tag:theconversation.com,2011:/global/topics/global-health-emergency-28455/articlesGlobal health emergency – The Conversation2023-10-30T16:14:51Ztag:theconversation.com,2011:article/2154112023-10-30T16:14:51Z2023-10-30T16:14:51ZTB vaccine: WHO expert explains why it’s taken 100 years for a scientific breakthrough, and why it’s such a big deal<iframe id="noa-web-audio-player" style="border: none" src="https://embed-player.newsoveraudio.com/v4?key=x84olp&id=https://theconversation.com/tb-vaccine-who-expert-explains-why-its-taken-100-years-for-a-scientific-breakthrough-and-why-its-such-a-big-deal-215411&bgColor=F5F5F5&color=D8352A&playColor=D8352A" width="100%" height="110px"></iframe>
<p><em>The <a href="https://www.cdc.gov/tb/publications/factsheets/prevention/bcg.htm">BCG vaccine for TB</a> has been used for 100 years. It is largely effective for children under five, but less so in older people and can’t be used on patients who have certain medical conditions. Today we’re the closest we’ve ever been to discovering a vaccine that might replace or complement it. Charles Shey Wiysonge, the World Health Organization’s Regional Adviser for Immunisation, discusses the latest developments in the fight against one of the world’s deadliest diseases.</em></p>
<h2>Why has it taken so long?</h2>
<p>We do not yet have a new vaccine for TB. But, for the first time, there are several vaccine candidates that are at <a href="https://www.who.int/teams/global-tuberculosis-programme/research-innovation/vaccines">advanced stages</a> of clinical development. </p>
<p>Vaccine development usually takes decades and unfolds step by step. Experimental vaccine candidates are created in the laboratory and tested in animals before moving into progressively larger human clinical trials. </p>
<p>Clinical trials are research studies that test an intervention such as a vaccine in human beings and occur in phases, from phase 1 to phase 3. We say vaccines are in clinical development when they reach the clinical trial stage. </p>
<ul>
<li><p>A phase 1 trial is a first-in-human study which recruits a small number of healthy people (usually fewer than 100), to assess whether a candidate vaccine is safe. </p></li>
<li><p>Phase 2 trials are typically conducted among several hundred participants, to assess whether the candidate vaccine produces an immune response. </p></li>
<li><p>For phase 3 trials, thousands of people are enrolled to assess whether the vaccine is efficacious and safe. Phase 3 TB vaccine trials are currently going on in Gabon, Kenya, Russia, South Africa, Tanzania and Uganda.</p></li>
</ul>
<p>Even though we are still, at best, three years away from broad regulatory approval of a new TB vaccine, the scientific community can do a lot now to prepare for its use, and to inform the public so that the vaccine may be accepted when it becomes available. </p>
<p>TB vaccines are very challenging to develop. The bacterium that causes the disease is complex, and is proficient at evading the human immune system. We don’t yet have a full understanding of how to appropriately target the bacterium or what kind of immune responses are needed to induce immunity. But there are some interesting approaches in the pipeline and there have been some encouraging data from clinical trials that are providing clues.</p>
<h2>Why do we need a new TB vaccine?</h2>
<p>TB is a global health emergency. About <a href="https://www.who.int/news-room/fact-sheets/detail/tuberculosis">2 billion</a> people are currently infected with <em>Mycobacterium tuberculosis</em>, and of those, <a href="https://www.who.int/health-topics/tuberculosis#tab=tab_1">5% to 10%</a> may become ill with TB and will potentially transmit the bacterium. </p>
<p><a href="https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022">In 2021</a>, nearly 10.6 million people developed TB disease and 1.6 million died. We urgently need new tools to fight TB, including new and improved vaccines.</p>
<p>The <a href="https://www.cdc.gov/tb/publications/factsheets/prevention/bcg.htm">Bacille Calmette-Guérin</a> (BCG) vaccine has saved tens of millions of lives and is effective in children under the age of five in preventing TB deaths and severe forms of the disease. </p>
<p>The vaccine has variable efficacy for protection against <a href="https://medlineplus.gov/ency/article/000077.htm#:%7E:text=Pulmonary%20TB%20is%20caused%20by,infection%20is%20called%20primary%20TB.">pulmonary TB</a> (TB affecting the lungs) in adolescents and adults – and it is pulmonary TB that’s responsible for the majority of TB transmission. So new and improved vaccines that are effective in preventing pulmonary TB in adolescents and adults are essential to control TB, and to reduce transmission to all, including newborn babies.</p>
<p>TB is the leading cause of death among people living with HIV. People living with HIV have up to <a href="https://www.unaids.org/sites/default/files/media_asset/tb-and-hiv_en.pdf">20 times higher</a> risk of developing TB disease compared to those without HIV infection. The current BCG vaccine is not recommended for use in people living with HIV, for safety reasons. Although BCG is a safe vaccine in <a href="https://www.verywellhealth.com/immunocompetent-1069342">immunocompetent</a> infants (those whose immune systems are working properly), severe adverse events can occur in HIV-infected infants following vaccination with BCG.</p>
<p>These adverse events include a rare but life threatening condition known as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2718164/">disseminated BCG disease</a>. However, new TB vaccine candidates are being developed and evaluated to offer clinical benefit in people living with HIV. </p>
<h2>How effective has the BCG vaccine been?</h2>
<p>BCG vaccines are given to more than <a href="https://pubmed.ncbi.nlm.nih.gov/35961354/">100 million children</a> every year worldwide, at birth or soon after. The effectiveness of BCG can vary depending on several factors, including the prevalence of TB in a given area, the strain of the BCG vaccine used, and the age at which BCG was administered.</p>
<p><a href="https://iris.who.int/bitstream/handle/10665/260306/WER9308.pdf?sequence=1">Several studies</a> have shown that the effect of the BCG wanes as children approach adolescence. People may become infected with TB but not be aware of it. </p>
<h2>What will happen to the BCG vaccine?</h2>
<p>The BCG vaccine will not be replaced by another TB vaccine until and unless there is compelling data on the safety and efficacy of an alternative. Most of the current vaccines in advanced stages of clinical trials are tested in adolescents and adults. Their safety and efficacy would need to be proven in newborn infants to be able to replace BCG. </p>
<p>In addition, BCG vaccination has <a href="https://www.who.int/publications/i/item/who-wer9308-73-96">nonspecific beneficial effects on overall mortality</a> and leads to more reductions in child mortality than would be expected by just protecting against tuberculosis. There is thus a great possibility that BCG would remain in use.</p>
<h2>What will a new vaccine mean for the fight against TB?</h2>
<p>This depends on what the clinical trial data for the new vaccine candidates show. Most importantly, any new vaccine will need to be safe, and it will need to offer clear clinical benefit to populations at risk. We hope that the TB vaccine candidates that are in the pipeline will be effective at reducing TB infection, TB disease and TB transmission and can become part of a combination of tools in the fight against TB.</p>
<p><em>This article is part of a media partnership between The Conversation Africa and the 2023 Conference on Public Health in Africa.</em></p><img src="https://counter.theconversation.com/content/215411/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charles Shey Wiysonge previously received funding from the South African Medical Research Council.</span></em></p>In 2021 10.6 million people developed TB and 1.6 million died from the disease. Now, for the first time in 100 years, there are promising signs of a vaccine breakthrough.Charles Shey Wiysonge, Regional Adviser, Immunisation, WHO Regional Office for Africa, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2052822023-05-14T11:19:08Z2023-05-14T11:19:08ZLearning from COVID-19: The global health emergency has ended. Here’s what is needed to prepare for the next one<figure><img src="https://images.theconversation.com/files/525793/original/file-20230512-21-xs50y1.jpg?ixlib=rb-1.1.0&rect=998%2C22%2C5682%2C3507&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The World Health Organization has declared an end to COVID-19's status as a public health emergency of international concern.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/learning-from-covid-19--the-global-health-emergency-has-ended--here-s-what-is-needed-to-prepare-for-the-next-one" width="100%" height="400"></iframe>
<p>When the World Health Organization formally <a href="https://doi.org/10.1038/d41586-023-01559-z">declared an end</a> to the COVID-19 pandemic’s designation as a Public Health Emergency of International Concern (PHEIC), it may seem to have had<a href="https://theconversation.com/covid-is-officially-no-longer-a-global-health-emergency-heres-what-that-means-and-what-weve-learned-along-the-way-205080">little, if any, perceivable impact</a> on the daily lives of most people. </p>
<p>However, it would be a mistake to assume that this is a mere formality.</p>
<p>A PHEIC, like the one <a href="https://www.who.int/news/item/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">adopted for COVID-19 on Jan. 30, 2020</a>, is declared if a public health event is <a href="https://www.who.int/news/item/05-05-2023-statement-on-the-fifteenth-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-coronavirus-disease-(covid-19)-pandemic">determined to constitute</a>:</p>
<ol>
<li>an extraordinary event; </li>
<li>a public health risk to other states through the international spread, and </li>
<li>potentially requiring a co-ordinated international response. </li>
</ol>
<p>Under the <a href="https://www.who.int/health-topics/international-health-regulations#tab=tab_1">International Health Regulations (IHR)</a> — a legally-binding agreement which commits governments to certain actions when responding to the international spread of disease — the declaration of a PHEIC permits the WHO to issue temporary recommendations to national governments to support a co-ordinated and effective global response to such events. </p>
<figure class="align-center ">
<img alt="A man with a moustache adjusts his glasses in front of a World Health Organization logo on a blue wall." src="https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525821/original/file-20230512-23-qjsrry.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Tedros Adhanom Ghebreyesus, director-general of the World Health Organization, talks to the media at WHO headquarters in Geneva on Jan. 30, 2020, the day COVID-19 was declared a public health emergency or international concern.</span>
<span class="attribution"><span class="source">(Jean-Christophe Bott/Keystone via AP)</span></span>
</figcaption>
</figure>
<p>A PHEIC means the WHO is <a href="https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf">sounding the loudest possible alarm</a> to national governments to act together with urgency. A total of seven <a href="https://doi.org/10.1093%2Fjtm%2Ftaaa227">PHEICS have been declared</a> since the IHR took effect in 2007: H1N1, Ebola, Polio, a second Ebola outbreak, Zika, COVID-19 <a href="https://www.who.int/europe/news/item/23-07-2022-who-director-general-declares-the-ongoing-monkeypox-outbreak-a-public-health-event-of-international-concern">and Mpox</a>. </p>
<p>However, the heightened state of emergency under a PHEIC is not meant to be sustained indefinitely. The recommendations are temporary and require review every three months.</p>
<h2>Significance of the end of the COVID-19 PHEIC</h2>
<p>The lifting of PHEIC status for COVID-19 is significant for two reasons. </p>
<p>First, ending the emergency stands down the WHO’s formal authority to guide national COVID-19 policies. While the acute phase of the pandemic appears to have passed, this must still be balanced with continued response efforts aligned with the <a href="https://doi.org/10.1126/science.adi5890">ongoing risk posed by the ever-evolving SARS-CoV-2</a>. </p>
<p>Moreover, the phrase “<a href="https://www.gavi.org/vaccineswork/no-one-safe-until-everyone-safe?gclid=Cj0KCQjwpPKiBhDvARIsACn-gzBnSxNtyGxTap5iEuFfiao9E2LqUxZvbVZbDeVhaPTcwixcTQEMJDkaAimnEALw_wcB">no one is safe until everyone is safe</a>” may have become a familiar tagline during the pandemic. Yet, many people, mostly in low- and middle-income countries, still <a href="https://data.undp.org/vaccine-equity/">struggle to access</a> COVID-19 vaccines, diagnostics and treatments. Others, such as the immuno-compromised, remain subject to severe health outcomes. </p>
<p>With the impact of COVID-19 continuing to disproportionately affect vulnerable populations worldwide, the pandemic remains far from over.</p>
<p>Second, the standing down of the PHEIC declaration is accompanied by an understandable desire — and necessity — to “move on” from COVID-19 after three difficult years. Many high-income countries have been steadily returning to <a href="https://www.nytimes.com/2023/05/05/health/covid-who-emergency-end.html">pre-COVID-19 life</a>. </p>
<figure class="align-center ">
<img alt="A row of five coronaviruses in different shades, changing from red to purple" src="https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=217&fit=crop&dpr=1 600w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=217&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=217&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=272&fit=crop&dpr=1 754w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=272&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/525824/original/file-20230512-17-p1d3hs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=272&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">While the acute phase of the pandemic appears to have passed, this must still be balanced with continued response efforts aligned with the ongoing risk posed by the ever-evolving SARS-CoV-2 virus.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>However, the critical and challenging process of learning lessons from the pandemic — let alone addressing the shortcomings in the global response to COVID-19 — has just begun. Governments must ensure that “moving on” does not mean losing the opportunity to capture critical insights that will determine the effectiveness of future pandemic preparedness and response.</p>
<p>Perhaps the biggest lessons has been the failure of countries to co-ordinate on many aspects of the global COVID-19 response, such as access to vaccines and <a href="https://doi.org/10.1136/bmjgh-2020-004537">use of travel measures</a>. The lack of real-world authority by the WHO to enforce the legally binding IHR has become abundantly clear. </p>
<h2>Global co-ordination fell short</h2>
<p>The <a href="https://theindependentpanel.org/">Independent Panel for Pandemic Preparedness and Response</a>, convened by the WHO to review the global response to the pandemic, characterized February 2020 as a “<a href="https://theindependentpanel.org/wp-content/uploads/2021/05/COVID-19-Make-it-the-Last-Pandemic_final.pdf">lost month</a>” due to the overwhelming inaction of many countries after the PHEIC was declared. </p>
<p>Governments eventually began to take emergency action but only after the WHO made the strategic decision in March 2020 to <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020">declare COVID-19 a pandemic</a>. Still, what ensued fell far short of a co-ordinated global effort.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-19-vaccine-inequity-allowed-omicron-to-emerge-173361">COVID-19 vaccine inequity allowed Omicron to emerge</a>
</strong>
</em>
</p>
<hr>
<p>The need for collective action during global public health emergencies like COVID-19 has only been reinforced by the past three years. Our research on the <a href="https://www.pandemics-borders.org/">use of travel measures in response to COVID-19</a> has identified key policy areas where improving effectiveness depends on how willing countries are to act in a co-ordinated way. </p>
<p>For example, the chaos caused by varied and changing use of travel measures was due in part to the lack of an agreed risk-based approach. Among those that applied risk analysis, <a href="https://www.migrationpolicy.org/research/risk-analysis-border-covid19">how risk was defined and approached varied substantially</a>.</p>
<p>Additionally, travel measures implemented in <a href="https://www.theglobeandmail.com/opinion/article-by-reducing-air-travel-within-canada-covid-19-has-opened-another/">response to COVID-19</a>, and in <a href="https://doi.org/10.1016/S0140-6736(15)00946-0">previous PHEICs</a>, fell inequitably upon different population groups. <a href="https://www.pandemics-borders.org/projects/equity-canada-us-border-measures">Further research</a> is needed to understand and mitigate unfair impacts. Once again, better risk-based public health responses with more equitable outcomes will require countries to renew their commitment to work together.</p>
<p>If future co-ordination efforts are to be successful, governments must begin by understanding and addressing the shortcomings of existing legal frameworks, including the PHEIC and IHR.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-whos-international-pandemic-treaty-meaningful-public-engagement-must-inform-canadas-negotiations-203747">The WHO’s international pandemic treaty: Meaningful public engagement must inform Canada's negotiations</a>
</strong>
</em>
</p>
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<p>Towards this end, WHO member states have begun simultaneous negotiation of <a href="https://www.who.int/news/item/21-04-2023-governments-hold-third-round-discussions-on-proposed-amendments-to-the-international-health-regulations-(2005)">IHR amendments</a>, alongside a <a href="https://www.who.int/news/item/03-03-2023-countries-begin-negotiations-on-global-agreement-to-protect-world-from-future-pandemic-emergencies">new pandemic legal instrument</a>. </p>
<p>Previous outbreaks of concern, <a href="https://www.canada.ca/en/public-health/services/reports-publications/learning-sars-renewal-public-health-canada.html">notably SARS-CoV-1</a> and <a href="https://www.phac-aspc.gc.ca/about_apropos/evaluation/reports-rapports/2010-2011/h1n1/pdf/h1n1-eng.pdf">H1N1</a>, initially prompted new attention and investments in pandemic preparedness. However, these efforts were not sufficiently sustained. Whether and to what extent current efforts will compel countries to act in the collective interest is the crux of the issue.</p>
<p>Meanwhile, a new pandemic may already be on the horizon as the global and interspecies spread of <a href="https://doi.org/10.1038/d41586-023-00201-2">highly pathogenic avian influenza</a> is raising growing alarm. The adoption and now lifting of the PHEIC declaration during the COVID-19 pandemic, and actions taken by governments in between, offer clear lessons if the world is willing to learn them.</p><img src="https://counter.theconversation.com/content/205282/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Julianne Piper is funded by the Pacific Institute on Pathogens, Pandemics and Society which receives funding from the BC Ministry of Health</span></em></p><p class="fine-print"><em><span>Kelley Lee receives funding from the Canadian Institutes of Health Research, New Frontiers for Research Fund, and Social Sciences and Humanities Research Council of Canada. The Pacific Institute on Pathogens, Pandemics and Society (PIPPS) receives funding from the BC Ministry of Health.</span></em></p>After previous public health emergencies likes SARS and H1N1, there was renewed investment in pandemic preparedness, but it was not sustained. We cannot make the same mistake after COVID-19.Julianne Piper, Research Fellow, Health Sciences, Simon Fraser UniversityKelley Lee, Professor and Canada Research Chair in Global Health Governance; Scientific Director, Pacific Institute on Pathogens, Pandemics and Society, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1865182022-07-24T17:03:26Z2022-07-24T17:03:26ZMonkeypox: World Health Organization declares it a global health emergency – here’s what that means<p>The World Health Organisation (WHO) has <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">declared</a> the current monkeypox epidemic a global health emergency.</p>
<p>The committee of independent advisers who met on Thursday July 21 2022, were split on their decision on whether to call the growing monkeypox outbreak a public health emergency of international concern (PHEIC) – the highest level of alert. </p>
<p>The head of the WHO, Dr Tedros Adhanom Ghebreyesus, broke the deadlock and declared the outbreak a PHEIC. This is the first time the WHO director general has <a href="https://www.nytimes.com/2022/07/23/health/monkeypox-pandemic-who.html">side-stepped his advisers</a> to declare a public health emergency.</p>
<p>The first case of monkeypox was reported in a child in the Democratic Republic of the Congo (then Zaire) in 1970. Since then, outbreaks have generally been small and traceable to an individual who recently returned from a country where the virus is endemic – that is, countries in west and central Africa. But the current outbreak is unlike any previous one outside of Africa in that there is sustained person-to-person transmission of the infection. </p>
<p>As of July 22, there have been 16,593 confirmed infections in 68 countries <a href="https://www.cdc.gov/poxvirus/monkeypox/response/2022/world-map.html">that have not historically reported monkeypox</a>. Most infections have been reported from Europe. The large majority of infections have been in men who have sex with men, especially men who have sex with multiple partners. </p>
<p>Models presented to the WHO suggest the average number of people infected by a single infected person (the so-called R nought – remember this from the early days of the COVID pandemic?) is between 1.4 and 1.8 in <a href="https://www.who.int/news/item/23-07-2022-second-meeting-of-the-international-health-regulations-(2005)-(ihr)-emergency-committee-regarding-the-multi-country-outbreak-of-monkeypox">men who have sex with men, but less than 1.0 in other populations</a>. So although occasional infections can spill over into populations other than men who have sex with men, further significant spread is unlikely. </p>
<p>In Europe, in recent weeks there has been a <a href="https://www.ecdc.europa.eu/en/monkeypox-multi-country-outbreak/situation-update-eueea-western-balkans-turkey">slowing in the rate of increase</a> in new monkeypox cases each week. The large majority of infections are still occurring in men who have sex with men. </p>
<p>In the UK, 97% of cases are in men who have sex with men, but it does look as though the rate of growth in the epidemic has fallen to zero or <a href="https://www.gov.uk/government/publications/monkeypox-outbreak-technical-briefings/investigation-into-monkeypox-outbreak-in-england-technical-briefing-4">even become negative in recent weeks</a>. But it is plausible that the apparent dip in new infections is the gap between consecutive waves.</p>
<p>Experts have recently been debating whether <a href="https://www.webmd.com/a-to-z-guides/news/20220722/monkeypox-std-experts-debate">monkeypox is now a sexually transmitted disease</a>. Even though monkeypox is undoubtedly spread during sex, labelling it as an STD would be counterproductive, as the infection could spread through any intimate contact, even when wearing condoms or without penetrative sex. </p>
<figure class="align-center ">
<img alt="A graph showing cumulative monkeypox cases in the current outbreak" src="https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=424&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=424&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=424&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=532&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=532&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475731/original/file-20220724-17170-xnouom.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=532&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cumulative confirmed monkeypox cases in the current outbreak.</span>
<span class="attribution"><a class="source" href="https://ourworldindata.org/monkeypox">Our World in Data</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>For and against declaring a global health emergency</h2>
<p>Broadly, the WHO’s emergency committee arguments in favour of declaring a global health emergency included that monkeypox satisfies <a href="https://gh.bmj.com/content/5/6/e002502">the requirement of a PHEIC</a> under the WHO’s International Health Regulations: “an extraordinary event, which constitutes a public health risk to other States through international transmission, and which potentially requires a coordinated international response”. </p>
<p>Added to this are concerns that in some countries there is likely to be substantial under-reporting of case numbers, the occasional reports of <a href="https://www.nbcnews.com/health/health-news/2-children-us-diagnosed-monkeypox-officials-say-rcna39662">infections in children</a> and pregnant women, concerns that the infections could become endemic in human populations or be reintroduced into at-risk groups even after the current monkeypox pandemic is over. </p>
<p>Arguments against declaring it a global health emergency included the fact that the large majority of infections are currently being seen in just 12 countries in Europe and North America, and there is evidence of cases stabilising or even falling in those countries. </p>
<p>Almost all cases are in men who have sex with men and who have multiple partners, which provides opportunities to stop transmission with interventions targeted at this group. Another argument is that the severity of the disease outside appears to be low. </p>
<p>Although the emergency committee was not able to reach a consensus, Tedros took the <a href="https://www.who.int/director-general/speeches/detail/who-director-general-s-statement-on-the-press-conference-following-IHR-emergency-committee-regarding-the-multi--country-outbreak-of-monkeypox--23-july-2022">decision to declare a PHEIC</a>.</p>
<p>This declaration of a global health emergency will probably not lead to much change in control activities in the most affected counties outside of Africa. However, it may stimulate those countries that have seen few cases so far to ensure their health systems are better able to manage if the infection does spread within their countries. Hopefully, it may also stimulate funding for research and improvements in the capacity in endemic countries to manage the disease.</p><img src="https://counter.theconversation.com/content/186518/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Hunter consults for the World Health Organization. He receives funding from National Institute for Health Research, the World Health Organization and the European Regional Development Fund.</span></em></p>Cases may be stabilising but this could be the dip before a new wave.Paul Hunter, Professor of Medicine, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1309402020-01-31T13:04:04Z2020-01-31T13:04:04ZWHO declares global health emergency over coronavirus: 4 questions answered<figure><img src="https://images.theconversation.com/files/312967/original/file-20200130-41503-70aemk.jpg?ixlib=rb-1.1.0&rect=50%2C190%2C6590%2C4000&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man wearing a surgical mask makes a child wear one outside a hospital where a student who had been in Wuhan is kept in isolation in Thrissur, Kerala state, India. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-China-Outbreak/62bd9acb98534124bc9f6141cec155da/3/0">AP Photo</a></span></figcaption></figure><p><em>Editor’s note: The World Health Organization reversed course on Jan. 30 and <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">declared the coronavirus</a> a “<a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">Public Health Emergency of International Concern</a>.” The first <a href="https://www.nytimes.com/2020/01/30/world/asia/coronavirus-china.html">human-to-human transmission in the U.S.</a> was announced. <a href="https://www.nytimes.com/2020/01/30/world/asia/coronavirus-china.html">India has reported its first case</a>. <a href="https://www.nytimes.com/2020/01/30/world/asia/coronavirus-china.html">Russia has closed part of its border</a> with China, and more than 7,700 cases have been reported, with <a href="https://www.nytimes.com/2020/01/30/world/asia/coronavirus-china.html">170 deaths</a>.</em> </p>
<h2>1. What is a PHEIC?</h2>
<p>A <a href="https://www.who.int/ihr/procedures/pheic/en/">Public Health Emergency of International Concern</a> is a formal declaration from WHO that an ongoing outbreak or epidemic is a serious risk to multiple countries and needs concerted international effort in order to control the disease. PHEICs (pronounced “fakes”) have been called multiple times before and are used to help control outbreaks of disease.</p>
<h2>2. When has the WHO called a PHEIC before?</h2>
<p>The first PHEIC was called for the <a href="https://doi.org/10.1093/heapol/czq026">2009 H1N1 pandemic</a>. Since then, four PHEICs have been called, including <a href="http://polioeradication.org/polio-today/polio-now/public-health-emergency-status/">one for polio</a> in 2014 and one for <a href="https://www.who.int/news-room/detail/17-07-2019-ebola-outbreak-in-the-democratic-republic-of-the-congo-declared-a-public-health-emergency-of-international-concern">Ebola in 2014</a>; one for <a href="https://www.ecdc.europa.eu/en/news-events/who-ends-zika-public-health-emergency-international-concern">Zika in 2016</a>; and one in <a href="https://www.who.int/ihr/procedures/statement-emergency-committee-ebola-drc-july-2019.pdf">2019 for an Ebola outbreak</a> that is still ongoing. There are also several times that the WHO has decided not to call a PHEIC. This includes in 2018 and 2019 for the Ebola outbreak in the Democratic Republic of the Congo that is ongoing and is now a PHEIC, and the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6223a6.htm">2013 MERS epidemic</a>. Most recently, the <a href="https://www.who.int/news-room/detail/23-01-2020-statement-on-the-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">WHO declined</a> on Jan. 23 to declare a PHEIC for the novel coronavirus. At that time, the risk to other nations was deemed low.</p>
<h2>3. Why did the WHO do this now?</h2>
<p>Multiple instances of <a href="https://www.nytimes.com/2020/01/30/world/asia/coronavirus-china.html">human-to-human transmission</a> have occurred outside of China since last week. The fact that transmission has occurred in multiple countries, the severity of illness and concerns around how easily this virus may be transmitted led to the WHO calling a PHEIC.</p>
<h2>4. What will change?</h2>
<p>The PHEIC really serves as a call to action for the global community. It indicates that this is an extremely serious health threat. The PHEIC would give the WHO the ability to help increase efforts to control the outbreak. These include things like coordinating efforts between and across countries, making travel advisories, and reviewing control measures, such as the use of quarantines or active case finding, in countries to help ensure that the best public health practices are being used. </p>
<p>However, it is important to note that it does not change anything legally, meaning that each country still ultimately decides how it will handle an emergency. A PHEIC also indicates to people in affected countries that the situation is very serious and may help to persuade people to follow public health recommendations. </p>
<p>At the time of declaring a PHEIC, the WHO also issues advice specifically to the country or countries affected as well as the rest of the world. For instance, some of the <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">WHO recommendations to China</a> include: implementing a comprehensive risk communication strategy to inform citizens of China about the outbreak; implementing exit screening for all individuals leaving the country; and sharing full data on all human cases. It also urged China to identify the <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">zoonotic source</a> of the outbreak.</p>
<p>The WHO also advised that restrictions on the movement of people and goods during outbreaks are often not helpful and may cause unintended negative effects. It also advised the global community to <a href="https://www.who.int/news-room/detail/30-01-2020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committee-regarding-the-outbreak-of-novel-coronavirus-(2019-ncov)">“provide support to low- and middle-income countries to enable their response.”</a></p>
<p>[ <em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/130940/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aubree Gordon does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The World Health Organization declared the new coronavirus to be a public health emergency on Jan. 30, 2020. Does the action really change anything? An expert answers four questions.Aubree Gordon, Professor of Public Health, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/821892017-08-09T00:32:05Z2017-08-09T00:32:05ZTB’s stronghold in India: A tragedy there, and a grave concern for the rest of the world<p>A study published recently in The Lancet has drawn the world’s attention to the specter of particularly dangerous types of tuberculosis, called <a href="http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(17)30247-5/fulltext">multidrug-resistant and extensively drug-resistant, in four countries</a>. The study estimated that the percentage of multidrug-resistant TB among all cases in India, which already has the <a href="https://www.tbfacts.org/tb-statistics-india/">highest burden of the disease</a> of any country, is set to increase to more than 12 percent in India by 2040. </p>
<p>Also, TB that is extensively drug-resistant is likely to increase in India to almost 9 percent. </p>
<p>India had <a href="http://apps.who.int/iris/bitstream/10665/250441/1/9789241565394-eng.pdf">more cases of TB</a> than any other country in 2015, with more than two million new cases recorded during the year. India also accounted for more than a quarter of the world’s TB cases and deaths that year. </p>
<p>As a pediatrician who has treated hundreds of TB patients in India, I can personally speak to the devastating toll among children and families. I have seen dozens of Indian children die or become permanently handicapped from TB. </p>
<p>In today’s globalized world, TB has the potential to spread across the globe quite easily. One merely has to study the recent <a href="https://www.nytimes.com/2015/06/10/health/indian-woman-being-treated-in-us-for-drug-resistant-tuberculosis.html">case of an Indian with drug-resistant TB</a> who traveled to the U.S. to understand how this matter is of relevance to the entire world. </p>
<h2>Roadblocks that could prove disastrous</h2>
<p><a href="https://link.springer.com/chapter/10.1007/978-1-4939-6667-7_10">Drug-resistant TB</a> has been the focus of attention for Indian health care providers and authorities in recent years and has also received widespread media coverage. There are ongoing efforts to ensure good prescribing practices and compliance to prevent development of drug resistance. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=394&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=394&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=394&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=495&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=495&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181283/original/file-20170807-25576-1pjfvi7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=495&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A TB patient at the Chest Disease Hospital in Srinagar, India.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/India-World-Tuberculosis-Day/72f62cc31ebc4a28a9b2d88d4712dd36/5/0">AP Photo/Mukhtar Khan</a></span>
</figcaption>
</figure>
<p>While development of effective disease treatment strategies is essential, there seems to be a lack of focus as far as very obvious and basic preventive measures are concerned. There are a few aspects that need immediate attention of the government if India is to win its war on TB. Infectious diseases can be tamed only by development and proper implementation of preventive strategies.</p>
<h2>Isolation</h2>
<p>The developed world <a href="https://www.cdc.gov/tb/programs/laws/menu/isolation.htm">isolates people who are suspected of having TB until</a> they are proven to be not contagious. India does not have a quarantine policy, even for those who have the drug-resistant form and are highly contagious. Treating physicians recognize the <a href="http://www.hindustantimes.com/mumbai-news/tb-patient-who-is-resistant-to-12-out-of-13-drugs-could-spread-disease/story-KmTC7ZjDSIV3Y3wwBcAuBI.html">importance of quarantine</a> but are not able to recommend isolation due to the lack of a directive in the national TB policy.</p>
<p>Isolation of patients until they are no longer contagious raises philosophical and ethical issues. A governmental directive and concerted efforts to isolate a large number of patients will no doubt be met with resistance by advocacy groups, and for good reason. </p>
<p>However, allowing contagious TB patients to move around in the community or travel freely will ensure that India will probably never put an end to TB. A reasonable compromise would be to provide enough facilities so that isolated patients’ rights are minimally infringed upon. At the least, a public conversation regarding this matter needs to start.</p>
<h2>Failure to follow rules on masks</h2>
<p><a href="https://www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/GeneralHospitalDevicesandSupplies/PersonalProtectiveEquipment/ucm055977.htm">N-95 masks</a>, sometimes called respirators, are more effective at preventing TB than the ordinary surgical masks or no masks at all. Specialized training is required to use the masks correctly. They are disposable, cannot be reused and are more expensive than the surgical masks. </p>
<p>However, the cost is likely minuscule if one looks at the loss of productivity of those with TB as well as the financial burden of their treatment. The Indian government has mandated TB hospitals to use these masks. However, this <a href="http://www.dnaindia.com/mumbai/report-dna-impact-sewri-tb-hospital-will-get-n-95-masks-by-end-of-september-2126457">directive is often not followed</a>, possibly due to lack of funds, callous attitudes or even corruption.</p>
<p>There can be no compromise as far as the diligent use of N-95 masks is concerned. Health care workers who take care of patients with TB themselves often fall prey to the disease and become transmitters. During my three years treating children with TB in an Indian hospital, three of my colleagues acquired the disease, including one that spread to the brain and another one with the resistant form.</p>
<h2>Latent TB</h2>
<p>Anyone who is infected with TB but does not have the disease is classified as having latent TB. Typically, <a href="https://www.cdc.gov/tb/publications/factsheets/general/ltbiandactivetb.html">latent TB</a> is characterized by a positive reaction to a tuberculin skin test called Mantoux, or a positive blood test known as Interferon Gamma Release Assay. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/181407/original/file-20170808-10926-a81v9q.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Mycobacterium tuberculosis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/3d-illustration-bacterium-mycobacterium-tuberculosis-isolated-431684782?irgwc=1&utm_medium=Affiliate&utm_campaign=Hans%20Braxmeier%20und%20Simon%20Steinberger%20GbR&utm_source=44814&utm_term">Kateryna Kon/Shutterstock.com</a></span>
</figcaption>
</figure>
<p>The person with latent TB is not contagious, has a normal chest X-ray and no clinical manifestations. <a href="http://www.oneindia.com/feature/40-percent-of-india-s-population-play-host-the-tb-bacillus-as-latent-tuberculosis-2049544.html">At least one in three Indians has latent TB</a>. </p>
<p>In most of the developed world, latent TB is an <a href="https://www.cdc.gov/tb/topic/treatment/decideltbi.htm">indication to start treatment</a>. This treatment is shorter than the one for the disease and is found to be effective at decreasing the possibility of progression from infection to disease. In India, like the rest of the developing world, treatment is usually not offered for latent TB.</p>
<p>The World Health Organization for the first time <a href="http://apps.who.int/iris/bitstream/10665/136471/1/9789241548908_eng.pdf">released guidelines in 2014 for treatment of latent TB</a> including in the developing world. However, they are not definitive. In any case, India probably cannot blindly follow WHO guidelines, since local conditions have to be taken into account. India cannot use protocols followed by the developed world, either, because of the high number of those infected and drug resistance patterns.</p>
<p>Indian health care authorities need to formulate definitive protocols for treatment of latent TB that are based on local data. The first targets for treatment would likely be those who are at high risk for conversion of infection to TB disease, including young children who are exposed to contagious TB patients, health care workers, those living with HIV, homeless persons, prisoners and drug users. </p>
<p>Proper implementation of these protocols will be key, including ensuring patient compliance and easy access to medications. The Indian Council Of Medical Research recently announced a clinical trial for treatment of latent TB. However, many such trials need to be carried out and in a timely manner.</p>
<p>India can put an end to its TB ordeal. But sustained intervention and substantial allocation of funds by the government are needed. The Indian government needs to release definitive guidelines for treatment of latent TB and for quarantine. Additionally, it needs to ensure better implementation of guidelines including for the use of N-95 masks. Otherwise, India’s TB nightmare may end up as the elephant in the room that its burgeoning population problem has become due to the failure of the family planning initiatives. And in today’s globalized world, this will be bad news for the entire planet.</p>
<p><em>The author would like to thank Siddharth Varadarajan, the founding editor of TheWire.in, for helpful tips.</em></p><img src="https://counter.theconversation.com/content/82189/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jay Desai does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The health care debate in the US has focused on a looming crisis, with millions possibly losing insurance coverage. In India, an immediate crisis looms with tuberculosis.Jay Desai, Assistant Professor, University of Southern CaliforniaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/782352017-05-26T01:33:43Z2017-05-26T01:33:43ZWhy a monthly period is especially hard for millions of women and girls around the world<figure><img src="https://images.theconversation.com/files/171047/original/file-20170525-23260-15dwajo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Girls in Tanzania listen to an instructor who is teaching them about menstruation. </span> <span class="attribution"><span class="source">From menstrualhygieneday.org</span></span></figcaption></figure><p><a href="http://www.businessinsider.com/maps-flow-refugees-last-15-years-2017-5/#in-2008-afghan-and-iraqi-refugees-accounted-for-half-of-the-total-number-gathered-by-unhcr-india-also-became-a-major-asylum-for-roughly-100000-tibetan-refugees-somali-refugees">Millions of girls and women</a> are displaced and on the move right now globally. </p>
<p>An especially important but often overlooked issue is one of the most basic parts of life for women – menstruation. This routine part of female life is a pronounced burden for <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001962">women in low-income countries</a> and those who are displaced. It disrupts many girls’ abilities to participate actively in school, potentially consigning them to second-class status for the rest of their lives. A lack of easy <a href="http://www.wateraid.org/what-we-do/our-approach/research-and-publications/view-publication?id=5cfb752f-1929-41f9-9aa7-a69409bbad71">access to adequate toilets</a> in schools or elsewhere can also place them at higher risk for sexual violence as they seek out safe places to manage their menstruation and other sanitation needs.</p>
<p>As someone who is studying ways to help girls and women manage their periods with dignity, I see <a href="http://menstrualhygieneday.org">Menstrual Hygiene Day</a> on May 28 as a critical opportunity to talk about and bring attention to this too often taboo topic.</p>
<h2>Lack of privacy and access to facilities</h2>
<p>The <a href="https://www.rescue.org">International Rescue Committee</a> has partnered with Columbia University’s <a href="https://www.mailman.columbia.edu">Mailman School of Public Health</a>, with support from <a href="http://www.elrha.org/r2hc/home/">Research for Health in Humanitarian Crises</a>, to improve standards in menstrual hygiene management programming in emergencies across the world. </p>
<p>Its aim is to raise the bar and provide guidelines for a comprehensive response – one that considers more than just sanitary pads.</p>
<p>To do so, the project needed to ask adolescent girls and women what they actually need and want, and effectively integrate a variety of perspectives and experiences. </p>
<p>What we found was that the main difficulties women and girls faced went beyond a need for materials and included a lack of privacy and <a href="http://www.developmentbookshelf.com/doi/abs/10.3362/1756-3488.2016.024">facilities to manage their menstruation</a>. Living in tents without doors, with only curtains, they had no choice but to use the shared toilets, which were cramped, unclean, poorly lit and had no running water. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/171051/original/file-20170525-23267-zkuflu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A latrine at the Mtendeli Refguee Camp in Tanzania.</span>
<span class="attribution"><span class="source">Author provided.</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>This ranged from girls and women living in informal settlements in urban settings in the Middle East and Europe, to those in camps for refugees and internally displaced populations in Asia and Africa. </p>
<h2>Secrecy and taboos also complicate</h2>
<p>For women and girls displaced by conflict or natural disaster, <a href="http://msmagazine.com/blog/2015/10/20/the-syrian-refugee-struggle-no-ones-talking-about/">managing their monthly periods can be challenging</a>. Few female hygiene products are available, private sanitation facilities are hard to find and clean water is not always guaranteed. Often, even just talking about periods can be challenging, given the <a href="https://www.theguardian.com/global-development-professionals-network/2015/may/28/we-need-to-talk-about-periods-why-is-menstruation-still-holding-girls-back">secrecy and taboos that surround menstruation</a> in many societies. </p>
<p>Without the ability to properly manage their periods, women and girls are increasingly vulnerable in their day-to-day lives. It makes them more susceptible to <a href="http://journals.sagepub.com/doi/abs/10.1177/0956247814564528">gender-based and sexual violence</a> as they seek appropriate materials and private places to wash, dry and dispose of used materials. For example, many may need to seek out private spaces in forests or under cover or darkness to try to manage their washing and drying privately, but being alone puts them at risk of attack. </p>
<p>Other girls and women may encounter harassment when they go to pick up monthly distributions of pads. They risk embarrassment and ridicule from a menstrual leak, which can hinder their ability to engage socially, attend school or carry out daily activities. This can prove more challenging with limited laundry soap, water and few changes of clothes. </p>
<p>“If you take too long at the toilet someone will come in while you are changing and no one is supposed to see you during menstruation,” one girl shared.</p>
<p>“You must dry your underwear and pads in secret. People may steal it for witchcraft. This can cause you infertility,” said another.</p>
<p>We also found that disposal of waste materials was a common concern. There were no or few waste bins in the toilets in displacement camps, so women and girls needed to find their own ways of disposing of used pads. They were not willing to throw them away in the provided waste facilities in fear that people would see their pads and get hold of them. Strong cultural beliefs contributed to existing fears that if someone were to see their used menstrual material, they might be cursed.</p>
<p>In Myanmar, for example, women resorted to burying them in the ground at some distance from their homes, in the hours of darkness. Others tried to dispose of pads directly into toilets, leading to frequent blockages.</p>
<h2>Information lacking, and sometimes badly sourced</h2>
<p>Access to information was also scarce. Girls learned about menstruation from mothers, sisters or friends. As is often the case, this advice wove together folklore with more practical information. </p>
<p>For instance, we found that Syrian refugee girls in Lebanon believed that they were prohibited from washing themselves, cutting their hair or participating in physical activities while they were menstruating. </p>
<p>We found that women and adolescent girls strongly desired increased education around menstruation. Mothers especially wanted information on how best to discuss it with their daughters.</p>
<p>Instead, girls often learn about their periods from male teachers.</p>
<p>“When the teacher is telling them about menstruation, he is male, and there are boys there. The boys start to laugh and shout at them and afterward continue to tease us,” explained a Congolese girl in Nyarugusu Camp.</p>
<p>The humanitarian community has become better at <a href="https://nepal.oxfam.org/blog/oxfam-supports-adolescent-girl-students-after-earthquake">distributing materials to women and girls</a>, and in incorporating menstrual hygiene management into their responses. </p>
<h2>Working for solutions</h2>
<p>Making sure women and girls have access to suitable materials (and underwear!) and know how to use them is important; but there’s more to solving this problem.</p>
<p>Toilets and washrooms need to be private, safe and clean. Waste disposal systems need to address all waste flows generated in the camps effectively and discreetly. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3780686/">Schools need to be able to cater to girls</a> when they have their period. Better information is necessary to break societal taboos around menstruation. We’ve heard all of this from women and girls themselves.</p>
<p>The next step of our menstruation investigation project aims to finalize a comprehensive package of tools and guidelines to help agencies rapidly identify key needs; provide needed materials, facilities and support; and monitor the effectiveness of the program so that gaps can be identified and filled. </p>
<p>This is possible only if the humanitarian aid community works across sectors, including education, protection, health, water and sanitation, to provide the best possible programs in emergencies. </p>
<p>And it is possible only if aid workers talk with women and girls, listen to their concerns and provide appropriate programming, not just providing programs by the book. </p>
<p>Ultimately, a humanitarian response that allows women and girls to manage their menstruation in dignity is a better humanitarian response.</p><img src="https://counter.theconversation.com/content/78235/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marni Sommer received funding for this study from the Research for Health in Humanitarian Crises (R2HC) program
managed by Enhancing Learning and Research for Humanitarian Assistance (ELRHA). The R2HC programme (<a href="http://www.elrha.org/work/r2hc">www.elrha.org/work/r2hc</a>) aims to improve health outcomes by strengthening the evidence base for public health interventions in humanitarian crises. The £8 m programme is funded equally by the Wellcome Trust and UK Department for International Development. Marni Sommer is the Executive Director of Grow and Know, Inc, a non-profit that publishes puberty books for girls and boys in low-income countries. </span></em></p>For millions of girls and women, menstruation is a burden. Here’s why helping displaced and poor women and girls with their periods is a way to show true respect for them.Marni Sommer, Associate Professor of Sociomedical Sciences, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/752812017-04-05T01:09:30Z2017-04-05T01:09:30ZHow the Trump budget undercuts security risks posed by pandemics<figure><img src="https://images.theconversation.com/files/163652/original/image-20170403-21979-19gc0e.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"> Women in rural Malawi, outside an AIDS hospital. AIDS was the first of the ‘new’ pandemic threats, after bird flu.</span> <span class="attribution"><span class="source">Author provided. </span>, <span class="license">Author provided</span></span></figcaption></figure><p>President Trump proposed a <a href="https://www.nytimes.com/2017/02/27/us/politics/trump-budget-military.html">US$54 billion military budget increase</a> to solidify the security of our nation. However, the government also recognizes pandemic threats as an issue of national security – one that knows <a href="http://bit.ly/1iyixjV">no borders</a>. </p>
<p>In the last four years, we have faced the Ebola epidemic – contained after significant loss of life – and Zika, which is still not contained. Collectively, we will feel these effects for a generation, while children born with Zika-related defects and their families will feel the effects every day of their lives.</p>
<p>The U.S. is a leading member of the Global Health Security Agenda (GHSA), a growing international partnership created to respond to <a href="https://www.ghsagenda.org">infectious disease threats</a>. Yet the Trump budget slashes funding for the very agencies mandated to prevent pandemics. Take, for example, the <a href="https://www.nytimes.com/aponline/2017/02/28/us/politics/ap-us-trump-diplomatic-cutbacks.html">37 percent cut</a> to the $50 billion State Department and United States Agency for International Development (USAID) budget, more than <a href="https://www.theguardian.com/global-development/2017/feb/27/trump-first-budget-us-foreign-aid">one-third</a> of which targets global health security. As a global health researcher, I think this reveals a grave lack of understanding of the nuances and complexity of this national security issue.</p>
<p>The way the military protects America’s welfare is straightforward. The way that other U.S. agencies prevent pandemics is less understood. That it’s complicated shouldn’t stop our commitment to it. </p>
<h2>Threats are closer than we realize</h2>
<p>There are imminent threats that aren’t in the realm of hypothetical. Here’s an example: In January of this year, the government issued a travel warning in response to an active outbreak of H7N9 <a href="https://wwwnc.cdc.gov/travel/notices/watch/avian-flu-h7n9">bird flu in China</a>. </p>
<p>This strain of avian flu is worrisome because a few small mutations would allow it to spread from <a href="https://www.cdc.gov/flu/avianflu/h7n9-virus.htm">person to person</a>. This could be the next pandemic to sweep the globe. </p>
<p>Historically speaking, we are overdue for a bird flu disaster. They have been documented over the past two centuries and appear every 40 years on average; the last one was in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2862331/">1969</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=452&fit=crop&dpr=1 600w, https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=452&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=452&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=567&fit=crop&dpr=1 754w, https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=567&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/163656/original/image-20170403-21976-1h63xjn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=567&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Officials in southwest France ordered the slaughter of more than 600,000 ducks in February 2017 after an outbreak of bird flu.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/Search?query=bird+flu&ss=10&st=kw&entitysearch=&toItem=15&orderBy=Newest&searchMediaType=excludecollections">Bob Edme/AP</a></span>
</figcaption>
</figure>
<p>While preventing pandemics is expensive, it’s infinitely cheaper than the costs of actual pandemics. A report by the World Bank found a bird flu pandemic comparable to those from the last century could trigger a major global recession, with a <a href="http://www.reuters.com/article/us-reutersmagazine-davos-flu-economy-idUSBRE90K0F820130121">fall in global GDP</a> between 0.7 percent and 4.8 percent. While that might not sound like much, it represents $833 billion to <a href="http://statisticstimes.com/economy/countries-by-projected-gdp.php">$5.7 trillion</a>.</p>
<p>Billions have already been spent on pandemics this century. As an epidemiologist who worked for one U.S. pandemic prevention initiative sponsored by USAID, I don’t question the amounts being spent. What I do question is the return on investment using current unproven strategies that do nothing to address the urgency of the situation right now.</p>
<h2>National security, science and public health</h2>
<p>Since the 1970s, when USAID recognized that improved population health was integral to development goals, the number of infectious disease outbreaks has <a href="http://rsif.royalsocietypublishing.org/content/11/101/20140950">tripled</a>. In response, USAID created the <a href="https://www.usaid.gov/news-information/fact-sheets/emerging-pandemic-threats-program">Emerging Pandemic Threats program</a>, which focuses on discovering new animal viruses that may pose threats to human health.</p>
<p>However, it’s a big jump to identifying an animal virus with pathogenic potential to one that actually “spills over” and infects human populations. Instead of being an applied public health program with immediate potential to prevent pandemics, virus discovery is traditional scientific research. This research also does not address other pathogens that already pose pandemic threat, such as Zika, which is mosquito-borne, or superbugs (i.e., multidrug resistant bacteria). It turns out that the real problem to preventing pandemics is people.</p>
<p>Limited knowledge of human practices that increase risk of infection and of the diseases that pose the greatest risk represent the fundamental challenges to prevention. In 2015, the World Health Organization developed a list of emerging diseases likely to cause <a href="http://www.who.int/medicines/ebola-treatment/WHO-list-of-top-emerging-diseases/en/">severe outbreaks</a> in the near future: Crimean Congo hemorrhagic fever, Ebola virus disease and Marburg, Lassa fever, MERS and SARS coronavirus diseases, Nipah and Rift Valley fever. Three “serious” backup diseases didn’t make the final cut: chikungunya, severe fever with thrombocytopaenia syndrome and Zika (avian flu is treated separately). As history has shown us with Zika, we have a pretty good sense of what we’re up against in terms of disease. </p>
<h2>Is there a better way to prevent pandemics?</h2>
<p>Tools exist to determine which high-risk diseases are already circulating in human populations. Ebola provides a useful example. Decades before an outbreak was reported, a study found that Liberians <a href="http://www.who.int/bulletin/volumes/95/1/16-175984.pdf">had been exposed to Ebola</a> – and survived. </p>
<p>Although there are few studies like this, Liberia is not a unique example. Scientists in Gabon documented Ebola exposure years prior to its first reported outbreak. Disease exposure may predict countries at highest risk for future outbreaks, but provides no information about how people are infected.</p>
<p>That has changed. New tools exist which measure both the diseases that are circulating and the <a href="http://www.who.int/bulletin/volumes/95/1/16-175984.pdf">behaviors</a> that put people at risk of catching them. In fact, this approach, which integrates biological and behavioral surveillance, is already familiar to other successful USAID programs. </p>
<p>The closer we come to identifying where an outbreak will occur and which disease will be the likely culprit, the faster we can prioritize areas of highest risk. Targeted prevention strategies include developing diagnostics and vaccines in enough quantity to inoculate the population at immediate risk. </p>
<p>Since outbreaks often happen in remote areas with limited health infrastructure, the ability to vaccinate and detect disease will involve health systems strengthening – again beginning with regions at highest risk of known outbreak potential. </p>
<p>On March 3, the government stated increased concern regarding <a href="http://www.nbcnews.com/health/health-news/cdc-concerned-h7n9-bird-flu-s-sudden-spread-china-n728946">upgraded</a> H7N9 bird flu. Even if this is not the next pandemic, there is always another threat waiting in the wings. We have the tools to provide a formidable, cost-effective first pass at pandemic prevention. It’s time to get the most bang for the buck we still have left – and to protect our national security on all fronts.</p><img src="https://counter.theconversation.com/content/75281/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Maureen Miller does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>An active outbreak of a type of bird flu in China raises concerns about worldwide pandemics. Ebola and Zika viruses still threaten. Here’s why this is not the time to cut funding.Maureen Miller, Adjunct Associate Professor of Epidemiology, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/693432016-11-25T01:13:09Z2016-11-25T01:13:09ZZika ‘health emergency’ status removed but it’s sad news for reproductive health<p>The <a href="http://www.abc.net.au/news/2016-11-19/who-declares-end-to-zika-virus-emergency/8039566">recent announcement</a> the World Health Organisation (WHO) has <a href="http://www.who.int/mediacentre/news/statements/2016/zika-fifth-ec/en/">declared</a> Zika no longer a “public health emergency of international concern” is sad news. Rather than signalling a victory over this high profile global health threat, it is more a recognition the virus is <a href="https://blogs.scientificamerican.com/guest-blog/the-microbes-have-won-again/">here to stay</a>. </p>
<p>The announcement downgrades Zika to just another of the chronic, complex public health issues countries have to deal with. However, this one has a clear gender dimension. The losers will be women; poor, marginalised women who already have enormous threats to their reproductive health and the health of their babies.</p>
<p>Zika reached prominence in the past year as a <a href="https://theconversation.com/explainer-where-did-zika-virus-come-from-and-why-is-it-a-problem-in-brazil-53425">rapidly spreading outbreak</a> affecting Brazil and other parts of South America but now with active transmission in <a href="http://www.cdc.gov/zika/geo/active-countries.html">more than 60 countries and territories</a>. The particular features of Zika create a reproductive health nightmare that we now know is unlikely to end.</p>
<h2>Women will be disproportionately affected</h2>
<p>Zika in pregnancy has been linked to <a href="https://theconversation.com/explainer-what-is-microcephaly-and-what-is-its-relationship-to-zika-virus-54049">microcephaly</a> – a condition caused by the virus attacking brain cells and leading to small heads and brain damage in babies. </p>
<p>Zika infection often has no symptoms, so pregnant women may be silently infected, with potentially catastrophic outcomes for their child. Testing for mosquito-borne infections can be complex, making it difficult to be certain of infection on blood test alone. </p>
<p>This leaves pregnant women in an affected area unsure of their infection status and the impact on their baby. The only option is to monitor the baby by ultrasound and provide the choice of termination if the condition is detected early enough. An additional complexity for reproductive health is the fact that Zika has been transmitted <a href="https://theconversation.com/zika-via-sex-and-blood-how-worried-should-we-be-54174">sexually</a>.</p>
<p>Nearly 3000 babies have been born with microcephaly since the outbreak began. Although scientific investigations are still continuing, researchers conclude there is a <a href="http://www.cdc.gov/media/releases/2016/s0413-zika-microcephaly.html">link</a> with Zika infection. Although most microcephaly cases are in Brazil, there have been cases in other countries and the full extent of the problem is far from clear. </p>
<p>As a <a href="https://theconversation.com/zika-and-ebola-had-a-much-worse-effect-on-women-we-need-more-research-to-address-this-in-future-64868">recent article</a> highlighted, the gender dimensions of global health emergencies such as Zika and Ebola have not received enough attention. In both cases women of reproductive age have been particularly vulnerable to the effects of the outbreaks and tend to come from poor, marginalised communities where their access to reproductive health care is already limited. </p>
<p>In Sierra Leone, a country that already had one of the highest rates of maternal death, maternal and newborn deaths <a href="https://www.theguardian.com/world/2015/oct/07/baby-and-maternal-deaths-soar-in-sierra-leone-amid-ebola-fears-researchers">rose by a third</a> in the height of the Ebola outbreak. In Brazil, the areas most affected by Zika were those where women were <a href="https://www.chathamhouse.org/publication/ia/gendered-human-rights-analysis-ebola-and-zika-locating-gender-global-health#https://www.chathamhouse.org/publication/ia/gendered-human-rights-analysis-ebola-and-zika-locating-gender-global-health">least likely to have access to contraception</a> and medical care.</p>
<h2>Implications of the status downgrade</h2>
<p>When downgrading Zika’s emergency status WHO said its response would remain <a href="http://www.abc.net.au/news/2016-11-19/who-declares-end-to-zika-virus-emergency/8039566">robust</a>. However, this downgrade is a move from emergency response to long term development issue.</p>
<p>The decision is based on WHO’s assessment that the situation no longer meets criteria for a <a href="http://www.vox.com/2016/2/1/10871562/zika-health-emergency-who">public health emergency of international concern</a>. A WHO expert committee can declare such a public health emergency under legal structures set up to govern pandemics called the <a href="http://www.who.int/topics/international_health_regulations/en/">International Health Regulations</a>. </p>
<p>There have only been three previous declarations since the regulations began in 2007 (for swine flu, polio and Ebola). A declaration is a political tool that WHO uses to focus attention and expertise on “extraordinary” global health threats and can allow for trade and travel restriction. </p>
<p>The uncertainty around Zika and explosion of microcephaly cases in Brazil triggered the declaration to mobilise increased surveillance and global awareness. In removing the emergency status WHO has accepted this is not an acute situation that can be limited, that Zika is not going away, and that emergency structures are not the most appropriate framework for this now chronic situation. </p>
<p>WHO acknowledged Zika remains a “significant and enduring public health challenge”, one that should not be underestimated.</p>
<h2>Concerned about the announcement</h2>
<p>Public health experts have reacted with concern to the announcement. Global health expert <a href="https://www.law.georgetown.edu/faculty/gostin-lawrence-o.cfm">Lawrence Gostin</a> called the move <a href="https://www.washingtonpost.com/news/to-your-health/wp/2016/11/18/who-no-longer-considers-zika-a-global-health-emergency-2/">“quite worrying”</a> due to the possibility the international response could become “lethargic”. </p>
<p>The high-level attention, associated <a href="https://www.scientificamerican.com/article/congress-approves-1-1-billion-in-zika-funding/">mobilisation of funds</a>, and pressure for vaccine development, risk losing momentum if Zika is no longer seen as a crisis. </p>
<p>In the absence of a vaccine, which could be years away, women in affected areas face a devastating reproductive health crisis. Preventative measures to avoid mosquito bites have been unable to eliminate transmission in other mosquito-borne infections. </p>
<p>The advice to consider delaying pregnancy is not feasible long-term. Potential public health responses – sex education, access to contraception, access to ultrasound and antenatal care, access (and legal frameworks for) safe and accessible abortion – are already lacking or severely compromised in many areas affected. </p>
<p>The recent WHO announcement takes us into a new phase, one that is unknown and complex. Zika is now a reproductive health threat that is here to stay, another shadow of uncertainty hanging over thousands of women worldwide as they go through the vulnerable journey of pregnancy and childbirth.</p><img src="https://counter.theconversation.com/content/69343/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Bateman Steel receives funding from the National Health and Medical Research Council and the Royal Australasian College of Physicians to do a PhD in gender equity and global health </span></em></p>The World Health Organisation no longer sees Zika as a health emergency. But what does this downgrade mean for the health of mothers and babies?Catherine Bateman Steel, Adjunct Lecturer and PhD student, School of Social Sciences, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/648682016-10-19T19:10:27Z2016-10-19T19:10:27ZZika and Ebola had a much worse effect on women: we need more research to address this in future<figure><img src="https://images.theconversation.com/files/140679/original/image-20161006-20110-s4c85k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregnant women in Sierra Leone, Guinea and Liberia were faced with the double fear of dying from Ebola as well during childbirth. </span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/unmeer/16075719060/in/photolist-quygd1-qTRgVy-rdJgMa-q2bC8E-qjrA94-qBtyYD-qgVJhF-rghj2V-rbqLBd-rdznSk-pX9qSP-qjeqm3-rdCnRU-qYMv2i-qW9x4u-qNwU29-rbr83o-pV9LQX-oPRK3S-rgd93e-qMihHA-qBtwhM-qRVMVR-dtTWk9-qBtucz-qBtzcV-rg9v2d-rdznhH-oEq7Yu-oH6sAV-qzmww9-rdUTtm-rbqKZb-qgVFMv-pudFgi-pX9r6p-qRCJCd-pWVAtQ-rghiXg-qBmjFo-qBv2w4-pX9q9e-rghiKn-oTDnsX-qWifKt-qjvJUH-rgb17K-rdUUDh-piAso6-GFGPP3">UNMEER/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Outbreaks of the Ebola virus – declared as a public health emergency in 2015 – and, more recently, Zika, had a disproportionate impact on women. In issuing emergency advice, international agencies acknowledged the different experiences of men and women during both crises. </p>
<p>But as we found in our recently published article in <a href="https://www.chathamhouse.org/publication/ia/gendered-human-rights-analysis-ebola-and-zika-locating-gender-global-health#https://www.chathamhouse.org/publication/ia/gendered-human-rights-analysis-ebola-and-zika-locating-gender-global-health">International Affairs</a>, the advice they offered did not take into account women’s limited capacity to protect themselves from infection.</p>
<p>We found less than 1% of published research papers around the time of both outbreaks, and that related to the outbreaks, actually explored their gendered impact. Research that examines the gendered inequality of public health emergencies must be conducted to inform future international responses.</p>
<h2>Exacerbating existing inequality</h2>
<p>By the end of 2015, the three West African countries most affected by Ebola – Guinea, Liberia and Sierra Leone - <a href="http://apps.who.int/ebola/current-situation/ebola-situation-43-report-4-November-2015">had a total of 8,703 cases of the virus</a> in women compared to 8,333 in men. But the sex tally of those infected does not reveal the <a href="http://www.undp.org/content/dam/undp/library/crisis%20prevention/Recovering%20from%20the%20Ebola%20Crisis-Full-Report-Final_Eng-web-version.pdf">social impact</a> of the disease on local populations.</p>
<p>In October 2014, it was estimated more than 600,000 <a href="http://www.rhm-elsevier.com/article/S0968-8080(14)44820-1/abstract">women would be giving birth</a> in Liberia, Guinea and Sierra Leone over the next 12 months. In these countries, where maternal death rates are usually high, pregnant women <a href="http://www.rhm-elsevier.com/article/S0968-8080(14)44820-1/abstract">were said to now be facing</a> “the double fear of dying from Ebola and during childbirth”. </p>
<p>In addition, estimates published in the Lancet medical journal showed an extra 4,022 women <a href="http://www.thelancet.com/journals/langlo/article/PIIS2214-109X(15)00065-0/fulltext">would die annually in childbirth</a> in the three affected countries as a result of a shortage of health care workers who had died from the virus. </p>
<p>Although the outbreak is over, women <a href="http://thelancet.com/journals/langlo/article/PIIS2214-109X(16)30175-9/fulltext">continue to be at risk</a> of contracting the disease from unprotected sexual intercourse with men who were previously infected by Ebola.</p>
<p>Given Zika’s <a href="https://theconversation.com/explainer-what-is-microcephaly-and-what-is-its-relationship-to-zika-virus-54049">link to microcephaly</a> – a condition where babies of infected women are born with small heads – the outbreak more obviously affected pregnant women than did Ebola.</p>
<p>During the outbreak’s initial phase, there was open discussion about the links between the geographical location of microcephaly cases and the women most affected. These women were more likely to be Indigenous and come from either <a href="https://www.washingtonpost.com/news/world/wp/2016/02/24/zika-exposes-class-differences-in-brazil-where-most-victims-are-poor/">urban poor or remote locations</a>, as well as lack access to contraceptives and abortion.</p>
<p>The irony <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)00331-7/abstract">was noted</a>: already marginalised women were being asked by governments to avoid pregnancy. This was <a href="http://www.bbc.com/news/world-latin-america-35388842">without acknowledgement by these same governments</a> of their own role in hindering women’s access to contraceptives, sex education and safe abortion practices in the first place.</p>
<h2>Our study</h2>
<p>In the case of both outbreaks, we were concerned about the lack of international bodies’ early discussion on how to support women to take preventive measures again the diseases. We wondered if lessons had been learnt from the Ebola outbreak to enable a different gender experience during the Zika outbreak.</p>
<p>To answer our question, we searched articles published in the Scopus journal database (covering 29 million abstracts in over 15,000 peer-reviewed titles from more than 4,000 publishers) for Zika– and Ebola–related pieces.</p>
<p>Between 1 January 2015 and 15 May 2016, just 21 articles of 608 publications explored the relationship between “Zika” and “human rights”. Two articles explored “human rights”, “gender” and “Zika infection”. But only one article talked about women’s risk of Zika infection due to gender inequality.</p>
<p>In the case of the Ebola outbreak in West Africa, using a date range from 1 January 2014 to 15 May 2016, we searched “Ebola” and “human rights”; “Ebola” and “gender”; “Ebola” and “human rights” and “gender”. </p>
<p>Of 4,236 articles published on Ebola in Scopus during this period, 335 examined Ebola and human rights; 14 examined gender relations in the context of the Ebola outbreak; and one examined the relationship between human rights, gender relations and the outbreak. </p>
<h2>Why is this important?</h2>
<p>The social and economic conditions affecting women’s options and ability to control their risk of infection has received comparatively little attention to that of the overall consequences of both outbreaks. </p>
<p>Even if women adequately protect themselves from infection and survive Zika and Ebola, they are still unlikely to have improved equitable health opportunities after these emergencies. Indeed, they face the risk of worse health and inequality.</p>
<p>More research examining the effect of gendered inequality of public health emergencies must be conducted to inform future international advice and responses, so those affected can survive the crisis without compounding existing inequalities.</p><img src="https://counter.theconversation.com/content/64868/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara Davies receives funding from Australian Research Council.</span></em></p><p class="fine-print"><em><span>Belinda Bennett does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>We found that less than 1% of published research papers around the time of both outbreaks, that related to the outbreaks, actually explored their gendered impact.Sara Davies, ARC Future Fellow, Griffith UniversityBelinda Bennett, Professor of Health Law in the Australian Centre for Health Law Research, Queensland University of TechnologyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/607992016-06-16T13:08:07Z2016-06-16T13:08:07ZWhy new-fangled mosquito controls should not replace tried and tested methods<figure><img src="https://images.theconversation.com/files/126741/original/image-20160615-14027-1wmpx9s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Controlling mosquitoes has a large effect on controlling the diseases they carry.</span> <span class="attribution"><span class="source">Alvin Baez/Reuters</span></span></figcaption></figure><p>In the last 40 years of mosquito-borne viruses such as malaria, yellow fever and dengue, scientists have introduced myriad interventions to control the population of mosquitoes. This is because controlling mosquitoes has a large effect on controlling the diseases since the mosquito is the vector that carries them. </p>
<p>Novel mosquito-control approaches have included everything from deploying sterile male mosquitoes to soaps that could prevent people in high-risk malaria areas from contracting mosquito-borne diseases. </p>
<p>Zika, the latest mosquito-borne virus to be declared a <a href="http://www.portal.pmnch.org/emergencies/zika-virus/articles/one-year-outbreak/en/">global health emergency</a>, has once again propelled innovations to tackle the control of mosquitoes. </p>
<p>There is talk of trying to stop Zika by giving mosquitoes a <a href="http://www.recode.net/2016/5/31/11825676/gates-foundation-chief-code-conference-">sexually transmitted disease</a> and even injecting plants with a bacterium that would alter the <a href="http://www.smithsonianmag.com/science-nature/malaria-zika-and-dengue-could-meet-their-match-mosquito-borne-bacteria-180959271/?no-ist">mosquito’s genome</a> and eliminate its thirst for blood.</p>
<p>Many of these innovations are good ideas but collectively they are only one of the tools in the armament of fighting mosquito-borne diseases. And they should not draw focus away from the tried and tested public health measures to control mosquito-borne diseases. These include environmental sanitation and access to clean water. </p>
<h2>Different innovations</h2>
<p>Making male mosquitoes sterile was one of the first innovations introduced in the 1970s when malaria was considered a problematic disease. This was becase the malaria parasite had become resistant to front line drugs.</p>
<p>Several other quick fixes have also been offered. <a href="http://www.cdc.gov/malaria/malaria_worldwide/reduction/vector_control.html">These</a> include fungi, worms and fish that parasitise and kill larval mosquitoes before they transform into adult mosquitoes. But these innovations were all found to be ineffective.</p>
<p>Changing the genetic makeup of the mosquito has also been explored. It results in mosquitoes that are not susceptible to the parasite. But this approach is still many years from application in field settings. </p>
<p>Having grown up on the banks of a heavily polluted canal in Nigeria and with limited access to potable water, the innovation that most fascinated me is a <a href="http://www.foxnews.com/health/2016/05/12/mosquito-repellent-soap-invention-seeks-to-wash-away-africa-malaria-threat.html">mosquito-repellent soap</a>.</p>
<p>Two African scientists created the soap from natural oils and plants. The hope was that it could successfully prevent mosquito-borne diseases because it is cheap to produce and relies on existing habits such as bathing, cleaning and doing laundry.</p>
<p>But there is a catch. People need access to clean water to use the soap. Given that globally more than 700 million people still lack <a href="http://www.who.int/water_sanitation_health/hygiene/en/">access to safe water</a>, an innovation like a mosquito-repellent soap could become just another quick fix that only serves some but distracts from the complex task of providing more workable solutions.</p>
<p>The use of <a href="http://www.malariaprotection.com/es/wp-content/downloads/research/lindsay.pdf">mosquito-repellent soaps</a> is in fact not a new idea. Natural insect repellents have been in use for millennia and soaps containing such ingredients have been available for at least 30 years.</p>
<p>But natural mosquito-repellent soaps have been shown to have lower efficacy when compared to soaps containing the synthetic repellent DEET. More so, most of those natural ingredients could be <a href="https://malariajournal.biomedcentral.com/articles/10.1186/1475-2875-10-S1-S11">harmful to health</a>. Many of them cause cancer.</p>
<p>Some of these innovations have worked on a small scale but are not as effective on a larger scale. And although the innovations focus on mosquito control, this is only one of many factors that result in the spread of mosquito-borne diseases. </p>
<h2>A complex set of diseases</h2>
<p>The reality is that there are many <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2640300/pdf/9716967.pdf">factors responsible</a> for the persistence and global spread of mosquito-borne diseases. These are complex.</p>
<p>They include: </p>
<ul>
<li><p>insecticide and drug resistance;</p></li>
<li><p>changes in public health policies;</p></li>
<li><p>emphasis on emergency response;</p></li>
<li><p>demographic and societal changes; and </p></li>
<li><p>genetic changes in pathogens. </p></li>
</ul>
<p><a href="http://www.wpro.who.int/mvp/climate_change/about/en/">Climate change</a> is also implicated. Since insects have no internal control over their body temperature, as ambient temperatures rise their distribution may expand through increased reproductive rate, biting behaviour, and survival. </p>
<p>Humidity and the availability of water for breeding in areas that are usually dry also promotes vector distribution and longevity. The incubation period of pathogens in vectors is temperature-dependent and becomes shorter in warmer conditions. </p>
<p>Unprecedented population growth, mostly in developing countries, has resulted in major movements of people, primarily to urban centres. This unplanned and uncontrolled urbanisation has led to inadequate housing and deteriorating water, sewage, and waste-management systems. These produce ideal conditions for mosquito-borne diseases to be transmitted. </p>
<p>My personal experiences and those of the hundreds of patients I treated for recurrent malaria in the slums of southern Nigeria are proof of this.</p>
<h2>The best approach</h2>
<p>So, what is the best way to prevent mosquito-borne diseases? </p>
<p>The variation in malaria’s epidemiology in and between countries shows that a multi-pronged approach is needed. This includes:</p>
<ul>
<li><p>providing and improving public health infrastructure;</p></li>
<li><p>research to develop effective drugs and vaccines; and </p></li>
<li><p>improved vector control using proven techniques while taking up new innovations.</p></li>
</ul>
<p><a href="http://www.sciencedirect.com/science/article/pii/S1473309905702681">Research</a> has shown that mosquito control measures built around environmental management are non- toxic, cost-effective, sustainable and highly effective in reducing morbidity and mortality. Those environmental measures including standing water, vegetation and drainage management all rely on access to clean water and sanitation.</p>
<p>The <a href="http://www.unicef.org/wash/3942_statistics.html">impact</a> of adequate access to clean water, sanitation and hygiene go beyond mosquito control. They are essential for human survival. Access to these basic needs has a positive impact on the overall health, wealth and economic development of people and communities around the world.</p>
<p>Improving access to water also goes a long way in preventing – and even eliminating – other water and sanitation-related diseases such as cholera, <a href="http://www.mayoclinic.org/diseases-conditions/trachoma/basics/definition/con-20025935">trachoma</a>, <a href="http://www.who.int/mediacentre/factsheets/fs115/en/">schistosomiasis</a>, worm infestations and <a href="http://www.who.int/dracunculiasis/disease/en/">guinea worm disease</a>. </p>
<p>UNICEF <a href="http://www.unicef.org/wash/3942_statistics.html">estimates</a> that if countries in need were able to get basic, low-cost water and sanitation facilities, the world would save around US$263 billion a year. Those savings would come from obviated health and labour expenses. </p>
<p>The threats that mosquito-borne diseases pose to global health are as real as the are complex. The response must be broad and calculated. It must apply proven interventions while trying out new ideas. </p>
<p>Public health innovations should be considered as just one tool in our armament. They should not distract us, as they sometimes have, from the complex task of protecting and promoting global health through interventions like improving access to clean water, sanitation and hygiene.</p><img src="https://counter.theconversation.com/content/60799/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Utibe Effiong does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Innovations targeted at mosquito control are good but should not draw focus away from the tried and tested public health measures to control mosquito-borne diseases.Utibe Effiong, Resident Physician at St Mary Mercy Hospital and Research Scientist for the Exposure Research Laboratory, University of MichiganLicensed as Creative Commons – attribution, no derivatives.