YEAR-END REPORT - 2020 Published 21-Dec-2020 HPTS Issue Brief 12-21-20.5 Health Policy Tracking Service - Issue Briefs Business of Health International Healthcare This Issue Brief was written by Melissa D. Berry, a principal attorney editor on the Publisher's Staff and a member of the Ohio bar. 12/21/2020 I. AFRICA Health Tech Pins Hope on Africa's Pandemic Shift to Online Care (Reuters) - When Loveth Metiboba's baby had diarrhea, she worried that taking him to a clinic near her home in Nigeria's capital, Abuja, [FN2] might expose them both to the coronavirus. “The idea of going to the clinic was very scary,” said Metiboba, a researcher for a charity. Instead, the clinic, run by Nigerian health technology firm eHealth Africa, sent her a web browser link to hold a video chat with a doctor who diagnosed her son with a mild illness and prescribed medicine to avoid dehydration. Across the globe, the COVID-19 pandemic has accelerated changes in the way medicine is practiced as medical care increasingly begins with an online consultation rather than a face-to-face meeting. But the opportunities in Africa, where access to medical care is often restricted, are transformational and offer growth prospects to companies that provide online consultations and online sales of medicine. Mukul Majmudar, chief executive of CureCompanion, which developed the online platform Metiboba used, said the Texas-based company had seen a 12-fold increase in business in Africa this year from 2019. That compares with a 10-fold rise in online medicine across all seven countries - Armenia, Honduras, India, Saudi Arabia, United Arab Emirates and the United States, as well as Nigeria - where it is present. Helium Health, a Nigerian company that specializes in digitizing medical records, brought forward to February the launch of its online consultation platform, which had been planned for later in the year, to meet demand resulting from the pandemic. In May, it raised $10 million from investors, including Chinese technology giant Tencent. Helium Health's CEO Adegoke Olubusi said dozens of hospitals and clinics had subscribed to the service. They include a private clinic in the Victoria Island business district of Lagos. It is run by doctor Ngozi Onyia, who said she had signed up for a 150,000 naira ($394.22) monthly subscription with Helium Health and that most of the clinic's patients had opted for online consultations, referred to as telemedicine, within weeks of Nigeria's first cases of the novel coronavirus. The online consultations cost 10,000 naira each - half the cost of an in-person examination. “This kept us going - we held on to our patients and even gained new ones,” Onyia said. PRIVATE FUNDING, GOVERNMENT USE Even before the pandemic, public health experts and investors saw the potential for telemedicine to help Africa cater for the needs of rapidly-expanding populations. Funding from development agencies and venture capitalists alike has flowed into tech companies providing healthcare in Africa. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -1- Data from San Francisco-based investment firm Partech showed venture capital investment in Africa's health tech companies grew to $189 million in 2019 from around $20 million in both 2017 and 2018. Even in the turmoil of the pandemic, some $97 million was raised in the first half of 2020, Partech said. Of last year's total, $69 million was spread across 12 deals and $120 million went to Zipline, a Californian drone firm that launched in Rwanda in 2016. It estimates that its drones, carrying medical equipment, can reach 95% of the mountainous East African country from two distribution centers. In 2019 it expanded into Ghana, where the government enlisted it during lockdown in May to deliver coronavirus test samples, vaccines and protective clothing, such as gloves. “It became very handy during this pandemic where we needed to send samples quickly to testing centers,” Nsiah-Asare, health adviser to Ghana's president said. The government is in talks with Zipline about expanding its operations in Ghana by creating three new distribution centers in addition to the four Zipline already operates there, Nsiah-Asare and the company's country director Daniel Marfo told Reuters. The government in Nigeria, Africa's most populous country, has also seen the potential for high tech help. Authorities in the capital Abuja contracted the charitable arm of eHealth Africa to roll out a system that alerts patients who test negative for the novel coronavirus that causes COVID-19 with an automated text message. Those who test positive for the coronavirus require medical help and contact-tracing, but for negative tests, a message is enough. Chikwe Ihekweazu, who heads the Nigeria Centre for Disease Control (NCDC), said automating the process would help authorities handle increased testing after the resumption of international flights from Sept. 5. “Almost everything we're doing right now, from logistics to managing the outbreak itself, is being migrated into different technological platforms,” Ihekweazu said. ECONOMIC CRISIS For all the potential for technology to help, it is likely to be constrained as the COVID-19 pandemic adds to Africa's economic problems. The International Monetary Fund (IMF) forecast a 3.2% contraction in sub-Saharan Africa's gross domestic product in 2020. In addition, the pandemic has put around 20 million jobs at risk across the continent, the African Union has said, which will reduce people's ability to spend on healthcare. Already Africa spends less on healthcare than the rest of the world. It makes up 16% of the world's population and carries 23% of the global disease burden, but accounted for just 1% of total global health expenditure in 2015, according to the most recently available data provided by the Brookings Institution, a Washington-based think tank. In per capita terms, the rest of the world spends 10 times more, it said. The widespread adoption of health technology may also be stymied by poor internet connectivity and patchy electricity. Metiboba switches between two network providers to overcome connectivity problems. It's an approach that is too costly for many, but for Metiboba it means she has continued to use remote consultations since her son's health scare and plans to continue to do so. “It works for me,” she said. II. AMERICAS Trump Proposes Rule for Importing Drugs from Canada; Industry Says It Won't Cut Costs (Reuters) - The Trump administration on Wednesday said it is proposing a rule to allow states to import prescription drugs from [FN3] Canada, advancing a plan announced in July that the president has said will bring cheaper prescription drugs to Americans. Importation of drugs from Canada to lower costs for U.S. consumers has been considered for years. Alex Azar, secretary of the Department of Health and Human Services (HHS), called the move “a historic step forward in efforts to bring down drug prices and out- of-pocket costs.” Industry trade groups in both countries opposed the plan, saying it will not lower costs and could hurt Canada's drug supplies. Groups representing pharmaceutical and biotech companies called the proposal a political gesture. Azar said HHS would offer guidance to drugmakers that wish to voluntarily bring drugs they sell more cheaply in other countries into the United States for sale here. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -2- The pathways for importation were announced in July, when Azar unveiled a “Safe Import Action Plan.” The proposed rule still needs to pass through a 75-day comment period before being finalized, Azar said. “We're moving as quickly as we possibly can,” he added. Governors of states including Florida, Maine, Colorado, Vermont and New Hampshire have already expressed interest in importing drugs from Canada once the pathway is fully in place, Azar said. States would be required to explain how any proposed drug imports would reduce drug prices for consumers. Jim Greenwood, head of biotech industry trade group BIO and a former Republican congressman, said importation would not result in lower prices for consumers, citing nonpartisan budget experts and past U.S. Food and Drug Administration commissioners. “Today's announcement is the latest empty gesture from our elected lawmakers who want us to believe they're serious about lowering patients' prescription drug costs,” Greenwood said in a statement. CANADA DRUG SUPPLY “INSUFFICIENT' FOR U.S. MARKET The Canadian government criticized the plan. Its U.S. ambassador said last month that importing medicines from Canada would not significantly lower U.S. prices. Reuters previously reported that Canada had warned U.S. officials it would oppose any import plan that might threaten the Canadian drug supply or raise costs for Canadians. ”Our government will protect our supply of and access to medication that Canadians rely on,” said Alexander Cohen, a spokesman for Canada's Minister of Health. “We continue to be in communication with the White House and the U.S. Department of Health and Human Services and our message remains firm: we share the goal of ensuring people can get and afford the medication they need ? but these measures will not have any significant impact on prices or access for Americans.” The plan also drew pushback from Canadian drug distributors. “The drug supply is insufficient for the Canadian market, let alone trying to divert it to a much larger market like the U.S.,” said Daniel Chiasson, president of the Canadian Association for Pharmacy Distribution Management. Speaking to reporters in Florida on Wednesday, Azar said Canadians' cheaper drug prices were the result of a free ride off of American investment and innovation. “Obviously the Canadians are going to be looking out for Canadians,” he said. “We're here to put American patients first.” Many prescription medicines would be excluded from importation from Canada, such as biologic drugs, including insulin, controlled substances and intravenous drugs. U.S. President Donald Trump, a Republican, has struggled to deliver on a pledge to lower drug costs for U.S. consumers. Healthcare costs are expected to be a major focus of Trump's re-election campaign and for Democrats vying to run against him in the November 2020 election. The Trump administration in July scrapped an ambitious policy that would have required health insurers to pass billions of dollars in rebates they receive from drugmakers to Medicare patients. Also in July, a federal judge struck down a Trump administration rule that would have forced pharmaceutical companies to include wholesale prices of their drugs in television advertising. Both the House of Representatives and the Senate are putting forth drug pricing bills that contain some of the proposals Trump has advocated, such as basing public drug reimbursements on foreign drug costs. Trump has said he will veto the Democratic-led House bill if it comes to his desk on the grounds that it would slow innovation. “Once again, the Trump White House is tip-toeing around big pharma with a spectacularly pinched and convoluted proposal that excludes insulin and has no actual implementation date,” said Henry Connelly, a spokesman for U.S. Speaker of the House Nancy Pelosi, a Democrat. “If President Trump actually wants to lower drug prices, he should pick up the phone and tell Senator McConnell to send him the House-passed Lower Drug Costs Now Act.” U.S. Declares Coronavirus a Public Health Emergency (Reuters) - The Trump administration on Friday declared a public health emergency over the coronavirus outbreak and said it would [FN4] take the extraordinary step of barring entry to the United States of foreign nationals who have traveled to China. Starting on Sunday, U.S. citizens who have traveled to China's Hubei Province within the last 14 days will be subject to a mandatory 14-day quarantine, Health and Human Services Secretary Alex Azar told a media briefing at the White House on Friday. The administration will also limit flights from China to seven U.S. airports, he said. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -3- “The actions we have taken and continue to take complement the work of China and the World Health Organization to contain the outbreak within China,” Azar said. Centers for Disease Control and Prevention Director Robert Redfield said there were six confirmed cases of coronavirus in the United States. He said there were 191 individuals under investigation for the disease. Redfield said the risk to the U.S. public from the outbreak is low. The flu-like virus, which originated in the Chinese city of Wuhan and was first identified earlier this month, has resulted in 213 deaths in China. More than 9,800 people have been infected in China and more than 130 cases reported in at least 25 other countries and regions, with Russia, Britain, Sweden and Italy all reporting their first cases on Thursday or Friday. The U.S. State Department warned Americans on Thursday not to travel to China because of the epidemic. FDA Identified 20 Drugs with Shortage Risks Due to Coronavirus Outbreak (Reuters) - The U.S. Food and Drug Administration has contacted producers of about 20 drugs that either source all of their main [FN5] ingredients from or are finished in China to gauge if they will face shortages due to the coronavirus outbreak. None of the companies reported that a shortage is expected for their drugs due to the outbreak, an FDA spokeswoman said. “We have been in contact with those firms to understand if they face any drug shortage risks due to the outbreak,” FDA spokeswoman Stephanie Caccomo said in a statement late on Monday. “None of these firms has reported any shortage to date.” Caccomo did not identify any of the drugs or the companies. She said the FDA has also reached out to more than 180 manufacturers to remind them of their requirement to notify the regulator of any expected supply disruptions. U.S. officials raised concerns this week about the security of the U.S. drug supply chain in the wake of the coronavirus outbreak in China, where a significant portion of the ingredients used to make prescription drugs is manufactured. Around 88 percent of the active pharmaceutical ingredients used in drugs for the U.S. market were manufactured overseas in 2018, according to the FDA. About 14 percent of the API for U.S. drugs in that year were produced in China, the FDA said. U.S. FDA Says No Medical Device Shortages Due to Virus Outbreak (Reuters) - The U.S. Food and Drug Administration said on Thursday there were no reported shortages of medical devices within the [FN6] country due to the ongoing coronavirus outbreak. The FDA said it had contacted 63 companies, having 72 manufacturing facilities in China, which produce medical devices that may be prone to a potential shortage in the case of a supply disruption. Coronavirus Infects 29 Medical Workers at Mexico Hospital (Reuters) - Nearly 30 medical workers at a hospital in northern Mexico have been infected with coronavirus, the regional health [FN7] department told Reuters on Tuesday, in one of the worst outbreaks to hit the country's healthcare system so far. Mexico has so far reported 1,215 coronavirus cases and 29 deaths, and officials have warned that hospitals and clinics could be overwhelmed if the number of infections rise to levels seen in Europe. The health department at the northern border state of Coahuila said 29 medical and nursing staff of the publicly owned IMSS General Hospital in Monclova had tested positive for coronavirus as of late Tuesday. The outbreak began when one of the hospital's doctors contracted coronavirus from a patient at his private practice earlier this month, and then that doctor spread the virus to his colleagues while on duty, the department said. He was hospitalized late last week and is currently in an isolated area of the intensive care unit. It said no patients have been affected so far. Coahuila's health department said the Monclova hospital's supplies are currently being reviewed. Critics say the government of President Andres Manuel Lopez Obrador has acted slower than other countries in the region to combat the virus and has carried out a relatively low number of tests that might mean many more cases are undetected. Like elsewhere in the world, scores of Mexican healthcare workers have held protests against the lack of protective gear as they battle the virus outbreak. Earlier this week, medical workers at a public hospital in Torreon, which is also in Coahuila, rallied to denounce the lack of gloves, protective suits, and high-quality face masks, local media reported. Mexico declared a health emergency earlier this week and issued stricter rules aimed at containing the fast-spreading coronavirus after the number of cases surged past 1,000 and the death toll rose sharply. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -4- It has one of the world's highest rates of both obesity and diabetes, and experts have recently sounded the alarm that its population could therefore be more vulnerable than its relatively young average age might suggest. Brazil's Indigenous People Call for WHO Emergency Fund to Fight Coronavirus (Reuters) - Indigenous leaders in Brazil asked the World Health Organization (WHO) on Monday to set up an emergency fund to help [FN8] protect their communities from the threat of the coronavirus pandemic. Many of Brazil's 850,000 indigenous people live in remote Amazon areas with little access to healthcare, and indigenous groups say the government of President Jair Bolsonaro has not included the communities in national plans to fight the virus. In a letter to WHO head Tedros Adhanom Ghebreyesus they asked for help to provide personal protective equipment that is unavailable to health workers in tribal reservations and villages. 'It is a real emergency,' Joenia Wapichana, the leader of the appeal to the WHO and the first indigenous woman elected to Brazil's Congress, told Reuters. 'Indigenous people are vulnerable and have no protection.' The number of indigenous people in Brazil killed by the virus has risen to 18, said indigenous umbrella organization APIB, though the government has only officially reported six. That is because the indigenous health service Sesai only reports deaths in tribal villages and not those of tribe members who have moved to urban areas. By Sunday, 107 indigenous people in the Amazon were confirmed to be infected, with the majority, or 59, in the upper reaches of the Amazon river near the border with Colombia and Peru, APIB said. The Coordination of Indigenous Organizations of the Brazilian Amazon (Coiab) has complained about Sesai's lack of testing and absence of care for people living outside their traditional villages in cities such as Manaus, where virus cases have overwhelmed the hospital system. Bolsonaro's new health minister, Nelson Teich, has said protecting indigenous people is a priority. The government's indigenous affairs agency, FUNAI, has stopped Christian missionaries from evangelizing isolated tribes during the epidemic to avoid contagion. The appeal by indigenous groups came a day after an open letter to Bolsonaro from dozens of international artists, musicians and actors urging him to protect Brazil's indigenous people. Signers included artists Ai Weiwei and David Hockney, musicians Sting and Paul McCartney, actors Glenn Close and Sylvester Stallone, and film and TV host Oprah Winfrey. The ‘extreme threat’ faced by indigenous people in Brazil was amplified by invasions of protected tribal lands by illegal miners, loggers and cattle ranchers, the letter warned. 'These illicit activities have accelerated in recent weeks, because the Brazilian authorities charged with protecting these lands have been immobilized by the pandemic,' it added. Mexico Has World's Most Health Worker Deaths from Pandemic, Amnesty International Says (Reuters) - More health workers have died from the coronavirus in Mexico than any other country on the planet, Amnesty International [FN9] said on Thursday, highlighting the high toll the pandemic was taking on frontline medical staff around the globe. At least 7,000 health workers around the world have died after becoming infected with the coronavirus, including 1,320 in Mexico, Amnesty said. Other countries with high mortality rates include United States, Brazil and India, where health worker death tolls stand at 1,077, 634 and 573. “Many months into the pandemic, health workers are still dying at horrific rates in countries such as Mexico, Brazil and the USA,” said Steve Cockburn, Head of Economic and Social Justice at Amnesty International. “There must be global cooperation to ensure all health workers are provided with adequate protective equipment, so they can continue their vital work without risking their own lives.” The United States, Brazil and India have registered the highest number of overall deaths and confirmed cases. Between them, they have recorded more than 14 million coronavirus cases and almost 387,000 deaths, according to Reuters data. A Reuters analysis of Mexican government data in August found that the healthcare workers' risk of dying in Mexico is four times higher than in the United States, and eight times higher than in Brazil. Mexico has registered more than 610,000 cases and nearly 66,000 deaths. Mexico's government earlier this week said 102,494 health workers had contracted coronavirus and the death toll had climbed to 1,378. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -5- Amnesty called for more help for workers, citing Brazil as an example of a place where health professionals complain about the lack of protection equipment. “Throughout the pandemic governments have hailed health workers as heroes, but this rings hollow when so many workers are dying from a lack of basic protection,” added Cockburn. III. ASIA Amgen CEO Expects 25% of Growth to Come from Asia in Next Decade (Reuters) - Biotechnology giant Amgen Inc expects up to a quarter of its growth to come from Asia over the next decade, Chief [FN10] Executive Officer Robert Bradway told Reuters. The forecast marks a shift for 40-year-old Amgen, which still relies on the U.S. market for more than 75% of its sales, 30 years after it won U.S. marketing approval for its first drug, red-blood-cell-booster Epogen. “China and Japan are the second and third largest markets in our industry,” Bradway said in an interview on Monday on the sidelines of the JP Morgan healthcare conference in San Francisco. “In the case of China, it is a rapidly growing market. ... Japan has an aging population and we expect that will be a growth market for us.” Amgen, based in Thousand Oaks, California, late last year acquired a 20.5% stake in Beijing-based BeiGene Ltd in a deal to expand its presence in China. In Japan, Amgen expects by the second quarter of this year to dissolve its current joint venture with Astellas Pharma Inc and begin for the first time to operate an independent marketing unit in that country. Bradway said the Astellas venture is a model for what Amgen aims to do with BeiGene - “work on a basket of drugs together, then after a period of time, the rights would return to us.” Under the deal, BeiGene can retain rights to one of Amgen's cancer products. Bradway said Amgen drugs such as osteoporosis treatments Prolia and Evenity as well as potent cholesterol fighter Repatha are tailor- made for aging populations. “Where there are therapies available to prevent disease, it makes sense for society to identify people who are at risk,” Bradway said. “The alternative is to fix that which is broken.” Amgen, which is facing more U.S. competition for older biotechnology drugs for which “biosimilar” versions are becoming available, needs new sources of growth. Bradway said Amgen will announce its 2020 financial outlook on Jan. 30, when it presents fourth-quarter 2019 results. He said the company is unlikely to return to its previous pattern of issuing five-year financial plans, due in part to “a much more uncertain environment.” In addition to biosimilar competition, pharmaceutical companies are grappling with backlash from politicians and consumers to the industry's practice of routinely hiking list prices, and then giving some of that money back to health insurers in return for preferential reimbursement terms. For 2019, Amgen forecast that its global net sales prices would drop by a rate in the mid-single digits. Bradway said Amgen continues to see growth in Europe, where product sales volumes are increasing by rates in the high-single-digits or low-double-digits. As in most European countries, the governments of both Japan and China negotiate prices for pharmaceuticals paid for by state- operated health plans. Bradway said Amgen does not currently have any of its drugs authorized for coverage on China's National Reimbursement Drug List, but the company does plan to apply to have drugs like Repatha and leukemia treatment Blincyto approved for inclusion. Drugmakers Slash Prices To Be Eligible for China's Bulk-buy Program (Reuters) - Global pharmaceutical majors and generic drugmakers chopped by 53% on average prices of some of their off-patent [FN11] products in the latest bidding round under China's national bulk-buy program, government officials said late on Friday. Beijing has been pushing forward the program where drugmakers have to go through a bidding process and cut prices low enough to be considered over generic copies and be allowed to sell their products at public hospitals via large-volume government procurement. Some global firms such as AstraZeneca and Merck have already cautioned about intensifying price pressures on their mature brands in the world's second largest drug market, as China expands the usage of the program. In the latest bidding on Friday that involved 33 drugs and 122 companies, Bayer slashed the price of its popular diabetes treatment Acarbose to 0.18 yuan per pill, 78.5% lower than the price ceiling set by the government in December last year, elbowing some Chinese generic providers out of the tender, according to a Reuters calculation based on the preliminary results released by the authority overseeing the program. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -6- Bayer was not immediately available for a comment. “Products that won bids in this round of centralized procurement saw a huge price drop, which squeezes out unreasonable overpricing that has existed in drug distribution for a long time,” the authority said in a statement published alongside the preliminary result on Friday. Sale prices of over 100 types of commonly used drugs are on average about 17 to 18 times of their manufacturing costs, the statement said. Chinese copycats won bids for most of the 33 drugs, including generic versions for drugs ranging from Johnson & Johnson's prostate cancer treatment Zytiga to Eli Lilly's erectile dysfunction treatment Cialis, the results showed. In Friday's bidding, for products with two bid winners, 60% of the government procurement volume can be shared among the winners, according to official document detailing the tender rules released in December. For products with four winners and more, as much as 80% of the volume can be shared among the companies. In the first round of the nationwide implementation of the bulk-buy program in September, global drugmakers including Sanofi and Eli Lilly managed to cut some prices low enough to levels close to those offered by local generic makers. Coronavirus Outbreak May Be Over in China by April, Says Expert (Reuters) - The coronavirus outbreak is hitting a peak in China this month and may be over by April, the government's senior medical [FN12] adviser said on Tuesday, in the latest assessment of an epidemic that has rattled the world. In an interview with Reuters, Zhong Nanshan, an 83-year-old epidemiologist who won fame for combating the SARS epidemic in 2003, shed tears about the doctor Li Wenliang who died last week after being reprimanded for raising the alarm. But Zhong was optimistic the new outbreak would soon slow, with the number of new cases already declining in some places. The peak should come in the middle or late February, followed by a plateau and decrease, Zhong said, basing the forecast on mathematical modelling, recent events and government action. “I hope this outbreak or this event may be over in something like April,” he said in a hospital run by Guangzhou Medical University, where 11 coronavirus patients were being treated. Though his comments may soothe some global anxiety over the coronavirus - which has killed more than 1,000 people and seen more than 40,000 cases, almost all in China - Zhong's previous forecast of an earlier peak turned out to be premature. “We don't know why it's so contagious, so that's a big problem,” added Zhong, who helped identify flaws in China's emergency response systems during the 2002-03 SARS crisis. He said there was a gradual reduction in new cases in the southern province of Guangdong where he was, and also in Zhejiang and elsewhere. “So that's good news for us.” With China taking unprecedented measures to seal infected regions and limit transmission routes, Zhong applauded the government for locking down Wuhan, the city at the epicentre which he said lost control of the virus at an early stage. “The local government, local healthcare authority should have some responsibility on this,” he said. “Their work had not been done well.” The virus is believed to have originated in a seafood market in Wuhan in early December. Authorities have also come under fire for their heavy-handed treatment of the late doctor Li, who was detained for publicising the disease before becoming its best-known fatality last Friday. “The majority of the people think he's the hero of China,” Zhong said, wiping tears. “I'm so proud of him, he told people the truth, at the end of December, and then he passed away.” Behind him stood hundreds of other doctors all wanting to tell the truth and now being encouraged by the government to do so, he said. “We really need to listen,” he said. GLOBAL “SENTRY” SYSTEM The virus has now infected more than 40,000 people on the Chinese mainland and spread to at least 24 countries. Zhong, who said the government's unwillingness to share information prolonged the SARS crisis, said Beijing had done much better this time on issues like transparency and cooperating with the World Health Organization (WHO). But more should be done, he said, including an end to wildlife trade, better international cooperation on hygiene technology, improved operation of disease control centres, and a global “sentry” system to warn of potential epidemics. “If we have better cooperation and coordination, we can find it earlier and figure out the human-to-human transmission earlier,” he said, adding that the outbreak would not be quite so serious if such a system was in place. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -7- Zhong said uncertainties remained about how the coronavirus was infecting patients, if it can spread via faeces and whether so-called “superspreaders” were helping transmit the disease. So far, China's data shows the recovery rate to be quite low, with less than 10% of confirmed patients discharged, but Zhong said authorities were leaving nothing to chance, with many patients still quarantined in wards now reasonably healthy. “They didn't know if they were going to re-infect or not... so that's why the cure rate up to now is not that high.” Wearing masks outside contagion zones was not always necessary, he said, and the United States' and others' entry ban on Chinese was an over-reaction. Furthermore, it appeared children were less vulnerable, he added. Global, apolitical cooperation was crucial, Zhong said. “I think maybe we should be going closer, I mean in particular our colleagues and scientists, and have more cooperation,” he said. “We're just dealing with the disease - nothing to do with the political, nothing.” Indian Generic Drugmakers May Face Supply Shortages from China if Coronavirus Drags on (Reuters) - Shortages and potential price increases of generic drugs from India loom if the coronavirus outbreak disrupts suppliers of [FN13] pharmaceutical ingredients in China past April, according to industry experts. An important supplier of generic drugs to the world, Indian companies procure almost 70% of the active pharmaceutical ingredients (APIs) for their medicines from China. India's generic drugmakers say they currently have enough API supplies from China to cover their operations for up to about three months. “We are comfortably placed with eight to 10 weeks of key inventory in place,” said Debabrata Chakravorty, head of global sourcing and supply chain for Lupin Ltd, adding that the company does have some local suppliers for ingredients. Optimism that the worst of the outbreak centered in China's Hubei province and its capital Wuhan would be over by April took a major hit late on Wednesday. Chinese health officials, using a broader method of confirming coronavirus cases, said they shot up by nearly 15,000 in Hubei with total deaths in China nearing 1,400. The outbreak and severe travel restrictions aimed at containing its spread has taken a toll on the world's second largest economy and disrupted international businesses dependent on Chinese supplies. Sun Pharmaceuticals Industries Ltd said it has sufficient inventory of API and raw materials for the short term and has not seen any major disruption in supplies at the moment. The Indian drugmaker, however, said supply has been impacted for a few API products and the company is closely monitoring the situation. It did not identify the products. An extended outbreak that limits the volume of active ingredients and drugs available for export from China could lead to drug shortages and price increases, particularly in the United States - where prices are subject to market forces - according to rating agency Moody's. India supplies nearly a third of medicines sold in the United States, the world's largest and most lucrative healthcare market. Daara Patel, secretary general of the Indian Drug Manufacturers Association, which represents over 900 drug producers, said he expects supplies to be disrupted from April. Patel said vitamins and antibiotics are likely to be among the hardest hit as India is a major global producer of both. International pharmaceutical companies including Swiss drugmaker Novartis AG and Britain-based GlaxoSmithKline Plc have so far predicted minimal disruption in the near term to their supply chain. “Companies are continuously monitoring the situation and are working proactively to prevent and mitigate potential shortages,” Holly Campbell, spokeswoman for pharmaceutical industry trade group PhRMA, said by email. Sudarshan Jain, secretary general of the Indian Pharmaceutical Alliance (IPA) trade group, said there are no API shortages at the moment because drugmakers had stocked up on inventory ahead of the Lunar New Year holiday in China, which was later extended to contain the virus. China Pushes for Cheaper Health Insurance Products to Battle Virus (Reuters) - China is nudging insurers to work on cheaper medical cover linked to the coronavirus and is assuring them of fast-track [FN14] approval for these new products, people with knowledge of the matter said. The move will mark a shift in the Chinese insurance market where the bulk of existing products are essentially investment schemes and pure healthcare coverage accounts for only about a fifth of the total life insurance premium. In the last one week, China Life, China Pacific Insurance, Ping An Insurance Group and Zhong An Online P&C Insurance Co., among others, have included coverage for the virus in their existing medical insurance products, according to their websites. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -8- At least half a dozen more are in the process of requesting approval for products with coronavirus coverage in the coming weeks, said the people, declining to be named as they were not authorized to speak to the media. The scramble comes as the Chinese province of Hubei, at the epicenter of the outbreak, reported a record surge in the death toll on Thursday and as global health experts warned the epidemic could get far worse before it is brought under control. China's Banking and Insurance Regulator (CBIRC) last week adjusted actuary rules for healthcare, accident and life insurance as well annuity insurance, which will help lower premiums for such insurance by 3% to 5%. The sources said the lower premiums and push for cheaper, basic medical cover, were largely prompted by the need to deal with treatment for those who may get infected by the coronavirus. CBIRC did not respond to Reuters request for comment. QUICK APPROVALS, AWARENESS Despite a weak government healthcare system, private health insurance has been slow to take off in China as insurers mainly catered to demand for high-margin investment-like insurance products. The high cost of coverage for critical illness products, which typically exclude insurance for epidemics, has put them out of reach of many, industry officials said. Beijing, however, has been pushing private insurance firms to expand their product coverage to ease pressure on the healthcare system, and as part of a broader crackdown on the sale of shadow banking-linked investment products by insurers. As a result, health insurance in 2019 accounted for 23% of life premiums in China, up from just 8% in 2003, according to Fitch Ratings. In the United States, this figure is about 30% of the life premiums. That share in China is expected to go up significantly in the near future as individuals rush to buy coverage for treatment of the new virus with a large number seeking admissions to private hospitals, the people said. The regulator has assured insurers of approvals to launch those products within a few days, they said, compared to the usual timeline of two weeks or more for investment-linked insurance products. The premium charges for low-severity medical insurance, which will typically include virus treatment coverage, could be 15%-30% cheaper than the critical illness products, industry officials said. The demand for products with basic healthcare coverage, including for coronavirus, is already soaring. “There is no doubt that awareness for insurance will significantly increase in the near future,” said Sam Radwan, president of consultant ENHANCE International, which advises China's top insurers. “Customers will be more understanding of the need to buy these products as opposed to in the past when my clients had a very difficult time convincing customers to buy these products and the net result was acquisition costs were very high.” China Guards Against Second Wave of Coronavirus Coming from Abroad (Reuters) - The growing number of imported coronavirus cases in China risked fanning a second wave of infections at a time when [FN15] “domestic transmission has basically been stopped,” a spokesman for the National Health Commission said on Sunday. “China already has an accumulated total of 693 cases entering from overseas, which means the possibility of a new round of infections remains relatively big,” Mi Feng, the spokesman, said. In the last seven days, China has reported 313 imported cases of coronavirus but only 6 confirmed cases of domestic transmission, the commission's data showed. There were 45 new coronavirus cases reported in the mainland for Saturday, down from 54 on the previous day, with all but one involving travelers from overseas. Most of those imported cases have involved Chinese returning home from abroad. Airlines have been ordered to sharply cut international flights from Sunday. And restrictions on foreigners entering the country went into effect on Saturday. Five more people died on Saturday, all of them in Wuhan, the industrial central city where the epidemic began in December. But Wuhan, the capital of Hubei province, has reported only one new case on the last 10 days. A total of 3,300 people have now died in mainland China, with a reported 81,439 infections. Saturday marked the fourth consecutive day that Hubei province recorded no new confirmed cases. The sole case of domestically transmitted coronavirus was recorded in Henan province, bordering Hubei. With traffic restrictions in the province lifted, Wuhan is also gradually reopening borders and restarting some local transportation services. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -9- “It's much better now, there was so much panic back then. There weren't any people on the street. Nothing. How scary the epidemic situation was,” a man, who gave his surname as Hu, told Reuters as he ventured out to buy groceries in Wuhan. “Now, it is under control. Now, it's great, right?” All airports in Hubei resumed some domestic flights on Sunday, with the exception of Wuhan's Tianhe airport, which will open to domestic flights on April 8. Flights from Hubei to Beijing remain suspended. A train arrived in Wuhan on Saturday for the first time since the city was placed in lockdown two months ago. Greeting the train, Hubei Communist Party Secretary Ying Yong described Wuhan as “a city full of hope” and said the heroism and hard work of its people had “basically cut off transmission” of the virus. More than 60,000 people entered Wuhan on Saturday after rail services were officially restarted, with more than 260 trains arriving or traveling through, the People's Daily reported on Sunday. On Sunday, streets and metro trains were still largely empty amid a cold rainy day. Flashing signs on the Wuhan Metro, which resumed operations on Saturday, said its cars would keep passenger capacity at less than 30%. The Hubei government on Sunday said on its official WeChat account that a number of malls in Wuhan, as well as the Chu River and Han Street shopping belt, will be allowed to resume operations on March 30. Concerns have been raised that a large number of undiagnosed asymptomatic patients could return to circulation once transport restrictions are eased. China's top medical adviser, Zhong Nanshan, played down that risk in comments to state broadcaster CCTV on Sunday. Zhong said asymptomatic patients were usually found by tracing the contacts of confirmed cases, which had so far shown no sign of rebounding. With the world's second-biggest economy expected to shrink for the first time in four decades this quarter, China is set to unleash hundreds of billions of dollars in stimulus. The ruling Communist Party's Politburo called on Friday for a bigger budget deficit, the issuance of more local and national bonds, and steps to guide interest rates lower, delay loan repayments, reduce supply-chain bottlenecks and boost consumption. Tokyo Coronavirus Cases Jump in Record Daily Rise: NHK (Reuters) - Tokyo has confirmed 68 new coronavirus cases, a record daily increase, public broadcaster NHK reported on Sunday, as [FN16] the Japanese capital scrambles to prevent a wider outbreak, while a cluster of infections increased near the city. Japan has so far been spared a major spreading of the coronavirus that has hit Europe and North America, but authorities fear a rise in cases with no known source of infection could signal a bigger new wave. Authorities confirmed 28 new coronavirus cases from a cluster related to a home for the disabled in Chiba prefecture, adjacent to Tokyo, NHK said. The outbreak has infected more than 1,800 people in Japan, with 55 deaths as of Sunday afternoon, excluding 712 cases and 10 deaths from a cruise ship that was moored near Tokyo last month, NHK said. Prime Minister Shinzo Abe on Saturday promised an unprecedented package of steps to cushion the world's third-biggest economy from the coronavirus pandemic, warning that Japan may need to prepare for a national emergency. Tokyo Governor Yuriko Koike has also asked the tens of millions of people in the city and surrounding regions to avoid non-essential, non-urgent outings until April 12, as the city has become the center of Japan's coronavirus epidemic. Of the 68 new cases in Tokyo, more than 20 are linked to a hospital in the eastern Tokyo ward of Taito, where many patients and staff have already tested positive, NHK said. Tokyo authorities had no immediate comment on the NHK report. Huge Fentanyl Haul Seized in Asia's Biggest-ever Drug Bust (Reuters) - Myanmar police say they have seized a huge haul of liquid fentanyl, the first time one of the dangerous synthetic opioids [FN17] that have ravaged North America has been found in Asia's Golden Triangle drug-producing region. In a signal that Asia's drug syndicates have moved into the lucrative opioid market, Reuters can reveal more than 3,700 litres of methylfentanyl was discovered by anti-narcotics police near Loikan village in Shan State in northeast Myanmar. The seizure of the fentanyl derivative was part of Asia's biggest-ever interception of illicit drugs, precursors and drug-making equipment, including 193 million methamphetamine tablets known as yaba. At 17.5 tonnes, the yaba almost equaled the amount seized in the previous two years in Myanmar. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -10- The U.N. Office on Drugs and Crime (UNODC) said the scale of the bust was unprecedented and Myanmar's anti-drug authorities had ‘dismantled a significant network’ during a two-month operation involving police and military. Also seized were almost 163,000 litres and 35.5 tonnes of drug precursors, as well as weapons. There were more than 130 arrests. Even so, the methylfentanyl discovery was an ominous indicator for the region's illicit drug market, the U.N. agency and a Western official based in Myanmar told Reuters. 'It could be a game-changer because fentanyl is so potent that its widespread use would cause a major health concern for Myanmar and the region,' said the Western official, who declined to be identified. In an interview with Reuters, the head of law enforcement for Myanmar's counter-narcotics agency, Colonel Zaw Lin, said the methylfentanyl had been verified using state-of-the-art equipment. The seizure showed the methods of the drug syndicates were changing, he said. Fentanyl and its derivatives have caused more than 130,000 overdose deaths in the United States and Canada in the past five years, according to government agencies. The opioid epidemic has not swept Asia, Europe or Australasia but there have been signs it is an emerging threat. 'We have repeatedly warned the region fentanyl could become a problem but this is off the charts,' said the UNODC's Southeast Asia and the Pacific representative Jeremy Douglas. 'It is the shift in the market we have been anticipating, and fearing.' DEADLY MIX While Myanmar police did not disclose the purity and exact make-up of the methylfentanyl found, it comes in two main variants, both more potent than fentanyl, according to the European Union's drug monitoring agency. Fentanyl itself is 25 to 50 times stronger than heroin. Increasingly, drug traffickers have been mixing fentanyl and its derivatives with heroin, meth and cocaine, adding to their potency and lethality. Half of all heroin and cocaine overdoses in the United States included substances with traces of synthetic opioids in 2017, a Rand Corporation analysis found. A Canadian survey found 73% of those who tested positive for fentanyl did not know they had consumed it. Zaw Lin said the methylfentanyl and other drugs and precursors were found in clearings near Loikan village where several drug factories were located but had been abandoned when the raids took place. 'Upon interrogation, the offenders revealed most of the drugs would be distributed inside Myanmar and distributed around neighboring countries,' he said. 'But we are still conducting interrogations. We haven't totally got the final destinations yet.' Liquid fentanyl is usually converted into powder before being sold, often in tablet form, two analysts, who asked not to be identified, told Reuters. CHEAP TO MAKE, EASY TO TRAFFIC As well as being easier and cheaper to produce than heroin, strong synthetic opioids like fentanyl can be readily concealed and transported as only small amounts can deliver thousands of doses. At a time when the coronavirus pandemic has closed borders and curbed movements in many countries, the UNODC is concerned that fentanyl will still spread around the world. For decades, Asian crime syndicates in partnership with ethnic minority militias have used the Golden Triangle - centred on northern Myanmar and including parts of Laos and Thailand - to grow opium and refine heroin. More recently, meth production by groups such as the Sam Gor syndicate has exploded in the region, in part due to a crackdown in neighboring China. Zaw Lin said the methylfentanyl had come from a neighboring country but declined to identify it. Myanmar police documents reviewed by Reuters said most of the seized drugs, precursors and equipment had come from China. China, along with Mexico, has been a major supplier of fentanyl to North America but escalating law enforcement efforts have brought a slump in Chinese exports of the synthetic opioid to the United States, according to the U.S. Drug Enforcement Administration. Mexican cartels have picked up the slack but the UNODC said recent difficulties obtaining precursors from China had crimped their fentanyl production. Northern Myanmar's proximity to China makes it an attractive alternative for Asian drug syndicates looking to produce fentanyl and other synthetic opioids, analysts said. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -11- 'The alliances between Myanmar's ethnic militias and transnational crime groups must be broken or the synthetic drug problem will continue to deteriorate,' said the UNODC's Douglas. Zaw Lin said Myanmar was stepping up efforts to disrupt the syndicates and was increasing cooperation with other nations. 'Myanmar is carrying out counter-drug operations as one of our top national priorities,' he said. With Apps and Remote Medicine, Japan Offers Glimpse of Doctor Visits in Post-corona Era (Reuters) - The coronavirus crisis has prompted Japan to ease regulations on remote medical treatment, creating an opening for tech [FN18] companies and offering a glimpse of the future of healthcare in the world's most rapidly ageing society. As coronavirus cases spiked in April, Japan temporarily eased restrictions on remote medical care, allowing doctors to conduct first- time visits online or by telephone and expanding the number of illnesses that can be treated remotely. The changes mark a potential shake-up in one of the world's biggest medical markets, which has lagged countries like Australia, China, and the United States in telemedicine. The reforms could also help Japan grapple with both a skyrocketing healthcare burden and few doctors in rural areas. Previously Japanese doctors were only allowed to treat recurring patients remotely, and for a limited number of diseases. The rapid pace of change caught executives at Line Corp off guard, forcing Japan's most popular social networking service to accelerate plans for the roll-out of its Line Healthcare business in the coming months. 'The effect that COVID-19 brought was a huge innovation in the healthcare industry,' said Shinichiro Muroyama, representative director of Line Healthcare. ‘The situation has totally changed, much more rapidly than we thought.’ Line, which says it has 84 million users in Japan, aims to link doctors and patients by video. Homegrown medical start-ups such as Medley Inc and MICIN Inc say they have also seen a surge in demand. Both companies offer application services for appointments, video consultations and payments. Telehealth, or telemedicine, refers to technology that includes online consultations, cloud-based medical records, remote monitoring of patients and use of artificial intelligence to screen for diseases. Japan's market for such technology is set to grow by 60% to nearly 20 billion yen ($185 million) in the five years to March 2024, according to the Yano Research Institute. Japanese Prime Minister Shinzo Abe has made deregulating the medical industry part of his growth strategy. BETTER OUTCOMES So Ishii, a doctor who runs a clinic in Tokyo that started offering telehealth in 2017, has seen a jump in online consultations since the outbreak, with 600 patients using the service as of mid-June compared to 400 two months earlier. IshII said telehealth could lead to better treatment for patients with lifestyle-related diseases that require continuous attention because it gave them easier access to doctors. Such ailments typically include diabetes and high-blood pressure. 'Ideally, medical care should be designed to provide necessary support for patients regardless of whether it is online or on site,' he said. About 16,100 Japanese medical institutions excluding dentists - nearly 15% of all such facilities - offered remote medical services, including by telephone, as of early July, according to the health ministry. That marks substantial growth since July 2018, when only 970 medical institutions were registered to offer online care. Still, the health ministry has not decided whether to make the changes permanent, while the national medical association is less than enthusiastic, citing concerns about misdiagnosis. 'We should be extremely cautious about using evidence drawn from telemedicine in the emergency situation for consideration of how it should be after the coronavirus infection wanes,' Japan Medical Association President Toshio Nakagawa told Reuters. He was vice- president at the time of the interview. Analysts say telehealth can also put smaller clinics at a financial disadvantage. Goichiro Toyoda, representative director and a medical doctor at Medley, agrees doctors can better check first-time patients in person but says telehealth suits patients who want second opinions, have trouble visiting hospitals or need long-term treatments. 'Telemedicine will not replace face-to-face treatment,' said Toyoda. ‘But I've been stressing the importance of it becoming an option.’ Alibaba Health Raises $1.3 billion in HK's Biggest Secondary Share Sale in 5 Years (Reuters) - Alibaba Health Information Technology has raised nearly $1.3 billion in Hong Kong's largest follow-on share sale since [FN19] 2015, and industry experts say this could prompt more firms to tap investors for cash in the Asian financial hub. The Chinese company, an arm of internet retail giant Alibaba Group, said on Wednesday it would issue 499 million new shares priced at HK$20.05 ($2.59) apiece, an 8% discount to the stock's HK$21.80 closing price in Hong Kong on Tuesday. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -12- Alibaba Health shares were down 2.75% at HK$21.20 in the first session since the deal was finalized. The size of the deal was increased by 25% during the institutional bookbuild overnight on high demand from investors. This is the largest ever healthcare follow-on in Hong Kong. The transaction, according to experts, could trigger more capital raisings in Hong Kong as companies take advantage of positive sentiment toward healthcare stocks amid the coronavirus pandemic. 'Follow-on deals can be done very quickly, it comes down to sentiment and price,' said a capital markets lawyer, who could not be named because he was not authorized to speak to media. 'Companies in healthcare and biotech are doing very well, I think we will see more deals like this happening in Hong Kong.' The deal was the largest Hong Kong follow-on share sale since CSPC Pharmaceutical Group's $1.26 billion transaction in 2015, Refinitiv data showed. Ahead of the Alibaba Health deal, Hong Kong's equity capital markets volumes for 2020 stood at $42.7 billion versus $22.3 billion at the same time last year, Dealogic data shows. Alibaba Health said the cash would be used to develop its pharmaceutical e-commerce business, which has benefited from the growth of the online service sector amid the health crisis. South Korea Orders Striking Doctors Back to Work Amid Surge in Coronavirus Cases (Reuters) - South Korea ordered doctors in the Seoul area to return to work on Wednesday as they began a three-day strike in protest [FN20] of several government proposals, including one to boost the number of doctors to deal with health crises like the coronavirus. Trainee doctors have been staging ongoing walkouts, and thousands of additional doctors were due to stage a three-day strike starting on Wednesday. The strikes come as South Korea battles one of its worst outbreaks of the coronavirus, with 320 new cases reported in the 24 hours to midnight Tuesday, the latest in more than a week and a half of triple-digit increases. The walkouts on Wednesday forced South Korea's five major general hospitals to limit their hours and delay scheduled surgeries, Yonhap news agency reported. Earlier in the week, the doctors reached an agreement with the government to continue to handle coronavirus patients, but failed to find a compromise on the broader issues. 'The government now has no choice but to take necessary legal actions such as an order to open business to not put the citizens' lives and safety in danger,' Health Minister Park Neung-hoo said in a briefing. ‘We urge all trainee and fellow doctors to immediately return to work.’ He said the Korean Medical Association (KMA) and the Korean Intern Resident Association (KIRA) had rejected several of the government's offers. In a statement, KMA said the medical community was always open to all possibilities in talks with the government, and that the doctors did not want to have to strike. 'We sincerely do want to return,' the statement said. ‘We ask you citizens to listen to our voice so that we can meet our patients as soon as possible.’ KMA and KIRA members have said they oppose government plans to boost the number of medical students over several years, establish public medical schools, allow government insurance to cover more oriental medicine, and introduce more telemedicine options. The government said its goal to increase the number of medical students by 4,000 over the next 10 years is necessary to better prepare for public health crises like the coronavirus pandemic. Student doctors, however, said the plan would unnecessarily flood an already competitive market, and that the extra funding would be better spent improving the salaries of existing trainees, which would encourage them to move out of Seoul to rural areas where more health professionals are needed. IV. EUROPE On Eve of Brexit, Britain Faces Critical Test to Defend Drug Trial Crown (Reuters) - It's 2023. Britain's brightest and best drug researchers are packing their bags as clinical trials start to dwindle, leaving a [FN21] nation renowned as a global leader in pharmaceutical development to face a future in the slow lane. This is a worst-case scenario outlined by some scientists and industry experts in the wake of Brexit, which they say could deprive the country of its role as Europe's leader in early-stage drug research, designing and hosting pan-EU trials. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -13- Pamela Kearns, professor of pediatric oncology at the University of Birmingham, worries that over time Britain will in particular lose out in the field of medicines that treat rare diseases and childhood cancers, where trials often need to collaborate and recruit across Europe to find enough patients. “It would be a real disadvantage to children in this country if we were not part of those networks,” she told Reuters. “It will disadvantage us massively.” Kearns's university sponsored the BEACON Neuroblastoma trial, held up as a model of cooperation, and the type of project that could be in jeopardy after Britain's EU exit on Friday and a transition period that runs until the end of 2020. The British designed clinical trial is testing a combination of drugs to tackle a rare aggressive cancer that affects children. It is partly funded by European groups, and is being trialed on patients across the continent. Kearns said her team, among their Brexit contingency plans, had selected a legal representative within the EU - in Dublin - that could enable them to continue playing a key role in trials, as well as an EU distributor to supply drugs for patients. It has also added new legal provisions to contracts should Britain no longer be covered by the bloc's GDPR laws for exchanging data. Yet all these steps may only help in the long term if the UK stays closely aligned to EU research regulations. Brussels is launching a new portal and database that will help co-ordinate the design, data collection and oversight of pan-EU trials, a system that Britain is likely to be excluded from after it fully leaves the bloc at the end of 2020. Some company executives argue that fears of Britain losing ground are overly pessimistic though, and the country could in fact thrive under a nimbler drug development and approval system unshackled from 27 EU states. “If you're a single approver versus one with 28 people sitting around the table you can probably do things a little bit faster,” said Hugo Fry, UK boss of French drugmaker Sanofi. Whether to diverge or align encapsulates the fundamental tension underlying Brexit: can Britain differentiate itself enough to make a success of the historic break, and does the freedom to innovate trump being part of a larger group? CASTING A WIDE NET Kearns' concerns are echoed by UK pharmaceutical industry body the ABPI, which warns of a brain drain from a sector that contributes about 2.7 billion pounds ($3.55 billion) to the economy and around 47,500 jobs. “Without the ability to influence the design of research programs, leading researchers are likely to move out of, or not move into, the UK and this loss of globally recognized and highly skilled researchers will drastically undermine the UK's research base,” it said. It is not only the United Kingdom that faces risks though; the European Union stands to lose the expertise of a country that has accounted for an average of 28% of EU clinical trial applications over the past 10 years. Britain leads Europe in early-stage - phase I and II - trials, with particular strength in cancer research. Industry experts, from academics to executives, say the best way to limit potential damage on both sides is for Britain to remain closely aligned to EU rules so researchers can maintain collaborations and prevent the duplication of costs and paperwork from having two separate regulatory systems. But the nation's decision to leave the bloc was driven by a desire to forge its own path, set its own rules and strike its own deals. Britain has previously said it will seek to align with the EU on clinical trials “where possible”. “After Brexit, clinical trials will continue to be approved at a national level, working to international standards and we are determined to maintain the UK's position as one of the best locations globally to run clinical trials,” the government said. Britain's leading role in developing drugs is underpinned by its research clusters that bring together publicly funded hospitals, top universities like Oxford and Cambridge and companies such as AstraZeneca and GSK. However domestic expertise is often not enough. A look at the work of leading charity Cancer Research UK illustrates how closely Britain is entwined with the continent; nearly a third of the roughly 200 trials currently being funded by the organization involves European collaboration. Emlyn Samuel, its head of policy development, said the emergence of drugs that target tumors according to their genetic make-up rather than cancer type meant more trials would need to cast a wide net to find suitable patients. “If we're outside we might be able to move more quickly in some areas but I don't think that outweighs the benefits of being part of a broader regulatory system,” he said. “IS THIS THE PLACE TO COME?' Denmark's Novo Nordisk, a leader in diabetes drugs, has opened a research center in Britain. While fully committed to the country, it has concerns about the broad impact of Brexit. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -14- ”If there are processes that mean it becomes more complex then companies will look twice at, “Is this the first place to come and do clinical trials, or is it easier to recruit patients elsewhere?”' its UK boss Pinder Sahota told Reuters. Britain's Medicines & Healthcare products Regulatory Agency (MHRA) is however looking at how being independent of the EU could give it a freer hand to improve its systems, company sources say. It could, for example, cut the time it takes to approve a trial design or complete the early phases. But some are wary in a testing industry with little room for divergence and risk. By the time Britain has fully left the EU after the transition period, researchers on the BEACON trial will hope to be embarking on phase III testing. Kearns has already had to reassure European partners it can continue to lead such trials. But she does fear for the future. “We've got fantastic investigators in the UK ... we've got a brilliant set of statisticians and trial methodologists and the expertise, so we're very much the trusted partner to lead,” she said. “We could find ourselves in the position of going back to just following.” Italy Coronavirus Deaths Rise by 889 in a Day to 10,023 (Reuters) - The death toll from an outbreak of coronavirus in Italy has surged by 889, the Civil Protection Agency said on Saturday, the [FN22] second highest daily tally since the epidemic emerged on Feb. 21. Total fatalities in Italy have reached 10,023, by far the highest of any country in the world. Italy's largest daily toll was registered on Friday, when 919 people died. Prior to that, there were 712 deaths on Thursday, 683 on Wednesday, 743 on Tuesday and 602 on Monday. The total number of confirmed cases in Italy rose on Saturday to 92,472 from a previous 86,498. Italy has the second highest number of cases, behind the United States. It surpassed China's tally on Friday. In Italy, of those originally infected nationwide, 12,384 had fully recovered on Saturday, compared to 10,950 the day before. There were 3,856 people in intensive care against a previous 3,732. Spain Toughens Restrictions as Coronavirus Death Toll Surges (Reuters) - Spain prepared to enter its third week under near-total lockdown on Sunday, as the government approved a strengthening [FN23] of measures to curb the spread of the coronavirus and the death toll rose by 838 cases overnight to 6,528. Second only to Italy in fatalities, Spain also saw infections rise to 78,797 from 72,248 the day before. Prime Minister Pedro Sanchez, in a televised address to the nation on Saturday night, announced that all non-essential workers must stay at home for two weeks, the latest government measure in the fight against coronavirus. [L8N2BL0LH] He said workers would receive their usual salaries but would have to make up lost hours at a later date. The measure would last from March 30 to April 9. On Sunday, Labor Minister Yolanda Diaz said the measure was “flexible” and workers would be paid but would be expected to make up their lost days before Dec. 31. “We need to reduce mobility to the level of Sundays,” she said, adding that taking into account the Easter holidays, measures would cover eight working days. She added to Prime Minister Sanchez's calls for the EU to react, saying “we need a Europe in which workers' rights are reinforced”. Unions welcomed the measures and business groups CEOE and CEPYME said that while they would comply with the new rule, “it will generate an unprecedented huge impact on the Spanish economy, especially in sectors such as industry”. The slowdown “may lead to a deeper crisis in the economy that could become social”, they warned in a statement. On Sunday, health emergency chief Fernando Simon repeated a warning that intensive care wards were becoming saturated, but said cases were stabilizing and “the rise in new cases has been falling for a few days.” In Madrid, birdsong drowned out traffic on deserted streets on Sunday morning as police reinforced patrols, stopping buses and cars to check passengers had reason to be out of their homes. The number of beds at a makeshift hospital to treat coronavirus patients in the IFEMA conference center will soon reach 1,400, Madrid's regional government said. It also announced an official period of mourning for those who have died. Flags will fly at half-mast and a daily minute's silence will be held. Schools, bars, restaurants and shops selling non-essential items have been shut since March 14 and most of the population is house- bound as Spain tries to curb the virus. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -15- EU Scrambles to Buy Intensive Care Drugs to Tackle COVID Shortages (Reuters) - The tender, which will seek drugs for ten European Union member states, asks drugmakers to submit offers by Thursday. [FN24] It is the latest move by the executive Commission to coordinate purchases of critical treatments, vaccines and equipment for EU members amid the COVID-19 pandemic. The Commission was not immediately available for comment. There are shortages of analgesics, antibiotics, muscle relaxers, anaesthetics and resuscitation drugs, among others, the source said, without identifying the names of the medicines being sought in the tender, because the procedure is not yet concluded. An internal EU document seen by Reuters shows that in April about 100 medications for COVID-19 patients were in short supply in EU countries. Among those not available or at risk of shortages in a large number of EU states were analgesic paracetamol; anaesthetics Fentanyl, Midazolam and Propofol; resuscitation drugs Dobutamine and Noradrenaline; muscle relaxers Cisatracurium and Rocuronium; and antibiotics Piperacillin, Azithromycin and Amoxicillin. These drugs are mostly used in critically ill COVID-19 patients who need to be sedated for intubation. Steroid Dexamethasone was also seen in April at risk of shortages in Ireland, Cyprus and Luxembourg. The drug, which is made by several generic drugmakers, reduces death rates in hospitalized COVID-19 patients, according to British research. After the bids, the Commission could strike deals with companies that agree to supply the bloc with their drugs. EU states would then be able to place their orders with the manufacturers. Joint tenders are meant to avoid competition among EU states for drugs and critical equipment. Some EU governments have complained EU procedures are too complex, EU officials said. A tender to buy face masks initially received no offers in March. Supplies began flowing later after a second tender. Most of the 27 EU countries reached a peak in COVID-19 cases, hospitalizations and deaths a few weeks ago, but many have recently seen a resurgence of cases and large localized outbreaks, the bloc's public health body, the European Centre for Disease Prevention and Control (ECDC), said last week. EU Eyes COVID-19 Vaccines at Less than $40, Shuns WHO-led Alliance - Sources (Reuters) - The European Union is not interested in buying potential COVID-19 vaccines through an initiative co-led by the World Health Organisation as it deems it slow and high-cost, two EU sources told Reuters, noting the bloc was in talks with drugmakers for [FN25] shots cheaper than $40. The position shows the EU has only partly embraced a global approach in the race for COVID-19 vaccines as, while it is a top supporter of initiatives for worldwide equitable access, it prefers prioritizing supplies for the EU population. It could also deal a blow to the WHO-led COVAX initiative to secure vaccines for all. “Using COVAX would lead to higher prices and later supplies,” one of the two officials said. The COVAX mechanism meant to buy vaccines in advance is targeting a $40 price for COVID vaccines for wealthy countries, the official said, adding the EU could buy at cheaper prices with its own scheme for upfront purchases. A spokeswoman for GAVI, a public-private vaccine alliance which also co-leads the COVAX initiative, declined to comment on the $40 target, saying it was impossible at this stage to predict the exact price of future doses. “Any pricing structure will need to reflect (the) at-risk investments in R&D and manufacturing necessary, as well as meet expectations that eventual vaccines are made available during the acute phase of the pandemic as a global good,” she said. The WHO had no immediate comment. On Wednesday, Pfizer (PFE.N) and BioNtech (22UAy.F) said the U.S. government had agreed to pay nearly $2 billion to secure their potential COVID-19 shot which, if successful, would be used to vaccinate 50 million people at a price of about $40 dollar per person. The EU is currently in talks with several drugmakers to secure in advance their potential vaccines against the coronavirus, officials told Reuters last week. These possible deals would be financed with about 2 billion euros ($2.3 billion) from an EU rainy-day fund known as Emergency Support Instrument (ESI), officials said. The EU also wants to secure vaccines by the end of the year, should they be available. This timetable “is not feasible” for COVAX, one official said. PARALLEL TRACKS © 2021 Thomson Reuters. No claim to original U.S. Government Works. -16- The European Commission, which is the bloc's executive arm and leads EU talks with drugmakers, has advised EU states to join COVAX if they wish, but not for buying vaccines, the official said. A Commission spokesman declined to comment. An official said joining the two initiatives may not be legally feasible, as EU states have accepted an exclusivity clause when they backed the EU advance purchase scheme. Some EU states have expressed interest in joining COVAX but have not yet signed up. The EU has been a keen supporter of global initiatives to secure vaccines for all. It has promoted two global fund-raising campaigns that have so far raised nearly $19 billion, of which three quarters came from EU states and institutions, to help develop COVID-19 vaccines and ensure equitable access. However, taken aback by U.S. moves to secure potential vaccines and drugs, the EU has recently taken a more assertive role in the global race. If COVID-19 vaccines prove effective in trials they are unlikely to be immediately available in large amounts. Buying them for the EU population could thus temporarily deprive poorer countries of doses. The official said however that the two tracks to buy vaccines remained complementary, but added, “budgets are limited.” V. GLOBAL ISSUES Global Downturn Looms as Countries Struggle to Contain Coronavirus Outbreak (Reuters) - The coronavirus spread further on Friday, with cases reported for the first time in at least six countries across four [FN26] continents, battering markets and leading the World Health Organization (WHO) to raise its impact risk alert to “very high.” Hopes that the epidemic that started in China late last year would be over in months, and that economic activity would quickly return to normal, have been shattered. World shares were on course for their largest weekly fall since the 2008 financial crisis, bringing the global wipeout to $5 trillion as supply chains were disrupted, travel plans postponed and major events canceled. The WHO said it was raising its assessment of the global risk to “very high' from “high', which its head of emergencies Dr Mike Ryan said was intended to put national authorities on full alert. ”I think this is a reality check for every government on the planet - wake up, get ready, this virus may be on its way and you need to be ready,” Ryan said. The latest WHO figures indicate over 82,000 people have been infected, with over 2,700 deaths in China and 57 deaths in 46 other countries. Mexico, Nigeria, New Zealand, Lithuania, Belarus and Azerbaijan reported their first cases, all with travel history connected to epicenters in Italy and Iran. Mexico is the second Latin American country to register the virus, after Brazil. The Nigerian case, an Italian man, is the first in sub-Saharan Africa. The man traveled through the capital and other parts of Nigeria for almost two days before he was isolated and quarantined, authorities said, underlining the difficulties already overstretched health services will have in containing the disease. Potentially making it even harder to eradicate, a growing number of discharged coronavirus patients in China and elsewhere are testing positive again, sometimes weeks after being allowed to leave the hospital. In addition to stockpiling medical supplies, some governments ordered schools shut and canceled big gatherings to try to halt the flu- like disease. Switzerland canceled next week's Geneva international car show, one of the industry's most important gatherings. The New York Stock Exchange said it had “robust contingency plans” to allow it to continue operating if its floor had to close. SURGING OUTSIDE CHINA The outbreak appears to be easing in China, where it first emerged late last year in an market illegally trading wildlife. Mainland China reported 327 new cases in the last 24 hours, the lowest in the country in more than a month, and China's three biggest airlines restored some flights. But the virus is surging elsewhere. Countries other than China now account for about three-quarters of new infections. South Korea, with the most cases outside China, reported 571 new infections on Friday, bringing the total to 2,337, with 13 people dead. The death toll in Italy rose to 21, with nearly 900 testing positive. Cafes and schools have been closed as daily life has ground to a halt. The WHO's Ryan said Iran's outbreak may be worse than realized. Its toll of 34 dead is the highest outside China, although there are reports of much higher numbers. A WHO team is expected to be in Iran by Sunday or Monday. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -17- In the United States, the outbreak of the new coronavirus and efforts to prepare for its possible spread have become political in a presidential election year. Federal government health officials told lawmakers the country had insufficient testing resources, a source said, and Democratic presidential candidates slammed the government's response. But the White House played down the coronavirus crisis and called the high level of news coverage a ploy to hurt U.S. President Donald Trump. The Trump administration plans to use defense legislation to boost production of protective gear like masks and gloves, the health secretary said. Online retailer Amazon.com joined other companies in implementing travel restrictions for its employees. Japan is scheduled to host the 2020 Olympics in July but Ryan said discussions were being held about whether to go ahead. Organizers will decide next week on the ceremonial torch relay, due to arrive on March 20 for a 121-day journey. Confirmed cases in Japan have risen above 200, with four deaths, excluding more than 700 cases on a quarantined cruise liner, Diamond Princess. Six people from the ship have died, including a man who was reported on Friday as the first British person to die from the disease. World Health Organization Calls Coronavirus Outbreak ‘Pandemic’ for First Time (Reuters) - The World Health Organization described the new coronavirus as a pandemic for the first time on Wednesday, adding that [FN27] Italy and Iran were now on the frontline of the disease and other countries would soon join them. ”We are deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction. We have therefore made the assessment that COVID-19 can be characterized as a pandemic,” WHO Director General Tedros Adhanom Ghebreyesus told a news conference on Wednesday. He urged the global community to redouble efforts to contain the outbreak, saying aggressive measures could still play a big role to curb it “This is the first pandemic caused by a coronavirus. We cannot say this loudly enough, or clearly enough, or often enough: all countries can still change the course of this pandemic. This is the first pandemic that can be controlled,” he later tweeted. While he acknowledged the characterization did not change what WHO was doing or what countries needed to do, it sounded an alarm the organization has not used so far as the virus spreads. WHO officials have signaled for weeks that they may use the word “pandemic” as an descriptive term but have stressed that it does not carry legal significance. The WHO no longer has a category for declaring a pandemic, except for influenza. The novel coronavirus is not the flu. The coronavirus, which emerged in China in December, has spread around the world, halting industry, bringing flights to a standstill, closing schools and forcing the postponement of sporting events and concerts. The WHO declared a public health emergency of international concern, its “highest level of alarm”, on Jan. 30 when there were fewer than 100 cases of COVID-19 outside China and eight cases of human-to-human transmission of the disease. Now there are more than 118,000 cases in 114 countries and 4,291 people have died, Tedros said, with the numbers expected to climb. In the past two weeks the number of cases outside China had risen 13-fold, and the number of countries affected had tripled, a sombre- looking Tedros said, displaying little of his normally upbeat persona. ON THE FRONTLINE Mike Ryan, head of the WHO's emergencies program, said the situation in Iran was “very serious” and the agency would like to see more surveillance and more care for the sick. “We need to move now. Italy and Iran are in the frontline now. They are suffering but I guarantee you other countries will be in that situation very soon,” Ryan said. Ryan said that some countries were only testing the elderly or people who had traveled to China and urged them to update their monitoring and contact-tracing measures as well as do more to protect health workers exposed to the virus. He said the experience with influenza led many people to the false conclusion that a pandemic was uncontrollable once it started. The experience of South Korea, Singapore, and China in combating the new virus showed this was not true, he said. “We have observation that tells us that there is a strong element of controllability in this disease,” he told the news conference. “That doesn't mean we will completely stop it but what it does mean is there is a real chance to blunt the curve, there is a real chance to bend the curve and reduce the number of cases that our health system has to cope with and give the health system a chance to save more lives,” he said. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -18- Ryan said healthcare workers in Iran and Italy were under a lot of strain, citing nearly 900 people in intensive care in Italy. Confirmed cases across Italy rose to 12,462 on Wednesday, from a previous 10,149, with 827 having died. He also pointed to shortages of protective gear, ventilators and oxygen in Iran, where the death toll has topped 350 people with around 9,000 infected. “We've made clear that those supplies are very, very short and we are struggling to find other supplies externally,” he said. Lockdowns and Entry Bans Imposed Around the World to Fight Coronavirus (Reuters) - France and Spain joined Italy in imposing lockdowns on tens of millions of people, Australia ordered self-isolation of arriving [FN28] foreigners and other countries extended entry bans as the world sought to contain the spreading coronavirus. Panic buying in Australia, the United States and Britain saw leaders appeal for calm over the virus that has infected over 156,000 people globally and killed more than 5,800. Several countries imposed bans on mass gathering, shuttered sporting, cultural and religious events, while medical experts urged people to practice “social distancing” to curb the spread. Austria's chancellor urged people to self-isolate and announced bans on gatherings of more than five people and further limits on who can enter the country. All of Pope Francis' Easter services next month will be held without the faithful attending, the Vatican said on Sunday, in a step believed to be unprecedented in modern times. The services, four days of major events from Holy Thursday to Easter Sunday, usually draw tens of thousands of people to sites in Rome and in the Vatican. Australian Prime Minister Scott Morrison said from midnight Sunday international travelers arriving in the country would need to isolate themselves for 14 days, and foreign cruise ships would be banned for 30 days, given a rise in imported cases. Australia's latest restrictions mirror those announced by neighboring New Zealand on Saturday. TRAVEL BANS, AIRLINE CUTBACKS Donald Trump tested negative for the coronavirus, his doctor said on Saturday, as the U.S. president extended his country's travel ban to Britain and Ireland. Last week, Trump had met a Brazilian delegation in which at least one member has since been tested positive. Travel restrictions and bans, and a plunge in global air travel, saw further airline cutbacks, with American Airlines Inc planning to cut 75% of international flights through May 6 and ground nearly all its widebody fleet. China tightened checks on international travelers arriving at Beijing airport on Sunday, after the number of imported new coronavirus infections surpassed locally transmitted cases for a second day in a row. Anyone arriving to Beijing from abroad will be transferred directly to a central quarantine facility for 14 days for observation starting March 16, a city government official said. China, where the epidemic began in December, appears to now face a greater threat of new infections from outside its borders as it continues to slow the spread of the virus domestically. China has reported 80,984 cases and 3,203 deaths. The country imposed draconian containment policies from January, locking down several major cities. LOCKDOWNS, STAY HOME Spain put its 47 million inhabitants under partial lockdown on Saturday as part of a 15-day state of emergency to combat the epidemic in Europe's second worst-affected country after Italy. Streets in Madrid and Barcelona were deserted on Sunday. All major newspapers carried a front-page wrapper emblazoned with a government-promoted slogan: “Together we'll stop this virus.” Spain has had 193 deaths from the virus and 6,250 cases so far, public broadcaster TVE said on Sunday. France will shut shops, restaurants and entertainment facilities from Sunday with its 67 million people were told to stay home after confirmed infections doubled in 72 hours. French Prime Minister Edouard Philippe said the government had no other option after the public health authority said 91 people had died in France and almost 4,500 were now infected. “We must absolutely limit our movements,” he said. However, French local elections went ahead. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -19- “I am going to vote and keep living my life no matter what. I am not scared of the virus,” said a 60-year-old voter, who asked to be identified only as Martine, at a Paris polling station. Britain is preparing to ban mass gatherings and could isolate people aged over 70 for up to four months as part of plans to tackle coronavirus, Health Secretary Matt Hancock said. Argentina banned entry to non-residents who have been to any country highly affected by coronavirus in the last 14 days, while Colombia said it would expel four Europeans for violating compulsory quarantine protocols, hours after closing its border with Venezuela. Starting Sunday, South Korea began to subject visitors from France, Germany, Britain, Spain and the Netherlands to stricter border checks, after imposing similar rules for China, Italy and Iran which have had major outbreaks. Visitors from those countries now need to download an app to report whether they have symptoms. South Korea has been testing hundreds of thousands of people and tracking potential carriers using cell phone and satellite technology. World's Largest Glove Maker Sees Shortage as Coronavirus Fight Spikes (Reuters) - Malaysia's Top Glove Corporation Bhd, which makes one in every five gloves globally, expects a product shortage as [FN29] demand from Europe and the United States spikes because of the widening coronavirus outbreak is exceeding its capacity. The company has extended shipping times to cope with the demand surge, Executive Chairman Lim Wee Chai told Reuters by phone on Friday. Lim said orders received in the past few weeks, mainly from Europe and the United States, were almost double the company's production capacity. Top Glove can produce 200 million natural and synthetic rubber gloves a day. There are now more than 600,000 coronavirus cases across 202 countries and territories globally, with the United States overtaking China as the country with the most infections. Europe continues to report the most deaths. “Some customers panic order; normally they order 10 containers a month but now they suddenly increase to 20 containers,” he said. The World Health Organization warned on Friday that the “chronic global shortage of personal protective gear” is among the most urgent threats to the virus containment efforts. “Definitely there is a shortage. They order 100% more, we can only increase 20% so there is a shortage of about 50% to 80%,” he said. The exceptional buying momentum could last another three months but orders are expected to remain strong for up to nine months even as demand from Asian markets has started to slow slightly, Lim said. To cope, the company has adjusted its delivery time from as short as 30 days to as long as 150 days. Lim said the company was ensuring all its customers get a fair share of extra gloves delivered. “We manage their volume, limit them to buy so much per customer. We have to manage but it's a good problem for us to solve,” he said. Lim said the company is adding new machines every week, and could increase its production by as much as 30%. This month, Top Glove stepped up its factory utilization by 10% to 95% and expects to reach near maximum utilization in April. The company is rushing to source about 1,000 workers to keep up. Top Glove normally hires from Nepal but is now drafting workers from Malaysia because of travel restrictions. “We need about 10% extra workers. During this (travel curbs), we are also not able to bring in workers from Nepal. So we have no choice, we have to use some local workers to help out, in the packing especially.” Top Glove said its supply chain is well-diversified and was optimistic it would not have issues sourcing materials in the next few weeks. Malaysia has approved some manufacturers in the essential goods sectors to continue operating under specific conditions during the nation's lockdown that ends on April 14. Factbox: Latest on the Spread of the Coronavirus Around the World (Reuters) - U.S. deaths from coronavirus could reach 200,000 with millions of cases, the government's top infectious diseases expert [FN30] warned on Sunday as New York, New Orleans and other major cities warned they would soon run out of medical supplies. DEATHS, INFECTIONS * More than 662,700 people have been infected across the world and 30,751 have died, according to a Reuters tally. EUROPE * Italy's government will “inevitably” extend beyond April 3 the containment measures it had approved to stem the outbreak, the regional affairs minister said on Sunday. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -20- * The death toll in Italy surged past 10,000 on Saturday. Confirmed cases rose by about 6,000 to 92,472, the second-highest number of cases in the world behind the United States. * Spain prepared to enter its third week under near-total lockdown on Sunday, as the government approved a strengthening of measures and the death toll rose to 6,528. * Prime Minister Boris Johnson is warning Britons in a letter to 30 million households that things will get worse before they get better, as he himself self-isolates in Downing Street to recover from the coronavirus. * Britain has reported 17,089 confirmed cases of the disease and 1,019 deaths and the peak of the epidemic in the country is expected to come in a few weeks. * Germany's health system could face strains similar to those in Italy if the outbreak in the country worsens, the head of the Robert Koch Institute (RKI), the federal agency responsible for disease control, told a newspaper. AMERICAS * President Donald Trump said on Saturday that he would issue a travel warning for the hard-hit New York area to limit the spread of the coronavirus, backing off from an earlier suggestion that he might try to cut off the region entirely. * The U.S. death count crossed 2,100 on Saturday, more than double the level from two days ago. The United States has now recorded more than 123,000 cases, the most of any country in the world. * The U.S. House of Representatives on Friday approved a $2.2 trillion aid package and Trump quickly signed it into law. ASIA AND THE PACIFIC * Indian Prime Minister Narendra Modi asked the nation's poor for forgiveness as the economic and human toll from his 21-day nationwide lockdown deepens and criticism mounts about a lack of adequate planning ahead of the decision. * The International Olympic Committee (IOC) and Japanese organizers are in final stages of talks to set the opening date for the Tokyo Games in July next year, Japanese media said.[nL4N2BM012 * Doctors, politicians and human rights commissioners are calling on Indonesia's government to enact tighter movement restrictions as the death toll from coronavirus rose in the world's fourth most populous country. * A growing number of imported coronavirus cases in China risked fanning a second wave of infections when domestic transmissions had “basically been stopped”, a senior health official said on Sunday. MIDDLE EAST AND AFRICA * The United Arab Emirates on Saturday extended to April 5 a nightly curfew to sterilize public places to combat the spread of coronavirus as neighboring Qatar reported its first death from the disease. * To stem the spread of the virus in crowded jails, Iran's judiciary on Sunday extended furloughs for 100,000 prisoners. On March 17, Iran said it had freed about 85,000 people from jail temporarily, including political prisoners. * Turkey halted all intercity trains and limited domestic flights on Saturday. The number of cases jumped to 7,402, with 108 dead. ECONOMIC FALLOUT * Stocks across the globe fell on Friday after a historic three-day run-up, as skittish investors kept indices on track for their worst monthly and quarterly performances since 2008, while the dollar fell by the most in any week since 2009. [MKTS/GLOB] * Qatar Airways will have to seek government support eventually, Chief Executive Akbar al-Baker told Reuters on Sunday, warning that the Middle East carrier could soon run out of the cash needed to continue flying. * Egypt's central bank said it has instructed banks to put temporary limits on daily withdrawals and deposits amid concerns over the spread of the coronavirus. * South Africa may approach the International Monetary Fund and World Bank for funding, Finance Minister Tito Mboweni said in the Sunday Times newspaper. * Investors rushed into cash and out of bonds at a record pace over the past week, BofA's weekly fund flow data showed on Friday. Global Health Fund Calls for $8 billion to Begin COVID-19 Exit Strategy (Reuters) - A leading global health fund has asked international businesses and governments to provide $8 billion to support [FN31] development and production of COVID-19 tests, drugs and vaccines. British-based Wellcome Trust said the initiative, dubbed COVID-Zero, is aimed at the private sector and it is urging chief executives of multinational companies to join the coalition and save lives. An initial $8 billion by the end of April - a fraction of the sums wealthy governments have injected into struggling economies - would be enough to develop new COVID-19 tests, drugs and vaccines and to begin scaling up production, the fund said. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -21- “This is a global issue that will continue to plague the world and businesses for months, if not years, to come,” said Jeremy Farrar, Wellcome's director. “We want business leaders to give a small proportion of the money they are dedicating to coping with this crisis to solving it. We hope that governments will follow their example.” Wellcome says that $2 billion of the initial $8 billion needed would be used to help poorer and more vulnerable countries to build a stockpile of masks, medicines and other defenses against future outbreaks. The COVID-19 disease pandemic has triggered a sharp downturn in an already slowing global economy and sparked a rout across financial markets, wiping about $15 trillion from stock markets alone. More than 1.32 million people have been reported infected by the novel coronavirus and 74,087 have died. A Reuters snap poll of more 50 economists in North America, Europe and Asia over April 1-3 showed that the global economy is expected to contract by 1.2% this year, compared with a forecast of 1.6% expansion in a poll three weeks ago. Scientists around the world are working to develop vaccines and test existing drugs that could be potential treatments for COVID-19 while also seeking to improve diagnostic tests. But Farrar warned that these teams are in danger of running out of funding, without which new treatments might never get out of laboratories to reach clinical trials and, ultimately, the people who need them. “Drugs, vaccines and rapid diagnostics are the only way we have of saving lives, bringing this pandemic to an end and preventing it reappearing,” Farrar said. “This is the only exit strategy, but we do not have the funding we need.” WHO Readies Coronavirus App for Checking Symptoms, Possibly Contact Tracing (Reuters) - The World Health Organization (WHO) plans to launch an app this month to enable people in under-resourced countries to assess whether they may have the novel coronavirus, and is considering a Bluetooth-based contact tracing feature too, an official told [FN32] Reuters on Friday. The app will ask people about their symptoms and offer guidance on whether they may have COVID-19, the potentially lethal illness caused by the coronavirus, said Bernardo Mariano, chief information officer for the WHO. Other information, such as how to get tested, will be personalized according to the user's country. Though the WHO will release a version on app stores globally, any government will be able to take the app's underlying technology, add features and release its own version on app stores, Mariano said in a phone interview. India, Australia and the United Kingdom already have released official virus apps using their own technology, with common features including telling people whether to get tested based on their symptoms and logging people's movements to enable more efficient contact tracing. Several countries are ramping up contact tracing, or the process of finding, testing and isolating individuals who crossed paths with an infectious individual. It is seen as vital to safely opening economies, and apps that automate parts of the process could accelerate efforts. The WHO expects its app to draw interest in other countries, including some in South America and Africa where case numbers are rising. They may lack the technology and engineers to develop apps or be struggling to offer testing and education. “The value is really for countries that do not have anything,” Mariano said. “We would be leaving behind the ones that are not able to (provide an app), that have fragile health systems.” Engineers and designers, including some who previously worked at Alphabet Inc's Google and Microsoft Corp, have been volunteering for weeks to develop the new app with about five of them overseeing the process. They are designing it open-source on the hosting service GitHub, meaning code is open to public input. Several team members declined to comment. Mariano said he wants to include additional tools beyond the symptom checker, including a self-help guide for mental health care. The team also is considering what the WHO refers to as proximity tracing. Engineers have done preliminary work and talked to smartphone operating system makers Apple Inc and Google about possibly adopting technology the companies plan to release jointly this month to make tracing easier. The technology relies on virtual “handshakes” between phones that come within a few feet of each other for at least five minutes. Phones keep anonymized logs of such encounters, allowing someone who later tests positive to anonymously send notifications to recent contacts about their possible exposure to the virus. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -22- But Mariano said legal and privacy considerations have prevented the WHO from committing to such a feature yet. He expressed concern about the many businesses pitching proximity tools turning around and using any personal data they gather to generate revenue later. “We want to make sure we ring-fence all the risks around it,” he said. Apple and Google have said their system will not use any data for other purposes and will be stopped when the pandemic ends. The WHO plans to release guidance as soon as next week on issues countries should consider as they weigh their own proximity tracing apps. To reach people with limited internet access, the WHO is working to deliver information via text messages. In March, it launched an account on Facebook Inc's WhatsApp to provide users with information about the coronavirus, and it partnered with the company's Free Basics program to make some information available without users incurring data charges. The WHO also plans to release an app next week to inform health workers globally about best practices for donning protective gear, washing hands and treating the virus. The organization already has a general app, WHO Info, that largely mirrors its website. Trump Cutting U.S. Ties with World Health Organization over Virus (Reuters) - The United States will end its relationship with the World Health Organization over the body's handling of the coronavirus [FN33] pandemic, U.S. President Donald Trump said on Friday, accusing the U.N. agency of becoming a puppet of China. The move to quit the Geneva-based body, which the United States formally joined in 1948, comes amid growing tensions between Washington and Beijing over the coronavirus outbreak. The virus first emerged in China's Wuhan city late last year. Speaking in the White House Rose Garden, Trump said Chinese officials “ignored their reporting obligations” to the WHO about the virus - that has killed hundreds of thousands of people globally - and pressured the agency to “mislead the world.” “China has total control over the World Health Organization despite only paying $40 million per year compared to what the United States has been paying which is approximately $450 million a year,” he said. Trump's decision follows a May 18 pledge of $2 billion by Chinese President Xi Jinping at the World Health Assembly - the WHO decision-making body - to help deal with the coronavirus and economic and social development in affected countries, especially developing countries. It was not immediately clear how much of that money would actually go to the WHO. Trump last month halted funding for the 194-member organization, then in a May 18 letter gave the WHO 30 days to commit to reforms. “Because they have failed to make the requested and greatly needed reforms, we will be today terminating our relationship with the World Health Organization and redirecting those funds to other worldwide and deserving urgent global public health needs,” Trump said on Friday. It was not immediately clear when his decision would come into effect. A 1948 joint resolution of Congress on U.S. membership of the WHO said the country “reserves its right to withdraw from the organization on a one-year notice.” The World Health Organization did not immediately respond to a request for comment on Trump's announcement. It has previously denied Trump's assertions that it promoted Chinese “disinformation” about the virus. “It's important to remember that the WHO is a platform for cooperation among countries,” said Donna McKay, executive director of Physicians for Human Rights. “Walking away from this critical institution in the midst of an historic pandemic will hurt people both in the United States and around the world.” “ABSOLUTELY CRITICAL' The United States currently owes the WHO more than $200 million in assessed contributions, according to the WHO website. Washington also gives several hundred million dollars annually in voluntary funding tied to specific WHO programs such as polio eradication, HIV, hepatitis and tuberculosis. Amesh A. Adalja, a senior scholar at Johns Hopkins Center for Health Security, said that in practice Trump's decision was unlikely to change the operations of the WHO. ”From a symbolic or moral standpoint it's the wrong type of action to be taking in the middle of a pandemic and seems to deflect responsibility for what we in the U.S. failed to do and blame the WHO,” said Adalja. When Trump halted funding to the WHO last month, two Western diplomats said the U.S. suspension was more harmful politically to the WHO than to the agency's current programs, which are funded for now. The WHO is an independent international body that works with the United Nations. U.N. Secretary-General Antonio Guterres said last month that the WHO is “absolutely critical to the world's efforts to win the war against COVID-19.” When asked about Trump's decision, a U.N. spokesman said: “We have consistently called for all states to support WHO.” © 2021 Thomson Reuters. No claim to original U.S. Government Works. -23- Trump has long scorned multilateralism as he focuses on an “America First” agenda. Since taking office, he has quit the U.N. Human Rights Council, the U.N. cultural agency, a global accord to tackle climate change and the Iran nuclear deal. He has also cut funding for the U.N. population fund and the U.N. agency that aids Palestinian refugees. “The WHO is the world's early warning system for infectious diseases,” said U.S. Representative Nita Lowey, a Democrat who chairs the House Committee on Appropriations. “Now, during a global pandemic that has cost over 100,000 American lives, is not the time to put the country further at risk.” WHO Set to Resume Hydroxychloroquine Trial in Battle Against COVID-19 (Reuters) - The World Health Organization will resume its trial of hydroxychloroquine for potential use against the coronavirus, its chief [FN34] said on Wednesday, after those running the study briefly stopped giving it to new patients over health concerns. The U.N. agency last month paused the part of its large study of treatments against COVID-19 in which newly enrolled patients were getting the anti-malarial drug to treat COVID-19 due to fears it increased death rates and irregular heartbeats. The study continued with other medicines. But the WHO's director-general, Tedros Adhanom Ghebreyesus, said its experts had advised the continuation of all trials including hydroxychloroquine, whose highest-profile backer for use against the coronavirus is U.S. President Donald Trump. “The executive group will communicate with the principal investigators in the trial about resuming the hydroxychloroquine arm of the trial,” Tedros told an online media briefing, referring to WHO's initiative to hold clinical tests of potential COVID-19 treatments on some 3,500 patients in 35 countries. The WHO's decision to suspend its trial prompted others to follow suit, including Sanofi, which said on May 29 it was suspending recruitment for its trials. A Sanofi spokesman said the company would review available information and run consultations in the coming days to reassess its position following the WHO's latest decision on Wednesday. The WHO's chief scientist, Soumya Swaminathan, called for other trials of the drug to proceed. “We owe it to patients to have a definitive answer on whether or not a drug works,” she said, adding that safety monitoring should also continue. Swaminathan said the WHO would be keen to see more results of clinical trials of Avifavir, a drug she said would be used to treat COVID-19 in Russian hospitals “very soon”. In the same virtual briefing, WHO officials said they were especially worried about outbreaks in Latin America and in Haiti, one of the world's poorest nations, where infections have been spreading rapidly. The coronavirus has infected almost 3 million people in the Americas and more than 6.43 million worldwide. Global COVID-19 Fundraising Meeting raises $6.9 billion, Leaders Want Vaccine for All (Reuters) - A global fundraising meeting on Saturday raised 6.15 billion euros ($6.9 billion) from the United States, the European Commission and numerous countries to fight COVID-19, with many participants stressing that an eventual vaccine should be available [FN35] to anyone who needs it. The pledging summit, part of a joint initiative by the EU executive and advocacy group Global Citizen, also included a globally televised and streamed fundraising concert featuring Miley Cyrus, Justin Bieber, Shakira, Chloe X Halle, Usher and others. The Commission together with the European Investment Bank pledged 4.9 billion euros ($5.50 billion), the United States $545 million, Germany 383 million euros, Canada C$300 million ($219 million)and Qatar $10 million. Forty governments took part in the summit. The money will be used for COVID-19 tests, treatments and vaccines, and also to support the world's poorest and most marginalized communities. Commission President Ursula von der Leyen said it was crucial that everyone who needed it should have access to a vaccine. “I am trying to convince high-income countries to reserve vaccines not only for themselves but also for low- and middle income countries. This is a stress test for solidarity,” she said. British Premier Boris Johnson concurred. “If and when an effective vaccine is found, then we as world leaders have moral duty to ensure that it is truly available to all,” he said. French President Emmanuel Macron was adamant about pooling efforts together. “Let's refuse an every man for himself approach, let's continue to move forward together,” he said. Italy, one of the hardest hit by the pandemic, echoed his sentiment. The EU is championing global cooperation in efforts to control and end the pandemic, in contrast to the United States and China's focus on national initiatives. Latest on the Worldwide Spread of Coronavirus © 2021 Thomson Reuters. No claim to original U.S. Government Works. -24- (Reuters) - Polish President Andrzej Duda has tested positive for coronavirus, authorities said on Saturday, and police used tear gas on [FN36] several occasions as thousands of people protested in Warsaw against COVID-19 restrictions. Europe became the second region after Latin America to surpass 250,000 coronavirus deaths, according to a Reuters tally. EUROPE * Italy reported another daily record for COVID-19 cases on Saturday as the government planned further restrictions, despite a second night of street protests against curfews ordered this week. * Spain will hold a special cabinet meeting on Sunday to discuss a new state of emergency after regions urged government action to allow them to impose curfews to help tackle its escalating outbreak. * France on Saturday reported 45,422 new confirmed coronavirus cases over the past 24 hours, a new record, after reporting 42,032 on Friday. AMERICAS * Marc Short, the chief of staff for Vice President Mike Pence, has tested positive for coronavirus, a spokesman for the vice president said on Saturday. * Colombia surpassed 1 million infections on Saturday, becoming the eighth country globally to do so, tallying 1,007,711 confirmed infections and 30,000 deaths. ASIA-PACIFIC * Victoria state, Australia's COVID-19 hotspot, on Sunday delayed the eagerly awaited removal of strict lockdown restrictions for cafes, restaurants and pubs in the capital Melbourne because of an outbreak in the northern suburbs. MIDDLE EAST AND AFRICA * Algeria's 75-year-old President Abdelmadjid Tebboune is self-isolating because some officials in “upper ranks of the government” are sick with COVID-19, he said in a tweet on Saturday. * Iran's Supreme Leader Ayatollah Ali Khamenei called on Saturday for strict punishments for violators of COVID-19 restrictions as the Middle East's hardest-hit nation battled a third wave. MEDICAL DEVELOPMENTS * AstraZeneca Plc has resumed the U.S. trial of its experimental COVID-19 vaccine after approval by regulators, and Johnson & Johnson is preparing to resume its trial on Monday or Tuesday, the companies said on Friday. ECONOMIC IMPACT * Cisco's video-conferencing app Webex clocked 590 million participants in September and is on track to record over 600 million this month, nearly double the numbers recorded in March when countries started shutting down due to the pandemic. WHO-led COVID Drug Scheme Doubles Down on Antibodies, Steroids and Shuns Remdesivir (Reuters) - A World Health Organization-led scheme to supply COVID-19 drugs to poor countries is betting on experimental monoclonal [FN37] antibody treatments and steroids but shunning Gilead's remdesivir therapy, an internal document shows. The Oct. 30 WHO draft document seen by Reuters says priorities are to secure monoclonal antibodies in a tight market and to boost distribution of cheap steroid dexamethasone, of which it has already booked nearly 3 million courses of treatment for poorer countries. Monoclonal antibodies are manufactured copies of antibodies created by the body to fight an infection, and drugmakers including Roche and Novartis confirmed initial contact with the WHO scheme. The paper, which for the first time outlines how the scheme would spend donors' money, does not cite remdesivir among priority drugs - a significant omission as the antiviral is the only other medication alongside dexamethasone approved across the world for treating COVID-19. Gilead Science said the WHO scheme had not funded its COVID-19 trials and had never approached the firm for the possible inclusion of remdesivir in its portfolio. The drug-supply scheme is one of the four pillars of the so-called ACT Accelerator, a WHO-led project which also seeks to secure COVID-19 vaccines, diagnostics and protective gear for poorer countries by raising more than $38 billion by the beginning of 2022. “Immediate priorities for the (therapeutics) pillar are intensifying efforts on monoclonal antibodies while scaling up dexamethasone use,” says the document, which is subject to change but due for publication as soon as Friday. The scheme, co-led by the Wellcome Trust, a charity, and Unitaid, a health partnership hosted by the WHO, urgently needs $6.1 billion, $750 million of which by February, out of a total ask of $7.2 billion. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -25- More than half the cash would be used to procure and distribute monoclonal antibodies, the document shows, calling these therapeutics “game-changing” but in short supply. No monoclonal antibody has, so far, been approved against COVID-19, but the WHO scheme has already invested in research and secured production capacity at a Fujifilm Diosynth Biotechnologies plant in Denmark. Fujifilm didn't immediately comment. The scheme wants $320 million to make antibodies in that facility, the document says, estimating that would be enough to secure 4 million antibody courses, at about $80 per course. A spokeswoman for Unitaid confirmed that it wanted to raise and invest $320 million in securing monoclonal antibodies but said commercial deals were confidential. Another $110 million would be used for regulatory approval and other market preparation procedures for monoclonal antibodies in poorer countries, the document shows, while $220 million would fund clinical trials. “AFFORDABLE PRICE' Among companies developing experimental monoclonal antibodies against COVID-19 are U.S. firms Eli Lilly and Regeneron. U.S. President Donald Trump got their antibodies in October after testing COVID-19 positive. Eli Lilly has already agreed to produce antibodies at the Fujifilm plant from April and make them available at “an affordable price” to poorer countries, a company spokeswoman said. A U.S. government-run trial of Lilly's drug was paused in mid-October over safety concerns, but other trials continue and the U.S. administration last week sealed a $375-million supply deal. It is unclear how and whether the WHO scheme will raise the money needed for the antibody project. Roche, which has partnered with Regeneron to make up to 2 million doses of the so-called REGN-COV2 antibody annually by 2021, has had “preliminary discussions” with the ACT Accelerator over an access plan. ”These discussions were in the context of development and production,” a Roche spokesman said in an email. “It is too early to speculate on future decisions, but we will continue working with them and other groups regarding REGN-COV2.” Novartis, which expects results soon from a trial of its arthritis treatment canakinumab against COVID-19, said on Thursday it received a request several days ago from the WHO scheme seeking information about medicines to tackle the coronavirus. Novartis also makes dexamethasone. Despite being short of funds, the WHO drugs-supply scheme aims to distribute hundreds of millions of courses of COVID-19 drugs to poorer countries by 2022. Apart from monoclonal antibodies and dexamethasone, it is also eyeing other experimental drugs, including new antivirals and repurposed drugs. The scheme would spend another $100 million to seal deals with unspecified drugmakers from mid-2021, the document says, and next year plans to invest another $4.4 billion on drugs that succeed in clinical trials. The Unitaid spokeswoman said dexamethasone and its alternative, hydrocortisone, were the most promising among repurposed drugs. Unitaid confirmed the scheme had not procured or funded remdesivir, which was initially trialed against Ebola. It did not comment on why remdesivir did not appear among priority treatments in the document. Remdesivir has been authorized in multiple countries to treat COVID-19. However, preliminary findings of a WHO-sponsored trial concluded the antiviral had little or no benefit, contradicting previous positive trials. Governments however continue to buy it, with Germany this week announcing a 150,000-plus dose purchase. VI. MIDDLE EAST/NORTH AFRICA Israel Avoids Health Crisis with Last-minute New Drug Budget (Reuters) - Israeli ministers on Thursday averted a health care crisis by passing a last-minute allocation of 500 million shekels ($143 [FN38] million) to pay for new lifesaving medicines for thousands of patients. Israel is without a permanent government and has no state budget for 2020, meaning its ministries by law revert to the previous year's budget with no new spending. Thousands of patients suffering from all sorts of diseases feared this meant no money to cover new drugs or medical technologies that they hope will save or improve their lives. “This is important news for those who are sick and for the health system,” said Deputy Health Minister Yaakov Litzman after the health and finance ministries came up with the money. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -26- He did not say where the funds came from. The Israeli economy has so far weathered two inconclusive ballots and a year of successive caretaker governments, but the automatic spending freezes will weigh on economic growth as well as social services. Freezing spending on the country's subsidized “drug basket” would have been a political disaster. On Dec. 11 patient groups pleaded with lawmakers to budget extra funds before an end-of-year deadline. “It's not logical that the (political) situation in the country endangers my children's ability to see,” said Aharon Kabesa, a father of two children suffering from a rare retinal disease that leads to blindness. The drug he hopes will be included in the basket has a one-time cost of $850,000. Israel's annual health budget stands at around 54 billion shekels. Once a year patients, doctors and pharmaceutical companies ask that hundreds of new treatments enter the basket. A Health Ministry committee assesses and chooses some of them, examining things like efficacy, frequency and cost. The unique system is rigid in its timeline but flexible in its judgments, which has led to relatively broad universal drug coverage. Israel will hold another general election on March 2. Israel Links Coronavirus Aid for Gaza to Recovering Soldiers (Reuters) - Israel on Wednesday linked any assistance it might offer for the Gaza Strip's efforts against coronavirus to progress in its [FN39] attempt to recover two Israeli soldiers lost during the 2014 war in the Palestinian enclave. Blockaded and impoverished, Islamist Hamas-ruled Gaza has reported 12 coronavirus cases and authorities worry that local health facilities - with just 96 ventilators for a population of 2 million - are insufficient to contain a contagion. Both Israel and Hamas have closed the Gaza border to non-essential traffic as a precaution against the spread of the infection. But with Gaza authorities appealing for foreign humanitarian assistance, Israel has been weighing its role. 'The moment there is talk of the humanitarian world in Gaza - Israel also has humanitarian needs, which are mainly the recovery of the fallen,' Defense Minister Naftali Bennett told reporters, referring to an infantry officer and conscript who were killed in the 2014 war and their remains kept by Hamas. 'And I think that we need to enter a broad dialogue about Gaza's and our humanitarian needs. It would not be right to disconnect these things ... and certainly, our hearts would be open to many things.' It was not immediately clear if Bennett was speaking of a possible condition on Israel providing direct aid, or also on it enabling the transfer of other aid over its border with Gaza. Palestinian officials on Wednesday said 1,500 coronavirus testing kits would be brought into Gaza, with the help of the World Health Organization, after they were donated by the Palestinian administration in the Israeli-occupied West Bank. Hamas has never stated whether the two Israeli troopers are dead or alive, but neither has it provided a sign of life, something it did in a previous similar case. Hamas said returning the two soldiers - as well as two Israeli civilians who crossed into the territory - would require negotiating a prisoner swap and would not be done in exchange for humanitarian aid. 'Israel bears responsibility for any consequences should the disease spread in Gaza because it has been blockading it for 13 years,' said Hamas spokesman Fawzi Barhoum. 'A prisoner swap deal is a separate track,' he said. Israel in the past has freed hundreds of jailed Palestinians, including many militants, in exchange for the single-figure recovery of slain or captive Israelis. Bennett has made clear he would not agree to any further releases of Palestinian militants in the future. Hundreds of Disillusioned Doctors Leave Lebanon, in Blow to Healthcare (Reuters) - Fouad Boulos returned to Beirut in 2007 from the United States having trained there in pathology and laboratory medicine. [FN40] He was so confident that Lebanon was the right place to be that he gave up his American residence green card. Fourteen years later he is leaving his homeland with his wife and five children and returning to the United States to try his luck starting from scratch. In the past year, Lebanon has been through a popular uprising against its political leaders, the bankruptcy of the state and banking system, a COVID-19 pandemic and, in August, a huge explosion at the port that destroyed swathes of Beirut. Some of those who can leave the country have done so, and an increasing number of them are doctors and surgeons, many at the top of their profession. With them goes Beirut's proud reputation as the medical capital of the Middle East. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -27- 'This is a mass exodus,' said Boulos, Associate Professor of Clinical Pathology and Laboratory Medicine at the American University of Beirut (AUB). 'It will keep on going,' he told Reuters. ‘If I had hope I would have stayed but I have no hope - not in the near nor in the intermediate future - for Lebanon.’ As he spoke at his mountain residence in Beit Mery, a forested area with sweeping views over Beirut, his wife helped pack up their last possessions, ready to return to the United States. Suitcases lined the hallway, and one of his daughters was online saying final farewells to school friends and her teacher. 'It breaks my heart. It was the hardest decision I ever had to make, leaving everything behind,' Boulos added. Many highly qualified physicians, who were in demand across the United States and Europe before they returned to Lebanon after the 1975-90 civil war, are throwing in the towel, having lost hope in its future. They are not only seeing wages fall, but also face shortages of equipment, staff and even some basic supplies in their hospitals as Lebanon runs out of hard currency to pay for imports. BLEEDING TALENT Sharaf Abou Sharaf, head of the doctors' syndicate, said the departure of 400 doctors so far this year creates a major problem, especially for university hospitals where they both practice and teach. 'This bleeding of talent does not bode well, especially if the situation lasts long and there are others who are preparing to leave,' he said. Caretaker Health Minister Hamad Hassan agreed. 'Their expertise was built over many years and is very hard to lose overnight. We will need many years to return the medical sector to its former glory,' he told Reuters. Protests that erupted last year and brought down the government had raised hopes that politicians, selected by a system in which leaders of Christian and Muslim sects shared the top jobs, could be pushed aside. Then came the Aug. 4 blast, when large amounts of poorly stored ammonium nitrate exploded, killing 200 people, injuring 6,000, making 300,000 people homeless and destroying large parts of the capital Beirut including several hospitals. 'The explosion was the final nail in the coffin,' Boulos said. 'It crystallized all the fears, all the pain and all the difficulties that we were living through,' added the medic, who trained at Vanderbilt University in Nashville, Tennessee. 'CORRUPT TO THE CORE' Boulos said he had lost faith in the country's leadership, after years of instability caused by political bickering. 'Lebanon is corrupt to the core,' he said, echoing the chants of thousands of protesters who packed city streets during the last year. The country has also had to deal with the influx of more than a million Syrians fleeing civil war, an economy that has buckled under the weight of debt, mass unemployment, poverty, and, more recently, the coronavirus pandemic. On Tuesday, Lebanon ordered a nationwide lockdown for around two weeks to stem the spread of the virus, as intensive care units reached critical capacity. Hassan, the caretaker health minister, has said an agreement was reached with the central bank to allocate funds for private hospitals to set up COVID-19 wings and that the state would pay hospital dues for the first six months of 2020. The government had for years owed hospitals arrears and their unpaid bills are mounting. Ghazi Zaatari, Associate Dean for Faculty Affairs and Chair of the Department of Pathology & Laboratory Medicine at AUB, said he feared the exodus would accelerate. 'For the past 10 years we put a lot of effort into recruiting around 220 faculty members, and now it is very disheartening to see that many of those we hired are leaving again.' Doctors in Lebanon, although relatively well paid, generally earn less than they did abroad. Over the past year they have seen real incomes drop due to the 80% devaluation in the currency. The caretaker health minister said the state was seeking international help to prop up depreciated salaries of doctors to slow the exodus. But both Boulos and Zaatari said money was not the main problem. 'Money is an issue, but this lack of trust and confidence in the political leadership (for) a safe, secure and successful future is a huge factor,' Zaatari said. © 2021 Thomson Reuters. No claim to original U.S. Government Works. -28- 'I am one of those who came back in the mid-90s believing that there was a promise of a better future and a reconstruction plan, only to find that 20 years later everything is collapsing and the promises were false promises. We were robbed big time.' VII. RUSSIA AND EURASIA Nepal Warns of Healthcare Crisis as Coronavirus Infections Cross 100,000 (Reuters) - Nepal's total coronavirus infections passed 100,000 on Friday, the health ministry said, and are rising at a faster rate than [FN41] both Pakistan and Bangladesh which have far larger populations. The country of 30 million people wedged between China and India has reported 100,676 total cases of coronavirus and 600 deaths. On Friday it reported 2,059 new daily cases and ten deaths after performing 13,279 tests, according to official data. The number of new infections per day has been consistently increasing and are second only to India in the South Asia region, according to a Reuters tally. Nepal's biggest city of Kathmandu and its surrounding areas account for more than one third of all infections, and authorities said cases were on the verge of slipping out of control. “If the infections in the Kathmandu valley continue to increase at this rate hospitals will not be able to support the burden,” health ministry spokesman Jageshwar Gautam said. He said there were 181 intensive care units and 76 ventilators in Kathmandu and neighboring cities of Lalitpur and Bhaktapur with four million people. Less than half were occupied now, he said. But patients interviewed by local media said ICU beds were hard to find and some hospitals were refusing to admit the COVID-19 patients. Nepal enforced strict lockdown measures after its second positive case in March and infections were below many South Asian neighbors, with Prime Minister K.P. Sharma Oli playing down the risks. Cases increased exponentially after the government began to ease restrictive measures in June to prop up its faltering economy. Experts also say the government failed to enforce strict protocols ? wearing masks, individual distancing and sanitation ? and failed to keep those suspected of having the virus under strict supervision. “In absence of proper monitoring of home quarantines, infected people moved freely to mingle with crowds and spread the virus,” said Rabindra Pandey, a public health expert. Nepal's government says the country has the capacity to test 23,000 samples every day, but Pandey said daily average was currently around 13,000, leading to some cases not being traced and isolated. “These people in turn became the source of transmission,” Pandey said. © Copyright Thomson/West - NETSCAN's Health Policy Tracking Service [FN2] . Alexis Akwagyiram, Health tech pins hope on Africa's pandemic shift to online care, Reuters (September 7, 2020). [FN3] . Michael Erman and Carl O'Donnell, Trump proposes rule for importing drugs from Canada; industry says it won't cut costs, Reuters (Dec. 18, 2019). [FN4] . Jeff Mason, U.S. declares coronavirus a public health emergency, Reuters (Jan. 31, 2020). [FN5] . Michael Erman, FDA identified 20 drugs with shortage risks due to coronavirus outbreak, Reuters (Feb. 25, 2020). [FN6] . Trisha Roy, U.S. FDA says no medical device shortages due to virus outbreak, Reuters (Feb. 27, 2020). [FN7] . Tom Hogue, Miral Fahmy and Stefanie Eschenbacher, Coronavirus infects 29 medical workers at Mexico hospital, Reuters (April 1, 2020). © 2021 Thomson Reuters. No claim to original U.S. Government Works. -29- [FN8] . Rosalba O'Brien, Anthony Boadle and Clarence Fernandez, Brazil's indigenous people call for WHO emergency fund to fight coronavirus, Reuters (May 5, 2020). [FN9] . Raul Cortes Fernandez, Mexico has world's most health worker deaths from pandemic, Amnesty International says, Reuters (September 3, 2020). [FN10] . Deena Beasley, Amgen CEO expects 25% of growth to come from Asia in next decade, Reuters (Jan. 14, 2020). [FN11] . Roxanne Liu and Brenda Goh, Drugmakers slash prices to be eligible for China's bulk-buy program, Reuters (Jan. 18, 2020). [FN12] . David Kirton, Coronavirus outbreak may be over in China by April, says expert, Reuters (Feb. 11, 2020). [FN13] . Ankur Banerjee, Indian generic drugmakers may face supply shortages from China if coronavirus drags on, Reuters (Feb. 13, 2020). [FN14] . Sumeet Chatterjee, Cheng Leng and Zoey Zhang, China pushes for cheaper health insurance products to battle virus: sources, Reuters (Feb. 13, 2020). [FN15] . Brenda Goh and Thomas Suen, China guards against second wave of coronavirus coming from abroad, Reuters (March 28, 2020). [FN16] . Makiko Yamazaki, Tokyo coronavirus cases jump in record daily rise: NHK, Reuters (March 29, 2020). [FN17] . Tom Allard, Huge fentanyl haul seized in Asia's biggest-ever drugs bust, Reuters (May 19, 2020). [FN18] . Kaori Kaneko and Izumi Nakagawa, With apps and remote medicine, Japan offers glimpse of doctor visits in post-corona era, Reuters (July 9, 2020). [FN19] . Scott Murdoch, Alibaba Health raises $1.3 billion in HK's biggest secondary share sale in 5 years, Reuters (August 5, 2020). [FN20] . Sangmi Cha and Josh Smith, South Korea orders striking doctors back to work amid surge in coronavirus cases, Reuters (August 26, 2020). [FN21] . Kate Holton and Paul Sandle, On eve of Brexit, Britain faces critical test to defend drug trial crown, Reuters (Jan. 30, 2020). [FN22] . Gavin Jones, Reuters, Italy coronavirus deaths rise by 889 in a day to 10,023, Reuters (March 28, 2020). [FN23] . Jessica Jones, Spain toughens restrictions as coronavirus death toll surges, Reuters (March 29, 2020). [FN24] . Francesco Guarascio, EU scrambles to buy intensive care drugs to tackle COVID shortages, Reuters (July 8, 2020). [FN25] © 2021 Thomson Reuters. No claim to original U.S. Government Works. -30- . Francesco Guarascio, EU eyes COVID-19 vaccines at less than $40, shuns WHO-led alliance - sources, Reuters (July 24, 2020) at: https://www.reuters.com/article/us-health-coronavirus-eu-vaccines-exclus/exclusive-eu-eyes-covid-19-vaccines-at-less-than-40-shuns- who-led-alliance-sources. [FN26] . Stephanie Nebehay and Ryan Woo, Global downturn looms as countries struggle to contain coronavirus outbreak, Reuters (Feb. 27, 2020). [FN27] . Emma Farge, World Health Organization calls coronavirus outbreak ‘pandemic’ for first time, Reuters (March 11, 2020). [FN28] . Lockdowns and entry bans imposed around the world to fight coronavirus, Reuters (March 15, 2020). [FN29] . Liz Lee, World's largest glove maker sees shortage as coronavirus fight spikes, Reuters (March 28, 2020). [FN30] . Frances Kerry, Factbox: Latest on the spread of the coronavirus around the world, Reuters (March 28, 2020). [FN31] . Kate Kelland, Global health fund calls for $8 billion to begin COVID-19 exit strategy, Reuters (April 7, 2020) at https:// www.reuters.com/article/us-health-coronavirus-wellcome/global-health-fund-calls-for-8-billion-to-begin-covid-19-exit-strategy- idUSKBN21P1GQ. [FN32] . Paresh Dave, WHO readies coronavirus app for checking symptoms, possibly contact tracing, Reuters (May 9, 2020). [FN33] . Steve Holland and Michell Nichols, Trump cutting U.S. ties with World Health Organization over virus, Reuters (May 29, 2020) at: https://www.reuters.com/article/us-health-coronavirus-trump-who/trump-cutting-u-s-ties-with-world-health-organization-over-virus- idUSKBN2352YJ. [FN34] . Michael Shields and Emma Farge, WHO set to resume hydroxychloroquine trial in battle against COVID-19, Reuters (June 3, 2020) at: https://www.reuters.com/article/us-health-coronavirus-who/who-set-to-resume-hydroxychloroquine-trial-in-battle-against-covid-19- idUSKBN23A2LT. [FN35] . Foo Yun Chee, Global COVID-19 fundraising meeting raises $6.9 billion, leaders want vaccine for all, Reuters (June 27, 2020). [FN36] . Frances Kerry, Latest on the worldwide spread of coronavirus, Reuters (October 25, 2020). [FN37] . Francesco Guarascio, WHO-led COVID drug scheme doubles down on antibodies, steroids and shuns remdesivir, Reuters (November 5, 2020). [FN38] . Tova Cohen and Ari Rabinovitch, Israel avoids health crisis with last-minute new drug budget, Reuters (Dec. 19, 2019). [FN39] . Dan Williams and Nidal al-Mughrabi, Israel links coronavirus aid for Gaza to recovering soldiers, Reuters (April 1, 2020). [FN40] . Imad Creidi, Samia Nakhoul, Nancy Mahfouz, Laila Bassam, Mike Collett-White and Issam Abdallah, Hundreds of disillusioned doctors leave Lebanon, in blow to healthcare, Reuters (November 12, 2020). © 2021 Thomson Reuters. No claim to original U.S. Government Works. -31- [FN41] . Gopal Sharma, Nepal warns of healthcare crisis as coronavirus infections cross 100,000, Reuters (October 9, 2020). Produced by Thomson Reuters Accelus Regulatory Intelligence 14-Mar-2021 © 2021 Thomson Reuters. No claim to original U.S. Government Works. -32-