from global health policymakers in Geneva, to national health ministries, to field level health workers is being forced into difficult trade-offs: how do you maintain immunisation and infectious disease treatments even as significant resources and existing infrastructures are re-geared towards addressing COVID-19? As they redraw priorities, decision-makers must also vie for limited sources of funding, all at a time when the world is facing difficult economic conditions without parallel.
Inevitably, some of the most vulnerable people will fall off the map and suffer for want of vaccines and life-saving drugs for existing conditions. The consequences will be worst felt where life is hardest: from the teeming slums of Mumbai to humanitarian hotspots in the Middle East, Africa, and elsewhere that are already ravaged by conflict and drought.
“The conflicts in Syria, in Yemen, in Iraq, still exist. The fragilities in Mali and South Sudan, in the Sahel, still exist. So we continue to be focused on working on COVID-19, as well as dealing with other things that we do,” Dr. Mike Ryan, head of emergencies at the World Health Organisation, told a recent press briefing. “We have done our best to try and preserve our services, and support countries over all of these areas. But I have to admit that it is not easy in the context of the resource constraints we face in continuing those programmes.”
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The Inter-Agency Standing Committee (IASC), a humanitarian decision-making forum that gathers the heads of UN agencies and non-UN organisations, has announced a COVID-19 response plan that requires more than $2 billion to deal with the pandemic in the poorest settings of the world just until the end of the year. This spending commitment is expected to grow.
Even before considering additional deaths linked to COVID-19, HIV, tuberculosis, viral hepatitis, malaria, neglected tropical diseases, and sexually-transmitted infections were expected to kill an estimated four million people in 2020.
Dr. Seth Berkeley, head of the global vaccine alliance Gavi, warned recently – citing a London School of Tropical Hygiene and Medicine study – that deaths from other infectious diseases could outweigh COVID-19 fatalities by a factor of 100 to one in Africa.
It won’t be easy to maintain essential services and responses on other infectious diseases during the pandemic, and to reduce vaccine-preventable deaths. This briefing takes stock of the challenges.
Resurgent measles
Measles has made a comeback in recent years thanks to a range of factors, from anti-vaccination beliefs to weak health systems, erupting in countries as diverse as Ukraine, Congo, Syria, and even Samoa.
It claimed more than 140,000 lives in 2018, mostly of children and babies. Global death figures for 2019 have not been confirmed, but there were more than half a million infections and hundreds of thousands more suspected cases.
Measles killed more than 6,000 people in the Democratic Republic of Congo alone in 2019, even as health workers and the population was fighting Ebola.
On the Pacific Island nation of Samoa, vaccine hesitancy and low immunisation rates contributed to an outbreak that by the end of January had killed dozens and infected at least 5,700 people – equivalent to more than two percent of the country’s population.
The pandemic is likely to make numbers worse.
“In 2020 there are increasing concerns about another resurgence, especially if vaccination rates fall due to delay or suspension of scheduled immunisation activities as a result of COVID-19,” the WHO said last month.
More than 117 million children across 37 countries may miss out on receiving a life-saving measles vaccine – many in regions, including Latin America, with ongoing outbreaks.
More than 117 million children across 37 countries may miss out on receiving a life-saving measles vaccine – many in regions, including Latin America, with ongoing outbreaks.
“Measles immunisation campaigns in 24 countries have already been delayed; more will be postponed,” the Measles & Rubella Initiative (M&RI) said in a 14 April statement. Campaigns expected to take place later in 2020 in an additional 13 countries may not be implemented.
UNICEF estimates that measles vaccinations averted an estimated 21.1 million deaths between 2000 and 2017.
Lingering Ebola
Videos of jubilation in early March showed health workers dancing as a woman – then the last person confirmed to have Ebola in Congo – was discharged from a treatment centre. Unfortunately, this moment of relief was premature.
“Just a single case could reignite the epidemic,” warned Dr. Ibrahima Socé Fall, the WHO’s assistant director-general for emergency response. “We have to be prepared for other cases emerging.”
Sure enough, in mid-April, new cases emerged – and health workers were soon presented with the same set of challenges: from a confirmed case refusing treatment and disappearing, to trouble accessing communities still wary of responders.
On 14 April, the WHO declared the outbreak – the second deadliest ever, with more than 3,400 cases and over 2,200 deaths – still constitutes a Public Health Emergency of International Concern, or PHEIC.
A “major funding gap” is meanwhile hampering response efforts, according to the WHO, which said $21.5 million is needed to ensure its teams can continue operating on the ground.
While it’s hoped some resources and manpower used to combat Ebola can be mobilised against COVID-19, the risk of survivors relapsing or infecting others through body fluids, means health responders may be grappling with both diseases for a while longer.
Polio successes at risk
One of global public health’s big success stories – polio eradication – is also at risk due to the pandemic. It may suffer a double blow: not only burden-sharing due to COVID-19, but also reduced funding, notably from the United States.
Over the last 20 years, 2.5 billion children have been vaccinated, and the number of children paralysed by polio has fallen by more than 99 percent, according to UNICEF.
Even before COVID-19 struck, significant gains risked being reversed, with new outbreaks having emerged in several countries over the past year.
In March, the WHO’s emergency polio committee recommended that the risk of international spread remains a PHEIC and extended its measures, including on surveillance and vaccinations, for a further three months. According to the committee, the risk is at the highest point since 2014, when it was declared a PHEIC. “This new and unprecedented pandemic is likely to substantially negatively impact the polio eradication programme and outbreak control efforts,” it said.
The committee noted the widespread transmission in Pakistan fuelled by vaccine hesitancy and the politicisation of the national polio eradication programme. It also flagged the insecurity in Afghanistan that makes children more susceptible in inaccessible areas.
“The rapid emergence of multiple… strains in several countries is unprecedented and very concerning, and not yet fully understood.”
Authorities found a significant increase in wild polio cases worldwide in 2019: 175 compared to 33 the year before. By 28 April this year, there were 54 cases of wild polio.
In addition, there is added pressure due to the detection and ongoing spread of what is referred to as “circulating vaccine-derived poliovirus (cVDPV)”, which originates in areas with inadequate sanitation facilities and under-immunised populations.
“The rapid emergence of multiple… strains in several countries is unprecedented and very concerning, and not yet fully understood,” the committee noted. “Unlike historical experience, cross-border spread… has become quite common.” By 28 April this year, there were 99 cases of cVDPV, globally.
The committee is also concerned about the availability of vaccines. Countries have been advised to postpone campaigns until 1 June and then re-evaluate based on the status of COVID-19. It is understood that the 2019-2023 “endgame strategy” of the WHO-run Global Polio Eradication Initiative (GPEI) is being reviewed in light of the pandemic.
Cholera concerns
When the pandemic broke into Yemen last month – the first case was reported 10 April – the country had not only been ravaged by five years of civil war but also by cholera.
Cholera is endemic to Yemen and should be relatively easy to treat, but the conflict contributed to water shortages, poor sanitation, and decimated the health system, and by mid-2017 it was taking one life an hour. Overall, there have been more than 3,910 deaths related to the disease since October 2016, out of more than 2.3 million suspected cases.
Yemenis are contracting and dying of cholera at a much lower rate now, but that does not mean the threat is over, especially with the rainy season just beginning and parts of the country already struggling with heavy downpours and flash floods. Cholera is spread when a person eats or drinks something contaminated with the bacterium Vibrio cholerae, and UNICEF is concerned that the recent displacement and destruction caused by the floods, along with interrupted access to safe drinking water and sanitation, provide a “perfect recipe” for the spread of cholera.
“A further spread of cholera, high levels of malnutrition, and outbreaks of vaccine-preventable diseases compounded by COVID-19 will only exacerbate the burden that children and their families already face,” said Sara Beysolow Nyanti, UNICEF’s representative in Yemen, in a recent statement.
According to the agency, there have already been more than 110,000 suspected cases of cholera and acute watery diarrhoea (AWD) in Yemen this year. The umbrella term AWD covers all diarrhoeal diseases caused by viruses, bacteria, and parasites, including cholera.
“A further spread of cholera, high levels of malnutrition, and outbreaks of vaccine-preventable diseases compounded by COVID-19 will only exacerbate the burden that children and their families already face.”
Cholera has also been a source of concern in the crowded refugee camps near Bangladesh’s Cox Bazar that are home to roughly 900,000 Rohingya from Myanmar.
In December 2019, the WHO and UNICEF vaccinated over 160,000 Rohingya refugee children and more than 520,000 Bangladeshi children against cholera.
According to statistics from Bangladesh's government and the WHO, 191,057 cases of AWD have been reported in Cox's Bazar district, which includes the Rohingya refugee camps and some surrounding host communities.
Vector-borne spread
While some scientists have expressed concern that climate change could alter humans’ ability to defend themselves against pathogens like influenza and COVID-19, the jury is very much still out. There are no such doubts about dengue and malaria.
It is already accepted that global warming has extended the reach of vector-borne diseases by widening the habitat of the female mosquitoes that transmit malaria and dengue from tropical climes to more temperate zones.
Dengue, known to exist in fewer than 10 nations in the 1970s, has now spread to at least 128 countries. One of the worst-hit regions is Latin America. In 2019, infections reached new records: more than three million cases were confirmed – six times more than the previous year – and over 1,300 people died from the disease in the region.
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An effective and safe vaccine for dengue has eluded scientists for decades, with prevention efforts focused on nets, spraying, and other ways of keeping the vectors at bay.
On World Malaria Day on 25 April, the WHO announced new modelling analysis and asked sub-Saharan African countries – at this stage of the COVID-19 outbreak at least – to maintain essential control services and keep distributing malaria prevention and treatment tools.
“Under the worst-case scenario, in which all insecticide-treated net campaigns are suspended and there is a 75 percent reduction in access to effective antimalarial medicines, the estimated tally of malaria deaths in sub-Saharan Africa in 2020 would reach 769,000, twice the number of deaths reported in the region in 2018,” it warned.
Immunisation warning
Although immunisation is understood as an essential health service, it has still been affected by the pandemic, not least because of the need to maintain physical distancing.
Marking annual World Immunisation Week (24-30 April), the WHO warned that shutting down immunisation services could risk triggering a resurgence of vaccine-preventable diseases. “These diseases will come roaring back if we do not vaccinate,” warned WHO Director-General Tedros Adhanom Ghebreyesus.
Even without any disruption from the pandemic, 13 million children, mostly living in countries with fragile health systems, miss out on any kinds of vaccines, the WHO says.
To enable countries to protect critical services, the WHO is recommending governments temporarily pause immunisation campaigns where there is no active outbreak.
It has also drawn up a wider list of guidelines on how to maintain essential health services during an outbreak, and put out an updated strategic response plan for country preparedness.
In the UN’s global COVID-19 response plan, Secretary-General António Guterres called on donors to maintain core support to programmes for the most vulnerable.
“To divert funding from humanitarian needs at this time would create an environment in which cholera, measles, and meningitis would thrive, even more children would become malnourished, and the narratives of violent extremists would take deeper hold,” he said.
Asked during a recent press briefing about the WHO’s preparedness on other infectious diseases, Ryan, the WHO’s emergencies chief, said a dedicated team had been set up to focus on verifying and responding to other epidemic-prone diseases as they emerge.
In addition to cholera and the resurgence of Ebola in Congo, Ryan also flagged concerns around Yellow Fever threats in parts of East Africa.
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