United Kingdom’s Foreign Affairs Committee’s Inquiry on Global Health Security

Medicines for Malaria Venture (GHS0010)

 

 

MMV submits this response[b] to the Foreign Affairs Committee’s Inquiry on Global Health Security to share the strengths of its partnership model, as we believe that global health security can be achieved through international collaboration at every level.

 

What lessons has the COVID-19 pandemic taught us about the importance of international collaboration in securing global preparedness and resilience against biosecurity threats? 

  1. In MMV’s experience, the COVID-19 response has so far been characterized by unprecedented international collaboration and unparalleled financial commitment across all sectors to quickly advance treatments and vaccines. Once these treatments and vaccines are authorized for use, this collaboration must continue to ensure their equitable and timely access for everyone everywhere.
  2. Responding to a lethal pandemic like COVID-19 after its onset is not sufficient. Prevention and preparedness are critical areas for international collaboration and investment, including tackling the lack of access to essential health services for marginalized and underserved people worldwide. The 2030 Agenda for Sustainable Development target on the provision of universal health coverage (UHC), is the best framework for action against health insecurity. To implement it effectively, global cooperation and solidarity are more important than ever.
  3. In MMV’s experience the following critical factors need to be considered:
    1. The disproportionate burden of epidemics and pandemics on developing countries and the need to maintain control measures for existing epidemics, such as malaria, without which health systems will become even more strained and more lives will be lost. The WHO estimates that depending on the level of service disruption due to COVID-19 there could be an excess of malaria deaths of somewhere between 20,000 and 100,000, most of them in young children[c]. The Roll Back Malaria Partnership to End Malaria noted: ‘While COVID-19 is the shock pushing 40–60 million people back into poverty, malaria will be the force preventing them from climbing back out again[d].’ Lest we forget, 272,000 children died from malaria in 2018[e], a number which has likely been exacerbated in 2020 due to the COVID-19 pandemic. 
    2. Ongoing epidemics of febrile disease such as malaria, can delay the identification of emerging pathogens/epidemics and complicate the diagnosis and management of new epidemic/pandemic illness. This has been seen in the impact of malaria on Ebola virus outbreaks, H5N1 avian influenza outbreaks, and to some extent COVID-19.
    3. Existing and new epidemics need to be addressed with a robust, concurrent response, and key elements need to be in place to support health systems, like adequate protection of the essential supply of treatments for major poverty-related diseases, such as malaria, HIV and TB.
    4. International collaboration with partners with capability to leverage existing assets (including private-sector partner networks), and competencies can be instrumental in such a response.
    5. Ability to quickly pivot to accelerate the response (see section 4 below). This is facilitated through solid and unstinting support to global health research and development (R&D) to ensure the timely availability of funding, capacity and new health tools to respond to existing and new threats.
    6. Mechanisms to collect real-time data on manufacturing and supply for key interventions, and potential demand, coupled with the mechanisms to facilitate rapid scale-up and production of key starting materials and active pharmaceutical ingredients.
    7. PDPs as a source of expertise and resilience in the global health system during times of crisis.
  4. Within weeks of the pandemic outbreak, MMV reprioritized its areas of strategic focus for 2020 to include support for the COVID-19 effort. MMV was quick to share its end-to-end expertise and experience with partners and other actors in the global hunt for therapies to treat and prevent COVID-19.
    1. MMV was contacted by manufacturers of active pharmaceutical ingredients who were encountering issues with sourcing key starting materials from China. MMV alerted the Global Fund, the World Health Organization (WHO) and other partners and took a lead on mapping the supply chains to identify emerging bottlenecks.
    2. In collaboration with partners, MMV is coordinating a WHO-led COVID-Malaria workstream on supplies and commodities, which has been able to identify, prevent and address bottlenecks in supply of malaria commodities globally.
    3. Discovering solutions for malaria and pathogens such as SARS-CoV-2 are not mutually exclusive efforts. With support from UK FCDO and other donors, MMV has pioneered open approaches to boost early-stage drug discovery for malaria and other infectious diseases by promoting transparency and collaboration among project partners, giving scientists access to free compounds and materials. In return researchers are expected to share data resulting from their research in the public domain within 2 years of its generation. MMV’s Pandemic Response Box, which contains 400 diverse drug-like molecules active against viruses, bacteria or fungi, is helping researchers identify hits and leads against a wide range of pathogens including pandemic fever viruses. Through this work MMV has also assembled a broad network of partners with assays and screening capabilities, covering a range of diseases. MMV used its pre-existing compound collections and networks to facilitate the screening of existing drugs against SARS-CoV-2 to determine whether any could be repurposed for COVID-19. Four compounds were identified and are currently being trialed in an FCDO-supported Phase II clinical study.

d.     MMV's Modelling and Simulation platform was able to rapidly simulate the levels of key drugs and their metabolites in the lungs of patients – bringing a level of clinical sophistication to discussions about repurposing existing drugs for COVID-19.

How effective is the UK’s current approach to global health security? 

  1. A leader in global health security, the UK has used this position to support low‐ and middle‐income countries (LMICs) to build surveillance, detection and emergency response capacity. At a global level, the UK has led the way as a major funder of global health activities.
  2. Antimicrobial resistance (AMR) is a major threat to global health security, and the UK is a front-runner in supporting efforts to quell it. AMR encompasses a wide variety of microbes, including the malaria parasite. Today, antimalarial resistance represents a major health security hazard to the whole Asia-Pacific region. Concerning signs of potential resistance to artemisinin-based combination therapy has also been recently detected in Rwanda and require continued vigilance as well as novel drugs to treat resistant parasites. Without the development of new interventions, deaths from drug resistance will likely add to the heavy toll of lives lost to malaria each year. It is important that AMR continues to be a priority in the UK’s global health security agenda. With UK support, MMV has been working to replenish the antimalarial pipeline with new tools to tackle antimalarial resistance, as continued research into new medicines is the best insurance against the risk of resistance. Fighting antimalarial resistance is relevant to the effort to contain all forms of antimicrobial resistance.
  3. The UK’s investments in PDPs such as MMV, DNDi, CEPI and others has seen phenomenal returns in terms of new medicines and diagnostics for infectious diseases and consequently, precious lives saved. The UK's long-term investments in malaria R&D which began over 20 years has led to the strongest malaria treatment pipeline the world has ever seen. To remain effective and retain its reputation as a global leader in health, the UK must continue to raise its investment in R&D to support the development of medicines and vaccines with novel mechanisms of action and simplified regimens, as well as technologies which improve broader access to healthcare. The UK’s enormous pool of public and private sector scientists and researchers, as well as government agencies and NGOs working closely with the PDPs, are a portal into collaborative networks. Since 2008, MMV has entered into over 400 agreements with UK-based scientific and policy partners, and together, this collective effort has made significant contributions to global health security. UK FCDO has also supported the MMV-Open programme to leverage its assets and knowledge against non-malarial diseases and take drug discovery to the next level.
  4. Progress in the fight against malaria over the last 20 years has demonstrated that sustained investments in health and the right mix of strategies can result in significant achievements. As a leader in the fight against major poverty-related diseases such as malaria, the UK has helped prevent millions of deaths, including those of pregnant women and children who are most at risk. Continued investment is needed to scale up development of and access to innovative interventions in the fight against deadly diseases, as well as to ensure stronger and more resilient health systems globally – our first line of defense against existing and emerging health threats.

 

What role should the Foreign, Commonwealth and Development Office (FCDO) play in bringing about a resolution to the COVID-19 pandemic and preventing future pandemics? 

  1. The forthcoming G7 UK Presidency offers a key opportunity for UK leadership on the Global Heath Security Agenda among industrialized countries to ensure delivery on promises, determined action to make significant progress in the measures needed to leverage the mandate of multilateral institutions, and strengthen countries' efforts in the detection, prevention, and control of communicable diseases and biological threats.
  2. Regardless of where a pandemic starts, once underway, it will hit LMICs the hardest, given their weaker health systems and limited capacity to handle a surge in cases. Sustained support to ensure that COVID-19 and future pandemics are managed equally across all countries is therefore critical. The World Bank estimates that COVID-19 will push an additional 88 million to 115 million people into extreme poverty this year[f]. The UK's leadership as one of only six countries with 0.7% of its GDP earmarked for overseas development assistance in legislation, the majority spent on health, is critical for global health security, and must be maintained. Keeping this commitment to the world’s poorest communities is crucial.
  3. It is encouraging that the UK is taking a leading role in creating a new, global approach to health security, including towards the international response to developing countries in the COVID-19 crisis. It is vital that the response to COVID-19 is funded with new money and not drawn from already committed funding for ongoing threats from other infectious diseases, such as malaria (see sections 3a and 6 on existing threats). 
  4. Most urgent is investment in drug assay platforms before a crisis emerges. We have known and have been able to test drugs against SARS-COV-1 for over 10 years, but without funding for such research no headway has been made.  A way forward would be to identify a key list of priority health threats (one in each viral class) and put in place a coordinated effort to study available compounds/drugs against them.
  5. To bring about a resolution to the COVID-19 pandemic and prevent future pandemics, the UK Government and G7 members would do well to prioritize and promote the following actions:

(i)                  Sustain and increase global investment in R&D against infectious diseases.

(ii)                 As a technical partner, ensure equitable access to vital interventions for COVID-19 without hindering access to interventions for other pre-existing epidemics of infectious diseases, such as malaria.

(iii)               Support the harmonization of regional regulatory structures so that approved products can be quickly moved through under-resourced systems.

(iv)               Ensure effective health tools, including essential drugs and personal protective equipment, are available, affordable, accessible, timely and equitably distributed.

(v)                 Work with other donors and funding mechanisms to ensure that the necessary resources for the global COVID-19 response do not divert resources away from malaria or other public health priorities. 

(vi)               Scale-up work with partners on the use of global purchasing power to stimulate local production in LMICs of quality approved products for malaria, HIV and TB and other diseases.

(vii)             Promote international collaboration to strengthen health systems and research capability of LMICs to enhance their capacity to respond to an emerging infectious threat.

(viii)            Provide continued support to multilateral organizations such as the WHO and the Global Fund to fight AIDS, TB and Malaria.

 

Has the UK effectively used its position in multilateral organizations to promote international collaboration in response to COVID-19 and the global health security agenda? 

  1. The UK’s long-standing commitment to the work of multilateral organisations has been extremely effective and is more critical than ever to ensure normative bodies, like the WHO, can carry out their mandate. The UK Government’s increased contribution to the WHO, and its allocation to COVAX, are excellent examples of its leadership. Further, generous support from donors, including the UK, has enabled the Global Fund to work with governments and international partners to ensure a coordinated response to COVID-19 while maintaining ongoing AIDS, TB and malaria programmes.
  2. Supporting LMICs in addressing major, long-standing epidemics of infectious diseases will help increase their capacity to prepare and respond to future health crises and will thus contribute to global health security. As the WHO’s Director General said this year: ‘No one is safe until everyone is safe.’
  3. FDCO is represented on the Board of Directors of CEPI and has provided invaluable support to COVID-19 vaccine development, manufacturing and equitable access strategy and implementation.
  4. In addition, FCDO supported FIND in assuming a leadership role in the COVID-19 diagnostics, MMV in compound screening for COVID-19, MMV and DNDI in COVID-19 clinical trials and MMV in COVID-19/malaria drug supply chain management.

 

What should the FCDO be doing to support research and distribution of a COVID-19 vaccine? How can the FCDO ensure that COVAX is successful? What are likely to be the main challenges associated with worldwide distribution of a vaccine?

  1. Vaccines are fragile pharmacological products that demand strict temperature controls and real-world conditions will greatly limit their global roll out. To avoid unnecessary wastage, it would be important to support development of vaccines that do not require extreme cold chain conditions and initiatives that support control, distribution and storage. In addition, it is important to note that a vaccine should not be used in isolation; health care workers in the field would also need access to drugs to treat COVID-19 as well as other infectious diseases like malaria.
  2. Rolling out any product globally is a mammoth task and will require international collaboration of logistic experts, governments, manufacturers, and cold chain experts.
  3. Efforts must be made to counter misinformation and enhance public confidence in vaccines.
  4. FCDO must continue to engage with the expertise of global vaccine procurement and distribution vehicles like GAVI.

 

What should a ‘global pandemic early warning system’ look like? What role should the UK Government play in its creation?

  1. A ‘global pandemic early warning system’ must include robust surveillance systems and treatment strategies to enable identification of the current zoonotic pathogen reservoir, and if possible, isolate pathogens which are likely to jump species.
  2. The capacity of LMICs to bear additional stress is limited, and cost is an important consideration. Pricing commitments for health interventions in these countries need to be incorporated from the very start.
  3. Accurate differential diagnosis is critical. Before the advent of an outbreak it is difficult to predict which pathogen will pose the greatest threat to global health security. Early clinical presentations of febrile illnesses, such as malaria and influenza, are typically similar to emerging infectious diseases, compromising early detection efforts. For example, during the H5N1 avian influenza outbreak in Vietnam in 2004-05, avian flu was difficult to detect as it was often mistaken for malaria.
  4. A ‘global pandemic early warning system’ must also prioritize real time surveillance of existing infectious diseases in order to reduce background ‘noise’. This can be achieved by improving diagnostic tools, training front-line health workers and expanding screening efforts in tandem with pro-active treatment strategies. These strategies should also consider the practical implications and dangers posed by the emergence of drug resistance.
  5. In the development of a ‘global pandemic early warning system’ the UK must consider putting in place agile mechanisms to maximize communication and information sharing, resources and technological innovations by supporting open-source tools and approaches, and continue to support the creation of effective global real-time, disease surveillance systems.

 

 

 

 

 

 

December 2020

 

6

 

[a] Product Development Partnerships (PDPs) are international non-profit organizations that bring together stakeholders from the private and public sectors to research, develop and support access to new health technologies that target diseases disproportionately affecting developing countries.

[b] MMV is responding to the questions relevant to its mandate and experience.

[c] https://www.reuters.com/article/health-malaria-who/malaria-death-toll-to-exceed-covid-19s-in-sub-saharan-africa-who-idUSL8N2IB5W9

[d] https://committees.parliament.uk/writtenevidence/4541/html/

[e] https://www.who.int/news-room/feature-stories/detail/world-malaria-report-2019

[f] https://www.worldbank.org/en/publication/poverty-and-shared-prosperity#:~:text=Poverty%20and%20Shared%20Prosperity%202020%3A%20Reversals%20of%20Fortune%20provides%20new,on%20global%20poverty%20and%20inequality