COVID-19 Begins To Impact Drug Supplies; Infections Accelerate in Iran, Across Europe & United States
Workers in full personal protective gowns help unload 7.5 metric tons of medical supplies to support the COVID-19 response in Iran

As the COVID-19 continued its march across the planet, shortages of some key drug ingredients were beginning to be felt in some markets, and iconic events such as the World Bank’s annual spring meeting were to be moved to a virtual platform.

In Geneva, parallel sessions and side events involving the ongoing annual meetings of the Human Rights Council were cancelled. The Geneva Health Forum, Switzerland’s own premier global health event, originally planned for the end of the month, was postponed until mid-November.  This followed a Swiss ban of gatherings of more than 1,000 people.

India Surprise Announcement Restricting Exports of Key Drug Ingredients

India’s surprise announcement on Wednesday of restrictions on exports of two dozen pharmaceutical ingredients (APIs) and products, including such common drugs as paracetamol, acyclovir, and the anti-parasitic agent metronidazole, seemed to catch drug agencies and pharmaceutical industry observers by surprise.

The FDA also announced shortages of pindolol, a drug commonly used for the treatment of hypertension and cardiovascular disease. That followed an FDA announcement last week of a pending shortage of “one human drug” on US markets, without referring to the compound by name.

About 40% of APIs for the US generic drug market come from India.

Some observers, however, cautioned that it was too soon to assess how significant supply interruptions in China and India were, or how they would affect markets elsewhere.

“We have heard reports of export restrictions in China and India…Whether it’s there is a real supply shortage or there is a certain amount being set aside for domestic use, and they are cutting exports…We need to learn a little bit more about that,” Outi Kuivasniemi, of Finland’s Ministry of Social Affairs and Health, at a seminar on the COVID-19 crisis at the Geneva Graduate Institute.

Until now, it had been widely thought that India’s generics industry could hopefully make up for the shortfalls in China’s manufacturing of key APIs, or drug ingredients, which is still reeling from a month of COVID-19 shutdowns.

“China’s manufacturing of APIs still trying to come back online,” Paul Mollinaro, WHO’s head of logistics told reporters at a WHO press briefing on Tuesday, noting the fear that the “ripple effects will create shortages in medicines as well.”

Global Cases of COVID-19 as of 4:30PM CET 4 March 2020.

More Cases in Europe; Rising Concerns About Iranian Epidemic 

Around the world, there were now 94,250 cases of COVID-19 and 3,214 deaths as of 4:15 pm Central European Time.   More than 800 new cases were reported in the European Union and the United Kingdom overnight, according to the European CDC, reporting the acceleration of the epidemic across the continent.  Italy continued to be the epicentre with 2502 cases and 79 deaths in total.  But more cases were being reported in France, Spain, Switzerland, Germany and the United Kingdom as well.

In contrast, China had reported only 119 new cases in the past 24 hours, another record low since the outbreak began accelerating in the country in late January. In Asia, South Korea now was facing the biggest battle to control the disease, with a cumulative total of 5,621 cases and 28 deaths, while Iran was reporting 2922 cases and 92 deaths. WHO has rushed a team of medical advisors as well as a shipment of supplies to Tehran, including 100,000 testing kits, which arrived earler this week.

There were, however, concerns that numbers of those affected by the outbreak in Iran had been under-reported, as media accounts of bungled COVID-19 control measures and a slow reaction by health authorities came to light.

In a blistering op-ed, the Washington Post’s Editorial Board described Iran as: “a worrying scenario: a government in denial, a people cynical and distrustful, and a burgeoning infection. Strictly from a health point of view, Iran has become a dangerous epicenter for COVID-19, a hazard not only for its population but also the world.”

As many as three top Iranian officials, including an advisor to Iran’s Supreme Leader Ali Khamenei Mohammad Mirmohammadi, have died from the disease, noted Suerie Moon, co-director of the Geneva Graduate Institute’s Global Health Centre, in a seminar Wednesday on government and public responses to the crisis. According to VOX news, Iranian Vice President Masoumeh Ebtekar tested positive for COVID-19 just a day after attending a high-level cabinet meeting with the Supreme leader himself. Already last week, Iran’s deputy health minister announced that he had tested positive for COVID-19.

Reports of a growing COVID-19 outbreak in Iranian prisons have also emerged, leading to the reported furloughing of some prisoners. In one account, the law firm Perseus Strategies, described the case of an Iranian-US executive Siamak Namazi held in Evin Prison since 2015, where prisoners continued to be housed in crowded cells of 10-20 people each, even after one prisoner tested positive for the coronavirus. Family membes of the Iranian-British woman, Nazanin Zaghari-Ratcliffe, a project manager with the Thomson Reuters Foundation detained in Evin Prison since 2016, have also stepped up their diplomatic battle to have her released, saying that she lacked access to basic hygiene and also had symptoms of COVID-19 infection, something that Iranian authorities have denied.

Southeast Asia Reporting More Cases – US Fears of Community Transmission

WHO’s Regional Director for South-East Asia, meanwhile warned that for India along with the rest of South-East Asia “more cases can be expected” of the coronavirus which is now slowly appearing across the sub-continent too. On Wednesday, densely populated India was now reporting 28 cases, along with 43 cases in Thailand, 2 in Indonesia and 1 each in Sri Lanka and Nepal.

“Rapidly identifying these cases, isolating them and following their contacts are important initiatives to help limit person to person transmission. The speed of our response is critical, which is only possible if we are prepared,” said the Regional Director, Dr Poonam Khetrapal Singh.

Port of entry temperature screening in Bhutan, part of WHO’s Southeast Asia Region

Community transmission seemed to be a rising problem in the United States, which was reporting 128 cases including a growing cluster of community transmission in Washington State, which has seen 27 cases and 9 deaths, and the first confirmed cases in the country’s most densely populated urban hub, New York City.

But as with emerging clusters elsewhere, those numbers may only be the tip of the iceberg, experts said.

Trevor Bedford, head of the Seattle-based Bedford Lab estimated that the real number of cases Washington State’s Snohomish County was more likely around 570 with an 90% uncertainty interval of between 80 and 1500 infections.”

His modelling estimates, published in the Laboratory’s blog, are based on the fact that due to delays in testing, the first people infected may have quietly exposed others else to the virus between Jan 15 and Jan 19 before they were isolated.

“If this second case was mild or asymptomatic, contact tracing efforts by public health would have had difficulty detecting it,” Bedford said, adding, “After this point, community spread occurred and was undetected due to the CDC narrow case definition that required direct travel to China or direct contact with a known case to even be considered for testing.”

He called this delay in testing a “critical error” that allowed an outbreak in Snohomish County to grow to a “sizeable problem” before it was detected.

In another development, a leading group of US public health experts called upon the US Government to make COVID-19 testing and treatment free – so that costs would not pose a barrier to disease containment.

In an open letter to Mike Pence, US Vice President, and designated head of the nation’s COVID-19 response, 489 public health, law, human rights, and medical experts and 14 organizatios published called on the government to “make sure that the burdens of COVID-19, and our response measures, do not fall unfairly on people in society who are vulnerable because of their economic, social, or health status.”

While the high cost of health care in the US, leaving tens of millions of uninsured, has been a longtime domesitc political football, the issue has now also become critical to COVID-19 containment as reports began to proliferate in media about Americans saddled with large medical bills after they submitted to quarantine or treatment.

On Tuesday, New York State Governor Andrew Cuomo became the first issue a directive requiring state health insurers as well as state supported Medicaid to wave co-pay costs associatd with testing and medical care for anyone infected. Ruben Gallego, Arizona’s democratic representative for the US House of Representatives announced that he plans to introduce a bill to cover medical testing and treatment costs associated COVID-19.

“Coronavirus could spread even more quickly if people avoid testing and treatment due to astronomical medical costs,” Gallego said. “Nobody should be forced to put their own health and lives – and the health and lives of those around them – at risk because they can’t afford critical medical care.

Global Fund Says Countries can Repurpose Some Grants for COVID-19 Response

In Geneva, The Global Fund to Fight AIDS, Tuberculosis and Malaria, said it would allow countries to “reprogramme” unused funds from existing grants and “redeploy” underused resources to bolster overall health system response to COVID-19 in low- and middle-income countries.

“COVID-19 could derail progress on HIV, TB and malaria, through disruption to treatment or other interventions or supply chains of critical medicines and medical supplies,” a press release from the Global Fund stated.

“As was the case with Ebola, the Global Fund is committed to a pragmatic and flexible approach in supporting countries in the fight against COVID-19,” said Peter Sands, Executive Director of the Global Fund, in a press release. “Our priority is to ensure continuity of lifesaving programs to end HIV, TB and malaria. However, COVID-19 could knock us off track. People infected with HIV, TB and malaria could prove more vulnerable to the new virus given that their immune systems are already under strain.”

Additional activities under the new COVID-19 guidelines include, but are not limited to, epidemic preparedness assessment, laboratory testing, sample transportation, use of surveillance infrastructure, infection control in health facilities, and information campaigns.

The news follows announcement on Tuesday of an immediate US$12 billion grant by the World Bank to support COVID-19 response activities.

World Bank Plans “Virtual” Spring Meeting; But Iraq Continues Plans For Mass Pilgrimage Event 

While the Bank announced that it would be holding its annual Spring Meeting, virtually, to avoid risks of infection among the tens of thousands who usually attend, plans were going ahead in Iraq for a major series of Shi’ite pilgrimage events set to occur this month – bolstered by technical support from WHO on infection prevention measures.

“As millions are expected to visit Iraq in the coming month for religious events, WHO is working with religious leaders and health officials to discuss necessary preventive measures to improve planning for mass gathering events during visits to holy sites to protect visitors from possible coronavirus disease (COVID-19) infections,” a press release from WHO’s Eastern Mediterrenean Region Office, stated.

“So far, the measures taken by the Government of Iraq to limit the spread of COVID-19 comply with WHO recommendations. Other urgent preparations, however, are critically needed, such as designating proper isolation facilities,” WHO Representative in Iraq Dr Adham Ismail, was quoted as saying. “Iraq has conducted a risk assessment and health authorities are calling on clerics to support Iraq’s decision to avoid gatherings as much as possible to prevent the spread of this disease. WHO supports that position,” he added.

The Islamic month of Rajab, which this year extends from 25 February-23 March, is marked by an important series of days of celebration, remembrance and mourning in the Shi’ite Islamic calendar, when Shi’a pilgrims from around the world typically visit religious centres such as the Al Kadhimiya Mosque in Baghdad.

“Strict measures have been taken by religious authorities at Al-Kadhimain Holy Shrine to preserve the safety of workers and visitors alike. These measures include the use of personal protective equipment, such as masks and gloves, by all shrine workers, in addition to closing the site for sterilization,” the Secretary-General of Kadhimain Holy Shrine, Dr Haider Hussain Al-Shammari, was quoted in the WHO press release as saying.

“WHO is providing technical advice and recommendations on visits to holy sites to prevent the spread of disease, including COVID-19. This includes best methods for sterilizing surfaces and equipment, the use of thermal detection devices at entrances and checkpoints, and proper referral and isolation measures for suspected cases.”

Iraq announced the first COVID-19 infection on 25 February 2020. This number has since increased to 26 cases on 3 March, all among nationals coming from Islamic Republic of Iran.

Asked by Health Policy Watch if WHO was in fact recommending that the Shi’a mass gatherings still proceed – even after Saudi Arabia has suspended foreign visits to its year-round “umrah” pilgrimage over fears of the virus, a WHO spokeswoman didn’t respond.

Meanwhile, across Europe, conferences and meetings, both large and small continued to be cancelled in the face of the burgeoning COVID-19 epidemic on the continent.

While France has banned mass gatherings of 5,000 or more, Switzerland has banned gatherings of more than 1,000 people.

In Geneva’s international health and development hub, Geneva Cantonal health authorities told the many non-profit groups operating in the city that they are free to meetings involving fewer participants.

But they should undertake a risk assessment to determine if the event is really necessary at this moment in time.  NGOs or their participants also need to be prepared to bear the costs of state-mandated treatment, should someone develop symptoms during their time in the city, as well as costs of quarantine for any close contacts of identified COVID-19 cases,” officials have said.

It is not yet clear how the Swiss directive might affect one of the next really big UN gatherings in the city, the World Health Assembly, which usually takes places in late May and draws thousands of participants from around the world.

On the other side of the Atlantic, however, the World Bank was setting a carefully-watched precedent, in its announcement that virtual channels would be used for its Spring Meeting, which covers a wide range of health and development topics:

“Like everyone else around the world, we have been deeply concerned by the evolving situation of the Coronavirus and the human tragedy surrounding it. Given growing health concerns related to the virus, the Management of the IMF and World Bank Group and their Executive Boards have agreed to implement a joint plan to adapt the 2020 IMF-World Bank Spring Meetings to a virtual format.”

The decision was hailed on some social media channels as a milestone move that could save on high travel costs and related carbon emissions that are often associated with big global gatherings.

“This *could* be the moment when we collectively finally crack videoconferencing on a mass scale, for good,” said The Wellcome Trust’s Director of Strategy, Ed Whiting in a Tweet filled with emojis of airplanes and then trees, “Bring it. Interested how tech steps up.”

 

 

 

 

 

 

 

 

 

 

Image Credits: Twitter: @WHOEMRO, John's Hopkins CSSE, WHO Bhutan.