Vaccines and Global Health: The Week in Review 9 August 2014

Vaccines and Global Health: The Week in Review will resume publication on 23 August following a short annual leave for the Editor]

Vaccines and Global Health: The Week in Review is a weekly digest — summarizing news, events, announcements, peer-reviewed articles and research in the global vaccine ethics and policy space. Content is aggregated from key governmental, NGO, international organization and industry sources, key peer-reviewed journals, and other media channels. This summary proceeds from the broad base of themes and issues monitored by the Center for Vaccine Ethics & Policy in its work: it is not intended to be exhaustive in its coverage. You are viewing the blog version of our weekly digest, typically comprised of between 30 and 40 posts below all dated with the current issue date

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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa

Ebola outbreak in west Africa: Meeting of the International Health Regulations Emergency Committee
8 August 2014 — The first meeting of the Emergency Committee convened by the Director-General under the International Health Regulations (2005) regarding the 2014 Ebola Virus Disease outbreak in West Africa was held by teleconference on 6-7 August 2014. The Director-General accepted the Committee’s assessment and on 8 August 2014 declared the Ebola outbreak in West Africa a Public Health Emergency of International Concern.

WHO Statement on the Meeting of the International Health Regulations Emergency Committee Regarding the 2014 Ebola Outbreak in West Africa
WHO statement
8 August 2014
[full text]
The first meeting of the Emergency Committee convened by the Director-General under the International Health Regulations (2005) [IHR (2005)] regarding the 2014 Ebola Virus Disease (EVD, or “Ebola”) outbreak in West Africa was held by teleconference on Wednesday, 6 August 2014 from 13:00 to 17:30 and on Thursday, 7 August 2014 from 13:00 to 18:30 Geneva time (CET).

Members and advisors of the Emergency Committee met by teleconference on both days of the meeting1. The following IHR (2005) States Parties participated in the informational session of the meeting on Wednesday, 6 August 2014: Guinea, Liberia, Sierra Leone, and Nigeria.

During the informational session, the WHO Secretariat provided an update on and assessment of the Ebola outbreak in West Africa. The above-referenced States Parties presented on recent developments in their countries, including measures taken to implement rapid control strategies, and existing gaps and challenges in the outbreak response.

After discussion and deliberation on the information provided, the Committee advised that:
:: the Ebola outbreak in West Africa constitutes an ‘extraordinary event’ and a public health risk to other States;
:: the possible consequences of further international spread are particularly serious in view of the virulence of the virus, the intensive community and health facility transmission patterns, and the weak health systems in the currently affected and most at-risk countries.
:: a coordinated international response is deemed essential to stop and reverse the international spread of Ebola.

It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) have been met.

The current EVD outbreak began in Guinea in December 2013. This outbreak now involves transmission in Guinea, Liberia, Nigeria, and Sierra Leone. As of 4 August 2014, countries have reported 1 711 cases (1 070 confirmed, 436 probable, 205 suspect), including 932 deaths. This is currently the largest EVD outbreak ever recorded. In response to the outbreak, a number of unaffected countries have made a range of travel related advice or recommendations.

In light of States Parties’ presentations and subsequent Committee discussions, several challenges were noted for the affected countries:
:: their health systems are fragile with significant deficits in human, financial and material resources, resulting in compromised ability to mount an adequate Ebola outbreak control response;
:: inexperience in dealing with Ebola outbreaks; misperceptions of the disease, including how the disease is transmitted, are common and continue to be a major challenge in some communities;
:: high mobility of populations and several instances of cross-border movement of travellers with infection;
:: several generations of transmission have occurred in the three capital cities of Conakry (Guinea); Monrovia (Liberia); and Freetown (Sierra Leone); and
:: a high number of infections have been identified among health-care workers, highlighting inadequate infection control practices in many facilities.
The Committee provided the following advice to the Director-General for her consideration to address the Ebola outbreak in accordance with IHR (2005).
::
States with Ebola transmission
:: The Head of State should declare a national emergency; personally address the nation to provide information on the situation, the steps being taken to address the outbreak and the critical role of the community in ensuring its rapid control; provide immediate access to emergency financing to initiate and sustain response operations; and ensure all necessary measures are taken to mobilize and remunerate the necessary health care workforce.
:: Health Ministers and other health leaders should assume a prominent leadership role in coordinating and implementing emergency Ebola response measures, a fundamental aspect of which should be to meet regularly with affected communities and to make site visits to treatment centres.
:: States should activate their national disaster/emergency management mechanisms and establish an emergency operation centre, under the authority of the Head of State, to coordinate support across all partners, and across the information, security, finance and other relevant sectors, to ensure efficient and effective implementation and monitoring of comprehensive Ebola control measures. These measures must include infection prevention and control (IPC), community awareness, surveillance, accurate laboratory diagnostic testing, contact tracing and monitoring, case management, and communication of timely and accurate information among countries. For all infected and high risks areas, similar mechanisms should be established at the state/province and local levels to ensure close coordination across all levels.
:: States should ensure that there is a large-scale and sustained effort to fully engage the community – through local, religious and traditional leaders and healers – so communities play a central role in case identification, contact tracing and risk education; the population should be made fully aware of the benefits of early treatment.
:: It is essential that a strong supply pipeline be established to ensure that sufficient medical commodities, especially personal protective equipment (PPE), are available to those who appropriately need them, including health care workers, laboratory technicians, cleaning staff, burial personnel and others that may come in contact with infected persons or contaminated materials.
:: In areas of intense transmission (e.g. the cross border area of Sierra Leone, Guinea, Liberia), the provision of quality clinical care, and material and psychosocial support for the affected populations should be used as the primary basis for reducing the movement of people, but extraordinary supplemental measures such as quarantine should be used as considered necessary.
:: States should ensure health care workers receive: adequate security measures for their safety and protection; timely payment of salaries and, as appropriate, hazard pay; and appropriate education and training on IPC, including the proper use of PPEs.
:: States should ensure that: treatment centres and reliable diagnostic laboratories are situated as closely as possible to areas of transmission; that these facilities have adequate numbers of trained staff, and sufficient equipment and supplies relative to the caseload; that sufficient security is provided to ensure both the safety of staff and to minimize the risk of premature removal of patients from treatment centres; and that staff are regularly reminded and monitored to ensure compliance with IPC.
:: States should conduct exit screening of all persons at international airports, seaports and major land crossings, for unexplained febrile illness consistent with potential Ebola infection. The exit screening should consist of, at a minimum, a questionnaire, a temperature measurement and, if there is a fever, an assessment of the risk that the fever is caused by EVD. Any person with an illness consistent with EVD should not be allowed to travel unless the travel is part of an appropriate medical evacuation.
:: There should be no international travel of Ebola contacts or cases, unless the travel is part of an appropriate medical evacuation. To minimize the risk of international spread of EVD:
– Confirmed cases should immediately be isolated and treated in an Ebola Treatment Centre with no national or international travel until 2 Ebola-specific diagnostic tests conducted at least 48 hours apart are negative;
– Contacts (which do not include properly protected health workers and laboratory staff who have had no unprotected exposure) should be monitored daily, with restricted national travel and no international travel until 21 days after exposure;
– Probable and suspect cases should immediately be isolated and their travel should be restricted in accordance with their classification as either a confirmed case or contact.
:: States should ensure funerals and burials are conducted by well-trained personnel, with provision made for the presence of the family and cultural practices, and in accordance with national health regulations, to reduce the risk of Ebola infection. The cross-border movement of the human remains of deceased suspect, probable or confirmed EVD cases should be prohibited unless authorized in accordance with recognized international biosafety provisions.
:: States should ensure that appropriate medical care is available for the crews and staff of airlines operating in the country, and work with the airlines to facilitate and harmonize communications and management regarding symptomatic passengers under the IHR (2005), mechanisms for contact tracing if required and the use of passenger locator records where appropriate.
:: States with EVD transmission should consider postponing mass gatherings until EVD transmission is interrupted.
::
States with a potential or confirmed Ebola Case, and unaffected States with land borders with affected States
:: Unaffected States with land borders adjoining States with Ebola transmission should urgently establish surveillance for clusters of unexplained fever or deaths due to febrile illness; establish access to a qualified diagnostic laboratory for EVD; ensure that health workers are aware of and trained in appropriate IPC procedures; and establish rapid response teams with the capacity to investigate and manage EVD cases and their contacts.
:: Any State newly detecting a suspect or confirmed Ebola case or contact, or clusters of unexplained deaths due to febrile illness, should treat this as a health emergency, take immediate steps in the first 24 hours to investigate and stop a potential Ebola outbreak by instituting case management, establishing a definitive diagnosis, and undertaking contact tracing and monitoring.
:: If Ebola transmission is confirmed to be occurring in the State, the full recommendations for States with Ebola Transmission should be implemented, on either a national or subnational level, depending on the epidemiologic and risk context.
::
All States
:: There should be no general ban on international travel or trade; restrictions outlined in these recommendations regarding the travel of EVD cases and contacts should be implemented.
:: States should provide travelers to Ebola affected and at-risk areas with relevant information on risks, measures to minimize those risks, and advice for managing a potential exposure.
:: States should be prepared to detect, investigate, and manage Ebola cases; this should include assured access to a qualified diagnostic laboratory for EVD and, where appropriate, the capacity to manage travelers originating from known Ebola-infected areas who arrive at international airports or major land crossing points with unexplained febrile illness.
:: The general public should be provided with accurate and relevant information on the Ebola outbreak and measures to reduce the risk of exposure.
:: States should be prepared to facilitate the evacuation and repatriation of nationals (e.g. health workers) who have been exposed to Ebola.
The Committee emphasized the importance of continued support by WHO and other national and international partners towards the effective implementation and monitoring of these recommendations.
Based on this advice, the reports made by affected States Parties and the currently available information, the Director-General accepted the Committee’s assessment and on 8 August 2014 declared the Ebola outbreak in West Africa a Public Health Emergency of International Concern (PHEIC). The Director-General endorsed the Committee’s advice and issued them as Temporary Recommendations under IHR (2005) to reduce the international spread of Ebola, effective 8 August 2014. The Director-General thanked the Committee Members and Advisors for their advice and requested their reassessment of this situation within 3 months.

Ebola – West Africa (to 9 August 2014)

WHO to convene ethical review of experimental treatment for Ebola
WHO statement
6 August 2014
Early next week, WHO will convene a panel of medical ethicists to explore the use of experimental treatment in the ongoing Ebola outbreak in West Africa. Currently there is no registered medicine or vaccine against the virus, but there are several experimental options under development.
The recent treatment of two health workers from Samaritan’s Purse with experimental medicine has raised questions about whether medicine that has never been tested and shown to be safe in people should be used in the outbreak and, given the extremely limited amount of medicine available, if it is used, who should receive it.
“We are in an unusual situation in this outbreak. We have a disease with a high fatality rate without any proven treatment or vaccine,” says Dr Marie-Paule Kieny, Assistant Director-General at the World Health Organization. “We need to ask the medical ethicists to give us guidance on what the responsible thing to do is.”
The gold standard for assessing new medicine involves a series of trials in humans, starting small to make sure the medicine is safe to use. Then, the studies are expanded to more people to see how effective it is, and how best to use it.
The guiding principle with use of any new medicine is ‘do no harm’. Safety is always the main concern.

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 9 August 2014]
http://www.who.int/csr/don/en/
:: Ebola virus disease update – West Africa 8 August 2014

CDC/MMWR Watch [to 9 August 2014]

http://www.cdc.gov/mmwr/mmwr_wk.html

:: CDC’s surge response to West African Ebola Outbreak – Press Release
August 6, 2014
The Centers for Disease Control and Prevention (CDC) is rapidly increasing its ongoing efforts to curb the expanding West African Ebola outbreak and deploying staff to four African nations currently affected: Guinea, Sierra Leone, Liberia, and Nigeria.
MMWR Weekly – August 8, 2014 / Vol. 63 / No. 31
No new digest content identified.

Ebola: World Bank Group Mobilizes Emergency Funding to Fight Epidemic in West Africa
WASHINGTON, August 4, 2014 – With the latest death toll from the West Africa Ebola epidemic now at 887, the World Bank Group today pledged as much as US $200 million in emergency funding to help Guinea, Liberia, and Sierra Leone contain the spread of Ebola infections, help their communities cope with the economic impact of the crisis, and improve public health systems throughout West Africa

WHO statement on the second meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus

WHO statement on the second meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus
WHO statement
3 August 2014
[full text; Editor’s text bolding]

On 5 May 2014 the Director-General declared the international spread of wild poliovirus in 2014 a Public Health Emergency of International Concern (PHEIC) under the International Health Regulations [IHR 2005], issued Temporary Recommendations to reduce the international spread of wild poliovirus, and requested a reassessment of this situation by the Emergency Committee in 3 months. The 2nd meeting of the Emergency Committee was held by teleconference on Thursday 31 July 2014 from 13:00 to 17:15 Geneva time (CET) 1.

The affected States Parties that met the criteria for ‘States currently exporting wild poliovirus’ participated in the informational session of the meeting and were as follows: Cameroon, Equatorial Guinea, Pakistan and the Syrian Arab Republic.

During the informational session the WHO Secretariat updated the Committee on wild poliovirus transmission and international spread since 5 May 2014. The above affected States Parties presented information on the implementation of the Temporary Recommendations issued on 5 May 2014, including the national declaration of a public health emergency and recommendations for travellers, and recent developments in the intensification of national polio eradication strategies.

Using the criteria applied to the declaration of the PHEIC in May, the Committee considered whether the conditions for a PHEIC still apply. After discussion of the information provided, the Committee advised that the international spread of polio in 2014 continues to constitute an extraordinary event and a public health risk to other States for which a coordinated international response continues to be essential.

Since 5 May 2014, and the onset of the high transmission season for polio, there has been new international spread of wild poliovirus in central Asia (from Pakistan to Afghanistan as recently as June 2014) and a poliovirus originating in Central Africa (Equatorial Guinea) was reported from the Americas. The latter had been detected in a single sewage sample that was collected in Brazil in March 2014 at a site that covered an international airport in the state of Sao Paolo. Equatorial Guinea was consequently confirmed as a ‘State currently exporting wild poliovirus’ and informed of the need to implement the relevant Temporary Recommendations, bringing to four the total number of ‘States currently exporting wild poliovirus’. Two of the ‘States currently exporting wild poliovirus’, Pakistan and Cameroon, have had additional cases and geographic expansion of the infected area within each country since 5 May 2014. The possible consequences of international spread have worsened since the declaration of the PHEIC, as susceptible populations living in polio-free but conflict-torn States and areas have increased, with further deterioration of their routine immunization services.

The international spread of poliovirus in 2014 continues to threaten the ongoing effort to eradicate globally one of the world’s most serious vaccine preventable diseases. It was the unanimous view of the Committee that the conditions for a Public Health Emergency of International Concern (PHEIC) continue to be met.

All four ‘States currently exporting wild poliovirus’ had initiated implementation of the Temporary Recommendations issued by the Director-General on 5 May 2014, and further intensified national eradication efforts. While recognizing and appreciating these efforts, the Committee noted that the application of the Temporary Recommendations by affected States Parties remains incomplete. Additional efforts are required to declare and/or operationalize national emergency procedures, to improve vaccination coverage of international travellers and to ensure eradication strategies are fully implemented to international standards in all infected and high risk areas.

The Committee reiterated that the over-riding priority for all polio-infected States must be to interrupt wild poliovirus transmission within their borders as rapidly as possible through high quality application in all geographic areas of the polio eradication strategies. The Committee reinforced the need for a coordinated regional approach to accelerate interruption of virus transmission in each epidemiologic zone.
The Committee provided the following advice to the Director-General for her consideration to reduce the international spread of wild poliovirus.
:: States Currently Exporting Wild Poliovirus: Pakistan, Cameroon, Equatorial Guinea and the Syrian Arab Republic continue to meet the criteria for such States and pose the highest risk for further wild poliovirus exportations in 2014. The Temporary Recommendations issued by the Director-General on 5 May 2014 for such States should continue to be implemented.
:: States Infected with Wild Poliovirus but Not Currently Exporting: Afghanistan, Ethiopia, Iraq, Israel, Nigeria, and Somalia continue to meet the criteria for such States and pose an ongoing risk for new wild poliovirus exportations in 2014. The Temporary Recommendations issued by the Director-General on 5 May 2014 for such States should continue to be implemented.
The Committee reaffirmed that any polio-free State which becomes infected with wild poliovirus should immediately implement the advice for ‘States infected with wild poliovirus but not currently exporting’. In the event of new international spread from an infected State, that State should immediately implement the requirements for ‘States currently exporting wild poliovirus’. The Committee noted that although a single wild poliovirus of Equatorial Guinea origin had been detected in Brazil in March 2014, Brazil was not considered polio-infected in the context of the global eradication initiative, as there was no evidence that this poliovirus exposure had resulted in transmission2. The Committee stressed the importance of surveillance in all polio-infected and polio-free countries.
The Committee acknowledged the efforts that Affected States have made to address the Temporary Recommendations, and recognised the challenges experienced by Affected States in their implementation. However, cognizant of the grave implications of any new international spread of poliovirus for the global eradication effort, the Committee considered whether additional Temporary Recommendations were needed at this time to further mitigate this risk. The Committee decided that additional time is first required to fully gauge the impact of the existing Temporary Recommendations in reducing the international spread of wild poliovirus. The Committee recommended, however, that this situation be reviewed again after 3 months.
Noting the challenges, both material and technical, that States had reported in implementing the Temporary Recommendations, the Committee emphasized the importance of continued support by WHO and the Global Polio Eradication Initiative partners towards the effective implementation and monitoring of these recommendations.
Based on this advice and the reports made by affected States Parties, the Director-General accepted the Committee’s assessment and declared that the international spread of wild poliovirus in 2014 continued to constitute a Public Health Emergency of International Concern (PHEIC). The Director-General thanked the Committee Members and Advisors for their advice, requested their reassessment of this situation in 3 months and extended the following Temporary Recommendations under the IHR (2005), effective 3 August 2014:
::
States currently exporting wild poliovirus
These States should:
:: officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency;
:: ensure that all residents and long-term visitors (i.e. > 4 weeks) receive a dose of OPV or inactivated poliovirus vaccine (IPV) between 4 weeks and 12 months prior to international travel;
:: ensure that those undertaking urgent travel (i.e. within 4 weeks), who have not received a dose of OPV or IPV in the previous 4 weeks to 12 months, receive a dose of polio vaccine at least by the time of departure as this will still provide benefit, particularly for frequent travellers;
:: ensure that such travellers are provided with an International Certificate of Vaccination or Prophylaxis in the form specified in Annex 6 of the International Health Regulations (2005) to record their polio vaccination and serve as proof of vaccination;
:: maintain these measures until the following criteria have been met: (i) at least 6 months have passed without new exportations and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until at least 12 months have passed without new exportations.
::
States infected with wild poliovirus but not currently exporting
These States should:
:: officially declare, if not already done, at the level of head of state or government, that the interruption of poliovirus transmission is a national public health emergency;
:: encourage residents and long-term visitors to receive a dose of OPV or IPV 4 weeks to 12 months prior to international travel; those undertaking urgent travel (i.e. within 4 weeks) should be encouraged to receive a dose at least by the time of departure;
:: ensure that travellers who receive such vaccination have access to an appropriate document to record their polio vaccination status;
:: maintain these measures until the following criteria have been met: (i) at least 6 months have passed without the detection of wild poliovirus transmission in the country from any source, and (ii) there is documentation of full application of high quality eradication activities in all infected and high risk areas; in the absence of such documentation these measures should be maintained until at least 12 months without evidence of transmission.

GPEI Update: Polio this week – As of 6 August 2014

GPEI Update: Polio this week – As of 6 August 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: On 31 July, the second meeting of the International Health Regulations (IHR) Emergency Committee on polio was held by teleconference, to reassess the situation and examine the actions that countries have taken since the declaration of the ‘public health emergency of international concern’ (PHEIC) in May. The Director-General of WHO accepted the advice of the Committee and has declared that the international spread of polio in 2014 continues to constitute a PHEIC. She has extended the Temporary Recommendations, effective 3 August, and requested the Committee to reassess the situation in a further 3 months. Of note, the Committee had expressed concern that application of the existing Temporary Recommendations remains incomplete. For more, including the full report of the Committee, please click here.
:: The United Arab Emirates (UAE) have produced a short film to sensitize migrant workers to the importance of vaccinating their children against polio. The three-minute film will be shown on Etihad Airways flights from Lahore, Islamabad, Peshawar and Karachi, Pakistan, throughout August. Special public screenings in high-risk neighbourhoods will also be organized. To view the short film, please click here.
Pakistan
:: Two new WPV1 cases were reported in the past week, from Khyber Agency, Federally Administered Tribal Areas (FATA) and Peshawar, Khyber Pakhtunkhwa (KP), bringing the total number of WPV1 cases for 2014 to 104. The most recent WPV1 case in the country had onset of paralysis on 9 July, from South Waziristan, FATA
Central Africa
:: Two new WPV1 cases were reported from Cameroon (from Est province, with onset of paralysis on 1 July and 9 July). In 2014, ten cases were reported in central Africa: five in Cameroon and five in Equatorial Guinea.
:: The two cases are from a refugee camp in the east of the country, among refugees from Central African Republic (CAR). Coordination with NGOs and organizations such as UNHCR is being strengthened.
:: Given the new cases detected in Est region, Cameroon is developing a rapid response plan.
:: Efforts are also ongoing to improve immunity levels and surveillance sensitivity in neighbouring CAR. With evidence of declining surveillance and immunity levels, coupled with large-scale population movements, the risk of spread of polio into CAR is high. Coordination with NGOs and other health organizations on the ground is strong. Plans are under discussion to conduct polio campaigns. As part of this, active searches for acute flaccid paralysis (AFP) will be conducted, and communities and health centres sensitized on the need for immunization and detection of AFP cases.
:: Equatorial Guinea has conducted three national campaigns using bivalent OPV. Two more national activities are planned for all children aged less than 15 years in August (7-10 and 28-31). In addition, two more activities are planned (20-23 September for <5s, and in November – exact dates and age group to be confirmed). A house-to-house search for AFP cases will be conducted during the campaign; a similar search is currently taking place in Gabon. Countries across central Africa are conducting campaigns.

Weekly Epidemiological Record (WER) 8 August 201

The Weekly Epidemiological Record (WER) 8 August 2014, vol. 89, 32/33 (pp. 357–368)
includes:
:: Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj), 2014
:: Global Polio Eradication Initiative: 10th meeting of the Independent Monitoring Board
:: Monthly report on dracunculiasis cases, January– June 2014
http://www.who.int/entity/wer/2014/wer8932_33.pdf?ua=1

WHO: Humanitarian Health Action [to 9 August 2014]

WHO: Humanitarian Health Action [to 9 August 2014]

:: Gaza Conflict 6 August 2014
Hospitals are treating a constant influx of casualties in already overcrowded facilities and with vastly reduced supply of electricity. More than 17,000 patients utilized UNRWA’s 13 open clinics on 2-3 August, higher than the pre-war average of 14,000 patients a day. Currently more than 30% of clinic patients are displaced persons staying in shelters. The public health needs are: fuel, electricity and medical supplies; follow up care for the injured; health care for the displaced people; mental health interventions for patients, their family members and support to children; elective surgeries for patients whose surgeries were postponed.
:: Read the health situation report from the Regional Office website