WRITTEN EVIDENCE BY RESULTS UK TO THE INTERNATIONAL DEVELOPMENT COMMITTEE INQUIRY ON HUMANITARIAN CRISES MONITORING: IMPACT OF CORONAVIRUS

ABOUT RESULTS UK

RESULTS UK seeks to mobilise the public and political will to end extreme poverty. We undertake strategic policy advocacy, work closely with parliamentarians engaged in international development issues and campaign publicly through our nationwide grassroots network and international partners. Our work covers three key determinants of poverty: economic opportunities, health and education, with a key focus being placed on child vaccinations, tuberculosis (TB), education and nutrition.

This submission will explore the following points, as outlined in the inquiry’s Terms of Reference:
 

●        The direct and indirect impacts of the outbreak on developing countries

●        The impact of the outbreak on the Department for International Development’s (DFID) operations
 

This submission will begin by setting out some of the broader challenges COVID-19 poses to health before looking at TB, immunisation and nutrition individually. As a member of both Bond and Action for Global Health, RESULTS UK endorses their submissions to this inquiry.

EXECUTIVE SUMMARY

●        A combination of malnutrition, other infectious diseases, overcrowded living conditions, poor access to quality healthcare, and to clean water and sanitation, as well as misinformation about COVID-19 will aggravate the crisis among the poorest and most vulnerable. Those living with respiratory conditions such as TB are particularly vulnerable.

●        Previous outbreaks, such as the 2014-16 Ebola outbreak, demonstrate that deaths from other conditions can increase during a pandemic. The secondary impacts of COVID-19 could prove more deadly than the disease itself, with an additional 30 million children’s lives put at risk due to increases in other diseases and conditions such as malnutrition[1].

●        Manufacturing capacity and, supply and procurement systems for diagnostics and drugs, are being severely impacted by lockdowns, posing risks to the availability of medical commodities globally.

●        The redirection of funding to COVID-19 responses means that both domestic and international funding for health will be significantly lower than expected in the long term, at a time when it is most needed.

●        Developing countries’ National TB Programmes (NTPs) are diverting vital TB programme funding and infrastructure, such as respiratory specialists, personal protective equipment (PPE) and diagnostic tests, to COVID-19 responses with an alarming impact on access to TB services as a result.

●        RESULTS UK is deeply concerned about the impact of COVID-19 on routine immunisation in the least developed countries and humanitarian settings. It is crucial that routine immunisation services are maintained during the COVID-19 response to prevent further illness and loss of life from secondary outbreaks of other vaccine-preventable diseases such as measles.

●        Organisations such as Gavi, the Vaccine Alliance (Gavi), the Global Fund to Fight AIDS, TB and Malaria (the Global Fund) and the Global Polio Eradication Initiative (GPEI) are playing a crucial role in the global response to COVID-19. It is crucial that these organisations have the resources and expertise to respond dynamically to the COVID-19 outbreak.

●        Gavi, which has its replenishment in 2020, must be fully-funded to ensure continued support for health systems in the world’s poorest countries and the rollout of a COVID-19 vaccine in Gavi-supported countries once available.

●        The pausing of polio eradication campaigns and responses to focus resources on COVID-19 response, heightens the risk of increased spread of both wild and circulating vaccine-derived polioviruses, and the number of children paralysed as a result.

●        The COVID-19 pandemic is impacting livelihoods of the poorest in many developing countries and is projected to have a severe impact on nutrition and food security while lockdowns are simultaneously making interventions to tackle malnutrition more challenging.

GENERAL RECOMMENDATIONS:

●        Despite the challenges associated with programme delivery during a pandemic, DFID must either scale up or maintain key health and social protection measures in order to protect the most vulnerable.

●        DFID should adapt its programmes so that they can continue while adhering to restrictions in place to prevent the COVID-19’s spread.

●        DFID should ensure that key multilateral partners and grantees have the additional and flexible funding they need to respond to the COVID-19 outbreak.

●        DFID should regularly review operational guidance on maintaining essential health services, for example from the WHO[2], and issue such guidance to its country offices to ensure programmes can continue.

What are the immediate effects of COVID-19 on those living with TB, TB programming, and health systems in developing countries?

1. TB is the world’s biggest infectious disease killer, with 10 million new cases and 1.5 million deaths every year. TB treatment normally requires regular contact with health workers and takes between 6 to 9 months for those with drug-sensitive TB, and up to two years for drug-resistant TB. Furthermore, TB often impacts the poorest, most marginalised and vulnerable people in society. COVID-19 could negatively impact diagnosis rates which are already low in “normal” times. It could impact treatment success rates, which for DR-TB are already very poor at 55% for multi-drug resistant TB and 30% for extensively drug-resistant TB. Every effort must be made to minimise the harm caused in the short-term and to ensure that long-term gains can be made.

2. Evidence suggests that people with TB or who have had TB will be vulnerable to COVID-19 due to pre-existing lung damage. Furthermore, people who are vulnerable to TB are also at increased risk from COVID-19, because of their HIV status, diabetes, or chronic respiratory illness, and lack access to healthcare or nutritious food, or live in close quarters. Individuals on TB treatment are frequently asked to attend a health clinics multiple times a week to receive their medication and additional social support over many months. All of these services will be rendered impossible by COVID-19. The World Health Organization has issued guidance for TB programmes to manage these interruptions as effectively as possible, but TB programmes will need rapid support to implement these. A failure to do so will be catastrophic for the millions of people currently on treatment and the millions who will fall ill over the coming months, with some experts warning of a 50% increase in TB mortality.

3. NTPs find themselves at the frontline of the COVID-19 response. They are staffed by respiratory specialists, have experience in infection control and rely on the same screening and diagnostic tools that are used to diagnose COVID-19, including contact tracing, chest X-rays and diagnosis using GeneXpert machines. Many high-burden TB countries will find themselves in a better position to respond to COVID-19 thanks to decades of investment into their TB programmes, including through the Global Fund.

4. We are already seeing the impact of COVID-19 on these programmes. In South Africa, health workers are being asked to provide TB services using only surgical masks as N95 respirators are rediverted for COVID-19; in Nigeria, 300 GeneXpert diagnostic machines have been repurposed for COVID-19 testing; in Vietnam a proportion of the national TB budget has been requisitioned to respond to COVID-19; in Georgia and China drug-resistant TB wards are being converted into COVID-19 wards while in India, the country with the highest number of TB cases globally, the case notification rate is already dropping. During the 2014-15 Ebola epidemic, there was a 53% decrease in the diagnosis of TB and a doubling of the TB mortality rate in Guinea.

5. Manufacturing and procurement systems for TB will also be severely affected by COVID-19. The first rapid COVID-19 test to receive regulatory approval from the US FDA is manufactured by Cepheid and uses the GeneXpert diagnostic platform. GeneXpert is the most widely used rapid diagnostic test for TB, having seen massive roll-out campaigns through national TB programmes over the last five years. As Cepheid shifts its production to meet the huge global demand for its COVID-19 cartridges, TB diagnostic capacity will plummet both due to the availability of TB cartridges and the capacity of GeneXpert modules in-country. Similarly, the majority of the antibiotics used to treat TB around the world are generics manufactured in India often made-to-order without large stockpiles. Due to the Indian lockdown, pharmaceutical manufacturing plants throughout the country are currently working at 25% capacity and groups like the Stop TB Partnership’s Global Drug Facility are expecting numerous stockouts over the coming months. Drug-resistant TB already represents one third of all antimicrobial resistance-associated deaths, and treatment interruptions will lead to a significant increase in drug-resistance, which is far more difficult to diagnose and treat. 

6. The Global Fund is the single biggest funder of TB programmes as well as health systems strengthening more broadly. The UK is one of the Global Fund’s biggest donors, pledging to invest £1.4 billion between 2020-22. The Global Fund has announced unprecedented funding flexibilities as part of a major effort to rapidly mobilise funds for low-resource countries to prepare and respond to COVID-19. These flexibilities are to be welcomed, especially given the Global Fund’s proven track record in managing such funds in a transparent and effective way. However, the long-term implication is that funding for TB programmes will be significantly lower than expected, precisely at a time that they will need this funding the most.

RECOMMENDATIONS

●        DFID should issue rapid guidance to its country offices to ensure essential routine health programmes, including TB programmes, are sustained during the COVID-19 response.
 

●        DFID should provide additional flexible funding to key multilateral partners responding to COVID-19, including the Global Drug Facility, which works to coordinate TB drug supply and procurement, and prevent stock outs around the world. It should also ensure the Global Fund receives additional resources to replenish any funding made

available to countries responding to COVID-19.
 

●        Ensure any expansion of capacity within national respiratory health systems as a result of COVID-19, including the expansion of diagnostic facilities, scale-up of digital health technologies and increased laboratory capacity, are leveraged and built on as part of a long-term health systems and pandemic preparedness plan. 
 

How is COVID-19 impacting immunisation?

1. RESULTS UK is deeply concerned about the impact that the spread of COVID-19 could have on disrupting routine immunisation services in the least developed countries and humanitarian settings.

2. Fragile settings pose serious challenges for infectious disease prevention and control. The poorest and most marginalised groups are disproportionately denied access to clean water and health services, including routine immunisation and essential primary health care, exponentially increasing their vulnerability to COVID-19. 
3. The global COVID-19 pandemic poses a major risk within countries of secondary outbreaks from other vaccine-preventable diseases, including measles, meningitis and pertussis. Historically, global crises have diverted resources away from lifesaving interventions. For example, the 2019 Ebola outbreak in the Democratic Republic of Congo claimed more than twice as many lives from the secondary outbreak of measles as Ebola did.[3] Other impacted immunisation services include oral cholera, pertussis, yellow fever and rotavirus. 
4. Organisations such as Gavi and GPEI play an integral role in supporting national health systems with capacity to respond to outbreaks in some of the world’s poorest and most vulnerable countries. The COVID-19 pandemic is already affecting more than 60 countries supported by Gavi. Without a successful replenishment of Gavi in 2020 the vital work it undertakes in response to global emergencies is at risk of being undermined.

5. Gavi is at the forefront of the global pandemic response and is providing support to strengthen the preparedness of countries' health systems in low income countries. Gavi has already approved additional support in 13 countries totalling $29million[4] and is currently reviewing requests from a further 21 countries that could mean providing further support of up to $200million in the coming days and weeks.[5]

6. Gavi has previously demonstrated crucial leadership in responding to global pandemics. The Ebola crisis was brought under control through vaccination with support provided by Gavi. Once a COVID-19 vaccine has been developed Gavi remains well-positioned to ensure a stockpile is developed and rapid response is facilitated in low-income countries.
    

RECOMMENDATIONS:

●        To support Gavi in their vital work in responding to the COVID-19 outbreak, we urge the UK government to make an ambitious pledge to Gavi ahead of the Global Vaccine Summit 2020 and continue to press other international donors to make early and ambitious pledges.

●        The UK should highlight the importance of maintaining immunisation systems during and after the COVID-19 outbreak to prevent further loss of life and disease outbreaks and mitigate the secondary impacts of disruption to immunisation services.

●        DFID must highlight the importance of maintaining availability of key immunisations assets including trained health workers, availability of supply chains and disease surveillance in order to support resilient health systems needed to withstand the primary and secondary effects of COVID-19.

What are the specific impacts of COVID-19 on polio?

1. The impact of the COVID-19 pandemic will be felt severely in countries which continue to experience outbreaks of polio or require sustained immunisation efforts to prevent it from returning.

2. Polio is a highly infectious disease that can cause paralysis and, if the breathing muscles are affected, can be life threatening. The number of cases of polio has been reduced by over 99% since the establishment of GPEI in 1988, representing a historic success[6]. The UK’s contribution to these efforts has been critical, including a recent pledge to GPEI of up to £400m in November 2019. However, the world remains at risk of this progress slipping without sustained, and strengthened, immunisation and surveillance systems.

3. Pakistan and Afghanistan remain polio-endemic; both countries experienced a combined 175 cases last year and continued transmission in 2020 too. Furthermore, outbreaks of circulating vaccine-derived poliovirus (cVDPV) continue to occur: In 2019 there were 365 cases of cVDPV across Pakistan and a number of countries in Africa and Asia; in the year-to-date, 78 cases of cVDPV have already been identified.[7]
    
4. Serious challenges already remained in achieving sustainable polio eradication, with the most vulnerable, hard-to-reach and poorest communities often missing out on vital polio vaccinations and routine immunisation services.

5. GPEI’s Polio Oversight Board (POB) has recommended[8] that all preventative polio campaigns should be postponed until the second half of 2020 in order to halt the spread of COVID-19. Furthermore, it has advised that outbreak response campaigns be paused until 1 June 2020 at the earliest. The focus on slowing the spread of COVID-19 amongst frontline polio workers and the communities they serve is welcome, but there remains a significant risk that this will result in the increased spread of both wild and circulating vaccine-derived polioviruses, and the number of children paralysed as a result.

RECOMMENDATIONS

●        In order to reduce the severe impact COVID-19 will have on the spread of polio, DFID should call on GPEI to ensure eradication efforts are re-started as soon as it is safe to do so, and support countries in this process.

●        DFID should request GPEI to fully assess the programmatic and financial impacts of the response to COVID-19, and clearly and continuously communicate to donors and partners about how these will be addressed.

●        The UK should use its leadership position within GPEI to strengthen the partnership’s engagement with Gavi in order to ensure that delivery of the Inactivated Polio Vaccine is fully funded and that where necessary GPEI functions as services are taken forward by Gavi when domestic governments lack capacity.

How is COVID-19 affecting nutrition?

1. The pandemic is causing loss of livelihoods and income to buy food. Restrictions on the movement of goods is likely to cause food shortages and price rises. Many in the agri-food chain will end up with products they cannot sell, which has implications for both their income and food security. In Burkina Faso, the number of food insecure people is set to triple to 2.1 million due to the pandemic[9]. Women’s livelihoods, which often rely on the informal sector, are particularly at risk. The pandemic is likely to increase the burden on women's time through added unpaid domestic labour and care work. Both of these problems will affect the health and nutrition of whole families.
2. COVID-19 presents serious challenges in the delivery of nutrition programmes, given that many are delivered through stretched health services or involve gathering large groups of people. Travel restrictions on humanitarian staff and disruptions to supply chains are making it harder than ever to distribute essential supplies to many of the world’s most vulnerable people.

RECOMMENDATIONS

In order to continue vital nutrition programmes, DFID should:

●        Ensure community health workers have appropriate PPE and are able to implement no-touch techniques, such as using dolls, to safely demonstrate to parents how they can screen their own children for malnutrition.
 

●        Incorporate social distancing measures into programmes wherever relevant.
 

●        Enable parents to treat malnourished children while in self-isolation by ensuring they are able to access relevant medication and nutrition related health products; and ensuring breastfeeding mothers know what to do if they fall ill with the virus.
 

●        Ensure life-saving activities, such as the distribution of food, nutrition related health products and cash, are classified as essential and exempt from restrictions by authorities.
 

●        Anticipate supply chain problems and help governments to pre-position stocks of food and supplements.
 

●        Ensure that the DFID staff who are still in country are sufficiently briefed on nutrition, given that many DFID staff have returned to the UK, including those with responsibility for nutrition.

●        To mitigate the effects of COVID-19 on health and nutrition, DFID should strengthen existing community health services in order to ramp up screening for malnutrition, together with screening for COVID-19 symptoms and to promote social distancing and hygiene messages. This will prevent a surge in malnutrition cases and reduce the spread of the virus in a cost effective and timely manner.

●        To mitigate the effects of COVID-19 on incomes, livelihoods and food security, DFID should expand food assistance and social protection measures, including rolling out cash transfer schemes.

●        DFID should support local food production and transportation and, where needed, ensure people have physical access to food, including through blanket feeding. DFID can do this by working with country governments to ensure continuity in value chains and support farmers to ensure the continuity of food production. DFID should also support countries to monitor food prices and markets to help mitigate price rises.