Research Roundup: Phase 3 chikungunya vaccine results, a promising antimalarial, and CEPI funding

Last Friday, President Joe Biden signed into law a $1.5 trillion spending bill that will fund the US government through the remainder of fiscal year 2022 (FY22), which began October 1, 2021, and concludes in September. The outcome followed months of tense negotiations by Congress—which had passed a series of temporary funding measures, known as continuing resolutions, to keep the government funded at FY21 levels since the start of this fiscal year—and last-minute maneuvering to try to pair annual spending with emergency aid for Ukraine and the COVID-19 response domestically and globally.While the bill ultimately included welcome boosts across key agency programs that fund global health and medical research, summarized below, in very disappointing news, emergency funding for COVID-19—including $4.5 billion for the global response—was stripped from the final package at the 11th hour due to disagreements on how to cover costs. This leaves an uncertain path ahead for the Biden administration to execute its COVID-19 plan, as previously appropriated funds for the domestic and global response are nearly depleted—raising the prospect of having to halt ongoing government-sponsored COVID-19 research trials, among other impacts. House Democrats have promised to advance a stand-alone COVID-19 emergency funding package, which could provide an influx of urgently needed funds, but it’s unclear whether such legislation could gain the 60 votes needed in the Senate since Republicans are demanding any new bill be paid for via offsets of unspent funds, a requirement many Democrats are opposed to.Below GHTC takes a detailed look at the spending bill and its impact on accounts that finance global health research and development (R&D) programming.State and Foreign OperationsThe final spending bill included $9.8 billion in funding for Global Health Programs at the State Department and US Agency for International Development (USAID), which represents an increase of $630 million, or 6.9 percent, over FY21 enacted levels. The vast majority—$510 million—of that increase is designated for global health security programming at USAID, a 268 percent increase over FY21 funding. This funding includes a $100 million allocation for the Coalition for Epidemic Preparedness Innovations (CEPI) to support vaccine development for potentially epidemic threats, which is both welcome news and higher than the $50 million pledge for this fiscal year announced by USAID Administrator Samantha Power at the CEPI pledging summit just a few days prior.Beyond global health security, the remainder of the increase—$130 million—was spread across other global health accounts. The tuberculosis and maternal and child health program lines at USAID received the largest increases at $52 million (16.3 percent) and $34.5 billion (4 percent) respectively, while nutrition, malaria, and neglected tropical diseases were each increased by $5 million and vulnerable children was increased by $2.5 million. USAID’s HIV/AIDS and family planning lines received flat funding compared to last fiscal year while the President’s Emergency Plan for AIDS Relief, or PEPFAR, under the State Department, was boosted by $20 million (0.5 percent). No global health-related accounts at USAID or State saw their funding cut. In other important news, in the joint explanatory statement accompanying the bill, Congress included language, for which GHTC advocated, directing USAID to develop and publicly release a new multi-year strategy on health R&D detailing its goals and how it plans to invest across health areas. USAID’s current health R&D strategy runs through 2022, so the fulfillment of this congressional directive will help ensure continuity and that research remains a priority for USAID’s global health programming.While it was positive to see Congress provide a major funding boost for health security programming and some modest increases to other global health accounts, overall, these funding increases fell short of what many advocates had hoped for, and in many cases what the House and Senate bill drafts released in 2021 had proposed. The COVID-19 pandemic has increased both the challenges and costs of operating health and research programs worldwide, so this funding package, even with increases, fails to match the scale of today’s expanding needs.Health and Human ServicesThe spending bill provided much larger, but uneven, increases across Department of Health and Human Services (HHS) subagencies and programs that support global health R&D. The National Institutes of Health (NIH) received $44.96 billion in funding, representing a $2 billion, or 4.7 percent, increase over FY21 levels. This included an increase of $253.1 million, or 4.2 percent, for the National Institute of Allergy and Infectious Diseases and a $2.8 million, or 3.4 percent, increase for the Fogarty International Center, which works to strengthen research capacity in low- and middle-income countries.Meanwhile, the Biomedical Advanced Research and Development Authority (BARDA)—an agency that supports development of medical countermeasures against health threats and a central player in COVID-19 R&D through then Operation Warp Speed—received a significant funding boost from Congress. It was appropriated $745 million in funding, a $148 million, or 24.9 percent, increase over the prior fiscal year. This funding envelope supports the agency’s entire research portfolio, which covers chemical, nuclear, radiological, and biological threats—both man-made and naturally occurring—so it is at the agency’s discretion to determine what of this funding it ultimately spends on R&D for naturally occurring health threats, including emerging infectious diseases, pandemic influenza, and antimicrobial resistance. Congress included in the bill’s accompanying joint explanatory statement language requested by GHTC expressing support for BARDA to expand its work on naturally occurring threats and provide more detailed reporting on such spending.The Centers for Disease Control and Prevention (CDC), which is a smaller but still important player in supporting global health R&D, received overall funding of $8.5 billion, a $582.4 million, or 7.4 percent, increase from the prior year. Within that, the Center for Global Health received a $54 million, or 9.1 percent, increase, with 93 percent of that increase designated for the global public health protection line focused on health security and the remainder spread across accounts funding global immunization, HIV/AIDS, tuberculosis, and parasitic diseases and malaria. The National Center for Emerging and Zoonotic Infectious Diseases, which funds select R&D for diagnostics and vaccines against infectious diseases, received a $45 million, or 6.9 percent, increase over FY21 enacted levels. These CDC increases were seen by many advocates as disappointing compared to evident needs. Challenges faced by the agency during the COVID-19 pandemic have underscored the need for a more significant influx of funding for this historically under-resourced agency to modernize its systems and improve staff retention.In addition to providing increases for the three HHS agencies above, Congress appropriated $1 billion for HHS to set up a new Advanced Research Projects Agency for Health, modeled after the Defense Advanced Research Projects Agency, to speed development of medical breakthroughs by funding high-risk, innovative projects. This funding was far lower than the $6.5 billion requested by the Biden administration and interestingly was designated to HHS to establish the agency under the Office of the HHS Secretary, rather than within NIH as the Biden administration and some congressional leaders had proposed. GHTC has pushed for this proposed agency to focus on poverty-related and neglected diseases, as a key area of market failure by industry; however, it remains unclear what health areas this new agency will initially prioritize as it is stood up.While FY22 was a bit of a mixed bag for global health R&D, with important increases across some programs but other areas falling short, advocates are already gearing up for the budget battle ahead for FY23, with the Biden administration expected to release its FY23 budget proposal soon.

International Women’s Day calls for action to address biases, discrimination, and inequities that continue to impact the quality of life of women and girls, including their access to healthcare, such as malaria prevention and treatment. Pregnant women and their babies are among the most at risk from malaria, and this is exacerbated by their limited access to antimalarial medicines. According to the World Health Organization (WHO), in 2020, nearly 12 million pregnant women were exposed to malaria, and they are particularly vulnerable as pregnancy can weaken their immune system. Malaria can have devastating effects on pregnant women and infants, from mothers with severe anemia and babies born with low birth weight to, in the worst case, the death of the mother and/or baby. According to research from 2020, one in ten maternal deaths in malaria-endemic countries is the result of malaria. WHO recommends intermittent preventive treatment in pregnancy (IPTp) to prevent malaria in pregnancy. Ideally, eligible pregnant women should receive three doses of sulfadoxine-pyrimethamine (SP) to prevent malaria in their second and third trimesters for optimal protection. Due to several factors, only 32 percent of eligible pregnant women received all three recommended doses of IPTp in the 33 sub-Saharan African countries assessed by WHO’s 2021 World Malaria Report. A 2019 review that looked at determinants of IPTp uptake in 18 sub-Saharan African countries found that poor policy implementation resulting from weak coordination between national malaria control and reproductive health programs and stockout of quality SP were the main barriers. The review also mentioned the pivotal role played by health providers in delivering IPTp, highlighting the correlation between their awareness of the policy and the IPTp coverage. In sub-Saharan Africa, between 70 and 90 percent of pharmaceuticals are imported, making it difficult to ensure a steady supply of treatments like SP. To help remedy this access gap, Medicines for Malaria Venture (MMV) is currently leading a UNITAID-funded project to enable the pharmaceutical companies Universal Corporation Ltd (Kenya), Swipha/Biogaran (Nigeria) and Emzor (Nigeria) to manufacture quality SP, not only for domestic use, but also for other countries in Africa. Community IPTp (C-IPTp) is another solution to help address the access gap, in which pregnant women visit “purposely trained and supervised, easily accessible community health workers” close to their homes to receive IPTp. C-IPTp is being explored by many countries with promising results in improving SP uptake. MMV is also involved in Transforming Intermittent Preventive Treatment for Optimal Pregnancy, otherwise known as TIPTOP, a Jhpiego-led project to increase the number of women able to benefit from C-IPTp.Under the umbrella of the Roll Back Malaria Partnership, MMV is participating in a signature campaign calling for global leaders to Speed Up Scale-Up IPTp through an open letter that asks for increased funding to address malaria in pregnancy, proper training for health care workers and the removal of the previously mentioned barriers to seeking care. Beyond statistics: Surviving malaria in pregnancy The need for new options for medicines is underscored by Eileen Buxton’s experience. Eileen, a Ghanaian nurse, was already aware of the risks of malaria in pregnancy as a health care worker in an endemic country. After falling ill while pregnant herself, Eileen “was scared… I knew how being sick during pregnancy could affect the mother and the child too.” She was admitted to a hospital for treatment. After her release, however, the fever came back within a couple of days. Eileen was experiencing severe malaria and had to be admitted to the hospital again, this time for about three weeks. “It took a long time for me to recover some strength,” she recalls. Despite this harrowing experience, Eileen can be described as one of the fortunate ones: after her recovery, she gave birth to healthy twin babies. Millions of women are not so lucky. Scaling up IPTp-SP access will prevent millions of women from going through experiences like Eileen’s. While International Women’s Day highlights women’s achievements, it is also a reminder of the existing challenges they face. When it comes to health and malaria specifically, it is also a reminder that we have not yet reached equity. Ending malaria means working to provide access to antimalarial prevention and scaling up access to IPTp and other treatment methods that are effective and safe for all people—like Eileen Buxton—who are most at risk. Ultimately, that’s a win for everyone. We urge you to add your name to the open letter and help protect more mothers and babies from malaria.