Public Health Ethics
Volume 4 Issue 3 November 2011
http://phe.oxfordjournals.org/content/current
Original Articles

Vaccination Policy and Ethical Challenges Posed by Herd Immunity, Suboptimal Uptake and Subgroup Targeting
Jeroen Luyten, Antoon Vandevelde, Pierre Van Damme, and Philippe Beutels
Public Health Ethics (2011) 4(3): 280-291 doi:10.1093/phe/phr032

Abstract
Vaccination policy is an ethically challenging domain of public policy. It is a matter of collective importance that reaches into the most private sphere of citizens and unavoidably conflicts with individual-based ethics. Policy makers need to walk a tight rope in order to complement utilitarian public health values with individual autonomy rights, protection of privacy, non-discrimination and protection of the worst-off. Whether vaccination is voluntary or compulsory, universal or targeted, every option faces complex ethical hurdles because of the interdependence of humans in infectious disease matters. In this article, we explore the following three policy questions. (i) Ethically, which policy measures should be addressed when vaccination coverage is insufficient in a population? Information campaigns, legal compulsion, or the use of financial incentives can all be effective, but also controversial policy options. (ii) Is it ethical to target vaccination programs at certain risk-groups? If such measures are necessary, we argue that policymakers will often have to decide which is more important to uphold: non-discrimination or the protection of privacy. And (iii), what is the ethical significance of adverse herd immunity effects? Some vaccination programs will improve average population health, but will at the same time increase the risk of severe morbidity and mortality for individuals in the worst-off groups of society.

Public Health Ethics
Volume 4 Issue 3 November 2011
http://phe.oxfordjournals.org/content/current

Original Articles
Advance Monopoly Commitment?
Jorn Sonderholm
Public Health Ethics (2011) 4(3): 297-302 doi:10.1093/phe/phr012

Abstract
This article is a critical discussion of the Advance Market Commitment (AMC) proposal for how to incentivize research and development of drugs for neglected diseases. The main claim of the article is that the ‘winner-takes-all’ problem that mars a simple prize proposal for how to incentivize research and development of drugs for neglected diseases also tarnishes the AMC proposal. The conclusion of the article is that the AMC proposal should be rejected as an incentivizing scheme for research and development of drugs for neglected diseases. This conclusion follows from the main claim of the article together with two plausible assumptions that are not argued for in the article.

Science        
9 March 2012 vol 335, issue 6073, pages 1137-1268
http://www.sciencemag.org/current.dtl
News & Analysis

Avian Influenza
Surprising Twist in Debate Over Lab-Made H5N1
Jon Cohen*

For the past several months, the media, the public, scientific groups, and a key U.S. government advisory panel on biosecurity have wrestled with how to deal with two unpublished studies they thought described the creation of a bird flu virus capable of triggering an influenza pandemic with the potential to kill millions of people. Now, a researcher who created one of the H5N1 mutants and a leading U.S. health official are offering clarifications and “new data” to better gauge the risk it presents. The researcher revealed that the virus made in his lab does not kill ferrets infected by the aerosol route. And it is more difficult to transmit the virus than previously described. These revelations promise to influence—although certainly not end—a contentious debate about whether to publish details about this virus and a second, related one that’s less virulent.

Science        
9 March 2012 vol 335, issue 6073, pages 1137-1268
http://www.sciencemag.org/current.dtl

Policy Forum
Public Health
Surveillance of Animal Influenza for Pandemic Preparedness
J. S. M. Peiris, L. L. M. Poon, and Y. Guan
Science 9 March 2012: 1173-1174.
Published online 16 February 2012 [DOI:10.1126/science.1219936]

The 2009 H1N1 pandemic was not as severe as initially feared. This has led to complacency in some quarters that future pandemics will be of comparable impact and as readily dealt with. However, by September 2009, just 5 months after the recognition of the novel pandemic H1N1 virus, almost 50% of children in Hong Kong were already infected (1), which reflects the speed of spread of the virus to and within international travel hubs. In most parts of the world, vaccines were not available in time to substantially affect the first wave of disease. A more virulent virus, such as one comparable to the 1918 H1N1 virus or the H5N1 “bird flu,” spreading with such speed would be a global catastrophe.

If you would like to receive Vaccines: The Week in Review as a weekly email summary, please send your request via email to david.r.curry@centerforvaccineethicsandpolicy.org.

You can also follow us on twitter: @vaxethicspolicy.

The pdf version of Vaccines: The Week in Review  5 March 2012, comprising te posts below for this date, is available here: Vaccines_The Week in Review_5 March 2012

WHO officially removed India “from the list of countries with active transmission of endemic polio, leaving only three countries which have never stopped indigenous wild poliovirus transmission: Afghanistan, Nigeria and Pakistan. India is no longer polio-endemic.” The official announcement was made at the Polio Summit 2012 in New Delhi. A letter written by WHO Director-General Dr Margaret Chan and delivered to the Indian Government on the morning of the Polio Summit confirmed the news. Prime Minister Manmohan Singh confirmed India’s commitment “to continuing to protect its children from possible re-importations of the poliovirus and to strengthening its routine immunization programme.” The Prime Minister noted that India’s success proved the viability of global polio eradication: “This gives us hope that we can finally eradicate polio not only from India but from the face of the entire mother earth.” The announcement was made “amidst thundering applause and a standing ovation by the 1400-plus participants from across the world, and India’s Health Minister, Ghulam Nabi Azad, said: “We have won the battle but the war is not yet over. Let us today rededicate ourselves and resolve that we will continue our efforts with the same vigour, so that India can be declared (certified) polio-free by 2014.”

http://www.polioeradication.org/tabid/461/iid/201/Default.aspx

Meeting Report and Documentation: SAGE extraordinary meeting to review the Global Vaccine Action Plan for the Decade of Vaccines (DoV)
WHO-HQ, 16-17 February 2012

Meeting Report
http://www.who.int/entity/immunization/sage/meetings/2012/february/SAGE_report_Feb2012_en.pdf

Background documents
– Session: Decade of Vaccines
Draft 3 of the Global Vaccine Action Plan
pdf, 1.16Mb
Memorandum
pdf, 181kb

– Session: Polio
Outline_Polio_EAP_16 Feb 2012_SAGE_final.pdf
pdf, 503kb

Presentations
– Session: Decade of Vaccines
Decade of Vaccine Collaboration: Global Vaccine Action Plan – consolidated presentation
pdf, 741kb
Disclaimer: Some of the information contained in this presentation is slightly at odd with version three of the Draft Global Vaccine Action Plan (GVAP) as circulated prior to the SAGE meeting and posted in the set of background documents. This has to do with the fact that the DoV Steering Committee met the day prior to SAGE and modified some of the goals sand indicators captured in the Draft. This presentation is also lacking some of the slides presented at the SAGE meeting and pertaining to Benefits, costs and funding. These slides contained preliminary figures and had to be treated as confidential.

– Session: Polio
Emergency Action Plan: Context & major elements
pdf, 888kb
Lessons from India
pdf, 789kb
Intensification of New Tactics to address Chronic Programme Gaps
pdf, 1.72Mb
Recommendations of Strategy Review Meeting
pdf, 643kb
Brief Orientation from the Polio Working Group on Policy Issues to be brought to SAGE at the April meeting
pdf, 428kb
http://www.who.int/immunization/sage/meetings/2012/february/presentations_background_docs/en/index.html

Speech: Anthony Lake, UNICEF Executive Director at the launch of State of the World’s Children report event

http://www.unicef.org/media/media_61867.html

Research Report: The State of the World’s Children 2012: Children in an Urban World.

UNICEF released its updated State of the World’s Children report, which notes that

“Greater urbanization is inevitable. In a few years…the majority of children will grow up in towns or cities rather than in rural areas. Children born in cities already account for 60 per cent of the increase in urban population.” UNICEF Executive Director Anthony Lake said,”When we think of poverty, the image that traditionally comes to mind is that of a child in a rural village. But today, an increasing number of children living in slums and shantytowns are among the most disadvantaged and vulnerable in the world, deprived of the most basic services and denied the right to thrive. Excluding these children in slums not only robs them of the chance to reach their full potential; it robs their societies of the economic benefits of having a well-educated, healthy urban population.”

IN the report, UNICEF urges governments “to put children at the heart of urban planning and to extend and improve services for all. To start, more focused, accurate data are needed to help identify disparities among children in urban areas and how to bridge them. The shortage of such data is evidence of the neglect of these issues.

While governments at all levels can do more, community-based action is also a key to success. The report calls for greater recognition of community-based efforts to tackle urban poverty and gives examples of effective partnerships with the urban poor, including children and adolescents.”

http://www.unicef.org/media/media_61839.html

UNICEF State of the World’s Children website:

http://www.unicef.org/sowc2012/

Full Report:

http://www.unicef.org/media/files/SOWC_2012-Main_Report_EN_21Dec2011.pdf

Research Report: IOM – Safe and Effective Medicines for Children: Pediatric Studies Conducted Under BPCA and PREA
Released: February 29, 2012
Board on Health Sciences Policy, Board on Children, Youth, and Families

Until 1997, most drugs used to treat children were tested for safety and effectiveness only in adults. It was then that Congress and the FDA created policies – including what are now the Best Pharmaceuticals for Children Act (BPCA) and the Pediatric Research Equity Act (PREA) – to encourage more pediatric studies of drugs used for children. The FDA asked the IOM to review aspects of pediatric studies and changes in product labeling that resulted from BPCA and PREA and their predecessor policies, as well as to assess the incentives for pediatric studies of biologics – drugs derived from human or animal sources, or microorganisms – and the extent to which biologics have been studied in children.

The IOM committee concludes that policies included in BPCA and PREA have helped provide clinicians who care for children with better information about the efficacy, safety, and appropriate prescribing of drugs. The IOM suggests that more can be done to increase knowledge about drugs used by children and thereby improve the clinical care, health, and well-being of the nation’s children.

http://www.iom.edu/Reports/2012/Safe-and-Effective-Medicines-for-Children.aspx

Research Report: Sustaining Progress: Creating US Policies to Spur Global Health Innovation – Global Health Technologies Coalition (GHTC)

GHTC released its third annual policy report which documents US leadership in driving the research and development that saves lives around the world. GHTC is housed at PATH and funded by the Bill & Melinda Gates Foundation. It includes almost 40 organizations advocating for research and development of tools to prevent, diagnose, and treat global diseases so health solutions are available when populations need them. The report also highlights recent scientific and policy achievements that have spurred the development of game-changing health products such as vaccines, drugs, and diagnostics. It also offers recommendations for how US policymakers can continue to make the critical investments that will produce the next generation of lifesaving health tools. The report makes recommendations in three areas: public financing, regulatory pathways, and incentives and innovative financing. http://www.ghtcoalition.org/policy-report/2012/index.php

IFPMA Code of Practice 2012

The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA) announced an expansion of its Code of Practice “to govern how companies interact with healthcare professionals, medical institutions and patient organizations.” IFPMA requires all member companies and member associations around the world to adopt and implement this new Code.” IFPMA noted that the new code of practice extends “coverage to all interactions with healthcare professionals, medical institutions, and patient organizations, and provides an effective framework for ethical business practices.”

Sabin Vaccine Institute executive vice president Ciro de Quadros, M.D., M.P.H., was awarded the BBVA Frontiers of Knowledge Award in Development Cooperation. Dr. de Quadros was honored for “leading the efforts to eliminate polio and measles from the western hemisphere and being one of the most important scientists in the eradication of smallpox around the world. These accomplishments, particularly the eradication of one of the most deadly enemies of mankind, represent one of the prime achievements of medicine.” The BBVA Foundation Frontiers of Knowledge Awards “recognize the role of science and cultural creation as levers of society’s progress and wellbeing. Their eight categories span the main scientific, technological, social and economic areas and challenges of our times.”

The prize jury noted that “De Quadros, furthermore, has championed a new supply model whereby a number of countries establish joint purchasing centers in order to acquire vaccines more cheaply…His programs have shown that introducing existing vaccines can be done in an economically sustainable way that promotes country ownership, particularly in low and middle income countries. This has facilitated an unprecedented effort against vaccine preventable diseases such as rubella, pertussis, rotavirus, pneumococcus and human papilloma virus, especially in high disease burden areas and underprivileged communities in Asia, Africa and the Americas.”

Dr. De Quadros commented, “I have no doubt that the 21st century will be known as the century of vaccines. Today we have a number of vaccines against chronic or degenerative diseases, and many more are being developed. We already have vaccines that help prevent liver and cervical cancer. Vaccines research is also underway to prevent diseases of extreme poverty. A century of vaccines could be extraordinary as long as we ensure that available vaccines reach everyone in the world who needs them.”

http://www.sabin.org/news-resources/in-news/2012/02/28/de-quadros-wins-bbva-foundation-frontiers-knowledge-award-developm

The National Institutes of Health (NIH) Clinical Center named Christine Grady, Ph.D. as chief of the Department of Bioethics. Dr. Grady has served as deputy director of the department since 1996 and served as acting chief since September 2011. Her research focuses on clinical research subject recruitment, incentives, vulnerability, consents, and international research ethics. Clinical Center Director John I. Gallin, M.D. commented, “Dr. Grady has had a strong international voice in human subjects protections, and under her leadership, the Department of Bioethics will continue its important, world-class work.” Grady is currently a member of President Obama’s Commission for the Study of Bioethical Issues and is a senior research fellow at the Kennedy Institute of Ethics. She is a fellow of both the American Academy of Nursing and the Hastings Center.

http://www.nih.gov/news/health/mar2012/cc-02.htm

PATH named David C. Kaslow, MD as director of the PATH Malaria Vaccine Initiative (MVI), which “drives the development of safe and effective vaccines for the fight against malaria.” PATH said Dr. Kaslow is a physician-scientist with more than 25 years of vaccine research and development experience, as well as a longstanding interest in the malaria parasite due to both its unique biology and its profound impact on global health. He has held key advisory positions with MVI and the Bill & Melinda Gates Foundation related to malaria vaccines, including—since 2008—serving as chair of MVI’s Vaccine Science Portfolio Advisory Council, the primary external advisory body for MVI. Dr. Kaslow is joining PATH from his position as vice president and head of Vaccines Project Leadership and Management at Merck Research Laboratories (MRL), where his responsibilities have included oversight of project leadership and management of Merck’s vaccine pipeline. http://www.path.org/news/pr120301-mvi-director.php

PATH and WHO announced the appointment of Dr. Marie-Pierre Préziosi as the new director of the PATH/WHO Meningitis Vaccine Project (MVP). Dr. Préziosi has been a member of the MVP team since 2003 and was most recently served director of Clinical Development for MVP, as part of her role as medical officer at WHO. Dr. Jean-Marie Okwo-Bele, director of WHO’s Immunization, Vaccines, and Biologicals department, commented, “We are very pleased that Marie-Pierre has been chosen to lead the MVP. Her wealth of experience, technical know-how, and dedication will be an asset as she takes on this important role. We are excited to work with Marie-Pierre to strengthen our partnership and continue rolling out MenAfriVac in all 25 countries in Africa’s meningitis belt.” Dr. Préziosi assumes this role from Dr. F. Marc LaForce, who announced last December that he was retiring after more than ten years with MVP. Under LaForce’s directorship, MVP successfully developed MenAfriVac™—a group A meningococcal meningitis conjugate vaccine specifically designed to eliminate the devastating meningitis epidemics that have been plaguing sub-Saharan Africa for more than a century. Around 55 million people aged 1 to 29 years have been vaccinated with MenAfriVac™ since the vaccine was introduced on the continent in December 2010.

http://www.path.org/news/pr1200301-mvp-director.php

The FDA said it approved first quadrivalent vaccine to prevent seasonal influenza – FluMist Quadrivalent – a vaccine to prevent seasonal influenza in people ages 2 years through 49 years, and the first influenza vaccine to contain four strains of the influenza virus, two influenza A strains and two influenza B strains. Karen Midthun, M.D., director of the FDA’s Center for Biologics Evaluation and Research, said, “Illness caused by Influenza B virus affects children, particularly young and school-aged, more than any other population. A vaccine containing the four virus strains most likely to spread and cause illness during the influenza season offers an additional option to aid in influenza prevention efforts.”

http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm294057.htm

The Gates Foundation announced Round 9 of its Grand Challenges Explorations initiative, described s a US$100 million grant initiative encouraging innovation in global health and development research. Proposals are being accepted through May 15, 2012 around “a new kind of topic this round, which challenges people to find new ways to tell the story of development aid and the powerful impact it can have around the world.”

Topics for Grand Challenges Explorations Round 9:

– Aid is Working. Tell the World (new!) – in partnership with Cannes Lions

– New Approaches for the Interrogation of Anti-malarial Compounds (new!)

– Protect Crop Plants From Biotic Stresses From Field to Market

– Design New Approaches to Optimize Immunization Systems

– Explore New Solutions for Global Health Priority Areas

http://www.gatesfoundation.org/press-releases/Pages/gce-round-9.aspx

WHO released new tables presenting recommendations for current routine immunization as well as interrupted and delayed vaccination. The announcement noted:

Every immunization programme in the world has a national vaccination schedule that specifies the age at which antigens are to be given. But as we well know, in real life things rarely go according to plan!

Inevitably, children and individuals come late for their vaccinations or for whatever reason, are unable to stick to the usual schedule. These irregular situations can be challenging to health workers who may not know what to do. If a child starts a vaccination series late, how many doses should be given? If a vaccination series is interrupted, does it need to be restarted or can it simply be resumed without repeating the last dose?

The Global Immunization Vision & Strategy 2006-2015 aims to protect more people by expanding beyond the traditional immunization target group. This includes those who may be “off schedule”. Regardless of when children and individuals come in contact with immunization services, it is important that their immunization status be checked and that they are provided with the vaccines they need or have missed.

To help guide national programmes, WHO has consolidated its recommendations for interrupted and delayed vaccination into one summary table:

http://www.who.int/immunization/newsroom/newsstory_recommendations_interrupted_delayed/en/index.html

In order to assist programme managers develop optimal immunization schedules WHO has compiled key information on its current routine immunization recommendations into three summary tables.

Table 1
– pdf, 195kb

Table 2
– pdf, 151kb

Table 3
– pdf, 204kb

Table 1 – en français
– pdf, 206kb

Table 2 – en français
– pdf, 187kb

– A User’s Guide to the Summary Tables
pdf, 998kb

Table 1 summarizes recommended routine immunizations for all age groups – children, adolescents, and adults. As such, it provides an overview of vaccine recommendations across the lifespan, including both primary series and booster doses.

Table 2 provides detailed information for routine immunizations for children, including age at first dose and intervals. It reiterates recommendations on the primary series and booster doses.

In Table 3, WHO has consolidated its recommendations for interrupted and delayed vaccination. These irregular situations can be challenging to health workers who may not know what to do.

It is important to note that these recommendations are only a compilation of existing WHO routine immunization recommendations in a new format. All the recommendations come from WHO Position Papers that are published in the Weekly Epidemiological Record. The tables are updated as soon as any new WHO recommendation is published.

The tables are designed for use by national immunization managers and key decision-makers, chairs and members of national advisory committees on immunization, and partner organizations, including industry.

The tables are not intended for direct use by health workers. Rather their purpose is to aid technical decisions with respect to the national vaccination schedule.

By consolidating its many recommendations into summary tables, WHO hopes to provide easy access to its policy advice and support national immunization programmes to critically examine, and possibly modify, their schedules.

It is hoped that the tables will prove useful in highlighting disparities among countries and in bringing awareness to recommendations that do not get followed. Several countries are appropriately providing additional vaccine antigens, but they lag behind in providing the adequate number of doses or booster doses for traditional vaccines and give little consideration to older age groups. These tables can serve as a driving force and reference tool to help review and improve schedules in keeping with the Global Immunization Vision and Strategy (GIVS), which promotes immunizing more persons across wider age groups.

WHO would like to receive feedback on the content and format of these tables.

http://www.who.int/immunization/policy/immunization_tables/en/index.html

The Weekly Epidemiological Record (WER) for 2 March 2012, vol. 87, 9 (pp 73–80) includes: Measles virus nomenclature update: 2012

http://www.who.int/entity/wer/2012/wer8709.pdf

Twitter Watch  [accessed 4 March 2012 18:05]
Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive.

Partners In Health ‏ @PIH
We have a plan to vaccinate 50,000 Haitians at risk of cholera infection. We need your support to scale up: ow.ly/9qlqX
2:00 PM – 3 Mar 12

GAVI Alliance ‏ @GAVIAlliance
Zambia launches multifaceted attack to combat #rotavirus and other causes of diarrhea. ht.ly/9kxBb
12:52 PM – 3 Mar 12

CDCgov ‏ @CDCgov
Children 11-18 without insurance coverage for the HPV vaccine may qualify for Vaccines for Children program. go.usa.gov/U6P
11:47 AM – 2 Mar 12

UNDP Policy Centre ‏ @UNDP_IPC
From @policypress: Ground-breaking International Study Reveals Extent of Global Child #Poverty – bit.ly/yVQJDM @UNICEFUS
3:35 PM – 1 Mar 12

Sabin Vaccine Inst. ‏ @sabinvaccine
“The 20th century was the century of antibiotics and chemotherapy. The 21st century will be the century of vaccines.” -de Quadros
1:15 PM – 1 Mar 12

Orin Levine ‏ @OrinLevine
In 2011 @UNICEF procured $955 million of #vaccines & 2.47 billion in 2,105 shipments. Wow! pic.twitter.com/JcJxD2Ag
Retweeted by GAVI Alliance
Hide photo
5:36 PM – 23 Feb 12

Brown University ‏ @BrownUniversity
Brown creates center for evidence-based medicine news.brown.edu/pressreleases/…
Retweeted by Amanda Glassman
2:51 PM – 2 Mar 12

PAHO/WHO ‏ @pahowho
Meeting of the Pan American Forum for Action on Noncommunicable Diseases – bit.ly/y0VAZQ
3:19 PM – 29 Feb 12

Seth Berkley ‏ @GAVISeth
Wonderful work taking place in Chad to immunise children against #measles a terrible disease: ht.ly/9m76U #vaccines #globalhealth
3:11 PM – 29 Feb 12

GAVI Alliance ‏ @GAVIAlliance
Track rollouts of #rotavirus #vaccine! Poorest countries will receive vax @ the same time as industrialised countries. ht.ly/9jfBL
4:34 AM – 29 Feb 12

CDCgov ‏ @CDCgov
Girls AND boys need 3 doses of HPV vaccine at 11 or 12 years old to protect them in the future. go.usa.gov/UVn
3:24 PM – 28 Feb 12

United Nations Photo ‏ @UN_Photo
Secretary-General Administers Polio Vaccine in Angola bit.ly/zObMkc #UN
5:33 PM – 27 Feb 12

AMA ‏ @AmerMedicalAssn
RT @amednews: Should flu vaccine be mandated for health care workers? bit.ly/AkYSQb
5:13 PM – 27 Feb 12

Forbes ‏ @Forbes
Should Doctors Fire Their Anti-Vaccine Patients? bit.ly/wU30Sl
11:36 AM – 26 Feb 12

Health Economics, Policy and Law 
Volume 7 – Issue 02 – April 2012
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

Empirically evaluating the impact of adjudicative tribunals in the health sector: context, challenges and opportunities
Steven J. Hoffman and Lorne Sossin
Health Economics, Policy and Law / Volume 7 / Issue 02, pp 147 – 174
Copyright © Cambridge University Press 2011
Published online: 26 August 2011
DOI:10.1017/S1744133111000156

Abstract
Adjudicative tribunals are an integral part of health system governance, yet their real-world impact remains largely unknown. Most assessments focus on internal accountability and use anecdotal methodologies; few, studies if any, empirically evaluate their external impact and use these data to test effectiveness, track performance, inform service improvements and ultimately strengthen health systems. Given that such assessments would yield important benefits and have been conducted successfully in similar settings (e.g. specialist courts), their absence is likely attributable to complexity in the health system, methodological difficulties and the legal environment within which tribunals operate. We suggest practical steps for potential evaluators to conduct empirical impact evaluations along with an evaluation matrix template featuring possible target outcomes and corresponding surrogate endpoints, performance indicators and empirical methodologies. Several system-level strategies for supporting such assessments have also been suggested for academics, health system institutions, health planners and research funders. Action is necessary to ensure that policymakers do not continue operating without evidence but can rather pursue data-driven strategies that are more likely to achieve their health system goals in a cost-effective way.

Health Economics, Policy and Law 
Volume 7 – Issue 02 – April 2012
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

Healthcare policy tools as determinants of health-system efficiency: evidence from the OECD
Dominika Wranik
Health Economics, Policy and Law / Volume 7 / Issue 02, pp 197 – 226
Copyright © Cambridge University Press 2011
Published online: 12 December 2011
DOI:10.1017/S1744133111000211

Abstract
This paper assesses which policy-relevant characteristics of a healthcare system contribute to health-system efficiency. Health-system efficiency is measured using the stochastic frontier approach. Characteristics of the health system are included as determinants of efficiency. Data from 21 OECD countries from 1970 to 2008 are analysed. Results indicate that broader health-system structures, such as Beveridgian or Bismarckian financing arrangements or gatekeeping, are not significant determinants of efficiency. Significant contributors to efficiency are policy instruments that directly target patient behaviours, such as insurance coverage and cost sharing, and those that directly target physician behaviours, such as physician payment methods. From the perspective of the policymaker, changes in cost-sharing arrangements or physician remuneration are politically easier to implement than changes to the foundational financing structure of the system.

Health Policy and Planning
Volume 27 Issue 2 March 2012
http://heapol.oxfordjournals.org/content/current

Review
Sheila Leatherman, Marcia Metcalfe, Kimberley Geissler, and Christopher Dunford
Editor’s Choice: Integrating microfinance and health strategies: examining the evidence to inform policy and practice
Health Policy Plan. (2012) 27(2): 85-101 doi:10.1093/heapol/czr014

Abstract
Introduction Single solutions continue to be inadequate in confronting the prevalent problems of poverty, ill health and insufficient health system capacity worldwide. The poor need access to an integrated set of financial and health services to have income security and better health.

Over 3500 microfinance institutions (MFIs) provide microcredit and financial services to more than 155 million households worldwide. Conservative estimates indicate that at least 34 million of these households are very poor by the definition in the Millennium Development Goals, representing around 170 million people, many in remote areas beyond the reach of health agencies, both private and governmental. A small but increasing number of MFIs offer health-related services, such as education, clinical care, community health workers, health-financing and linkages to public and private health providers.

Review of evidence Multiple studies indicate the effectiveness of microfinance and its impact on poverty. A small but growing number of studies also attempt to show that MFIs are capable of contributing to health improvement by increasing knowledge that leads to behavioural changes, and by enhancing access to health services through addressing financial, geographic and other barriers. While these studies are of uneven quality, they indicate positive health benefits in diverse areas such as maternal and child health, malaria and other infectious disease, and domestic violence. While more rigorous research is needed to inform policy and guide programme implementation to integrate microfinance and health interventions that can reliably enhance the well-being of the poor, there is useful evidence to support the design and delivery of integrated programmes now.

Conclusion Worldwide, current public health programmes and health systems are proving to be inadequate to meet population needs. The microfinance sector offers an underutilized opportunity for delivery of health-related services to many hard-to-reach populations.

The Lancet  
Mar 03, 2012  Volume 379  Number 9818  p777 – 866
http://www.thelancet.com/journals/lancet/issue/current

Comment
Offline: Is CDC a science-based organisation?
Richard Horton
Preview
When we published our first report describing discontent about the work of the Center for Global Health (CGH) at the US Centers for Disease Control and Prevention, CDC immediately contacted us to ask for an opportunity to reply. We agreed and await their response. Meanwhile, two further letters have arrived. They again signal severe concerns about the way in which CDC organises its global health work. Both correspondents are well informed about the details of the CDC’s work in global health. Their allegations are serious.

Editor’s Note 1:
The “first report” referenced above is not cited but appears to be a section of an Offline column by the same author published in the 11 February 2012 here: http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2960201-3/fulltext

We present it here for convenience:
“…Anonymous letters sometimes get submitted to editors. Here is one, a single page, neatly typed and addressed personally, but with no signature. I don’t know whether the critical statements made about the centre under scrutiny are true. But the questions being asked are interesting and worthy of answers. Here is a short sample of its contents. “Two years ago a new global health center was created at the [US] Centers for Disease Control and Prevention (CDC) with a lot of hope and promises. This new center was going to anchor the CDC commitment to global health. Unfortunately as 2012 begins it is unclear whether this new center will have the intended effect on global health, and it increasingly looks like a major missed opportunity…it is not too late to change the direction of this new and important global health center. An objective evaluation is urgently required to establish where to go from here with a clear strategic direction and key strategic priorities.” We would like to hear from the CDC about its Center for Global Health Leadership. What are its achievements? What is its strategy? What are its immediate priorities?…”

Editor’s Note 2 (8 March 2012):
The Lancet’s twitter feed included this reference to a letter by the CDC in response to the above published online at The Lancet on 7 March 2012 [see link]

TheLancet
Recently established @CDCGlobal plans to build on @CDCgov 60-year history of evidence-based global health programmes http://t.co/5zpArW5M

The Lancet  
Mar 03, 2012  Volume 379  Number 9818  p777 – 866
http://www.thelancet.com/journals/lancet/issue/current

Review
Early appraisal of China’s huge and complex health-care reforms
Winnie Chi-Man Yip, William C Hsiao, Wen Chen, Shanlian Hu, Jin Ma, Alan Maynard

Preview
China’s 3 year, CN¥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government’s undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable.

Urbanisation and health in China
Peng Gong, Song Liang, Elizabeth J Carlton, Qingwu Jiang, Jianyong Wu, Lei Wang, Justin V Remais

Summary
China has seen the largest human migration in history, and the country’s rapid urbanisation has important consequences for public health. A provincial analysis of its urbanisation trends shows shifting and accelerating rural-to-urban migration across the country and accompanying rapid increases in city size and population. The growing disease burden in urban areas attributable to nutrition and lifestyle choices is a major public health challenge, as are troubling disparities in health-care access, vaccination coverage, and accidents and injuries in China’s rural-to-urban migrant population. Urban environmental quality, including air and water pollution, contributes to disease both in urban and in rural areas, and traffic-related accidents pose a major public health threat as the country becomes increasingly motorised. To address the health challenges and maximise the benefits that accompany this rapid urbanisation, innovative health policies focused on the needs of migrants and research that could close knowledge gaps on urban population exposures are needed.

Pediatrics
March 2012, VOLUME 129 / ISSUE 3
http://pediatrics.aappublications.org/current.shtml

From the American Academy of Pediatrics
Policy Statement
HPV Vaccine Recommendations
COMMITTEE ON INFECTIOUS DISEASES

Abstract
On October 25, 2011, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommended that the quadrivalent human papillomavirus vaccine (Gardasil; Merck & Co, Inc, Whitehouse Station, NJ) be used routinely in males. The American Academy of Pediatrics has reviewed updated data provided by the Advisory Committee on Immunization Practices on vaccine efficacy, safety, and cost-effectiveness as well as programmatic considerations and supports this recommendation. This revised statement updates recommendations for human papillomavirus immunization of both males and females.

PLoS One
[Accessed 5 March 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Systematic Review of Economic Evaluations of Preparedness Strategies and Interventions against Influenza Pandemics
Román Pérez Velasco, Naiyana Praditsitthikorn, Kamonthip Wichmann, Adun Mohara, Surachai Kotirum, Sripen Tantivess, Constanza Vallenas, Hande Harmanci, Yot Teerawattananon
PLoS ONE: Research Article, published 29 Feb 2012 10.1371/journal.pone.0030333

Abstract 
Background
Although public health guidelines have implications for resource allocation, these issues were not explicitly considered in previous WHO pandemic preparedness and response guidance. In order to ensure a thorough and informed revision of this guidance following the H1N1 2009 pandemic, a systematic review of published and unpublished economic evaluations of preparedness strategies and interventions against influenza pandemics was conducted.

Methods
The search was performed in September 2011 using 10 electronic databases, 2 internet search engines, reference list screening, cited reference searching, and direct communication with relevant authors. Full and partial economic evaluations considering both costs and outcomes were included. Conversely, reviews, editorials, and studies on economic impact or complications were excluded. Studies were selected by 2 independent reviewers.

Results
44 studies were included. Although most complied with the cost effectiveness guidelines, the quality of evidence was limited. However, the data sources used were of higher quality in economic evaluations conducted after the 2009 H1N1 pandemic. Vaccination and drug regimens were varied. Pharmaceutical plus non-pharmaceutical interventions are relatively cost effective in comparison to vaccines and/or antivirals alone. Pharmaceutical interventions vary from cost saving to high cost effectiveness ratios. According to ceiling thresholds (Gross National Income per capita), the reduction of non-essential contacts and the use of pharmaceutical prophylaxis plus the closure of schools are amongst the cost effective strategies for all countries. However, quarantine for household contacts is not cost effective even for low and middle income countries.

Conclusion
The available evidence is generally inconclusive regarding the cost effectiveness of preparedness strategies and interventions against influenza pandemics. Studies on their effectiveness and cost effectiveness should be readily implemented in forthcoming events that also involve the developing world. Guidelines for assessing the impact of disease and interventions should be drawn up to facilitate these studies.

Science        
2 March 2012 vol 335, issue 6072, pages 1009-1136
http://www.sciencemag.org/current.dtl

Policy Forum
Public Health and Biosecurity
The Limits of Government Regulation of Science
John D. Kraemer and Lawrence O. Gostin
Science 2 March 2012: 1047-1049.
Published online 19 January 2012 [DOI:10.1126/science.1219215]

A transparent institutional review process will balance scientific freedom and national security better than publication restrictions.

Vaccine
Volume 30, Issue 13 pp. 2237-2396 (16 March 2012)
http://www.sciencedirect.com/science/journal/0264410X

Conference Report
Report of the Second European Expert Meeting on Rotavirus Vaccination
Pages 2237-2244
Carlo Giaquinto, Amy E.M. Jackson, Timo Vesikari
[No abstract]

Vaccine
Volume 30, Issue 13 pp. 2237-2396 (16 March 2012)
http://www.sciencedirect.com/science/journal/0264410X

Brief Reports
Survey of national immunization programs and vaccine coverage rates in Asia Pacific countries
Pages 2250-2255
Chun-Yi Lu, APECI members, Mathuram Santosham

Abstract
Children in the Asia Pacific region are still suffering from certain vaccine-preventable diseases. The current study surveyed the national immunization programs and vaccine uptake of traditional and newly developed vaccines in 12 countries in this area. The results showed children in most countries were well protected from conventional vaccine-preventable diseases, while immunization programs for certain diseases such as poliovirus or measles should be strengthened in certain countries. Protection against pneumococcus, rotavirus, and human papillomavirus infections were obviously inadequate in most of the countries in the region. Promoting coverage of newly developed vaccines will benefit a great number of children in this area.

Vaccine
Volume 30, Issue 13 pp. 2237-2396 (16 March 2012)
http://www.sciencedirect.com/science/journal/0264410X

Regular Papers
Willingness to receive pandemic influenza A (H1N1) vaccine among doctors and nurses in public health facilities in Ibadan, Nigeria

Original Research Article
Pages 2315-2319
Akinola Ayoola Fatiregun, Adeola Aisha Adeyemo, Samuel Anu Olowookere

Abstract
Background
As part of global efforts to contain the spread of the 2009 pandemic influenza A (H1N1), the Federal Ministry of Health of Nigeria is embarking on the vaccination of health care workers employed in health facilities nationwide. This study was designed to assess the willingness of doctors and nurses working in public health facilities in Ibadan, Nigeria to receive the influenza A (H1N1) vaccine.

Methods
A descriptive cross-sectional study design was employed. Stratified simple random sampling was used to select a total of 304 doctors and nurses who worked at the public primary (70), secondary (51) and tertiary (183) levels of health care facilities in Ibadan. A self-administered, structured questionnaire that contained items on socio-demographics, sources of information, knowledge about the infection and the vaccine, risk perception, willingness to receive the vaccine and suggestions to improve vaccination acceptance by health-care workers was used to collect the data.

Main findings
A total of 255 providers responded for an overall response rate of 84%. The mean age of the respondents was 35.0 ± 9.7 years. A high proportion (88.2%) of the participants, including 94.9% of the doctors and 87.0% of the nurses, reported a willingness to receive the vaccine. Perceptions regarding the risk of contracting influenza, the availability of effective vaccinations for prevention and beliefs that the disease is fatal were reasons given by respondents who reported willingness to receive the vaccination. Those participants who reported ever hearing about the pandemic (AOR 2.0, 95% CI 1.2–3.2) and those who had a high-risk perception of contracting the disease (AOR 2.0, 95% CI 1.2–3.7) were likely to receive the vaccine.

Conclusion
Doctors and nurses at the three levels of health care facilities in Ibadan were willing to receive the pandemic influenza A (H1N1) vaccine. Efforts should be made to deliver the vaccines via adequate planning.

Vaccine
Volume 30, Issue 13 pp. 2237-2396 (16 March 2012)
http://www.sciencedirect.com/science/journal/0264410X

Regular Papers
Multilevel correlates for human papillomavirus vaccination of adolescent girls attending safety net clinics
Original Research Article
Pages 2368-2375
Jasmin A. Tiro, Sandi L. Pruitt, Corinne M. Bruce, Donna Persaud, May Lau, Sally W. Vernon, Jay Morrow, Celette Sugg Skinner

Abstract
Background
Adolescent HPV vaccination in minority and low income populations with high cervical cancer incidence and mortality could reduce disparities. Safety-net primary care clinics are a key delivery site for improving vaccination rates in these populations.

Purpose
To examine prevalence of HPV initiation (≥1 dose), completion (receipt of dose 3 within 12 months of initiation), and receipt of 3 doses in four safety-net clinics as well as individual-, household-, and clinic-level correlates of initiation.

Methods
We used multilevel modeling to investigate HPV initiation among 700 adolescent females who sought primary care in four safety-net clinics in Dallas, Texas from March 2007 to December 2009. Data were abstracted from patients’ paper and electronic medical records.

Results
HPV vaccine uptake varied significantly by clinic. Across clinics, initiation was 36.6% and completion was 39.7% among those who initiated. In the total study population, only 15.7% received all three doses. In multivariate, two-level logistic regression analyses, initiation was associated with receipt of other adolescent vaccines, influenza vaccination in the year prior to data abstraction, being sexually active, and having more chart documentation (presence of health maintenance questionnaire and/or immunization record). There was no association between initiation and age, race/ethnicity, or insurance status.

Conclusions
In four urban safety-net clinics, HPV initiation rates paralleled 2008 national rates. The correlation of HPV initiation with other adolescent vaccines underscores the importance of reviewing vaccination status at every health care visit. HPV vaccine uptake in safety-net clinics should continue to be monitored to understand impact on cervical cancer disparities.