Vaccines and Global Health: The Week in Review 20 January 2018

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

.– Request an Email Summary: Vaccines and Global Health : The Week in Review is published as a single email summary, scheduled for release each Saturday evening before midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

 pdf version A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_20 Jan 2018

– blog edition: comprised of the approx. 35+ entries posted below.

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.

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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy

 

142nd session of the WHO Executive Board

Milestones :: Perspectives

142nd session of the WHO Executive Board
19 January 2018 – Next week the WHO Executive Board will set the agenda for the World Health Assembly, and determine how to best promote health, keep the world safe, and serve the vulnerable. The session takes place on
22–27 January 2018 in Geneva, Switzerland, and will be webcast live.
:: Provisional agenda
:: All documentation
[Selected Documentation]
EB142/10 – Public health preparedness and response
Implementation of the International Health Regulations (2005)
 
EB142/11 – Polio transition planning
 
EB142/13 – Addressing the global shortage of, and access to, medicines and vaccines

EB142/16 – Preparation for a high-level meeting of the General Assembly on ending tuberculosis
 
EB142/24 – Pandemic Influenza Preparedness Framework for the sharing of influenza viruses and access to vaccines and other benefits
 
EB142/35 – Global vaccine action plan
 
EB142/37 – Eradication of poliomyelitis

CDC to Scale Back Work in Dozens of Foreign Countries Amid Funding Worries

CDC to Scale Back Work in Dozens of Foreign Countries Amid Funding Worries

Efforts to prevent infectious-disease epidemics and other health threats were funded mostly through a five-year supplemental package
By  Betsy McKay
Wall Street Journal, Jan. 19, 2018 4:51 p.m. ET
The Centers for Disease Control and Prevention plans to scale back or discontinue its work to prevent infectious-disease epidemics and other health threats in 39 foreign countries because it expects funding for the work to end, the agency told employees.

The CDC currently works in 49 countries as part of an initiative called the global health security agenda, to prevent, detect and respond to dangerous infectious disease threats. It helps expand surveillance for new viruses and​ ​drug-resistant bacteria, modernize laboratories to detect dangerous pathogens​and train workers who respond to epidemics.

The activities are funded mostly through a five-year supplemental package that was awarded to the CDC and other government agencies in fiscal 2015 to respond to the Ebola epidemic in West Africa.

The package included $582 million in funds to work with countries around the world after the Ebola crisis in 2014 and 2015. But that funding runs out at the end of fiscal 2019.

Public health leaders had said they hoped dollars for the work would eventually be added into the CDC’s core budget, after the epidemic delivered a wake-up call about the world’s lack of preparedness for deadly epidemics. More than 11,300 people died in the Ebola epidemic, mainly in Africa.

In an email to U.S. and overseas leaders in its global health center, the CDC said it anticipates that if its funding situation remains the same, it will have to narrow activities to 10 “priority countries” starting in October 2019. The email was reviewed by The Wall Street Journal.

The Division of Global Health Protection “will have to scale its global health security portfolio to focus efforts based on existing resources,” wrote Rebecca Martin, director of the CDC’s Center for Global Health. “Faced with this anticipated fiscal reality, we have had to make some very difficult decisions.”

The 10 countries where global health security activities will remain are India, Thailand, Vietnam, Kenya, Uganda, Liberia, Nigeria, Senegal, Jordan and Guatemala, according to the email—countries of strategic or regional importance for the CDC.

Other countries where the agency currently conducts global health security agenda activities include Democratic Republic of the Congo, one of the world’s main hot spots for emerging infectious diseases and the site of the first Ebola outbreak in history; Pakistan; Indonesia; Haiti; and China, where CDC provides technical assistance to the country, which is devoting increasing resources to global health needs. In these 39 countries, the CDC “will plan for the completion of its country-based programs,” transitioning them to other possible funders by October 2020, according to the email.

But if more funding becomes available in fiscal 2019, work in the 10 priority countries could be enhanced and could continue in some of the other countries, according to the email.

Those countries next on the priority list, after the top 10, are China, the DRC, Ethiopia, Indonesia and Sierra Leone, according to another CDC document reviewed by the Journal.

The CDC said in a statement that it is taking these steps now because “we recognize the need for forward planning, and are confident that by planning now we will successfully achieve smooth transitions.”

The CDC is carrying out the work as part of a global health security agenda launched in 2014. Professionals trained in the initiative have helped quickly contain an anthrax outbreak in Kenya and yellow fever in Uganda and identify over 4,000 cases of measles in Sierra Leone.

Reductions now would halt critical work midstream and result in a loss of newly trained local experts, said Tom Frieden, the former CDC director who led the effort until a year ago and is now president and chief executive of Resolve to Save Lives, an initiative working on strengthening epidemic preparedness.

“They’re more likely to have outbreaks and less likely to be able to stop them themselves,” he said of countries that will be affected. “We’ll have to respond instead of having them respond.”
The global health security agenda is “the most important international intervention for emerging infectious disease infrastructure in many years,” said Tom Inglesby, director of the Center for Health Security of the Johns Hopkins Bloomberg School of Public Health. He added that U.S. leadership has helped persuade other nations to help fund the effort.

The CDC will continue to help respond to emerging disease threats and conduct work that had already been under way to improve detection of emerging infectious diseases globally. It will also continue programs combating HIV, tuberculosis, malaria, flu, and conducting immunization programs, Dr. Martin wrote.

Inoculate against a global vaccine crisis

Inoculate against a global vaccine crisis

By Laurie Garrett
Foreign Policy16 January 2018
On Feb. 27, 2017, the World Health Organization (WHO) named a dozen bacteria as major global health threats, underscoring the surge in antibiotic resistance and paucity of vaccines that, combined, now render incurable the infections caused by those germs.

There is plenty to fret about on the microbial front at the moment: Several scary strains of flu are circulating, and Australia’s winter 2017 flu season was one of the country’s deadliest in recent years. Any hope of protecting the world, generally, against the resurgence of old microbes, as well as the emergence of new ones — man-made biological menaces, for example — hinges on resolving the breakdown in the manufacturing of vaccines and moving the best, most applicable pharmaceutical innovations into the commercial pipeline for affordable access.

Ever since the 2014 Ebola epidemic in West Africa claimed 11,000 lives, global health experts, including those at Doctors Without Borders, have insisted on WHO reforms and an overhaul of the ways governments respond to outbreaks. But topping the list of needed changes is the speed with which the pharmaceutical industry develops new vaccines to guard against everything from Zika virus and tuberculosis to Ebola and drug-resistant bacteria.

But the reality is that … the world faces an even bigger problem: shortages and completely diminished stores of older but highly effective vaccines and a shrinking pool of manufacturers that can produce them.

This search for new protections against infection captured attention at the World Economic Forum in Davos, Switzerland, in January 2017 and at the G-20 summit later in July. It’s certainly appealing to imagine that pharmaceutical innovation fueled by Wall Street investments could lead to the quick creation of technological solutions to ward off outbreaks. But the reality is that, as 2018 begins, the world faces an even bigger problem: shortages and completely diminished stores of older but highly effective vaccines and a shrinking pool of manufacturers that can produce them.

In an average year between 2011 and 2015, data submitted to WHO and UNICEF showed that one-third of 194 countries ran out of a vaccine for a month or longer. Nearly 13 million infants received no vaccines at all in 2016, and by 2017 supplies of vaccines that target yellow fever, hepatitis B, cholera, meningitis C, diphtheria, whooping cough, tetanus, hepatitis A, and tuberculosis were critically low. And these shortages are acute in both poor and rich countries, with 77 percent of European nations telling WHO in 2015 that they had depleted supplies. By September 2017, Switzerland was experiencing shortages of 16 essential vaccines, prompting Daniel Desgrandchamps, an infectious diseases expert at the University of Geneva, to say, “This isn’t a Swiss problem — it’s an international problem.… I can’t remember a situation like this in my 30 years of professional life as a vaccination expert.”

The global pharmaceutical market is worth more than $1 trillion a year, but the vaccines portion of it is trivial, amounting to merely $24 billion — or about 2.4 percent. Yet the tried-and-true ways of targeting viruses and bacteria to prevent infection garner less industry interest. Though low profit margins, despite high demand, have long blocked the vaccine pipeline, the situation is worsening and now has impact on new product development. Few solutions have been suggested, but one country — Brazil — was able to handle a potentially catastrophic shortage better than any other because it manufactures its own vaccines in a unique public-private arrangement that fulfills the country’s constitutional requirement of providing health care for all of its citizens. The government sets production priorities and purchases from local pharmaceutical manufacturers, avoiding the unreliable international market.

In 2016, outbreaks of two mosquito-spread viruses — yellow fever and Zika — exploded in Angola and Brazil, respectively. The yellow fever outbreak spread to nearby Democratic Republic of the Congo as the entire world supply of yellow fever vaccine dwindled dangerously toward zero.

The irony is that the vaccine is almost 100 percent effective and a full dose protects patients for life. But the drug had become so cheap — by 2008, it cost a mere 60 cents for each vaccine — that few companies were interested in making it. With tens of millions of African lives at stake, WHO took a big gamble, diluting donated vaccines from countries such as Brazil — which donated 18 million doses — by 5 to 1 and hoping they would still work. Briefly, by January 2017, the epidemic seemed to be under control. But then it began to sweep across Brazil and the region, with cases popping up in the states of São Paulo and Rio de Janeiro. As the disease continued to spread, placing the global supply under further strain, stockpiles at the U.S. Centers for Disease Control and Prevention (CDC) disappeared. The CDC now estimates that its supplies won’t be replenished until the end of 2018, perhaps not until 2019.

The Zika epidemic and vaccine invention offer a cautionary tale of how these contradicting interests culminate in a less-than-desirable scenario. Before Zika first surfaced in Brazil in 2015 and then spread across the Americas, it had been too obscure to draw pharmaceutical industry interest. But once it hit Puerto Rico and Florida, the industry raced to create a vaccine, and the manufacturer Sanofi developed one that seemed safe and almost completely effective. Officials sighed in relief. But in 2017, when an epidemic in the wealthy United States failed to materialize, Sanofi shut down its Zika vaccine program. And as the year closed, another manufacturer, Merck, failed to apply to the U.S. Food and Drug Administration for approval of its Ebola vaccine — a product supported by strong clinical data — even after signing a $5 million advance purchase commitment with Gavi, the global vaccine alliance.

The challenge for 2018 will be finding a way to keep the pharmaceutical pipeline flowing, both for vaccines against 20th-century threats such as measles and cholera and for 21st-century challenges including SARS, MERS, new forms of deadly influenza, and the unknown microbes lurking out there. Many things have been tried: creating pots of gold for guaranteed bulk purchases, improving global shipping and delivery systems to better target limited supplies, and promoting the entry of vaccine manufacturers from emerging economies. These measures have acted like fingers in a dike, holding back a flood of further market failures. But Doctors Without Borders and many global health leaders fear that nothing less than a change to the capitalist underpinnings of the pharmaceutical industry will resolve the vaccine crisis — a step so extreme that only Brazil and a handful of left-leaning nations have dared put in practice.
     Garrett is a Pulitzer Prize-winning writer and global health policy analyst.

Vaccine mandates in France will save lives

Featured Journal Content

Science

18 January 2018
Letter
Vaccine mandates in France will save lives
by Stanley A. Plotkin, Paul Offit, Pierre Bégué
In their Letter “France’s risky vaccine mandates” (27 October 2017, p. 458), J. K. Ward et al. question the adoption of mandatory vaccination in France. Their prediction that such a step will encourage resistance to vaccination is unsupported by the facts and could prolong a dangerous situation in which French citizens have the right to allow their children to catch and transmit potentially fatal infections.
The French recommendation—which has now gone into effect (1)—was the product of two juries composed of both medical professionals and lay citizens (2), suggesting that Ward et al.’s concerns about acceptance by doctors and the public are unfounded. Moreover, evidence shows that mandates are effective. In California, immunization rates increased after so-called “philosophical exemptions” were eliminated (3).
Vaccine-hesitancy in French physicians has been found to be only moderate in prevalence (4). Even one vaccine-hesitant doctor is too many, but Ward et al. do not offer a solution to the problem, such as better education by medical schools. Furthermore, a reference cited by Ward et al. does not, as they claim, show that mandating vaccines increases antivaccinationism, but rather that citing dangers of diseases is more effective than arguing for safety of vaccination (5).
Ward et al.’s reasoning could be extrapolated to argue against mandating car seats for young    children. Like car seats, vaccination mandates will likely save lives.

References
.1. Association Française de Pédiatrie Ambulatoire, Obligation Vaccinale: Ce Qu’il Faut Savoir (2018); https://afpa.org/obligation-vaccinale/ [in French].
.2. Concertation Citoyenne sur la Vaccination, “Rapport sur la Vaccination” (2016); http://concertationvaccination.fr/la-restitution/.
.3. L. Sun, “California vaccination rate hits new high after tougher immunization law,” Washington Post (2017).
.4. P. Verger et al., Euro Surveill. 27, 30406 (2016).
.5. Z. Horne et al, ., Proc. Natl. Acad. Sci. U.S.A. 112, 10321 (2015).

Pan American Journal of Public Health

Featured Journal Content

Pan American Journal of Public Health
December 2017
Special Issue

The past, present, and future of immunization in the Americas
Jon Kim Andrus1, Ananda Sankar Bandyopadhyay2, M. Carolina Danovaro-Holliday3, Vance Dietz4, Carla Domingues5, J. Peter Figueroa6, Leila Posenato Garcia7, Alan Hinman8, Mirta Roses9, Cuauhtémoc Ruiz Matus10, Jose Ignácio Santos11, Fred Were12
The Pan American Journal of Public Health recognizes with appreciation the contributions of the members of the Editorial Committee, and authors of the Overview article. Their contributions and dedication to this issue on immunization in the Region of the Americas were extraordinary and helped make the manuscripts more interesting, more accurate, and more useful to our readers and all others who work to improve the health of the peoples of the Americas. The Journal would like to give special thanks to the General Coordination of the National Immunization Program, Department of Transmissible Disease Surveillance, Health Surveillance Secretariat, Ministry of Health, Brazil, whose financial and programmatic contributions were essential to the publication of this special issue.

Leadership in global health: the case of Ciro de Quadros, a testament to values, valor, and vision
Andrus, Jon Kim (2017-12)
When Dr. Bill Foege wrote “When Words Fail,” he was referring to how difficult it was for him to describe adequately, in written words, all the effort that is involved from the scientific conceptualization of a new …

Policies and processes for human papillomavirus vaccination in Latin America and the Caribbean
De la Hoz Restrepo, Fernando; Alvis Guzman, Nelson; De la Hoz Gomez, Alejandro; Ruiz, Cuauhtémoc (2017-12)
[ABSTRACT]. Objectives. Three highly effective vaccines are available to prevent human papillomavirus (HPV) infection, and they have been introduced in many countries around the world. This article describes advances and …

The Expanded Program on Immunization in the English- and Dutch-speaking Caribbean (1977–2016): reasons for its success
Lewis-Bell, Karen N.; Irons, Beryl; Ferdinand, Elizabeth; Jackson, Laura L.; Figueroa, J. Peter (2017-12)
[ABSTRACT]. The year 2017 marks the 40th year of the establishment of the Expanded Program on Immunization (EPI) by the Pan American Health Organization (PAHO), the regional office of the World Health Organization (WHO) …

Progress towards a comprehensive approach to maternal and neonatal immunization in the Americas
Ropero Alvarez, Alba Maria; Jauregui, Barbara; El Omeiri, Nathalie (2017-12)
[ABSTRACT]. Maternal and neonatal immunization (MNI) is a core component of the new immunization model in the Americas, which transitioned from immunization of children to that of the entire family. Immunization during …

Experiencia del desarrollo de herramientas para el monitoreo de coberturas de vacunación y quimioterapia preventiva
Saboyá-Díaz, Martha Idalí; Morice, Ana; Danovaro-Holliday, M. Carolina; Ruiz Matus, Cuauhtémoc; Castellanos, Luis Gerardo; Velandia-González, Martha Patricia (2017-12)
[RESUMEN]. Objetivo. Describir la experiencia y las lecciones aprendidas en el desarrollo de herramientas para el monitoreo de las coberturas de vacunación y de quimioterapia preventiva en las Américas. Métodos. Se …

El desafío de la sostenibilidad de los programas ampliados de inmunizaciones
Báscolo, Ernesto; Cid, Camilo; Pagano, Juan Pablo; Urrutia, María Soledad; Del Riego, Amalia (2017-12)
[RESUMEN]. Objetivo. Analizar la sostenibilidad y la integración de los programas prioritarios en el marco de la Estrategia para el acceso universal a la salud y la cobertura universal de salud (Salud Universal) de la …

The path towards polio eradication over 40 years of the Expanded Program on Immunization in the Americas
Pedreira, Cristina; Thrush, Elizabeth; Rey-Benito, Gloria; Chévez, Ana Elena; Jauregui, Barbara (2017-12)
[ABSTRACT]. This article synthesizes the important lessons learned from polio eradication in the Region of the Americas, including initial and more recent challenges and best practices, as well as particular factors …

Motivos de no vacunación en menores de cinco años en cuatro ciudades colombianas
Escobar-Díaz, Fabio; Osorio-Merchán, May Bibiana; De la Hoz-Restrepo, Fernando (2017-12)
[RESUMEN]. Objetivo. Conocer las barreras y los motivos de no vacunación en niños y niñas menores de cinco años en algunas ciudades de Colombia. Métodos. Diseño cualitativo basado en entrevistas y grupos focales a …

The evolution of Vaccination Week in the Americas
Ropero Alvarez, Alba Maria; Kurtis, Hannah Jane; Vulanovic, Lauren; Hasan, Hayatee; Ruiz, Cuauhtémoc; Thrush, Elizabeth (2017-12)
[ABSTRACT]. This report covers the background and evolution of Vaccination Week in the Americas (VWA), an initiative that started as a coordinated response to a 2002 measles outbreak in Colombia and Venezuela, and evolved …
 

Emergencies

Emergencies
 
POLIO
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 17 January 2018 [GPEI]
:: Summary of newly-reported viruses this week:
Afghanistan:  One new case of wild poliovirus type 1 (WPV1) reported in Kandahar province. Five new WPV1 positive environmental samples have been reported, three collected from Nangarhar province, one from Hilmand province, and one from Kunar province.
Pakistan: Pakistan: Three new WPV1 positive environmental samples have been reported, two collected from Balochistan province, and one from Punjab province.
Democratic Republic of the Congo: Five new cases of circulating vaccine-derived poliovirus type 2 (cVDPV2) have been reported in Tanganyika province.

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Syria cVDPV2 outbreak situation report 30, 16 January 2018
Situation update 16 January 2018
:: No new cases of cVDPV2 were reported this week. The total number of cVDPV2 cases remains 74.
:: The most recent case (by date of onset of paralysis) is 21 September 2017 from Boukamal district, Deir Ez-Zor governorate.
:: The first round of the second phase of the outbreak response started in Deir Ez-Zor city and in Hasakah and Homs governorates on 14 January. The round will commence in other parts of Deir Ez-Zor and in Raqqa in the coming days.

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WHO Grade 3 Emergencies  [to 20 January 2018]
The Syrian Arab Republic
:: Syria cVDPV2 outbreak situation report 30, 16 January 2018
[See Polio above for detail]

Yemen
:: Weekly epidemiology bulletin, 8–14 January 2018
Cumulative figures
– The cumulative total from 27 April 2017 to 14 Jan 2018 is 1,035,676 suspected cholera cases and 2,244 associated deaths,
(CFR 0.22%), 1100 have been confirmed by culture.

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WHO Grade 2 Emergencies  [to 20 January 2018]
Myanmar 
:: Nearly half a million children being vaccinated against diphtheria in Cox’s Bazar
SEAR/PR/1676
14 January 2018, Cox’s Bazar, Bangladesh – As part of an intensified response to the current diphtheria outbreak, WHO, UNICEF and health sector partners are working with the Bangladesh Ministry of Health and Family Welfare to vaccinate more than 475,000 children in Rohingya refugee camps, temporary settlements and surrounding areas.
“All efforts are being made to stop further spread of diphtheria. The vaccination of children in the Rohingya camps and nearby areas demonstrates the health sector’s commitment to protecting people, particularly children, against deadly diseases,” said Dr Bardan Jung Rana, ai WHO Representative to Bangladesh.
Nearly 150,000 children aged six weeks to seven years received pentavalent vaccine (that protects against diphtheria, tetanus, pertussis, haemophilus influenza type b and hepatitis B), and nearly 166,000 children aged 7 to 17 years were given tetanus and diphtheria (Td) vaccine, during a three-week vaccination campaign that ended on 31 December. Two more rounds of vaccination with a diphtheria-containing vaccine, at intervals of one month, are planned to fully protect the children in camps and surrounding areas.
“Children are particularly vulnerable to diphtheria. Volunteers are making door-to-door visits in the Rohingya settlements to ensure all children receive vaccination. The massive influx within a very short time has heavily affected basic services in the settlement areas. They have no choice but to live in a very congested environment, which is impacting their health and quality of life. We are making continued efforts to improve conditions of the camps. At the same time, diphtheria vaccination is vital to reducing the risk of further outbreak,” said the UNICEF Country Representative Mr. Edouard Beigbeder.
To limit the spread of diphtheria to communities living near the Rohingya camps and settlements, nearly 160,000 children in 499 schools of Teknaf and Ukhiya sub-districts are also being vaccinated. This initiative began on 1 January. Vaccination was initiated on a day when children attend school in large numbers to avail themselves of free books provided by the government at the start of the academic year.
WHO, UNICEF and other health partners are working with the Ministry of Health and Family Welfare to establish fixed locations for immunization in the Rohingya camps to continue to provide life-saving vaccines to children, in line with Bangladesh’s childhood immunization programme.

Democratic Republic of the Congo
15 January 2018
Cholera in Kinshasa – WHO is redeploying experts to control the epidemic
Kinshasa — On a 24-hour working visit to the Democrati Republic of Congo’s capital, heavily affected by the cholera epidemic, Dr Matshidiso MOETI, WHO Regional Director for Africa, told the Minister of Health, Public Health, Dr Oly ILUNGA Monday, of a reinforced emergency support mechanism putting all the experts from the Country Office and those deployed in the Democratic Republic of the Congo (epidemiologists, logisticians, data managers, specialists in communication on risks, social mobilization and community engagement etc.) available to the DPS to strengthen the response against cholera.

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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
:: 18 Jan 2018   Syria cVDPV2 Outbreak Situation Report #30 – 16 January 2018
:: Statement by the UN in Syria on civilians impacted by increase in hostilities [EN/AR]  17 January 2018
 
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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.
ROHINGYA CRISIS
:: ISCG Situation Report: Rohingya Refugee Crisis, Cox’s Bazar | 14 January 2018

Somalia
:: 17 Jan 2018  Somalia: US$1.6 billion urgently needed to save and protect 5.4 million lives from unprecedented drought
 
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Editor’s Note:
We will cluster these recent emergencies as below and continue to monitor the WHO webpages for updates and key developments.
 
Yellow Fever  [to 20 January 2018]
http://www.who.int/csr/disease/yellowfev/en/
16 January 2018
Updates on yellow fever vaccination recommendations for international travelers related to the current situation in Brazil
Information for international travellers
…Considering the increased level of yellow fever virus activity observed across the state of São Paulo, the WHO Secretariat has determined that, in addition to the areas listed in previous updates, the entire state of São Paulo should also be considered at risk for yellow fever transmission.
Consequently, vaccination against yellow fever is recommended for international travellers visiting any area in the state of São Paulo.
The determination of new areas considered to be at risk for the yellow fever transmission is an ongoing process and updates will be provided regularly…