Vaccines and Global Health: The Week in Review 22 July 2017

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

Milestones :: Perspectives

Milestones :: Perspectives

Editor’s Note:
We lead this “Milestones” section with the overview and commentary from most recent WHO and UNICEF immunization estimates. In the context of the aspirations of GVAP now past mid-point – and in principle – the numbers of un-vaccinated and under-vaccinated children should alarm us all.

1 in 10 infants worldwide did not receive any vaccinations in 2016
Joint news release UNICEF/WHO
GENEVA/NEW YORK, 17 JULY 2017  ─ Worldwide, 12.9 million infants, nearly 1 in 10, did not receive any vaccinations in 2016, according to the most recent WHO and UNICEF immunization estimates. This means, critically, that these infants missed the first dose of diphtheria-tetanus-pertussis (DTP)-containing vaccine, putting them at serious risk of these potentially fatal diseases.

Additionally, an estimated 6.6 million infants who did receive their first dose of DTP-containing vaccine did not complete the full, three dose DTP immunization series in 2016. Since 2010, the percentage of children who received their full course of routine immunizations has stalled at 86% (116.5 million infants), with no significant changes in any countries or regions during the past year. This falls short of the global immunization coverage target of 90%.

“Most of the children that remain un-immunized are the same ones missed by health systems,” says Dr Jean-Marie Okwo-Bele, Director of Immunization, Vaccines and Biologicals at WHO. “These children most likely have also not received any of the other basic health services. If we are to raise the bar on global immunization coverage, health services must reach the unreached. Every contact with the health system must be seen as an opportunity to immunize.”

Immunization currently prevents between 2-3 million deaths every year, from diphtheria, tetanus, whooping cough and measles. It is one of the most successful and cost-effective public health interventions.

Global immunization coverage levels
According to the new data, 130 of the 194 WHO Member States have achieved and sustained at least 90% coverage for DTP3 at the national level – one of the targets set out in the Global Vaccine Action Plan. However, an estimated 10 million additional infants need to be vaccinated in 64 countries, if all countries are to achieve at least 90% coverage. Of these children, 7.3 million live in fragile or humanitarian settings, including countries affected by conflict. 4 million of them also live in just three countries – Afghanistan, Nigeria and Pakistan – where access to routine immunization services is critical to achieving and sustaining polio eradication.

In 2016, eight countries had less than 50% coverage with DTP3 in 2016, including Central African Republic, Chad, Equatorial Guinea, Nigeria, Somalia, South Sudan, Syrian Arab Republic and Ukraine.

Globally, 85% of children have been vaccinated with the first dose of measles vaccine by their first birthday through routine health services, and 64% with a second dose. Nevertheless, coverage levels remain well short of those required to prevent outbreaks, avert preventable deaths and achieve regional measles elimination goals…

152 countries now use rubella vaccines and global coverage increased from 35% in 2010 to 47% in 2016. This is a big step towards reducing the occurrence of congenital rubella syndrome, a devastating condition that results in hearing impairment, congenital heart defects and blindness, among other life-long disabilities.

Global coverage of more recently-recommended vaccines are yet to reach 50%. These vaccines include vaccines against major killers of children such as rotavirus, a disease that causes severe childhood diarrhoea, and pneumonia. Vaccination against both these diseases has the potential to substantially reduce deaths of children under 5 years of age, a target of the Sustainable Development Goals.
Many middle-income countries are lagging behind in the introduction of these newer and more expensive vaccines. These countries often do not receive external support and their health budgets are often insufficient to cover the costs of procuring these vaccines.

Inequities in immunization coverage
National coverage estimates often mask large inequities in coverage within countries. The WHO report, State of inequality: Childhood immunization, highlights inequalities in childhood immunization coverage in low- and middle-income countries over the past 10 years. The report shows that global improvements have been realized with variable patterns of change across countries and that there is generally less inequality now than 10 years ago.

These findings were reinforced by a recent UNICEF study, which emphasized the cost effectiveness of investing in the poorest, most marginalized communities.

“Immunization is one of the most pro-equity interventions around,” says Dr Robin Nandy, Chief of Immunizations at UNICEF. “Bringing life-saving vaccines to the poorest communities, women and children must be considered a top priority in all contexts.”

Efforts to reduce inequalities related to household economic status and mother’s education are needed in many countries if immunization coverage is to be improved. Additionally, more than half of the global population resides in urban areas, including in rapidly growing slums in Africa and Asia. The urban poor is a group at high risk of being un- or under-immunized.

For the first time, WHO and UNICEF have collected disaggregated data on immunization coverage at the subnational level. Of 194 reporting countries, 125 reported on subnational coverage, covering nearly 20 000 districts and roughly two–thirds of the global infant population. These data will help shed more light on geographical disparities in access to vaccines.
Gavi [to 22 July 2017]
Vaccine progress in developing countries ‘in danger of stalling’
New figures show an increase in measles, pneumococcal and rotavirus vaccine coverage in developing countries, but basic vaccine coverage remains unchanged at 80%

Geneva, 20 July 2017 – “The extraordinary improvement in immunisation coverage made since 2000 is in danger of stalling, with conflict, human and animal migration, urbanisation and vaccine hesitancy adding new barriers to global vaccination efforts,” Dr Seth Berkley, CEO of Gavi, the Vaccine Alliance, said today.

New WHO/UNICEF figures released this week show that in 68 of the world’s poorest countries, while close to a million more children received the basic diphtheria-tetanus-pertussis vaccine in 2016 compared to 2015, the coverage rate has remained at 80% for the past three years. Millions of children remain under-vaccinated in countries torn apart by conflict, from Syria to South Sudan.

“Since 2000 an unprecedented international effort to improve immunisation in the world’s poorest countries has helped to save millions of children from killer diseases like measles, tetanus and whooping cough,” said Dr Berkley. “Thanks to vaccines more children are now living to see their fifth birthday than at any point in history.”

“However, while these figures need to verified by detailed country surveys, they appear to show that this extraordinary progress is in danger of stalling,” he said. “Growing trends like human and animal migration, urbanisation and vaccine hesitancy, as well as conflict, are combining to make the challenge of reaching every child even tougher. The fact that Nigeria has overtaken India as the country with the greatest number of under-vaccinated children, despite having less than a seventh of the population, is particularly concerning. We now need to work twice as hard to meet these challenges and ensure no child goes without lifesaving vaccines.”

“There are positives we can take from this data,” said Dr Berkley. “Newer vaccines protecting against the leading causes of pneumonia and diarrhoea are reaching millions more children across Africa. Liberia’s health system is recovering after the damage wrought by Ebola and India’s commitment to routine immunisation is also continuing to pay dividends.”

In the 68 countries supported by Gavi an additional 5.4 million infants received their second dose of measles vaccine in 2016, 4.8 million more children were vaccinated against the leading cause of pneumonia and 2.3 million more were vaccinated against rotavirus, the leading cause of severe diarrhoea.

The WHO and UNICEF Estimates of National Immunisation Coverage 2016 (WUENIC 2016) figures show that:
:: 19.5 million infants globally did not receive all three doses of diphtheria-tetanus-pertussis (DTP3) vaccine.
:: DTP3 coverage in Liberia increased to 79% from just 52% in 2015, while coverage in India edged up to 88% from 58% in 2000.
:: Nigeria has overtaken India as the country with the greatest number of under-vaccinated children, with 3.4 million children missing out on DTP3 compared to 2.9 million in India.
:: In 2016 coverage of Haemophilus influenzae type b (Hib), pneumococcal and measles vaccines for the 68 countries in which Gavi works increased markedly. Coverage of children receiving three doses of Hib rose from 67% to 78%, pneumococcal from 35% to 41%, and the second dose of measles vaccine from 43% to 50%.
:: One-quarter of infants in Gavi-supported countries are now protected against rotavirus, one of the leading causes of diarrhoea, with supported vaccines.
:: The difference in DTP3 coverage between Gavi-supported and high-income countries is now half of what it was in 2000 (2000: 33%, 2016: 16%)…
IMPUNITY MUST END: Attacks on Health in 23 Countries in Conflict in 2016
July 2017 :: 84 pages
This report should once again serve as an alarm about the scale and scope of attacks on health
care. In many cases, these violations amount to war crimes and crimes against humanity, and
collectively they threaten the health, well-being, and the lives of people who may number in the
millions. In 2016, these attacks continue to occur with impunity.

Excerpt from Introduction
This is the fourth annual report by the Safeguarding Health in Conflict Coalition documenting attacks on, interference with, and obstruction of health workers, patients, facilities, and transports during periods of armed conflict and political violence across the world. The Safeguarding Health in Conflict Coalition is a group of more than 30 civil society, health provider, and human rights organizations working to protect health workers and services  threatened by war or civil unrest. We have raised awareness of global attacks on health and pressed United Nations agencies for greater global action to protect the security of healthcare. We monitor attacks, strengthen universal norms of respect for the right to health, and demand accountability for perpetrators.
In this report, we review events in 23 countries affected by conflict or political volatility in 2016, compared to 19 countries in 2015. The countries we are reporting for the first time are Armenia, Egypt, Ethiopia, Jammu and Kashmir (India), Mozambique, and Niger. Two countries that were included in our 2015 report—Colombia and Thailand—are not included in this report because either there were no reported attacks or sound data were not available.

Excerpt from Executive Summary [p.10]
Community health workers often work tirelessly to deliver medications and vaccinations to ensure equitable access to health care and to protect groups from communicable diseases, especially polio. Their provision of services in communities often places them at high risk and they have been subject to targeted killings and abductions in Afghanistan, Nigeria, and Nigeria.  In recent years, under pressure to eradicate polio, Pakistan has increased police protection for vaccinators. The increased security has saved the lives of many vaccinators and has enabled children to receive the vaccinations they need, but it has also resulted in the targeting and killing of police and armed forces charged with providing security for vaccinators.

In Afghanistan, in 13 recorded attacks, 16 vaccinators were abducted and ten killed. Some armed opposition groups have reached agreements with the government to allow vaccination efforts to continue. However, other groups have demanded a halt to vaccination campaigns, abducted and killed vaccinators, and destroyed stores of vaccines.

In Pakistan, attacks on polio workers and police took place in January, March, April, May, September, and October. In the January attack, 15 people were killed at a vaccination center; in April, seven police providing security for vaccinators were killed. Physicians supervising the vaccine campaigns and police protecting community health workers were shot and killed.

In Nigeria, four polio workers were kidnapped and held for ransom, jeopardizing the progress made towards polio eradication. This type of intimidation represents one of the factors that contributed to an outbreak of the disease in the country for the first time in more than two years.


Public Health Emergency of International Concern (PHEIC)

Polio this week as of 19 July 2017 [GPEI]
:: The Polio Research Committee (PRC) issued a call for research proposals, to support the implementation of the Polio Eradication & Endgame Strategic Plan, with particular focus on:  vaccine schedule immunogenicity; surveillance; product development on innovative IPV formulations or administration techniques; epidemiology/virology; monitoring and evaluation; and, basic immunology.  The deadline for submission of proposals is 6 October 2017.  Submission guidelines and procedures are available here.

:: Animations from WHO on the Polio Surveillance System, Reaching Every last Child and Responding to a Polio Outbreak have won the Innovation (Screen) category of the EVCOM Clarion Awards, for offering a fresh and unique way of engaging audiences in projects concerning the environment, health, education, social welfare and sustainability.

:: Summary of newly-reported viruses this week:  Afghanistan – one new wild poliovirus type 1 (WPV1) isolated from an acute flaccid paralysis (AFP) case and one new WPV1-positive environmental sample; Syria – four new circulating vaccine-derived poliovirus type 2 (cVDPV2) isolated from AFP cases.

Ambassador Yousef Al Otaiba Joins Global Leaders in Pledging Additional Support for Fight to Eradicate Polio
— Embassy of the United Arab Emirates says since 2013, UAE Committed $150 Million to Deliver Vaccines in Afghanistan, Pakistan and Syria —
WASHINGTON, July 18, 2017 /PRNewswire-USNewswire/ — United Arab Emirates (UAE) Ambassador to the US Yousef Al Otaiba joined Gates Foundation Co-Chairman Bill Gates and other members of the Global Polio Eradication Initiative in Atlanta, Georgia to announce a $30 million gift from the Government of the UAE that will help drop the level of global polio infections down to zero. The gift was announced at the Rotary International Convention, along with representatives from other donor nations, such as Canada, Germany, Japan, and the European Commission…


WHO Grade 3 Emergencies  [to 22 July 2017]
:: Yemen cholera situation report no. 4   19 JULY 2017
:: National Emergency Operations Centres (EOCs) in Aden and Sana’a have now been redesigned and strengthened to harness the full capacity of United Nations agencies and partners to support the cholera response.
:: The national Case Fatality Ratio (CFR) has been reduced to 0.5%, with 99.5% of people with suspected cholera surviving.
:: Surveillance confirms a decline in suspected cases over the past two weeks in some of the most affected governorates (e.g. Amanat al-Asimah, Amran and Sana’a). This data should be interpreted with caution, however, given a backlog in the analysis of suspected cases. Even if the outbreak is beginning to slow in some areas, thousands are falling sick every day. Sustained efforts are required to stop the spread of this disease.
:: The World Health Organization (WHO) has successfully established 47 diarrhoea treatment centres of the 50 centres in the original plan.
  :: A cholera vaccination campaign originally planned for July 2017 has been postponed at the request of the health authorities, in favour of a much larger preventive campaign next year targeting millions of Yemenis at risk of the disease.
:: WHO and UNICEF are supporting a door to door awareness campaign at the end of July to help people understand how they can keep their families safe from cholera.

South Sudan
:: WHO scales up cholera response with 500 000 doses of oral cholera vaccine for vaccination campaign in South Sudan
Juba, South Sudan, 19 July 2017: The World Health Organization (WHO) received 500 000 doses of oral cholera vaccine (OCV) on 17 July 2017. WHO is working with the Republic of South Sudan’s Ministry of Health and partners to scale up cholera vaccination campaign from 28 July to 3 August 2017.

Cumulatively, a total of 17 785 cholera cases including 320 (CFR 1.8%) deaths have been reported from 24 counties in South Sudan since the outbreak in June 2106.

“Cholera is endemic in South Sudan and historically, outbreaks have occurred along major commercial routes and rivers in the dry season as well as during the rainy season,” said Dr Joseph Wamala, WHO Epidemiologist. “South Sudan has suffered from several major cholera outbreaks in the last four years. Following other successful oral cholera vaccine campaigns, WHO and partners can make a real difference in controlling the outbreak in Tonj and Kapoeta states and in other parts of the country.”

The use of the OCV is one of the strategies available to prevent and combat outbreaks. At the same time, South Sudan is implementing the integrated approach for cholera control. The strategy harnesses strategies for improving access to patient care, surveillance, social mobilisation, water, sanitation and hygiene, and use of oral cholera vaccines.

South Sudan recently requested OCV to complement the current response in areas with active cholera transmission. The country has developed extensive experience in deploying OCV to prevent cholera in endemic areas and to interrupt transmission for ongoing outbreaks. As a result of these integrated and comprehensive strategies, especially with deployment of OCV, cholera transmission in Bor, Mingkaman, Duk, Ayod, Bentiu, Leer, Aburoc, Malakal Town, and several other areas has been controlled.

A planned OCV campaign is scheduled to take place 28 July to 3 August, 2017 in four selected counties with high active transmission. These include Tonj East, Kapoeta South, Kapoeta North and Kapoeta East counties. In Tonj East, the surrounding payams will be targeted to limit further spread of the outbreak. WHO jointly with the Health Cluster, UNICEF and MSF-CH facilitated a training of over 26 supervisors drawn from the Ministry of Health and partners to oversee the OCV campaign in the above mentioned counties. County level cascade trainings are slated for 25-26 July 2017.

With some 6 million people in South Sudan facing starvation, WHO and partners have been responding across the country, particularly in places facing famine, food insecurity and disease outbreaks.

Furthermore, food insecurity is putting people at increased risk of starvation and malnutrition, which will further contribute to the risk of spread of the cholera outbreak in South Sudan. Drought has also led to the drying of water points in some regions leading to the population using contaminated water from the remaining few unprotected points leading to repeated outbreaks of water-borne diseases including cholera.

Many countries and partners have introduced OCVs as part of their cholera control programs in endemic and epidemic settings. Currently, the International Coordinating Group manages the global stockpile for emergency use of OCV.

Iraq  – No new announcements identified.
NigeriaNo new announcements identified.
The Syrian Arab Republic – No new announcements identified.
WHO Grade 2 Emergencies  [to 22 July 2017]
:: WHO and Health Cluster partners support rapid health assessments and response in flood-affected areas, Rakhine State
Since the beginning of July 2016 heavy monsoonal rains have hit several areas of Myanmar, resulting in floods in five townships of Rakhine State and putting other States and Regions of the country (Sagaing and Magway regions, Chin state) on high alert for flooding risk. Around 27,000 people have been affected by flooding according to Government and UN estimates, and many remain displaced due to high water levels in their townships…

Cameroon  No new announcements identified
Central African Republic  – No new announcements identified.
Democratic Republic of the CongoNo new announcements identified
EthiopiaNo new announcements identified.
LibyaNo new announcements identified.
Niger  – No new announcements identified.
Ukraine  – No new announcements identified
UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: 21 Jul 2017 Syria: EWARS Weekly Bulletin, Week No. 23 (4 Jun– 10 Jun 2017)
(4) AFP cases were reported during this week, (3) cases from Al-Mayadin in Deir-ez-Zor, (1) case from Rural Damascus. v A notable decrease in SM cases reported for three consecutive weeks.
(58) Suspected Measles cases were reported during this week: from Ar-Raqqa (17), Damascus (17), Deirez-Zor (14), and Dar’a (6)
:: 15 Jul 2017 Millions of Syrians benefit from cross-border operations
Three years after the adoption of a Security Council resolution on relief delivery across border lines in Syria, cross-border operations continue to play a pivotal role in the delivery of life-saving assistance to millions of Syrians.

:: Yemen Humanitarian Bulletin Issue 25 | 16 July 2017
:: 332,658 suspected cholera cases and over 1,759 cholera deaths reported between 27 April and 13 July.
:: Two million people more need assistance, bringing the number of people in need to 20.7 million from 18.8 million in January.
:: From January to April 2017, 4.3 million people were assisted across Yemen out of the total target population of 11.9 million.
:: 22 civilians were killed or injured in an air attack on a market in Sa’ada near the border with Saudi Arabia.
Worst cholera outbreak in the world
More than 330,000 suspected cases with 1,759 associated deaths reported in less than three months
The cholera epidemic sweeping across Yemen is currently the worst such outbreak in the world. At the end of June, suspected cases exceeded 200,000 people, increasing at an average of 5,000 every day, with one person dying nearly every hour. Children and the elderly are the most affected; children under the age of 15 account for 40 per cent of suspected cases and a quarter of the deaths while those aged over 60 represent 30 per cent of fatalities. The governorates most affected by cholera are Amanat Al Asimah, Al Hudaydah, Hajjah and Amran. The situation is particularly worrying in ‘’hot spots’ like Ibb, Raymah, Dhamar, Hajjah and Al Mahwit, where case fatality ratios, a reference to the proportion of deaths within a designated population, have exceeded the one per cent emergency threshold established by the World Health Organisation (WHO).

Cholera is endemic to Yemen, but the current outbreak is the direct consequence of more than two years of heavy conflict that has moved an already weak and impoverished country towards social, economic and institutional collapse. The war has decimated Yemen’s health system, damaged key infrastructure and cut off 15.7 million people from access to adequate clean water and sanitation. In the last 10 months, about 30,000 health and sanitation workers have not received their salaries; only a third of critical medical supplies have entered the country compared to the period before March 2015; and garbage has piled up in the cities. Indeed, the current numbers of cholera cases are likely to be an underrepresentation of the magnitude of the epidemic since only 45 per cent of health facilities are effectively functioning and surveillance systems are weak.
Data collection and verification is a major challenge throughout the country. Between 27 April and 13 July 2017, a total of 332, 658 suspected cholera cases and 1,759 deaths were reported in all governorates except the island of Socotra.

Response ramped up but the magnitude of the outbreak is outstripping capacity to respond
Humanitarian partners have ramped up efforts to contain the outbreak. However, the magnitude of the outbreak is beyond the capacity, presence and reach of humanitarian organisations who have had to reprogramme meagre resources available to tackle widespread food insecurity for the cholera response. Displacement and high levels of food insecurity compound the cholera crisis.

The current cholera outbreak has overwhelmed what remains of Yemen’s conflictbattered health system. Hospitals and treatment centres are struggling to cope with large numbers of patients and medicines and intravenous fluids are quickly running out. Various partners are racing to stop the acceleration of the cholera outbreak, working around the clock to detect and track the spread of disease and to reach people with clean water, adequate sanitation and medical treatment. Rapid response teams are going house-to-house to reach families with information about how to protect themselves by cleaning and storing drinking water. Medical supplies such intravenous fluids, and Oral Rehydration Salts and water chlorination tablets have been shipped in and plans are underway for a nationwide anti-cholera campaign from 15 July in priority districts. Despite these efforts, the response continues to lag behind. Some 5,006 Cholera Treatment Centre beds are needed but only 2,351 are currently available, along with 2,003 Oral Rehydration Points, of which only 624 are currently available. On 4 July, WHO reported that out of 309 districts with reported cholera cases, cholera partners are only present in 121 districts.

Even then, the risk of the epidemic affecting thousands more people is real as the health, water, sanitation and hygiene systems are unable to cope and humanitarian funding remains low. As of 16 July, the 2017 Yemen Humanitarian Response Fund is 40 per cent funded. Additionally, humanitarian organizations continue to face restrictions on movements of supplies and people to and from Yemen. Al Hudaydah port, which is the main entry point for humanitarian supplies, is operating at limited capacity due to damage sustained from attacks. In Sana’a, the main airport is closed to commercial traffic, thus preventing people seeking medical assistance not available in Yemen to travel abroad for treatment.

UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
:: Ethiopia Weekly Humanitarian Bulletin, 17 July 2017

:: Note d’informations humanitaires, 19 juillet 2017 : Mission du chef des affaires humanitaires des Nations Unies en République Démocratique du Congo
:: Horn of Africa: Humanitarian Impacts of Drought – Issue 8 (18 July 2017)

Dashboard: International Coordinating Group (ICG) on Vaccine Provision on cholera  [accessed 22 July 2017]
Country: Yemen
ICG request receive date: 14 Jun 2017
Status: Partially-approved
Context: Outbreak response
Doses shipped: 500,000
Confirmed delivery dates: Vaccine scheduled to arrive in Saana on 6 July before the request was cancelled by requestor
Vaccination implementation: Vaccine redirected to another country

The Lancet Infectious Diseases
Published: 17 July 2017
Oral cholera vaccines: exploring the farrago of evidence
The development of a cheap and effective oral cholera vaccine (OCV) is a remarkable achievement in the field of cholera prevention. A meta-analysis on the efficacy and effectiveness of OCVs by Qifang Bi and colleagues1 updates the estimates of the 2011 Cochrane review.2 Their analysis includes additional studies published since 2011, yet provides estimates that are almost the same.

The debate about the low efficacy of OCVs in children aged younger than 5 years has continued to dominate the policy discourse in endemic countries such as India, where children are the main target of immunisation programmes. Older estimates identified children younger than 5 years to be at a disproportionately higher risk of cholera than other age groups;3 however, updated estimates have shown that making robust assertions in the absence of accurate age-specific morbidity and mortality data is difficult.4 This uncertainty has further contributed to a policy-level hesitancy in adopting OCVs for widespread use in endemic countries. Crucially, more accurate estimates of cholera burden should be established to enable programmatic implementation of OCVs, and the reasons for poor immune responses to OCVs in children need to be understood. Furthermore, we propose that the extent of herd protection offered by OCVs should be established, especially in children, if a targeted vaccination policy covering all age groups is endorsed for highly endemic hotspots.5

Water, sanitation, and hygiene (WaSH) interventions are considered to be the best method of cholera control, but gaps have been shown in the knowledge about which interventions work best.6 In our experience, in-house contamination of water remains a major problem, which sometimes persists despite efficient programmatic implementation of WaSH strategies.7 Trials in India have shown similar problems, and a rural sanitation programme failed to show evidence of prevention of diarrhoea and soil-transmitted helminth infections or reduction in faecal contamination of water sources.8, 9, 10

Modelling studies have suggested that in areas with poor sanitation, isolated efforts for water quality improvement are likely to be met with low success.11 Further, considering the high endemicity of cholera in low-income and middle-income countries (LMICs), single-pathway interventions are likely to be inadequate in the control of diarrhoeal diseases, and cholera in particular because of environmental persistence of vibrios, which might not be eradicated even with stringent implementation of such interventions.11 Besides, deploying adequate WaSH interventions takes time because it involves significant investment in infrastructural improvements and behavioural changes. Keeping these issues in mind, cheap and effective OCVs emerge as a viable option to keep cholera at bay, reducing morbidity and mortality, while the definitive WaSH interventions are identified and rolled out. The successful expansion of the Swachh Bharat (Clean India) mission in India provides a governance-driven model of sanitation and hygiene promotion that can be replicated in other LMICs; however, its effectiveness in reducing numbers of cases and deaths from cholera or diarrhoeal diseases needs to be systematically studied.

Although cholera outbreaks in areas of political and civil unrest are a major concern, strategies to mitigate the risks have been poorly studied. Mortality and morbidity from cholera in complex emergencies remains high. A systematic review showed that the evidence on the effectiveness of WaSH interventions in times of humanitarian crises is scarce and of poor quality.12 Only point-of-use interventions and safe water storage were effective measures in reducing diarrhoea incidence.12 By contrast, a single-dose regimen was an effective strategy to combat a cholera outbreak in South Sudan and an endemic focus in Bangladesh.13, 14

The creation of an OCV stockpile, and the commitment of Gavi, the Vaccine Alliance, to support vaccination of emergency and endemic areas of cholera activity, provides a cost-effective method by which countries can access vaccines as they work towards universal deployment of adequate WaSH facilities. In our opinion, a balanced public health policy needs to be in place, in which OCVs are used as a synergistic tool for cholera control, while the most efficient, cost-effective, and locally feasible, acceptable, and relevant WaSH interventions are identified and deployed. Given that even in endemic countries, cholera is a public health menace only in specific regions, with multiple local factors contributing to disease epidemiology, health policies need to be customised to fit the local contexts, eschewing one-size-fits all approaches

WHO & Regional Offices [to 22 July 2017]

WHO & Regional Offices [to 22 July 2017]

Discovering who misses out on health: the example of Indonesia
21 July 2017 – While many countries have improved the overall health of their populations, national averages don’t tell the whole story: groups of people can miss out on health services for a variety of reasons. WHO has developed a set of resources to monitor health inequalities – one of which, the Health Equity Assessment Toolkit (HEAT), was recently tested in Indonesia, allowing the country to analyse and interpret inequalities in health.

WHO urges action against HIV drug resistance threat
News release
20 July 2017 | GENEVA – WHO alerts countries to the increasing trend of resistance to HIV drugs detailed in a report based on national surveys conducted in several countries. The Organization warns that this growing threat could undermine global progress in treating and preventing HIV infection if early and effective action is not taken.
The WHO HIV drug resistance report 2017 shows that in 6 of the 11 countries surveyed in Africa, Asia and Latin America, over 10% of people starting antiretroviral therapy had a strain of HIV that was resistant to some of the most widely used HIV medicines. Once the threshold of 10% has been reached, WHO recommends those countries urgently review their HIV treatment programmes.
:: HIV drug resistance report 2017
“Antimicrobial drug resistance is a growing challenge to global health and sustainable development,” said Dr Tedros Adhanom Ghebreyesus, WHO Director-General. “We need to proactively address the rising levels of resistance to HIV drugs if we are to achieve the global target of ending AIDS by 2030.”…

Training on refugee and migrant health for policy-makers and aid workers
July 2017 – Over 1.3 million refugees and migrants have arrived to Europe since 2015. To help aid workers and policy-makers better manage the health aspects of this mass influx of people WHO has launched the first Summer School on Refugee and Migrant Health.

New International Food Safety Standards protecting consumer health and ensuring fair practices in trade
July 2017 – Members of the international food standards-setting body, the Codex Alimentarius Commission, are considering today the adoption of international standards and code of practices.


Weekly Epidemiological Record, 21 July 2017, vol. 92, 29/30 (pp. 405–416)

:: Progress towards measles elimination in Bangladesh, 2000–2016 :: Performance of acute flaccid paralysis (AFP) surveillance and incidence of poliomyelitis, 2017

Disease outbreak news
:: Cholera – Kenya  21 July 2017
:: Dengue fever – Sri Lanka  19 July 2017
:: Human infection with avian influenza A(H7N9) virus – China  19 July 2017

WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: The HIV Self-Testing Africa (STAR) project in Zambia shows potential for increasing uptake and coverage of HIV testing  21 July 2017 [Lusaka]
:: WHO establishes an Emergency Hub in Nairobi  21 July 2017
:: Progress towards Malaria Elimination in The Gambia  21 July 2017
:: WHO’s support to the response of the acute watery diarrhoea outbreak in Ethiopia’s Somali Region  20 July 2017
:: Gambia launches National Tobacco Control Act 2016 whilst WHO honours national tobacco control champions for 2017  20 July 2017
:: WHO scales up cholera response with 500 000 doses of oral cholera vaccine for vaccination campaign in South Sudan  19 July 2017

WHO European Region EURO
:: European Union presidency discussions consider policy options for alcohol labelling 21-07-2017
:: Summer School sets course for intercountry collaboration and capacity-building on refugee and migrant health 19-07-2017
:: Rescue in the Mediterranean: learning from the Italian experience 18-07-2017
:: WHO to improve health care in northern Syria with integrated network 18-07-2017

CDC/ACIP [to 22 July 2017]

CDC/ACIP [to 22 July 2017]
Press Release

Wednesday, July 19, 2017
CDC reminds travelers to Europe: Protect against measles
With the peak summer travel season under way, the Centers for Disease Control and Prevention (CDC) is reminding travelers …
Press Release
Tuesday, July 18, 2017
New CDC report: More than 100 million Americans have diabetes or prediabetes
Press Release
Monday, July 17, 2017
CDC awards $12 million to help states fight opioid overdose epidemic

MMWR News Synopsis for July 20, 2017
Progress Toward Measles Elimination — Bangladesh, 2000–2016
To achieve and maintain measles elimination, additional measures are needed to strengthen routine immunization services in order to increase two-dose measles vaccine coverage to ≥95% in all districts. There is also a need to enhance the sensitivity of measles case-based surveillance by adopting a more sensitive case definition, expanding case-based surveillance sites nationwide, and enhancing capacity for epidemiological investigation and outbreak preparedness and response to rapidly identify and contain outbreaks. In 2014 Bangladesh adopted a goal for national measles elimination by 2018. This report summarizes progress toward measles elimination in Bangladesh during 2000–2016. During 2000–2016, estimated coverage with the first dose of measles-containing vaccine (MCV1) increased from 74 percent to 94 percent. Supplementary immunization activities vaccinated approximately 36 million children in 2005-06, 18.1 million children in 2010, and 53.6 million children in 2014. Reported suspected measles incidence declined by 82 percent during 2000–2016, from 34.2 to 6.1 cases per million population.
Notes from the Field:
Cluster of Acute Flaccid Myelitis in Pediatric Patients — Maricopa County, Arizona, October 2016
Hospital Contact Investigation for a Patient Who Developed a Zoster Vaccine–Related Rash — Maryland, February 2015



PATH [to 22 July 2017]
Announcement | July 21, 2017
Zambia and the BID Initiative celebrate commitment to close the immunization gap with better data
Today the BID Initiative is celebrating its partnership with the Ministry of Health (MOH) in Zambia to create a culture of data use in a showcase event. It will also mark the launch of Zambia’s electronic immunization registry (ZEIR). The celebration, which will include Zambia’s First Lady Esther Lungu, among other special guests, symbolizes both parties’ commitments to closing the immunization gap with timely, high-quality data.
Immunization is one of the best investments to improving health around the globe. Yet inaccurate or incomplete data about vaccine coverage rates, difficulties tracking patients who have missed a recent vaccine, labor-intensive reporting protocols, and poor visibility into vaccine stocks all make it difficult for health workers and health systems, particularly in low-resource settings, to protect their target population against life-threatening childhood diseases.
The BID Initiative, led by PATH, helps ensure that accurate data are both available and utilized, allowing health workers to make better decisions on how best to deliver care. Designed and implemented in partnership with the governments of Tanzania and Zambia, the BID Initiative enhances immunization and overall health service delivery by improving data collection, quality, and use. It holistically addresses immunization data challenges and strengthens evidence-based decisions through a package of interventions that build a culture of data use, including electronic immunization registries (EIR), barcodes or QR codes on child health cards, stock management tools, and peer support networks, among other data use tools. With better data, facilities can avoid stock-outs, identify defaulting patients, and better measure their performance against neighboring facilities…

Announcement | July 19, 2017
PATH welcomes $8.2 million grant from the Conrad N. Hilton Foundation to improve early childhood development in Mozambique, Kenya, and Zambia
PATH welcomes a four-year, $8.2 million grant from the Conrad N. Hilton Foundation to help thousands more children in Kenya, Mozambique, and Zambia develop to their full physical, cognitive, and social potential.
Children whose caregivers play and talk with them and are responsive to their needs show better education, health, social, and economic outcomes as adults. Yet globally, these activities, formally referred to as “nurturing care,” are often absent from children’s lives, especially during the critical window from birth until age three, when these activities have the greatest impact.
The investment builds on other PATH early childhood development (ECD) programs in sub-Saharan Africa, including the Hilton Foundation–supported Scaling Up Early Child Development project in Kenya and Mozambique, the Window of Opportunity project in South Africa and Mozambique (supported by BHP Billiton Sustainable Communities), and a US Agency for International Development-funded Public Private Partnership project in Mozambique.
PATH’s innovative approach integrates ECD services into the work of existing government health facilities and community-level health providers at a very low cost. The approach is particularly effective at reaching children younger than age three, who can benefit the most from ECD but are often missed by programs designed to reach children in school…

European Vaccine Initiative [to 22 July 2017]
20 July 2017
Role of vaccines in combatting anti-microbial resistance
19 July 2017
Current efforts in the development of effective Zika vaccines presented at the Zika Virus and other Mosquito-borne Viruses conference
FDA [to 22 July 2017]
July 18, 2017 –
FDA approves Vosevi for Hepatitis C
The U.S. Food and Drug Administration today approved Vosevi to treat adults with chronic hepatitis C virus (HCV) genotypes 1-6 without cirrhosis (liver disease) or with mild cirrhosis. Vosevi is a fixed-dose, combination tablet containing two previously approved drugs – sofosbuvir and velpatasvir – and a new drug, voxilaprevir. Vosevi is the first treatment approved for patients who have been previously treated with the direct-acting antiviral drug sofosbuvir or other drugs for HCV that inhibit a protein called NS5A.
“Direct-acting antiviral drugs prevent the virus from multiplying and often cure HCV. Vosevi provides a treatment option for some patients who were not successfully treated with other HCV drugs in the past,” said Edward Cox, M.D., director of the Office of Antimicrobial Products in the FDA’s Center for Drug Evaluation and Research…

What’s New for Biologics
Influenza Virus Vaccine for the 2017-2018 Season Updated: 7/20/2017
Recall of MENVEO [Meningococcal (Groups A, C, Y and W-135) Oligosaccharide Diphtheria CRM197 Conjugate Vaccine] Solution for intramuscular injection Posted: 7/18/2017
July 14, 2017 Approval Letter – Afluria and Afluria Quadrivalent (PDF – 32KB) Posted: 7/17/2017

European Medicines Agency [to 22 July 2017]
Meeting highlights from the Committee for Medicinal Products for Human Use (CHMP) 17-20 July 2017
Eleven medicines recommended for approval, including five orphans

EDCTP    [to 22 July 2017]
The European & Developing Countries Clinical Trials Partnership (EDCTP) aims to accelerate the development of new or improved drugs, vaccines, microbicides and diagnostics against HIV/AIDS, tuberculosis and malaria as well as other poverty-related and neglected infectious diseases in sub-Saharan Africa, with a focus on phase II and III clinical trials
21 July 2017
EC Call for Tender: burden of diseases preventable by maternal immunisation in sub-Saharan Africa
The European Commission Directorate-General for Research and Innovation issued a call for tender on 14 July 2017 on the topic…
Wellcome Trust [to 22 July 2017]
News / Published: 19 July 2017
Fiona Powrie joins our Board of Governors
Fiona Powrie, Director of the Kennedy Institute of Rheumatology at the University of Oxford, is joining Wellcome as a new Governor.
Industry Watch
:: Jul 17, 2017 Sanofi Pasteur Ships First of its U.S. Influenza Vaccine Doses for 2017-2018 Season
:: Jul 14, 2017, 16:56 ETGSK ships 2017-18 seasonal influenza vaccines for US market

PhRMA   [to 22 July 2017]
July 18, 2017
New Report Shows 74 Percent of Medicines in Development have Potential to be First-in-Class Treatments
Seventy-four percent of medicines in clinical development around the world are potentially first-in-class medicines, meaning they use a completely new approach to fighting a disease, according to a new report:
The Biopharmaceutical Pipeline: Innovative Therapies in Clinical Development
The biopharmaceutical pipeline contains thousands of significant and innovative new treatments with the potential to address unmet medical needs, save lives and improve patients’ health. A new report by the Analysis Group, “The Biopharmaceutical Pipeline: Innovative Therapies in Clinical Development,” examines the state of the drug development pipeline and provides insights into new approaches researchers are pursuing.
Key findings:
:: 74 percent of medicines in clinical development are potentially first-in-class medicines, meaning they represent a possible new pharmacological class for treating a medical condition.
:: 822 projects – defined as unique molecule-indication combinations – are designated by the U.S. Food and Drug Administration (FDA) as orphan drugs, which is critically important given only 5 percent of rare diseases have an approved medicine.
:: A range of novel scientific approaches are being pursued, including cell and gene therapies, DNA and RNA therapeutics and conjugated monoclonal antibodies.

Reports/Research/Analysis/Commentary/Conferences/Meetings/Book Watch/Tenders

Reports/Research/Analysis/Commentary/Conferences/Meetings/Book Watch/Tenders

Vaccines and Global Health: The Week in Review has expanded its coverage of new reports, books, research and analysis published independent of the journal channel covered in Journal Watch below. Our interests span immunization and vaccines, as well as global public health, health governance, and associated themes. If you would like to suggest content to be included in this service, please contact David Curry at:

Ending AIDS: progress towards the 90–90–90 targets – Global AIDS Update 2017
Joint United Nations Programme on HIV/AIDS (UNAIDS)
July 2017 :: 198 pages

Ending AIDS: progress towards the 90–90–90 targets, gives a detailed analysis of progress and challenges towards achieving the 90–90–90 targets. The report shows that for the first time the scales have tipped: more than half of all people living with HIV (53%) now have access to HIV treatment and AIDS-related deaths have almost halved since 2005. In 2016, 19.5 million of the 36.7 million people living with HIV had access to treatment, and AIDS-related deaths have fallen from 1.9 million in 2005 to 1 million in 2016. Provided that scale-up continues, this progress puts the world on track to reach the global target of 30 million people on treatment by 2020.

When I launched the 90–90–90 targets three years ago, many people thought they were
impossible to reach. Today, the story is very different. Families, communities, cities and
countries have witnessed a transformation, with access to HIV treatment accelerating in
the past three years. A record 19.5 million people are accessing antiretroviral therapy,
and for the first time more than half of all people living with HIV are on treatment. More
countries are paying for HIV treatment themselves. More people living with HIV are
employed, more girls are in school, there are fewer orphans, there is less ill health and less
poverty. Families and communities are feeling more secure.

With science showing that starting treatment as early as possible has the dual benefit of
keeping people living with HIV healthy and preventing HIV transmission, many countries
have now adopted the gold-standard policy of treat all. Our efforts are bringing a strong
return on investment. AIDS-related deaths have been cut by nearly half from the 2005
peak. We are seeing a downward trend in new HIV infections, especially in eastern and
southern Africa, where new HIV infections have declined by a third in just six years. This
good news is a result of the combined effect of a rapid scale-up of treatment and existing
HIV prevention interventions. Moving forward, every additional dollar invested in AIDS will
deliver a US$ 8 return.

But our quest to end AIDS has only just begun. We live in fragile times, where gains can
be easily reversed. The biggest challenge to moving forward is complacency.

Global solidarity and shared responsibility has driven the success we have achieved so
far. This must be sustained. But for several years now, resources for AIDS have remained
stagnant, and we are not on track to reach the US$ 26 billion of investment we need by
Without more domestic investments and international assistance, we cannot push

faster on the Fast-Track. More people will become infected with HIV and lives will be lost.
Without more community health workers, health systems will remain stretched. Without
changing laws, key populations will be left behind.

We must not fail children, women and girls, young people and key populations. We must
engage with men differently. Men are being left behind in the push to 90–90–90, in turn
affecting the lives of women and children.

I remain optimistic. This report clearly demonstrates the power of the 90–90–90 targets
and what can be achieved in a short time. It shows that innovations are possible at every
level—from communities to research laboratories, from villages to cities. It illustrates the
power of political leadership to make the impossible possible.
Michel Sidibé
UNAIDS Executive Director

Press Release
The scales have tipped—UNAIDS announces 19.5 million people on life-saving treatment and AIDS-related deaths halved since 2005
The 90–90–90 targets are galvanizing global action and saving lives. Eastern and southern Africa leading the way in reducing new HIV infections by nearly 30% since 2010—Malawi, Mozambique, Uganda and Zimbabwe have reduced new HIV infection by nearly 40% or more since 2010. Concerted efforts still needed for children, adolescents, men and key populations, and in certain regions.

GENEVA/PARIS, 20 July 2017—UNAIDS has released a new report showing that for the first time the scales have tipped: more than half of all people living with HIV (53%) now have access to HIV treatment and AIDS-related deaths have almost halved since 2005. In 2016, 19.5 million of the 36.7 million people living with HIV had access to treatment, and AIDS-related deaths have fallen from 1.9 million in 2005 to 1 million in 2016. Provided that scale-up continues, this progress puts the world on track to reach the global target of 30 million people on treatment by 2020.

“We met the 2015 target of 15 million people on treatment and we are on track to double that number to 30 million and meet the 2020 target,” said Michel Sidibé, Executive Director of UNAIDS. “We will continue to scale up to reach everyone in need and honour our commitment of leaving no one behind.”

The region showing the most progress is eastern and southern Africa, which has been most affected by HIV and which accounts for more than half of all people living with HIV. Since 2010, AIDS-related deaths have declined by 42%. New HIV infections have declined by 29%, including a 56% drop in new HIV infections among children over the same period, a remarkable achievement resulting from HIV treatment and prevention efforts that is putting eastern and southern Africa on track towards ending its AIDS epidemic.

90–90–90 progress
The report, Ending AIDS: progress towards the 90–90–90 targets, gives a detailed analysis of progress and challenges towards achieving the 90–90–90 targets. The targets were launched in 2014 to accelerate progress so that, by 2020, 90% of all people living with HIV know their HIV status, 90% of all people with diagnosed HIV are accessing sustained antiretroviral therapy and 90% of all people accessing antiretroviral therapy are virally suppressed.

The report shows that in 2016 more than two thirds (70%) of people living with HIV now know their HIV status. Of the people who know their status, 77% were accessing treatment, and of the people accessing treatment, 82% were virally supressed, protecting their health and helping to prevent transmission of the virus.

Eastern and southern Africa, western and central Europe and North America and Latin America are on track to reach the 90–90–90 targets by 2020. In eastern and southern Africa, 76% of people living with HIV know their HIV status, 79% of people who know their HIV-positive status have access to antiretroviral therapy and 83% of people who are on treatment have undetectable levels of HIV—this equates to 50% of all people living with HIV in eastern and southern Africa with viral suppression. The Caribbean and Asia and the Pacific can also reach the 90–90–90 targets if programmes are further accelerated.

Seven countries have already achieved the 90–90–90 targets—Botswana, Cambodia, Denmark, Iceland, Singapore, Sweden and the United Kingdom of Great Britain and Northern Ireland—and many more are close to achieving it.

“Ending AIDS is possible – it is a shared engagement and aspiration. One that cities can lead while promoting inclusive societies for all,” said Anne Hidalgo, Mayor of Paris…

In 2016 an estimated:
:: 19.5 million people were accessing antiretroviral therapy
:: 36.7 million [30.8 million–42.9 million] people globally were living with HIV
:: 1.8 million [1.6 million–2.1 million] people became newly infected with HIV
:: 1.0 million [830 000–1.2 million] people died from AIDS-related illnesses

Treatment for children living with HIV
Only 43% of children living with HIV have access to antiretroviral therapy, compared to 54% of adults. Ending AIDS also reveals that as many as two thirds of children under two years old are diagnosed late and start treatment with advanced immunodeficiency, resulting in a high mortality rate for children of this age group. More action is needed to diagnose and treat children living with HIV.

Young people are lagging behind
Young people (15–24 years) are lagging behind on multiple fronts—knowledge of HIV, HIV testing, treatment and prevention. Young people continue to be at great risk of HIV infection, especially young women in sub-Saharan Africa. New HIV infections among young women in sub-Saharan Africa are 44% higher than among young men of their age in the region. Around 610 000 new HIV infections occurred among young people aged 15–24 years; 59% of those new infections occurred among young women age 15–24 years.
In Malawi, Zambia and Zimbabwe, half of young people do not know their status and more than half do not have access to HIV treatment. Only 36% of young men and 30% of young women in sub-Saharan Africa had a basic knowledge of how to protect themselves from HIV. Population-based HIV Impact Assessments (PHIAs) conducted in Malawi, Zambia and Zimbabwe, and supported by the United States President’s Emergency Plan for AIDS Relief, found that less than 50% of young people living with HIV were aware of their HIV status, compared to 78% of adults aged 35–59 years.

Men not being reached
The report reveals that less than 50% of young men know how to protect themselves from HIV infection, that men are much less likely to know their HIV status or start treatment than women and that less than 50% of men living with HIV are accessing antiretroviral therapy. Many men who are diagnosed with HIV are diagnosed late and start treatment only when they fall ill, making them much more likely to die of AIDS-related illnesses than women. Deaths from AIDS-related illnesses were 27% lower among women than among men…

MSF/Médecins Sans Frontières [to 22 July 2017]
Press release
Doctors Without Borders Statement on New UNAIDS Report
July 20, 2017
UNAIDS released a report today that shows a reduction in AIDS-related deaths and states that more than half of all people living with HIV have access to treatment. Unfortunately, this report fails to recognize that sustained support is critical and that many people living with HIV/AIDS—like those in West and Central Africa—remain neglected and continue to suffer needlessly and die silently from AIDS-related diseases and infections. Today’s report finds that there were 1 million AIDS-related deaths last year, compared to 1.9 million in 2005.

Global Fund [to 22 July 2017];&country=
New Global Fund Results Show Accelerated HIV Treatment Progress
20 July 2017
GENEVA – Ahead of next week’s International AIDS Society Conference on HIV Science in Paris, France, the Global Fund to Fight AIDS, Tuberculosis and Malaria today announced new results that highlight accelerating progress in providing HIV prevention, treatment and care services.
The results show that 11 million people are receiving antiretroviral therapy for HIV through Global Fund-supported programs, an increase of 19 percent from a year before.
“Our partnership is achieving results on a scale that few of us thought was possible,” said Marijke Wijnroks, Interim Executive Director of the Global Fund. “But we need to do even more. The number of new infections is still too high and, as we continue to expand lifesaving HIV treatments we need a stronger focus on prevention, human rights and gender. Reaching key and vulnerable populations, youth, and adolescent girls and young women is absolutely essential.”
The results, based on data from the end of 2016, also show that programs supported by the Global Fund partnership provided 4.3 million pregnant women with antiretroviral medicines to prevent the transmission of HIV to their unborn children.
This incredible progress is due to the global partnership and commitment of governments, civil society groups, health workers and local and international organizations, along with support from major donors and organizations including the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), UNAIDS and WHO…

NIH  [to 22 July 2017]
July 20, 2017
NIH-supported scientists elicit broadly neutralizing antibodies to HIV in calves
Unique structure of bovine bNAbs may inform HIV vaccine, therapeutics design.