Tag Archives: WHO

It’s time to focus on an endgame for tobacco regulation

The Conversation

Kathryn Barnsley, University of Tasmania

New comprehensive research shows smoking imposes a heavy economic burden throughout the world, gobbling up almost 6% of global health spend and nearly 2% of the world’s GDP. In 2012 this amounted to US$1,436 billion (A$1,898 billion).

This is particularly evident in high income jurisdictions, like Australia, North America and Europe. Each year, smoking kills an estimated 15,000 Australians, and costs Australia A$31.5 billion in social (including health) and economic costs.

New initiatives in tobacco control are urgently needed. Plain packaging has been a success, but required steely determination by ministers to ensure continuity.

Smoking rates are declining in Australia, although the rate appears to be slowing. And there are still worryingly high rates of smoking in some populations and jurisdictions, such as the Northern Territory. In 2009 Australian researchers predicted smoking cessation rates would need to double to ensure Australian smoking prevalence dropped to the policy target of 10% by 2020.

Over a decade ago leading tobacco control expert Derek Yach, a Yale Professor and former senior World Health Organisation (WHO) executive, warned against complacency in tobacco control, and urged greater action. In 2016 Ruth Malone (former editor of the journal Tobacco Control) was still emphasising the point, highlighting current measures will not achieve an end to the tobacco pandemic. She asked,

Will caution and inertia shape another century of public health catastrophe?

Anti-science ideology

We are currently experiencing a crisis of public confidence in expertise, knowledge and evidence. The new US Vice President Mike Pence once famously wrote that “smoking doesn’t kill”.

New ways of thinking emphasise individual responsibility and de-emphasise population measures that regulate corporations. This is also having an impact on our health, and has led University of Melbourne’s Rob Moodie to call for change, saying:

The only evidence-based mechanisms that can prevent harm caused by unhealthy commodity industries are public regulation and market intervention.

Related to these global sentiments, the cigarette industry has some strategies in play. Big tobacco presents public arguments to counter reform, using terms that soften the need for regulation such as “nanny state” and “free choice”, and more recently “unintended consequences” and “sensible regulation”.

The tobacco industry is also actively evolving, for example through taking over e-cigarette production and sales.

Reform through endgame strategies and charismatic ideas

The tobacco endgame concept moves thinking away from the mere control of tobacco towards plans for ending the tobacco pandemic, and foresees a tobacco-free future. The unifying term “endgame” includes those policy approaches which orient researchers and decision-makers toward this goal.

WHO Director-General Margaret Chan championed endgame strategies in 2013 and urged a focus on precision, impeccable science, feasibility and realism.

Innovative strategies and “charismatic” ideas have also been proposed to counter an innovative tobacco industry. These ideas are canvassed below.

Reduction in retail outlets

In New Zealand, modelling undertaken at the University of Otago predicted reduction in retail outlets would modestly contribute to an endgame goal.

Others have suggested an increase in distance from home to the nearest tobacco retailer, or lowering density of outlets could assist quit rates.

Simply reducing access to cigarette retail outlets could lower smoking rates. thomashawk/flickr, CC BY-NC-SA

A tobacco-free generation

This idea was first proposed in Singapore, and followed up in Tasmania. It’s a supply-side measure that would, from January 2018, prohibit the sale of tobacco products to any person born after the year 2000.

It has drawn criticism from the tobacco industry, but has 75% community support, and even 72% among smokers.

More broadly, Australian smokers do want the government to regulate the industry more heavily, as they believe the tobacco industry is partly responsible for the predicament they find themselves in.

Regulation of markets and cigarette engineering

The regulated market model proposes the tobacco market be controlled by one agency, which tenders to manufacturers for tobacco products and then distributes to retailers. This would, in effect, make tobacco a controlled substance, like methadone.

Reducing palatability of tobacco products, and the banning of filter ventilation and other elements of cigarette engineering have been proposed in Australia for some years. The idea of reducing addictiveness by lowering nicotine content is attractive, particularly as it would assist existing as well as beginner smokers.

The federal government contracted two consultants to provide reports on cigarette palatability and engineering in 2013. Late on Friday 27 January 2017 the heavily redacted documents were released under FOI. However, it is possible to see the extent of comprehensive research that has been undertaken.

One document includes the disclaimer:

No regulatory decisions have been made by the Department of Health or the Australian Government about potential new tobacco product content regulation controls or revised disclosure requirements for tobacco products.

There is no independent regulatory oversight or quality control on the content of cigarettes themselves, and no recall provisions.

The ‘sinking lid’ – an idea from New Zealand

Another supply-side reduction proposal is to require regular reductions in the amount of cigarettes made available for sale and to increase prices. This is the “sinking lid” idea. Strong border controls and geographical isolation are prerequisites in order to reduce the potential for smuggling. Therefore island nations and states are ideal places to experiment with this proposal. Considerable support exists for this approach.

Together, these endgame proposals to lower tobacco use should be actively explored and implemented as appropriate by governments around Australia. The economic and social costs of tobacco smoking remain enormous, and it’s time to take action.

The ConversationKathryn Barnsley, Adjunct researcher, University of Tasmania

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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Here’s why we don’t have a vaccine for Zika (and other mosquito-borne viruses)

The Conversation

Suresh Mahalingam, Griffith University and Michael Rolph, Griffith University

As Zika fear rises, especially in the wake of the World Health Organization last night declaring a state of public health emergency, people are inevitably asking why we don’t have a vaccine to protect against the mosquito-borne virus.

Zika is generally a mild illness, causing fever, rash and joint pain, which usually resolves within seven to ten days. It was originally restricted to small outbreaks in the Pacific islands, Southeast Asia and Africa.

Due to the previously low impact of the virus and the estimated US$160-500 million it costs to develop a vaccine, Zika vaccine has not been on the radar. Other severe and potentially fatal mosquito-borne diseases such as malaria, dengue, and West Nile virus affect millions of people each year and have been a higher priority.

That has all changed with the recent “explosive” spread of Zika in the Americas and the potential link with microcephaly (reduced head size and brain damage) in babies of pregnant women who were infected.

Now we’re playing catch up on the research needed to develop vaccines. We know very little about how Zika replicates, how it causes disease, or how the immune system protects against infection.

So what is the status of Zika vaccine development? And how does this compare with the other mosquito-borne viruses that continue to have such a devastating impact on the world’s health?

Vaccine development

The ideal vaccine induces a strong response from the immune system, gives long-term protection with few doses, and causes no side effects. Though quickly developing such a vaccine is rarely this simple.


It’s early days, but scientists from the Public Health Agency of Canada, the Butantan Institute in Brazil, and the US National Institutes of Health have started work on Zika vaccines. These research teams may have vaccine candidates ready for initial clinical trials towards the end of the year.

Although full regulatory approval of a successful vaccine would take many years, it could potentially be used in public health emergencies within a year.

Yellow fever

The yellow fever vaccine, developed in 1938, has been highly successful at protecting against the virus, which can cause bleeding, jaundice, kidney and liver failure and, ultimately, death. Of the 44 countries at risk of yellow fever in Africa and the Americas, 35 have incorporated Yellow Fever vaccines into infant immunisation programs.

It is a live vaccine, in which a “weakened” virus induces a protective immune response against subsequent infection.

The Yellow Fever vaccine successfully protects against the virus, but is .

Live vaccines generally give strong protection, but safety is a significant issue, particularly in people with a weakened immune system.


Dengue fever is a widespread tropical disease caused by dengue virus, which is transmitted by mosquitoes. Late-stage clinical trials of dengue vaccines are underway, and a vaccine has recently been licensed for use, but so far only in Mexico.

The field is littered with promising but failed vaccines that could not provide protection against the major strains of dengue virus. Nonetheless, there is hope that one will be available more widely in the coming years.


Chikungunya virus has recently emerged as a serious human pathogen, causing fever and excruciating pain in the joints that can last months.

As with Zika, chikungunya was long considered unimportant because of its limited geographic distribution. Its dramatic expansion over the past decade, particularly in Southeast Asia and the Americas, has led to mobilisation of the vast medical research capabilities of the United States in response to the threat of it becoming established there.

Chikungunya vaccine development is proceeding rapidly, with a number of vaccines entering clinical trials. Researchers have reported early successes, but we are at least several years away from getting an approved vaccine.


The big one is malaria, which kills more than 400,000 people a year. Scientists have been working on malaria vaccines for decades.

The RTS,S vaccine, developed by Glaxo Smith Kline, was successful in clinical trials and may soon be routinely used.

However, it only worked for some patient groups and provided only partial protection. Given its partial efficacy, there is debate in the medical community about the vaccine’s value.

The search continues for better vaccines.

Why is it so difficult to develop vaccines?

There is no recipe for the perfect vaccine. Despite the ever-increasing sophistication of vaccine technology, vaccine development often comes down to “suck it and see”. Many vaccines look promising in pre-clinical testing, only to fall over during the slow and expensive clinical trial process.

For many infectious diseases, we still don’t know what type of immune response is the most effective in providing protection. Since vaccines induce a protective immune response against infection, this can make vaccine design very difficult.

Vaccine safety is a major issue. “Live” or “attenuated” vaccines that involve a related or weakened version of the pathogen are often the most effective. But there is still the potential for these vaccines to cause disease, especially in recipients with weakened immune systems.

Vaccines go through a long process of clinical trials and assessment by regulators before they are approved for routine human use. This is a necessary process, but it sets a very high bar for approval. One of the most successful vaccines ever produced – the smallpox vaccine – is a live vaccine and would probably not have been approved by today’s regulators due to safety concerns.

Smallpox was eradicated in 1980.
Pan American Health Organization/Flickr, CC BY-ND

For dengue, there is an additional complication. People previously infected with dengue are at risk of developing much more severe disease when infected with a second, related dengue strain. Similarly, dengue vaccination could also lead to enhanced disease, rather than protection, when a person subsequently encounters the virus. This additional safety concern has markedly complicated and slowed dengue vaccine development.

Urgent priority

Zika causes mild fever in humans that on its own does not make a strong argument for a vaccine. But the possible link to microcephaly in unborn children, even though not yet definitely confirmed, makes vaccine development – and necessary funding – an urgent priority.

It’s also important to fund basic research to provide a necessary springboard for current and future vaccine development programs.

In the meantime, people in affected areas, including travellers, should take care to avoid mosquito bites by wearing long clothing and using repellents, bed nets and window screens.

The ConversationSuresh Mahalingam, Principal Research Leader, Institute for Glycomics, Griffith University and Michael Rolph, Senior research fellow, Griffith University

This article was originally published on The Conversation. (Reblogged by permission). Read the original article.


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The water industry needs to join the fight against superbugs

The Conversation

By Peter Fisher, RMIT University and Peter Collignon, Australian National University

The fight against antibiotic-resistant bacteria – so-called “superbugs” – is a huge challenge, one that the World Health Organization has described as a grave global problem.

When superbugs hit the headlines it’s often because of hospital outbreaks, such as the outbreak of Vancomycin Resistant Enterococcus that infected babies in Melbourne in 2013. Yet the problem isn’t confined to hospitals – the wider environment can be important in the development and spread of these bugs, and people can be infected through food and water.

The problem of antibiotic resistance is being exacerbated worldwide by the pollution of waste water with leftover drugs, providing breeding grounds for resistant bacteria and their genes. The problem can persist for years, constantly refreshed by new discharges of both drugs and of resistant bacteria themselves, shed by people and animals.

Vancomycin Resistant Enterococcus, which is impervious to one of the antibiotics used as a last resort by many doctors. Source: 
Janice Henry Carr/US Centers for Disease Control and Prevention

Warning from history

The fact that penicillin was found in soldiers’ urine in the second world war was, in hindsight, an early indication that antibiotics are present in waste water, and that drugs like this might go on to have an afterlife in streams, lakes and other waterways, clinging to sediment particles and upsetting the delicate bacterial balances in soils and aquatic ecosystems.

But no-one gave the issue much thought until chance intervened in 1992, when German scientists looking for herbicides in rivers, groundwater and lakes stumbled across a chemical they didn’t recognise – it turned out to be the cholesterol-lowering drug clofibrate, a cousin of the weedkiller 2-4-D.

No end of pharmaceutical pollution has since been found in the world’s water – analgesics, antibiotics, lipid regulators, antiseptics, beta-blockers, contraceptive hormones, anticonvulsants and X-ray contrast agents. Detectable levels of clofibrate alone are now found throughout the North Sea.

We now know that partially degraded drugs and ointments can be converted back into their active form through chemical reactions once you’ve said goodbye to them in the loo or shower. Many biodegrade, but others can be very persistent in their new environmental home.

Water treatment plants are thus the last barrier to drug residues and other synthetic chemicals being set loose into soils and waterways (meanwhile, there is no barrier at all for freely administered livestock drugs such as the antibiotics sulphasalazine and oxytetracycline).

Crucial treatment

Treatment plants’ ability to strip out waste drugs varies enormously according to age, level of expertise and design standard. Even the best ones don’t remove all foreign chemicals. Advanced treatment processes are designed more for removing pathogens than for breaking down molecules, although chlorination and what’s known in the trade as “ozonation” do have some ability to change the chemistry of drug molecules (to exactly what is unclear).

As the use of recycled water increases, the quality of this water becomes more critical and good management of all sewer inputs by water companies becomes more important. Thus, pharmaceuticals are being identified as a potential risk in recycled water risk-management systems of utilities such as South East Water in Melbourne, Orange County Sanitation District in California, and Singapore’s NEWater scheme.

This is leading to an increased awareness of the waste contributions from domestic catchments and high-concentration point sources such as hospitals.

It is time for the health and water industries to strike a bargain. Health professionals need to be aware of the need for pharmaceuticals to be managed as organic and persistent pollutants. They can help the water treatment industry by being aware of what their activities are putting into the sewerage and waste disposal systems, in view of the limited extent to which these systems can deal with the large number of drugs that are stable. They should consider prescribing less toxic, less environmentally persistent, but equally effective drugs where possible, as well as trying to reduce overall drug use in the community.

Meanwhile, Australia should build on its reputation for innovation in water management by addressing this health issue. Tackling hot spots in “source control” such as hospitals and clinics could make significant inroads on the amount of waste drugs entering treatment plants. Treatment at source may be preferable to facing increased trade waste charges by utilities if they deem hospital wastewater inputs to be problematic. Water firms should discourage hospital staff from emptying half-empty syringes into wash basins (which is probably common despite being against protocols) should also be discouraged. Rubbish disposal systems that minimise medicines ending up in landfill are another must.

The water industry should to ensure that treatment plants are operating under optimal conditions and that the older ones are either replaced or upgraded. Where appropriate, the industry could also help hospitals with in-house waste treatment, and suggest ways for householders to dispose of unwanted drugs – perhaps along the lines of Orange County’s No Drugs Down the Drain” campaign.

The search for new antibiotics to beat superantibiotics goes on. The discovery of one of the very few new candidate antibiotics in the past 30 years, teixobactin, while encouraging, is no cause for complacency.

This article was co-authored by David Smith, water quality manager for South East Water, Melbourne.

The ConversationThis article was originally published on The Conversation. (Reblogged by permission). Read the original article.

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