Leveraging the positives from the pandemic to strengthen infectious disease care in low-income and middle-income countries

Abstract

The end of the emergency phase of the COVID-19 pandemic was announced by WHO on May 5, 2023. Reflecting on the legacy of the pandemic in low-income and middle-income countries (LMICs) where most excess deaths occurred, it will be remembered for the pervasive inequities that plagued every crucial aspect of the global response, from access to vaccines and therapeutics to gaps in health-care infrastructure.1Kyobutungi C Gitahi G Wangari M-C et al.From vaccine to visa apartheid, how anti-Blackness persists in global health.PLoS Glob Public Health. 2023; 3e0001663Crossref PubMed Google Scholar Despite the many failures of global solidarity, the pandemic also showcased the resilience and innovative capacity of LMICs, providing some positive aspects and a roadmap for continued improvement in infectious disease and health system strengthening. Three pieces in this Series explicitly amplify the voices of experts in LMICs on how to leverage the potential opportunities for sustainable vaccine capabilities in Africa,2Kana BD Arbuthnot P Botwe BK et al.Opportunities and challenges of leveraging COVID-19 vaccine innovation and technologies for developing sustainable vaccine manufacturing capabilities in Africa.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(22)00878-7Google Scholar combating the increasing threat of antimicrobial resistance (AMR),3Walia K Mendelson M Kang G et al.How can lessons from the COVID-19 pandemic enhance antimicrobial resistance surveillance and stewardship?.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(23)00124-XGoogle Scholar and establishing more equitable structures to ensure effective and fair collaboration among stakeholders and nations during future pandemics.4Alakija A Leveraging lessons from the COVID-19 pandemic to strengthen low-income and middle-income country preparedness for future global health threats.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(23)00279-7Google Scholar During the COVID-19 pandemic, vaccine nationalism caused substantial delays in vaccine access, particularly in the region of Africa that had the lowest coverage in the world. As a result, nations without local manufacturing capabilities suffered avoidable deaths from COVID-19.5Msemburi W Karlinsky A Knutson V Aleshin-Guendel S Chatterji S Wakefield J The WHO estimates of excess mortality associated with the COVID-19 pandemic.Nature. 2023; 613: 130-137Crossref PubMed Scopus (39) Google Scholar Moreover, the absence of vaccines created a void that allowed misinformation and vaccine hesitancy to spread, which also affected the uptake of other vaccines.6Yunusa A Cabral C Anderson E The impact of the Covid-19 pandemic on the uptake of routine maternal and infant vaccines globally: a systematic review.PLOS Glob Public Health. 2022; 2e0000628Crossref PubMed Google Scholar The pressing need to establish sustainable vaccine development and manufacturing capacity in the continent with the fastest-growing population is undeniable. Africa has a population of 1·2 billion, yet less than 1% of the vaccines used in Africa are manufactured on the continent.7Gennari A HT Jordi E Kaplow L Africa needs vaccines: what would it take to make them there?.https://www.mckinsey.com/industries/life-sciences/our-insights/africa-needs-vaccines-what-would-it-take-to-make-them-hereDate: April 14, 2021Date accessed: May 19, 2023Google Scholar Unless this crucial gap is addressed, Africa will be left behind again and have to wait for trickle-down charity from high-income countries (HICs). Bavesh Kana and colleagues examine the landscape of vaccine capability in Africa and propose a comprehensive continuum for vaccine manufacturing, which spans from fundamental discovery to production and distribution.2Kana BD Arbuthnot P Botwe BK et al.Opportunities and challenges of leveraging COVID-19 vaccine innovation and technologies for developing sustainable vaccine manufacturing capabilities in Africa.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(22)00878-7Google Scholar Building on initiatives that emerged during the pandemic, such as the WHO-sponsored mRNA hub, the authors emphasise strategies that can foster sustained growth in this field while establishing what will serve as key indicators for success: equitable access, quality, and affordability. To ensure the affordability of vaccines in Africa, it will be necessary to establish risk-sharing mechanisms among local vaccine manufacturers, governments, and societies. Additionally, the creation of multi-country platforms for vaccine manufacturing and resource pooling could facilitate trade and enhance the availability of vaccines across the continent. African countries can contribute to affordability by making advanced market commitments to purchase locally manufactured vaccines, even at higher prices, thereby increasing demand. Maintaining high manufacturing standards will necessitate a skilled workforce, incentives for quality improvements, and the implementation of robust regulatory and legal frameworks to ensure safety and efficacy. Embracing a broad portfolio of vaccines is especially relevant and essential to promote innovation and develop vaccines, which might not be prioritised by the pharmaceutical industry or HICs. The success of these initiatives will depend on building demand for locally manufactured vaccines, obtaining political buy-in from African governments to invest in vaccine manufacturing for the long term, ensuring geopolitical stability, and navigating existing trade and intellectual property restrictions that are designed to profit pharmaceutical companies and HICs. These challenges can be proactively addressed by treaties and bold trade and intellectual property regulatory frameworks, instead of a reactionary approach in times of crisis. It is crucial to ensure that the mRNA vaccine platform does not remain a monopoly of big pharma and HICs. This novel and highly adaptable platform should be equally available and accessible to LMICs and repurposed for developing new vaccines against other diseases (eg, HIV, malaria, tuberculosis, and influenza). COVID-19 exacerbated the considerable threat of AMR, which ranks among the top ten public health challenges worldwide. Overuse of antimicrobials spiked during the pandemic,8Nandi A Pecetta S Bloom DE Global antibiotic use during the COVID-19 pandemic: analysis of pharmaceutical sales data from 71 countries, 2020–2022.EClinicalMedicine. 2023; 57101848Summary Full Text Full Text PDF PubMed Scopus (4) Google Scholar and irrational use of ineffective therapies (eg, hydroxychloroquine and ivermectin) was rampant.9Sulis G Batomen B Kotwani A Pai M Gandra S Sales of antibiotics and hydroxychloroquine in India during the COVID-19 epidemic: an interrupted time series analysis.PLoS Med. 2021; 18e1003682Crossref PubMed Scopus (47) Google Scholar In 2019, sub-Saharan Africa and south Asia reported the mortality rates attributed to AMR, totalling 4·95 million lives lost and 1·27 million deaths directly caused by resistance.10Antimocrobial Resistance CollaboratorsGlobal burden of bacterial antimicrobial resistance in 2019: a systematic analysis.Lancet. 2022; 399: 629-655Summary Full Text Full Text PDF PubMed Scopus (1972) Google Scholar LMICs face unique challenges in fighting AMR due to factors such as inadequate hygiene practices, fragile health-care infrastructure, a lack of essential diagnostics, weak regulatory systems, and suboptimal implementation of infection control strategies. The urgency with which countries addressed the COVID-19 pandemic should be matched when confronting the AMR crisis. Kamini Walia and colleagues highlight the need for LMIC governments to prioritise AMR as a major public health crisis and allocate sufficient funding to mitigate its effects.3Walia K Mendelson M Kang G et al.How can lessons from the COVID-19 pandemic enhance antimicrobial resistance surveillance and stewardship?.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(23)00124-XGoogle Scholar Additionally, leveraging technology platforms (eg, molecular diagnostics and gene sequencing), which were scaled up during COVID-19, can be extended to enhance AMR diagnosis, surveillance, and reporting. Because of the pandemic, incredible improvements were made in scaling up molecular diagnostics and self-testing technologies. These investments should now be repurposed for other infectious diseases.11Hannay E Pai M Breaking the cycle of neglect: building on momentum from COVID-19 to drive access to diagnostic testing.EClinicalMedicine. 2023; 57101867Summary Full Text Full Text PDF PubMed Scopus (2) Google Scholar Telehealthcare, which saw tremendous expansion during the pandemic, also offers opportunities to extend clinical care, education, and antimicrobial stewardship practices. Effective risk communication is a crucial aspect in crafting an effective response to AMR, which can benefit from adopting a consistent and message-centred approach similar to that used during the COVID-19 pandemic. Many individuals within communities perceive AMR as an abstract concept lacking the immediate threat of a newly emerging virus. By improving risk communication on AMR, behavioural modifications can be achieved among both the general population and health-care practitioners, leading to potential long-term benefits. Countries have shown regulatory flexibility during the COVID-19 pandemic to swiftly provide vaccines to their populations. However, vaccination, which has the potential to reduce the need for frequent antibiotic prescriptions and contain AMR, remains underutilised. Expanding the scope of routine vaccination programs to include influenza, pneumococcus, typhoid, and Haemophilus influenzae type B vaccines is another strategy for reducing AMR. Generating evidence to support the economic effect of vaccination on AMR and its long-term effects on morbidity and mortality will inform decision making in this area. The urgent need for genuine solidarity within the global health system cannot be overstated. Insufficiently acting upon the idea resulted in the failure to deliver equity during the pandemic. Ayoade Alakija draws from the lessons of the COVID-19 pandemic and highlights the importance of tailoring interventions in response to pandemics to the unique circumstances of different regions.4Alakija A Leveraging lessons from the COVID-19 pandemic to strengthen low-income and middle-income country preparedness for future global health threats.Lancet Infect Dis. 2023; (published online June 5.)https://doi.org/10.1016/S1473-3099(23)00279-7Google Scholar For example, it is crucial to implement context-specific and evidence-based non-pharmaceutical interventions, which might have a differential effect on the economy and on the lives of individuals depending on the setting and available resources. Successfully instilling public trust and fostering adherence to these interventions cannot be reduced to a single, universal solution. The notion that what worked in affluent HICs will seamlessly translate to other contexts has proven to be misguided. Addressing these challenges will require deft advocacy, effective risk communication, and meaningful community engagement. As we emerge from the COVID-19 emergency, forging a new global health order mandates transparency, deep-rooted trust, global coordination, and substantial investments that can be sustained over time. Realising this vision will necessitate robust regional collaborations, facilitating platforms for cooperation among LMICs, and leadership of countries with limited resources in decision-making processes. Most importantly, it is time to shift from the charity and saviourism model of global health to a model that is rooted in equity, justice, and allyship.12Pai M Disrupting global health: from allyship to collective liberation.https://www.forbes.com/sites/madhukarpai/2022/03/15/disrupting-global-health-from-allyship-to-collective-liberation/?sh=7190b15f4e62Date: March 15, 2022Date accessed: May 21, 2023Google Scholar HICs should act on solidarity and support the vision of LMICs for self-determination, self-reliance, and self-sustenance.1Kyobutungi C Gitahi G Wangari M-C et al.From vaccine to visa apartheid, how anti-Blackness persists in global health.PLoS Glob Public Health. 2023; 3e0001663Crossref PubMed Google Scholar If all HICs supported the equity provisions in the pandemic accord that is under negotiation, that would demonstrate a concrete act of allyship. A pandemic accord that does not include equity, transparency, and accountability is destined to fail. Even as we reflect upon the failures during the COVID-19 crisis, we should capitalise on opportunities for growth and improvement. Amidst the devastation, some positives abound, particularly for LMICs. Seizing these opportunities in the present moment presents a chance to prevent the repetition of past mistakes and ensure better preparedness and a more equitable health future for all. MP serves as an advisor to non-profits organisations namely WHO, Stop TB Partnership, Bill & Melinda Gates Foundation, and Foundation for Innovative New Diagnostics. None of these organisations were involved in this Comment. We declare no competing interests. Opportunities and challenges of leveraging COVID-19 vaccine innovation and technologies for developing sustainable vaccine manufacturing capabilities in AfricaThe COVID-19 pandemic heralded unprecedented resource mobilisation and global scientific collaboration to rapidly develop effective vaccines. Regrettably, vaccine distribution has been inequitable, particularly in Africa where manufacturing capacity remains nominal. To address this, several initiatives are underway to develop and manufacture COVID-19 vaccines in Africa. Nevertheless, diminishing demand for COVID-19 vaccines, the cost competitiveness of producing goods locally, intellectual property rights issues, and complex regulatory environments among other challenges can undermine these ventures. Full-Text PDF How can lessons from the COVID-19 pandemic enhance antimicrobial resistance surveillance and stewardship?COVID-19 demanded urgent and immediate global attention, during which other public health crises such as antimicrobial resistance (AMR) increased silently, undermining patient safety and the life-saving ability of several antimicrobials. In 2019, WHO declared AMR a top ten global public health threat facing humanity, with misuse and overuse of antimicrobials as the main drivers in the development of antimicrobial-resistant pathogens. AMR is steadily on the rise, especially in low-income and middle-income countries across south Asia, South America, and Africa. Full-Text PDF Leveraging lessons from the COVID-19 pandemic to strengthen low-income and middle-income country preparedness for future global health threatsAlthough the global COVID-19 pandemic response was quick to develop medical countermeasures, it failed to fully prevent morbidity and mortality in high-income countries and low-income and middle-income countries (LMICs). As new variants and post-COVID-19 condition continue to emerge and affect health systems and economies, the full human and economic cost is yet to be felt. We should now learn from these shortcomings and implement more inclusive and equitable frameworks to prevent and respond to outbreaks. 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