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Global COVID-19 Update

In July 2022, Nahid Bhadelia, MD, MALD, joined the White House COVID-19 Response Team as senior policy advisor for Global COVID Response. The infectious disease physician, who is on sabbatical from Boston University, spoke with JAMA Associate Managing News Editor Jennifer Abbasi about the pandemic’s true burden of disease in low- and middle-income countries and ongoing COVID-19 vaccine inequity.

Correction: this Q&A includes some unclear wording in one of Dr Bhadelia’s responses. The correction can be viewed here.

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[Jennifer Abbasi] I'm Jennifer Abbasi for JAMA Medical News. My guest today is Dr. Nahid Bhadelia. Dr. Bhadelia recently joined the White House COVID-19 Response Team as Senior Policy Advisor for Global COVID Response. She is an associate professor of infectious diseases at Boston University's School of Medicine and founder of BU's Center for Emerging Infectious Diseases Policy and Research. She's here today to give us an update on the pandemic, particularly in lower and middle income countries. Thanks for joining us.

[Nahid Bhadelia] Thanks for having me, Jennifer.

[Jennifer Abbasi] Okay. You became the senior advisor for Global COVID response at the White House this July. Now that you're a few months on the job, I'm hoping you can answer what is a very broad question. How is the pandemic going for the rest of the world?

[Nahid Bhadelia] Thanks so much for that, Jennifer. I think the biggest thing when you look at the numbers is that it looks like we're coming off of our latest peak. I think July, August, you saw some of the more transmissible variants of Omicron, the BA.4, and then particularly BA.5, caused a huge surge in cases. You're in the last week now seeing particularly in the week ending September 11th, seeing a drop in cases globally, about almost a quarter of the cases down. The other thing is that although the cases are dropping, many countries, including the US, are still reporting a huge number of cases. However, when people think about this, I would just want them to take this with a caveat, which is that we're also seeing a drop in testing globally, particularly in low and middle income countries. FIND the organization that deals with diagnostic access for a low and middle income countries reported there was a 70% drop in use of COVID testing, and there has been a lag in reporting of COVID cases to WHO. It may be that there might be more cases out there, and partially because I think partly pandemic fatigue. I think partly many countries have started to use rapid testing, which as we know from our experience here, hasn't been reported. The results don't get reported. We don't really have a full idea of what the true number of cases are. However, overall, we now know that the cases and the deadliness of the disease over time is decreasing. The infection fatality rate is decreasing over the course of the pandemic.

[Jennifer Abbasi] And where are we now in terms of numbers? In terms of cases overall and deaths overall?

[Nahid Bhadelia] Yeah. In the weekend in September 11th, we had about 3.3 million cases globally. That brings us to over 6 million deaths globally and about 630 million cumulative cases. But I think for many reasons, that's probably an underestimate of the true number of cases that we've suffered as a world over the course of this pandemic.

[Jennifer Abbasi] That actually brings me to my next question. A July 2021 report from the Center for Global Development estimated that 3.4 to 4.9 million excess deaths occurred during the pandemic in India, which at the time had reported around 400,000 deaths. To what extent is it now believed that COVID deaths have been under reported worldwide?

[Nahid Bhadelia] The excess mortality is probably much higher than we think. A WHO study from this spring reported that likely the true excess mortality is somewhere 14.9 million. With a range somewhere between 13 and 16 million. A huge part of what that study found was that number was actually driven by 10 countries globally. India being a big contributor as you just mentioned. But even as we think about those numbers, I think what it belies is, that number, excess mortality, which is number of additional deaths than expected during a crisis, or seen during a crisis than expected during a normal time, doesn't actually take into account the true toll. I think you've seen disruptions in vaccinations and HIV treatments and tuberculosis diagnosis and treatments globally. You've seen drop in childhood vaccination rates. It was 86% in 2019, and now it's down to 81%. The secondary direct health impacts of the pandemic are probably much, much larger than even what the excess mortality tells us.

[Jennifer Abbasi] Okay. To date, all of Africa has reported only 9.3 million cases and fewer than 200,000 deaths. The Americas by contrast, have reported nearly 3 million deaths with more than a million of those in the US. What's your thinking on the idea that under reporting alone can't explain the relatively low numbers of cases and deaths in Africa? One theory I've read is that the population of Africa is relatively young and that younger age is protective.

[Nahid Bhadelia] I think it's certainly a possibility. I think the demographics probably have an impact because we know that COVID-19 is disproportionately, has a higher impact on patients with comorbidities, and particularly age is a big part of the high risk profile where the mortality rates go up. But the picture is probably a lot more complicated. I think we can't underestimate the impact of under-reporting. There was a WHO report that recently said that death registrations, information systems around registration of deaths in the Europe, there's 98% coverage. When you compare that to the registration of deaths that occur in Africa, that's like only 10%. That impact of under-reporting is probably much larger than people realize. But beyond that, I think there's also a shift, during the course of the pandemic. At the very beginning, the cumulative, when you only look at the cumulative impact of deaths in terms of the proportion, LMICs don't look like they're contributing that many deaths. But when you look at the course of the pandemic, once vaccines were introduced 2020, 2021. In spring of 2021, something very interesting happens, what you start seeing is that LMIC contribution to the share of daily global deaths actually shoots up. That's partly because of the access of vaccines that were made available in many high income countries.

[Jennifer Abbasi] So how is under counting these deaths potentially continuing to cause harm?

[Nahid Bhadelia] I think the biggest thing that I can think of is that you've gone through a course of time where populations have lived through the exposure to this virus, and if they're being told that the impact was not as high, or if that true toll is not being calculated, you may see populations, communities, and governments view the threat of COVID as not as high. And that affects the individuals acceptance of vaccines or seeking out testing if they need to or treatment. It affects governments investments in COVID-19, both interventions as well as prevention strategies. And so I think that under counting plays a role in of the continued impact of the virus in those countries.

[Jennifer Abbasi] And how can we get a better accounting of global COVID deaths, can we?

[Nahid Bhadelia] Yeah, so excess mortality gets us some part there because it certainly gives us a sense of both those deaths that may not have encountered. And the reason it's also complicated is because in many countries because of the lack of diagnostics, right? Fined, again, I'll just mention one of the statistics that they mention is that only 21% of diagnostics for COVID-19 are being conducted in low and middle income countries, despite low and middle income countries making up about 50% of the world's population. So there is a dearth of testing and diagnostics and making those things available to communities around the world helps us get a better sense. Not just of who's potentially dying of these diseases, but hey, to make early interventions possible. Particularly now that we have oral antivirals that might make a difference in the course of disease in areas where there might be higher infection fatality rate as I mentioned. So, that's one way. Two, we can get a better sense by investing in, and I think this is being done in many parts of the world, improving general core capacities of healthcare systems, which include data system, information systems to be able to capture that.

[Jennifer Abbasi] Let's talk a little bit more about vaccines. Dr. Bhadelia, where are we on vaccinations now? Where do the numbers stand?

[Nahid Bhadelia] Overall, globally for vaccinations, about 68% of the world has received at least one dose, and about 62% have finished their full primary series of two doses. But only 22% of low-income countries have received one dose, and when it comes to boosters, only 33% of the world has received that third dose.

[Jennifer Abbasi] As vaccines were being developed and rolled out, many people in public health argued for equitable global access to them, and that didn't happen. How did distribution initially play out around the world and who was left behind?

[Nahid Bhadelia] So COVAX, right, and the ACT Accelerator, which many people may know of is this partnership between global nonprofits as well as countries around the world was actually established to overcome some of the challenges that were seen during H1N1 pandemic, which was vaccines were developed and it took couple years before they were made accessible to many communities in low and middle income countries. And part of the goal of COVAX was to create a purchasing power that allows access for low and middle income countries to be able to access the new vaccine, a diversified vaccine portfolio. I think one of the struggles at the very beginning was that despite the COVAX utility being set up, I think you saw that it was not fully funded. And that on the open market it was competing with purchasing power from other high income countries. And that's why I think President Biden's leadership very early on in at least trying to stem some of the impact of those dynamics such as, for example, we were the first country that purchased vaccines for donations around the world. And that led to commitment from many G7 countries to sort do the same. We were the first ones to strike a deal with a vaccine manufacturer to purchase those vaccines. But donations are one thing. They've been an important part, right? They've been an important critical part of what we did in that period of time where there wasn't access, and we're still continuing to do that. But in the longer term, some of the things that this administration is invested in is interested in seeing is also investment in local manufacturing. Investment in capacity to be able to create vaccines in areas of the world that don't have that capacity.

[Jennifer Abbasi] Which areas really struggle to get access to vaccines maybe in the first six months to a year?

[Nahid Bhadelia] So some of the continent of Africa throughout this pandemic has had some of the lowest vaccination rates. And as you said, because of the lack of this access to vaccinations as well as infrastructure and resources to get shots in arms has had a lower rate now along the whole path of full two doses and now boosters as well. The other places that you see a potential inequity are those countries that at baseline have civil unrest or are areas where there's humanitarian complex humanitarian emergencies going on. Those are the two places I think that have had lagged the farthest behind. And our own contribution, the US contribution of this, to date us has donated about 624 million doses of vaccines in 116 countries. So we're the largest donor of vaccines. And when you look at the actual numbers, our donations are almost the equal of the donations of the rest of the world combined. But still a lot of work remains.

[Jennifer Abbasi] So there's plenty of vaccine now. What are the challenges now in lower and middle income countries?

[Nahid Bhadelia] So there has been an incredible lot of shift even in the last six months- Been an incredible lot of shift even in the last six months, particularly in the continent of Africa, you're seeing coverage increase. You had countries at the beginning of the year, you had about 34 countries that had less than 10% coverage, and that number in September went down to nine. Right. So that has decreased, but you're still seeing this continued lag, as I said, of vaccinations because of the complexity of, and the additional resources that are needed to take vaccines and turn them into vaccinations. And so there is still inequity. And what we're finding is that the supply is there, but the difficulty now is ensuring that the uptake occurs and that uptake is multifold. It's ensuring that we're able to get vaccines to the last mile where they're needed. The infrastructure exists to ensure the vaccines are viable by the time they get there. That we have enough of a healthcare worker staff. The other work that needs to be done is around vaccine confidence. We've seen both here in the US and around the world, disinformation and misinformation around COVID-19 vaccines and general increase in vaccine hesitancy. And that work requires long term investment in communities. It requires work with community stakeholders. It requires creating a space for patients to be in the same area that they get their regular care. Right now, many of the COVID vaccines, for example, are given through campaigns. And so ensuring that vaccines are available and distributed to all the areas where patients get their regular care, right, allows a space where community health workers, physicians, nurses can have a conversation with the patients to sort of help improve that. And that requires integration of COVID vaccination with the general work that's being done to help strengthen health systems. And that's all the work that still needs, we're working on it. I think it's improving. As I mentioned, the numbers are improving in terms of where we're getting, but it's work that we need to continue to invest in and work that needs to be done, partly because vaccines alone aren't enough. Vaccines plus vaccinations in shots is what removes vaccine inequity.

[Jennifer Abbasi] So now that well-resourced nations like the US are shifting towards Omicron specific vaccines, what's going to happen with the original vaccines and could that supply potentially help improve vaccination rates globally?

[Nahid Bhadelia] supply is not so much of an issue. And what the Strategic Advisory Group of Experts in Immunization, for example, is recently said for WHO, is the prototype vaccines are still useful and the boosters can be potentially used for that or the new variant vaccines that are available. I think it's less the vaccines themselves. I think it's ensuring that we are aiding our partners in low and middle income countries to build infrastructure for routine adult vaccination. And that includes, as I mentioned, the work that needs to be done to help strengthen healthcare systems. And ensuring that when we do that work isn't just aligned with COVID-19 vaccines alone, but that it's part of healthcare delivery. So other vaccinations, for example, influenza vaccination almost doesn't exist in many parts of, in the resource limited world, pneumococcal vaccines, meningococcal vaccines, adult vaccinations that are needed for vulnerable populations, ensuring that there's an infrastructure that is built for all of those within a healthcare system, delivery system ensures that continuity continues for COVID-19 plus for other diseases.

[Jennifer Abbasi] Is there value to the idea that resources for COVID vaccine campaigns might be better spent on other vaccine preventable diseases that potentially affect more people in lower and middle income countries?

[Nahid Bhadelia] I don't think the equation is either or. And the reason why is because when healthcare workers are affected by COVID-19, that takes away from the stability and the resilience of healthcare systems and their delivery. So it impacts everybody. Right. I think what we're seeing here, for example, among elderly is patients particularly, is that over time, the immunity against infection goes down, whether you've had prior infections or vaccinations. And so that booster actually helped improve not just protection in the near-term for infections, but also to revamp up protection against hospitalizations and deaths. And that's such an important part for low and middle income countries who may not have the same number of hospital beds for 100,000. Ensuring that we divert those hospitalizations and deaths helps preserve healthcare capacity and resilience against other things. And so in my mind, it can't be one or the other, but it does point to the fact that there is a struggle right now because there's so many priorities which require our attention, and that requires global collaboration to ensure that we're helping countries that are heavily affected move to the other side of this. One of the things that's often talked about is we've made all these investments in COVID-19. How do we use those investments as a jumping point, a leverage point, similar to what we did with HIV with PEPFAR programs? Could some of the investments we've made in COVID-19 help us diagonally improve the capacity for other provision of services, and maybe that's adult vaccination, as I mentioned, that could be used to help.

[Jennifer Abbasi] With so many priorities and your role, your global role, what do you hope to accomplish? What can you accomplish in your time in this position at the White House?

[Nahid Bhadelia] I think the number one thing is supporting the President's vision that if we want to end the pandemic here, we actually have to support the response globally. I think the important part of this is ensuring that we get congressional support to continue global activities for COVID-19. If we were to be funded, it would allow us to continue work on activities globally on COVID-19, as well as some of this transitional work, to ensure that there is diagonal development between COVID-19 and other critical healthcare capacities. That's one. Two, I took this job because I truly believe that pandemics tend to break us along known fault lines. Inequities actually make a pandemic deadlier for everybody. We've seen that domestically. We've seen that globally, and that's my guiding light. It's what drives me morally to do what I'm doing and what I hope continues to guide me in this position. And third, the interesting part of this position is its ability to coordinate activities. Agencies, USCID's work, CDC's work, all this incredible work, this exists out there. A position like this allows us to see connections between different areas. That's one of the things that I'm excited about, is seeing where those connections exist and where I can assist in making them happen.


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