In January, the World Health Organisation (WHO) published its list of the ten most pressing global health issues that require attention in 2019 from the organisation and the health sector as a whole.

The WHO list of threats for 2019 ranges from focusing on individual pathogens, such as Ebola and HIV, to failings of national healthcare systems and threats caused directly by negative human intervention.

Three of the most serious threats are air pollution, antimicrobial resistance and vaccine hesitancy.

Impact of air pollution on global health

Air pollution was designated by the WHO as the greatest environmental risk to health in 2019. The organisation estimates that 91% of the world’s population lives where air quality falls short of guideline limits and outdoor pollution is responsible for 4.2 million premature deaths a year, as well as causing a rise in hospital admissions and emergency room visits.

This is becoming an increasingly global problem as developing countries continue to industrialise on a large scale. The WHO states that 90% of global deaths from air pollution are in low and middle-income countries.

Recently, India was named as the most polluted country on earth, with Northern India housing all ten of the most polluted cities in the world. A report conducted by India State-Level Disease Burden Initiative Air Pollution Collaborators and supported by relevant state ministries and departments estimated that 2017 air pollution killed more than 1.24 million Indians and it lowered the country’s average life expectancy by 1.7 years.

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Although it can affect organs beyond the lungs, such as the heart, the main disease burden associated with air pollution are chronic respiratory illnesses, such as asthma, COPD, emphysema, and lung cancer.

Kaia Health vice-president of business development Mark Liber says: “The morbidity and mortality of pulmonary disease has risen in recent years in parallel with rising global air pollution levels.

“This is notably true for COPD – 90% of COPD-related deaths occur in low and middle- income countries, where ambient air pollution is often highest.”

Digital therapeutics as a solution to air pollution

Building upon previous initiatives, the WHO organised its first global conference on air pollution and health in November 2018. Participants agreed on a goal of reducing the number of deaths from air pollution by two thirds by 2030.

However, as Liber notes, this global initiative needs to be supported by “more stringent government emissions strategies” aiming “to reduce air pollution levels and mitigate the associated disease burden in the long-term”, such as by encouraging the development of new treatments for respiratory disorders.

In addition, companies including Kaia Health are using medical technology to provide digital therapeutics for respiratory disorders like COPD. Lider explains: “Kaia Health teamed up with leading providers and researchers of pulmonary rehabilitation and carefully digitized the key elements of the therapy to make it accessible in an easy-to-use, affordable and comprehensive smartphone application.”

The company recently initiated a feasibility study of the digital therapeutic in Japan, “where COPD poses a big burden on the healthcare system, with a high prevalence in Japan’s ageing population.”.

“With help from companies like Kaia extending access to care to the masses, the effect of air pollution on global health can be substantially mitigated,.” Liber says.

The threat of antimicrobial resistance

Despite public awareness of the widespread threat of antimicrobial resistance (AMR) for decades – the discoverer of the first antibiotic, penicillin,as far back as 1936, antibiotic pioneer Alexander Fleming warned resistance would gradually build up – it remains a serious threat to global health in 2019.

According to the WHO, AMR threatens to return the world to a time when physicians cannot easily treat common infections, as well as compromising surgery and life-saving procedures, such as chemotherapy.

Although AMR occurs naturally after micro-organisms are exposed to antimicrobial drugs, its effect is worsened by human action, such as over-prescription, patients not taking antibiotics as directed, poor hygiene and lack of infection prevention, as well as higher levels of global travel and migration.

The dramatic spread of AMR in recent years is exemplified by genes associated with antibiotic-resistant bugs being found by scientists in one of the most remote places on earth, the Arctic.

Pharma packaging supplier Origin’s head of new product development and innovation Jon Lant says: “[AMR] is claiming around 50,000 lives each year across Europe and the US; 700,000 lives globally.

“These figures are set to rise dramatically over the next 30 years. There are figures that claim that the mortality from AMR by 2050 [will be] a staggering 10 million per annum, which represents a greater death toll than cancer and diabetes combined.”

Solutions to control AMR spread: better packaged and location-focused treatments

As well as government and international initiatives to tackle growing antimicrobial resistance, such as the UK Government’s recent target of reducing antibiotic use by 15%, and the WHO’s annual Antibiotics Awareness Week, Origin believes innovations to pharma packaging could reduce the further spread of AMR.

A study in the British Medical Journal (BMJ) has shown that there is no evidence “for the arbitrary length of time that people are told to take antibiotics” and so “it is likely to be better for people to stop as soon as they do feel better to reduce the global growth of antibiotic- resistant bacteria”, according to Lant.

Packaging can play a role in the better labelling of drugs “to ensure pharmacists, who are dispensing the medicine, give the dose patients actually need, rather than an off-the-shelf, one-size-fits-all approach,.” Lant says.

However, Médecins Sans Frontières (MSF) Access Campaign executive director Els Torreele notes that it is important to not interpret “better use of antibiotics “ as simply reducing their use. Instead, what matters is that “access is prioritised, rather than reduced,” particularly in developing parts of the world where MSF focuses its work.

She notes that the importance of ensuring research and development of new antibiotics “targets the resistance patterns and the pathogens that most affect the populations in developing countries,”, as well as being affordable.

MSF is attempting to do this through the Global Antibiotic Research and Development Partnership (GARDP), which it created in partnership with the Drugs For Neglected Diseases initiative (DNDi) and WHO.

“The GARDP is focused on ensuring new drugs are being developed that address the needs of people in low and middle-income countries,” says Torreele. “They look at the priority list of pathogens very differently from what we sometimes [see] when initiatives are driven by governments, which are very much focused on protecting their own populations, which is not necessarily exactly the same.

“The approach that GARDP is taking is not just in terms of developing drugs up to registration, but providing the evidence base so that health systems…use these drugs in the right way.”

Vaccine hesitancy: understanding the problem

Vaccine hesitancy is how the WHO describes “delay in acceptance or refusal of vaccines despite availability of vaccination services”; the people who intentionally resist vaccine programmes are often referred to as ‘anti-vaxxers’.

As noted by UK Royal Society for Public Health (RSPH) chief executive Shirley Cramer, “It is clear that vaccine hesitancy is an international problem, and not one that is confined to higher income countries.

“We know that one in five children worldwide are still not receiving routine vaccinations, and while some of this can be chalked up to problems of access, the WHO has also noted how vaccine hesitancy can affect uptake rates despite local availability of immunisation services.”

There are a variety of reasons for anti-vaccine sentiment; the main ones identified by a WHO advisory group were complacency, inconvenience in assessing vaccines and lack of confidence in the efficacy of vaccines to treat disease.

Resolving vaccine hesitancy: disseminating trusted, credible information

The WHO’s recommendations for tackling vaccine hesitancy centre around better engagement between health services and communities, as well as capitalising on the trust people place in health workers by better supporting them.

A UK-focused report titled Moving the Needle, recently published by RSPH, found that 94% of parents identified scientific experts as the most trusted sources of advice on vaccines, and 92% most trusted doctors and nurses.

The dissemination of credible, trusted information by healthcare workers can be supported, particularly in developed countries, by “social media giants, like Facebook coming forward and taking positive steps themselves to limit ‘fake news’ – something that four in five of the UK public would back,” according to Cramer.

In a statement about the RSPH report, Cramer said: “We found worrying levels of exposure to negative messages about vaccinations on social media, and the spread of misinformation – if it impacts uptake of vaccines – could severely damage the public’s health.”

The RSPH research found that two in five parents with children under the age of 18 said they were exposed to negative messages about vaccinations online ‘often’; this figure rose to one in two for parents with children under five years old and one in ten said they trusted people on social media.

There is also evidence that repetitive exposure to negative messages can be mistaken for accuracy and negative messages are often viewed more than positive messages and spread more quickly.