Over 1 million treated with highly effective hepatitis C medicines

27 OCTOBER 2016 | GENEVA - Over one million people in low- and middle-income countries have been treated with a revolutionary new cure for hepatitis C since its introduction two years ago.

When Direct Acting Antivirals (DAAs) were first approved for hepatitis C treatment in 2013, there were widespread fears that their high price would put them out of reach for the more than 80 million people with chronic hepatitis C infections worldwide.

The new medicines have a cure rate of over 95%, fewer side effects than previously available therapies, and can completely cure the disease within three months. But at an initial estimated price of some US$85 000 they were unaffordable even in high-income countries.

Countries show hepatitis C treatment is achievable

Thanks to a series of access strategies supported by the World Health Organization (WHO) and other partners, a range of low- and middle-income countries, including Argentina, Brazil, Egypt, Georgia, Indonesia, Morocco, Nigeria, Pakistan, Philippines, Romania, Rwanda, Thailand and Ukraine – are beginning to succeed in getting drugs to people who need them. Strategies include competition from generic medicines through licensing agreements, local production and price negotiations.

"Maximizing access to lifesaving hepatitis C treatment is a priority for WHO," says Dr Gottfried Hirnschall, Director of WHO's Department of HIV and Global Hepatitis Programme. "It is encouraging to see countries starting to make important progress. However, access still remains beyond the reach for most people."

A new WHO report, Global Report on Access to Hepatitis C Treatment: Focus on Overcoming Barriers, released today shows how political will, civil society advocacy and pricing negotiations are helping address hepatitis C, a disease which kills almost 700 000 people annually and places a heavy burden on health systems’ capacities and resources.

"Licensing agreements and local production in some countries have gone a long way to make these treatments more affordable," says Dr Suzanne Hill, WHO Director for Essential Medicines and Health Products. For example, the price of a three-month treatment in Egypt dropped from US$900 in 2014 to less than US$200 in 2016.

"But there are still huge differences between what countries are paying. Some middle-income countries, which bear the largest burden of hepatitis C, are still paying very high prices. WHO is working on new pricing models for these, and other expensive medicines, in order to increase access to all essential medicines in all countries," says Dr Hill.

80% of people in need still face challenges

Among middle-income countries, the price for a three-month treatment of sofosbuvir and daclatasvir varies greatly. Costs range from US$9 400 in Brazil to US$79 900 in Romania.

High costs have led to treatment rationing in some countries, including in the European Union, where price agreements have not accounted for the full cost of treating the whole affected population.

"Today's report on access, prices, patents and registration of hepatitis C medicines will help create the much needed market transparency which should support country efforts to increase access to DAAs," said Dr Hirnschall. "We hope countries will update their hepatitis treatment guidelines, work to remove barriers to access, and make these medicines available promptly for everyone in need."

In May 2016, at the World Health Assembly, 194 countries adopted the first-ever Global Health Sector Strategy on Viral Hepatitis, agreeing to eliminate hepatitis as a public health threat by 2030. The strategy includes a target to treat 80% of people in need by this date.

Tobacco control can save billions of dollars and millions of lives

10 JANUARY 2017 | GENEVA - Policies to control tobacco use, including tobacco tax and price increases, can generate significant government revenues for health and development work, according to a new landmark global report from WHO and the National Cancer Institute of the United States of America. Such measures can also greatly reduce tobacco use and protect people’s health from the world’s leading killers, such as cancers and heart disease.

But left unchecked, the tobacco industry and the deadly impact of its products cost the world’s economies more than US$ 1 trillion annually in healthcare expenditures and lost productivity, according to findings published in The economics of tobacco and tobacco control. Currently, around 6 million people die annually as a result of tobacco use, with most living in developing countries.

The almost 700-page monograph examines existing evidence on two broad areas:

• The economics of tobacco control, including tobacco use and growing, manufacturing and trade, taxes and prices, control policies and other interventions to reduce tobacco use and its consequences; and
• The economic implications of global tobacco control efforts.

"The economic impact of tobacco on countries, and the general public, is huge, as this new report shows," says Dr Oleg Chestnov, WHO’s Assistant Director-General for Noncommunicable Diseases (NCDs) and mental health. "The tobacco industry produces and markets products that kill millions of people prematurely, rob households of finances that could have been used for food and education, and impose immense healthcare costs on families, communities and countries."

Globally, there are 1.1 billion tobacco smokers aged 15 or older, with around 80% living in low- and middle-income countries. Approximately 226 million smokers live in poverty.

The monograph, citing a 2016 study, states that annual excise revenues from cigarettes globally could increase by 47%, or US$ 140 billion, if all countries raised excise taxes by about US$ 0.80 per pack. Additionally, this tax increase would raise cigarette retail prices on average by 42%, leading to a 9% decline in smoking rates and up to 66 million fewer adult smokers.

"The research summarized in this monograph confirms that evidence-based tobacco control interventions make sense from an economic as well as a public health standpoint," says the monograph's co-editor, Distinguished Professor Frank Chaloupka, of the Department of Economics at the University of Illinois at Chicago.

The monograph’s major conclusions include:

• The global health and economic burden of tobacco use is enormous and is increasingly borne by low- and middle-income countries (LMICs). Around 80% of the world’s smokers live in LMICs.
• Effective policy and programmatic interventions exist to reduce demand for tobacco products and the death, disease, and economic costs resulting from their use, but these interventions are underused. The WHO Framework Convention on Tobacco Control (WHO FCTC) provides an evidence-based framework for government action to reduce tobacco use.
• Demand reduction policies and programmes for tobacco products are highly cost-effective. Such interventions include significant tobacco tax and price increases; bans on tobacco industry marketing activities; prominent pictorial health warning labels; smoke-free policies and population-wide tobacco cessation programmes to help people stop smoking. In 2013-2014, global tobacco excise taxes generated nearly US$ 269 billion in government revenues. Of this, less than US$ 1 billion was invested in tobacco control.
• Control of illicit trade in tobacco products is the key supply-side policy to reduce tobacco use and its health and economic consequences. In many countries, high levels of corruption, lack of commitment to addressing illicit trade, and ineffective customs and tax administration, have an equal or greater role in driving tax evasion than do product tax and pricing. The WHO FCTC Protocol to Eliminate Illicit Trade in Tobacco Products applies tools, like an international tracking and tracing system, to secure the tobacco supply chain. Experience from many countries shows illicit trade can be successfully addressed, even when tobacco taxes and prices are raised, resulting in increased tax revenues and reduced tobacco use.
• Tobacco control does not harm economies: The number of jobs dependent on tobacco has been falling in most countries, largely due to technological innovation and privatization of once state-owned manufacturing. Tobacco control measures will, therefore, have a modest impact on related employment, and not cause net job losses in the vast majority of countries. Programmes substituting tobacco for other crops offer growers alternative farming options.
• Tobacco control reduces the disproportionate health and economic burden that tobacco use imposes on the poor. Tobacco use is increasingly concentrated among the poor and other vulnerable groups.
• Progress is being made in controlling the global tobacco epidemic, but concerted efforts are needed to ensure progress is maintained or accelerated. In most regions, tobacco use prevalence is stagnant or falling. But increasing tobacco use in some regions, and the potential for increase in others, threatens to undermine global progress in tobacco control.
• The market power of tobacco companies has increased in recent years, creating new challenges for tobacco control efforts. As of 2014, 5 tobacco companies accounted for 85% of the global cigarette market. Policies aimed at limiting the market power of tobacco companies are largely untested but hold promise for reducing tobacco use.

Dr Douglas Bettcher, WHO Director for the Prevention of NCDs, says the new report gives governments a powerful tool to combat tobacco industry claims that controls on tobacco products adversely impact economies. "This report shows how lives can be saved and economies can prosper when governments implement cost-effective, proven measures, like significantly increasing taxes and prices on tobacco products, and banning tobacco marketing and smoking in public," he adds.

Tobacco control is a key component of WHO’s global response to the epidemic of NCDs, primarily cardiovascular disease, cancers, chronic obstructed pulmonary disease and diabetes. NCDs account for the deaths of around 16 million people prematurely (before their 70th birthdays) every year. Reducing tobacco use plays a major role in global efforts to achieve the Sustainable Development Goal of reducing premature deaths from NCDs by one-third by 2030.

Early cancer diagnosis saves lives, cuts treatment costs

3 FEBRUARY 2017 | GENEVA - New guidance from WHO, launched ahead of World Cancer Day (4 February), aims to improve the chances of survival for people living with cancer by ensuring that health services can focus on diagnosing and treating the disease earlier.

New WHO figures released this week indicate that each year 8.8 million people die from cancer, mostly in low- and middle-income countries. One problem is that many cancer cases are diagnosed too late. Even in countries with optimal health systems and services, many cancer cases are diagnosed at an advanced stage, when they are harder to treat successfully.

"Diagnosing cancer in late stages, and the inability to provide treatment, condemns many people to unnecessary suffering and early death," says Dr Etienne Krug, Director of WHO’s Department for the Management of Noncommunicable Diseases, Disability, Violence and Injury Prevention.

"By taking the steps to implement WHO’s new guidance, healthcare planners can improve early diagnosis of cancer and ensure prompt treatment, especially for breast, cervical, and colorectal cancers. This will result in more people surviving cancer. It will also be less expensive to treat and cure cancer patients."

All countries can take steps to improve early diagnosis of cancer, according to WHO’s new Guide to cancer early diagnosis.

The three steps to early diagnosis are:

• Improve public awareness of different cancer symptoms and encourage people to seek care when these arise.
• Invest in strengthening and equipping health services and training health workers so they can conduct accurate and timely diagnostics.
• Ensure people living with cancer can access safe and effective treatment, including pain relief, without incurring prohibitive personal or financial hardship.

Challenges are clearly greater in low- and middle-income countries, which have lower abilities to provide access to effective diagnostic services, including imaging, laboratory tests, and pathology – all key to helping detect cancers and plan treatment. Countries also currently have different capacities to refer cancer patients to the appropriate level of care.

WHO encourages these countries to prioritize basic, high-impact and low-cost cancer diagnosis and treatment services. The Organization also recommends reducing the need for people to pay for care out of their own pockets, which prevents many from seeking help in the first place.

Detecting cancer early also greatly reduces cancer’s financial impact: not only is the cost of treatment much less in cancer’s early stages, but people can also continue to work and support their families if they can access effective treatment in time. In 2010, the total annual economic cost of cancer through healthcare expenditure and loss of productivity was estimated at US$ 1.16 trillion.

Strategies to improve early diagnosis can be readily built into health systems at a low cost. In turn, effective early diagnosis can help detect cancer in patients at an earlier stage, enabling treatment that is generally more effective, less complex, and less expensive. For example, studies in high-income countries have shown that treatment for cancer patients who have been diagnosed early are 2 to 4 times less expensive compared to treating people diagnosed with cancer at more advanced stages.

Dr Oleg Chestnov, WHO Assistant Director-General for Noncommunicable Diseases and Mental Health, notes: "Accelerated government action to strengthen cancer early diagnosis is key to meet global health and development goals, including the Sustainable Development Goals (SDGs)."

SDG 3 aims to ensure healthy lives and promote well-being for all at all ages. Countries agreed to a target of reducing premature deaths from cancers and other noncommunicable diseases (NCDs) by one third by 2030. They also agreed to achieve universal health coverage, including financial risk protection, access to quality essential health-care services, and access to safe, effective, quality and affordable essential medicines and vaccines for all. At the same time, efforts to meet other SDG targets, such as improving environmental health and reducing social inequalities can also help reduce the cancer burden.

Cancer is now responsible for almost 1 in 6 deaths globally. More than 14 million people develop cancer every year, and this figure is projected to rise to over 21 million by 2030. Progress on strengthening early cancer diagnosis and providing basic treatment for all can help countries meet national targets tied to the SDGs.

Note to editors:

Most people diagnosed with cancer live in low- and middle-income countries, where two thirds of cancer deaths occur. Less than 30% of low-income countries have generally accessible diagnosis and treatment services, and referral systems for suspected cancer are often unavailable resulting in delayed and fragmented care. The situation for pathology services was even more challenging: in 2015, approximately 35% of low-income countries reported that pathology services were generally available in the public sector, compared to more than 95% of high-income countries.

Comprehensive cancer control consists of prevention, early diagnosis and screening, treatment, palliative care, and survivorship care. All should be part of strong national cancer control plans. WHO has produced comprehensive cancer control guidance to help governments develop and implement such plans to protect people from the onset of cancer and to treat those needing care.

Cancers, along with diabetes, cardiovascular and chronic lung diseases, are also known as NCDs, which were responsible for 40 million (70%) of the world’s 56 million deaths in 2015. More than 40% of the people who died from an NCD were under 70 years of age.

WHO, and the international community, have set targets to reduce such premature NCD deaths by 25% by 2025 and by one third by 2030, the latter as part of the SDGs. Countries have endorsed a range of targets to address NCDs, including making available and affordable basic medical technologies and essential drugs for treating cancers and other conditions in health facilities.

Rapid diagnosis of Buruli ulcer now possible at district-level health facilities

Geneva −− The World Health Organization, in collaboration with the Foundation for Innovative New Diagnostics, has started a thorough evaluation of an innovative diagnostic test developed by researchers at Harvard University that can lead to rapid confirmation of Buruli ulcer in a patient.

Initial results from recent field trials in Benin and Ghana show that the test can detect mycolactone, a toxin produced by the bacteria that causes tissue damage and leads to Buruli ulcer. The most important aspect of this new test – which is more sensitive than microscopy – is that it can be carried out by technicians with minimal training in district hospital laboratories.

The results are read within an hour.

““This is a game-changer” said Dr Kingsley Asiedu, Medical Officer at WHO’s Department of Control of Neglected Tropical Diseases. “Diagnosed in its early stages, Buruli ulcer can be completely cured through treatment by a combination of antibiotics.””

The challenge to overcoming Buruli ulcer is early detection and diagnosis, prompting WHO to advocate the development of a rapid point-of-care diagnostic test over the past decade. In 2010, the researchers made a breakthrough by using boronate-assisted fluorescent thin-layer chromatography to selectively detect mycolactone when visualized with ultraviolet light. Further improvements have since optimized the method and the reading of results.

Clinical diagnosis of Buruli ulcer currently relies on well-trained, experienced health workers. Polymerase chain reaction – the most widely used diagnostic test because of its high sensitivity – can be done only in reference laboratories, remote from affected communities; results are available in a few weeks.

The disease

Buruli ulcer is a chronic debilitating infection of the skin and soft tissue caused by a bacterium, Mycobacterium ulcerans. The infection begins as a painless nodule, plaque or oedema and develops into an ulcer, destroying the skin and soft tissue and causing large ulcers usually on the legs or arms. Patients presenting at health facilities with advanced ulcerative stages pose a major problem; treatment is complex, involving surgery and skin grafting, and frequently results in long-term disability.

Given the late detection of cases, many patients were referred to hospitals by community health workers at district level; lengthy travel and costly hospitalization were major constraints.

Buruli ulcer has been reported in 33 countries in Africa, the Americas, Asia and the Western Pacific. Some countries in West and Central Africa – Benin, Cameroon, Côte d’Ivoire, Democratic Republic of the Congo and Ghana – report the majority of cases. Australia and Japan are major endemic countries outside Africa.

Since there is no knowledge of how Buruli ulcer is transmitted, preventive measures cannot be applied. Health education and active surveillance remain the cornerstone for control of the disease.

Progress

Ten years ago, treatment relied almost exclusively on surgery that involved extensive excision, skin grafting and, in some patients, amputation of limbs. Significant progress has been made over the past decade and treatment is straightforward if the disease is detected early. Advances in the development of rapid point-of-care diagnostics have enhanced prospects for management of the disease.

Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates

On 16 June 2016 the National IHR Focal Point of United Arab Emirates (UAE) reported one additional case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

Details of the case

• A 37-year-old, non-national, male living in Abu Dhabi Emirate. He developed symptoms on 9 June, and was admitted to hospital on 11 June. The case, who has no comorbidities, tested positive for MERS-CoV on 16 June. Investigation of history of exposure to the known risk factors in the 14 days prior to the onset of symptoms is ongoing. The patient is currently in critical condition, admitted to the ICU on mechanical ventilation Investigation of household contacts, co-workers and healthcare contacts are ongoing.

Globally, since September 2012, WHO has been notified of 1,762 laboratory-confirmed cases of infection with MERS-CoV, including at least 629 related deaths.

WHO risk assessment

MERS-CoV causes severe human infections resulting in high mortality and has demonstrated the ability to transmit between humans. So far, the observed human-to-human transmission has occurred mainly in health care settings.
The notification of additional cases does not change the overall risk assessment. WHO expects that additional cases of MERS-CoV infection will be reported from the Middle East, and that cases will continue to be exported to other countries by individuals who might acquire the infection after exposure to animals or animal products (for example, following contact with dromedaries) or human source (for example, in a health care setting). WHO continues to monitor the epidemiological situation and conducts risk assessment based on the latest available information.

WHO advice

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.
Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.
Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease from MERS‐CoV infection. Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures, such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.
Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.
Given the lack of evidence of sustained human-to-human transmission in the community, WHO does not recommend travel or trade restrictions with regard to this event. Raising awareness about MERS-CoV among travellers to and from affected countries is good public health practic

Haemorrhagic fever syndrome – South Sudan

Between late December 2015 and early May 2016, the National IHR Focal of South Sudan notified WHO of an outbreak of haemorrhagic fever syndrome.
As of 9 May, a total of 51 suspected cases, including 10 deaths, had been reported from the counties of Aweil North (45 cases, including 10 deaths) and Aweil West (6 cases). No health care workers had been reported among the cases. The majority (74.5%) of the suspected cases are below 20 years of age. The last recorded death dates back to 28 February.
The most frequent symptoms include unexplained bleeding, fever, fatigue, headache and vomiting. The symptoms do not seem to be severe and rapidly resolve following supportive treatment. Currently, there is no evidence of person-to-person transmission of the disease.
Samples of 33 patients were shipped to WHO collaborating centres in Uganda (Uganda Virus Research Institute), Senegal (Institut Pasteur of Dakar) and South Africa (National Institute for Communicable Diseases). The samples were tested by plaque reduction neutralization test, polymerase chain reaction or enzyme-linked immunosorbent assay. All samples were negative for Crimean-Congo haemorrhagic fever, Ebola virus disease, Marburg virus disease, Rift Valley fever, yellow fever, West Nile virus and Zika virus; 5 samples tested positive for Onyong-nyong virus; 3 samples were positive for Chikungunya; and 1 sample tested positive for dengue virus.
Further laboratory testing is ongoing that may confirm the causative agent. Other causes under investigation include bacterial diseases (e.g., Leptospirosis) and food intoxication (mycotoxines). Ecological risk factors for arboviral disease transmission were identified in the affected areas.

Public health response

With support from WHO, national authorities have conducted a number of public health activities, including investigating and managing all newly reported suspected cases, strengthening infection prevention and control as well as improving disease surveillance. Furthermore, community meetings have been conducted to raise people’s awareness of haemorrhagic fever. Finally, in response to a request from the WHO Country Office, laboratory supplies have been mobilized by the WHO Regional Office for Africa.

WHO risk assessment

The laboratory results received so far do not explain the symptomatology (unexplained bleeding) of the reported cases nor the high mortality rate. Since the underlying cause of this public health event remains unknown, close monitoring and further epidemiological investigation is needed.
The area where the outbreak is occurring borders Darfur in Sudan where at least 469 cases of undiagnosed viral haemorrhagic fever, including 120 deaths, were reported between August and November 2015. Because of frequent population cross-border movement between Sudan and South Sudan, the risk of international spread of the disease cannot be ruled out. WHO continues to monitor the epidemiological situation and conduct risk assessments based on the latest available information.