Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage

The Lancet  
Jul 14, 2012  Volume 380  Number 9837  p75 – 186  e1
http://www.thelancet.com/journals/lancet/issue/current

Articles
Equity in financing and use of health care in Ghana, South Africa, and Tanzania: implications for paths to universal coverage
Anne Mills, John E Ataguba, James Akazili, Jo Borghi, Bertha Garshong, Suzan Makawia, Gemini Mtei, Bronwyn Harris, Jane Macha, Filip Meheus, Di McIntyre

Summary
Background
Universal coverage of health care is now receiving substantial worldwide and national attention, but debate continues on the best mix of financing mechanisms, especially to protect people outside the formal employment sector. Crucial issues are the equity implications of different financing mechanisms, and patterns of service use. We report a whole-system analysis—integrating both public and private sectors—of the equity of health-system financing and service use in Ghana, South Africa, and Tanzania.

Methods
We used primary and secondary data to calculate the progressivity of each health-care financing mechanism, catastrophic spending on health care, and the distribution of health-care benefits. We collected qualitative data to inform interpretation.

Findings
Overall health-care financing was progressive in all three countries, as were direct taxes. Indirect taxes were regressive in South Africa but progressive in Ghana and Tanzania. Out-of-pocket payments were regressive in all three countries. Health-insurance contributions by those outside the formal sector were regressive in both Ghana and Tanzania. The overall distribution of service benefits in all three countries favoured richer people, although the burden of illness was greater for lower-income groups. Access to needed, appropriate services was the biggest challenge to universal coverage in all three countries.

Interpretation
Analyses of the equity of financing and service use provide guidance on which financing mechanisms to expand, and especially raise questions over the appropriate financing mechanism for the health care of people outside the formal sector. Physical and financial barriers to service access must be addressed if universal coverage is to become a reality.

Funding
European Union and International Development Research Centre

Cambodian outbreak tests International Health Regulations

The Lancet Infectious Disease
Jul 2012  Volume 12  Number 7   p497 – 576
http://www.thelancet.com/journals/laninf/issue/current

[Reviewed earlier]
Online First
Cambodian outbreak tests International Health Regulations
The Lancet Infectious Diseases

Extract
The news that emerged from Cambodia in the first week of July of an unknown fatal illness that had killed at least 60 children in the previous 3 months, and the subsequent interagency response, shows how the International Health Regulations (IHRs) can work in practice. The event also serves as a timely reminder of the progress that still needs to be made to implement the IHR provisions in all WHO member states…

Mathematical Modelling: Replacing Prevnar7 with Prevnar13 in England and Wales

PLoS One
[Accessed 14 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Mathematical Modelling Long-Term Effects of Replacing Prevnar7 with Prevnar13 on Invasive Pneumococcal Diseases in England and Wales
Yoon Hong Choi, Mark Jit, Stefan Flasche, Nigel Gay, Elizabeth Miller
PLoS ONE: Research Article, published 13 Jul 2012 10.1371/journal.pone.0039927

Abstract 
Introduction
England and Wales recently replaced the 7-valent pneumococcal conjugate vaccine (PCV7) with its 13-valent equivalent (PCV13), partly based on projections from mathematical models of the long-term impact of such a switch compared to ceasing pneumococcal conjugate vaccination altogether.

Methods
A compartmental deterministic model was used to estimate parameters governing transmission of infection and competition between different groups of pneumococcal serotypes prior to the introduction of PCV13. The best-fitting parameters were used in an individual based model to describe pneumococcal transmission dynamics and effects of various options for the vaccination programme change in England and Wales. A number of scenarios were conducted using (i) different assumptions about the number of invasive pneumococcal disease cases adjusted for the increasing trend in disease incidence prior to PCV7 introduction in England and Wales, and (ii) a range of values representing serotype replacement induced by vaccination of the additional six serotypes in PCV13.

Results
Most of the scenarios considered suggest that ceasing pneumococcal conjugate vaccine use would cause an increase in invasive pneumococcal disease incidence, while replacing PCV7 with PCV13 would cause an overall decrease. However, the size of this reduction largely depends on the level of competition induced by the additional serotypes in PCV13. The model estimates that over 20 years of PCV13 vaccination, around 5000–62000 IPD cases could be prevented compared to stopping pneumococcal conjugate vaccination altogether.

Conclusion
Despite inevitable uncertainty around serotype replacement effects following introduction of PCV13, the model suggests a reduction in overall invasive pneumococcal disease incidence in all cases. Our results provide useful evidence on the benefits of PCV13 to countries replacing or considering replacing PCV7 with PCV13, as well as data that can be used to evaluate the cost-effectiveness of such a switch.

Vaccination Behaviour Influences Self-Report of Influenza Vaccination Status: A Cross-Sectional Study among Health Care Workers

PLoS One
[Accessed 14 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Vaccination Behaviour Influences Self-Report of Influenza Vaccination Status: A Cross-Sectional Study among Health Care Workers
Anna Llupià, Alberto L. García-Basteiro, Guillermo Mena, José Ríos, Joaquim Puig, José M. Bayas, Antoni Trilla
PLoS ONE: Research Article, published 11 Jul 2012 10.1371/journal.pone.0039496

Abstract 
Background
Published influenza vaccination coverage in health care workers (HCW) are calculated using two sources: self-report and vaccination records. The objective of this study was to determine whether self-report is a good proxy for recorded vaccination in HCW, as the degree of the relationship is not known, and whether vaccine behaviour influences self-reporting.

Methods
A cross-sectional study was conducted using a self-administered survey during September 2010. Considering the vaccination record as the gold standard of vaccination, the properties of self-report as a proxy of the record (sensitivity, specificity, positive predictive value, negative predictive value) were calculated. Concordance between the vaccination campaigns studied (2007–2010) was made using the Kappa index, and discordance was analyzed using McNemar’s test.

Results
248 HCW responded. The 95% confidence intervals of coverage according to the vaccination record and to self-report overlapped, except for 2007, and the Kappa index showed a substantial concordance, except for 2007. McNemar’s test suggested that differences between discordant cases were not due to chance and it was found that the proportion of unvaccinated discordant cases was higher than that of vaccinated discordant cases.

Conclusions
In our study population, self-reported influenza vaccination coverage in HCW in the previous two years is a good proxy of the vaccination record. However, vaccination behaviour influences the self-report and explains a trend to overestimate coverage in self-reporting compared to the vaccination record. The sources of coverage should be taken into account whenever comparisons are made.

Pap Smears, Self-Sampling and HPV Vaccination among Adult Women in Kenya

PLoS One
[Accessed 14 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Knowledge and Acceptability of Pap Smears, Self-Sampling and HPV Vaccination among Adult Women in Kenya
Anne F. Rositch, Ann Gatuguta, Robert Y. Choi, Brandon L. Guthrie, Romel D. Mackelprang, Rose Bosire, Lucy Manyara, James N. Kiarie, Jennifer S. Smith, Carey Farquhar screening
PLoS ONE: Research Article, published 10 Jul 2012 10.1371/journal.pone.0040766

Abstract 
Objectives
Our study aimed to assess adult women’s knowledge of human papillomavirus (HPV) and cervical cancer, and characterize their attitudes towards potential screening and prevention strategies.

Methods
Women were participants of an HIV-discordant couples cohort in Nairobi, Kenya. An interviewer-administered questionnaire was used to obtain information on sociodemographic status, and sexual and medical history at baseline and on knowledge and attitudes towards Pap smears, self-sampling, and HPV vaccination at study exit.

Results
Only 14% of the 409 women (67% HIV-positive; median age 29 years) had ever had a Pap smear prior to study enrollment and very few women had ever heard of HPV (18%). Although most women knew that Pap smears detect cervical cancer (69%), very few knew that routine Pap screening is the main way to prevent ICC (18%). Most women reported a high level of cultural acceptability for Pap smear screening and a low level of physical discomfort during Pap smear collection. In addition, over 80% of women reported that they would feel comfortable using a self-sampling device (82%) and would prefer at-home sample collection (84%). Nearly all women (94%) reported willingness to be vaccinated to prevent cervical cancer if offered at no or low cost.

Conclusions
These findings highlight the need to educate women on routine use of Pap smears in the prevention of cervical cancer and demonstrate that vaccination and self-sampling would be acceptable modalities for cervical cancer prevention and screening.

Stabilization of vaccines and antibiotics in silk and eliminating the cold chain

PNAS – Proceedings of the National Academy of Sciences of the United States
of America

(Accessed 14 July 2012)
http://www.pnas.org/content/early/recent

Stabilization of vaccines and antibiotics in silk and eliminating the cold chain
Jeney Zhanga,b,1, Eleanor Pritcharda,1, Xiao Hua, Thomas Valentina, Bruce Panilaitisa,
Fiorenzo G. Omenettoa, and David L. Kaplana,2
+ Author Affiliations
aTufts University, Department of Biomedical Engineering, Medford, MA 02155; and
bTufts University, Department of Chemical & Biological Engineering, Medford, MA 02155
Edited by Arnold L. Demain, Drew University, Madison, NJ, and approved June 12, 2012 (received for review April 12, 2012)

Abstract
Sensitive biological compounds, such as vaccines and antibiotics, traditionally require a time-dependent “cold chain” to maximize therapeutic activity. This flawed process results in billions of dollars worth of viable drug loss during shipping and storage, and severely limits distribution to developing nations with limited infrastructure. To address these major limitations, we demonstrate self-standing silk protein biomaterial matrices capable of stabilizing labile vaccines and antibiotics, even at temperatures up to 60 °C over more than 6 months. Initial insight into the mechanistic basis for these findings is provided. Importantly, these findings suggest a transformative approach to the cold chain to revolutionize the way many labile therapeutic drugs are stored and utilized throughout the world.

Science – Special Issue: HIV/AIDS in America

Science        
13 July 2012 vol 337, issue 6091, pages 125-256
http://www.sciencemag.org/current.dtl

Introduction to Special Issue: HIV/AIDS in America
Leslie Roberts

[Full text]
The epidemic of acquired immunodeficiency syndrome was first recognized in the United States. As clinicians from Los Angeles, California, reported in the 5 June 1981 issue of Morbidity and Mortality Weekly Report, they had seen odd immune problems and opportunistic infections in five young “active homosexuals.” Similar reports soon came in from all over the country and the world, making it clear that AIDS affected heterosexuals and homosexuals alike and also spread from mother to child and via tainted blood products and dirty needles. In the following years, U.S. researchers helped prove that HIV causes the disease, which led to a critical blood test to detect the novel retrovirus. The U.S. National Institutes of Health and the Centers for Disease Control and Prevention—prodded by AIDS activists such as Mark Harrington of the Treatment Action Group (pictured here)—steadily ramped up support for basic research as well as efforts to develop and test treatment and prevention interventions. In the early 2000s, the U.S. government poured billions of dollars into programs that now bring life-saving antiretrovirals to millions of people in cash-strapped countries.

By any measure, the United States has played a vital global role in unraveling HIV’s mysteries, providing help to the infected and protecting the vulnerable.

It may seem odd, then, that since 1990 this country has not hosted the International AIDS Conference, a megameeting that has gathered 20,000 participants every other year. But that will change on 22 to 27 July, when the gathering will take place in Washington, D.C. The meeting organizers shunned the United States because of an immigration ban on HIV-infected people imposed by Congress in 1987, which President Barack Obama ended in 2010.

In keeping with that shift, Science is focusing this special HIV/AIDS issue on America, now home to an estimated 1.2 million HIV-infected people—many of whom have little in common with the original five gay men in Los Angeles. The Deep South has become the epicenter; blacks—gay and straight—face a far higher risk of becoming infected than whites, and poverty is a major driver for all races. The biggest challenge the country faces today is diagnosing all of its HIV-infected people and helping them take full advantage of the existing treatments, which both stave off disease and make people less infectious. It is a problem shared worldwide.

Correspondent Jon Cohen, working with photographers Malcolm Linton and Darrow Montgomery, visited 10 U.S. cities this spring, and the package of stories that begins on p. 168 describes the varied epidemics and responses. A News Focus by Cohen spends a day with Anthony Fauci, who leads the NIH branch that funds more HIV/AIDS researchers than any institution in the world (p. 152). This special issue also includes an Editorial by Salim Abdool Karim (p. 133), who highlights problems rolling out what’s known as pre-exposure prophylaxis, as well as an update on HIV antibody research by Dennis Burton and colleagues (p. 183) that promises to inform AIDS vaccine development. Online, a slideshow offers more images and stories about the country’s epidemic, and Science Careers features profiles of two young HIV/AIDS public health workers making a big dent in big-city epidemics

Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and health care workers)

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Reviews
Acellular pertussis vaccine use in risk groups (adolescents, pregnant women, newborns and health care workers): A review of evidences and recommendations
Review Article
Pages 5179-5190
Angela Bechini, Emilia Tiscione, Sara Boccalini, Miriam Levi, Paolo Bonanni

Abstract
Background
Pertussis is an acute infectious illness, caused by the bacteria Bordetella pertussis and commonly known as “whooping cough”. Waning immunity after vaccination or after natural infection contributes significantly to the increasing incidence rates in adolescents and adults. Prevention of pertussis in industrialized countries is mainly based on immunization with acellular vaccines in combination with other antigens. A booster dose with an adult-formulation tetanus-diphtheria toxoid and acellular pertussis vaccine (Tdap) is now recommended for all adolescents by several countries, and replacement of the decennial Td dose with a single or more doses of Tdap is recommended for adults.

Objective
Our review aims at describing the current knowledge on the impact of acellular pertussis vaccination in adolescents and adults, with particular focus on specific risk groups: adolescents, pregnant women and their newborns, and health care workers (HCWs), and secondly at suggesting possible immunization strategies.

Methods
Data were retrieved by searches of Pubmed, references, from relevant articles and open-access websites.

Results
In countries where an adolescent booster dose was adopted, a certain decrease of incidence rates was observed. No serologic correlate of protection after immunization exists, but subjects with high antibody levels against pertussis antigens are less likely to develop the disease. Tdap vaccine was demonstrated to induce antibodies to pertussis antigens exceeding those associated with efficacy in infants, in both adolescents and adults. Tdap use in pregnant women seems to be safe and might represent a useful tool in order to prevent pertussis cases in the first months of life. Neonatal immunization with monovalent acellular pertussis vaccine can efficiently prime T and B cells and act as a basis for future immune responses. Cocooning strategies involving all those surrounding newborns have started to be implemented. Their impact on infant pertussis cases will be evaluated in the coming years. Coverage in HCWs should be increased, given their important role in pertussis transmission in health care settings.

Conclusions
Despite the more recent position paper of WHO gives priority to infant and childhood vaccination against pertussis and leaves adolescent, adult and risk group immunization as an option for the future, data are quickly accumulating to support the need to consider pertussis vaccination as a crucial preventative intervention even in adolescents and special risk groups.

Review: Malaria vaccines – Focus on adenovirus based vectors

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Reviews
Malaria vaccines: Focus on adenovirus based vectors
Review Article
Pages 5191-5198
Nathaniel J. Schuldt, Andrea Amalfitano

Abstract
Protection against malaria through vaccination is known to be achievable, as first demonstrated over 30 years ago. Vaccination via repeated bites with Plasmodium falciparum infected and irradiated mosquitoes provided short lived protection from malaria infection to these vaccinees. Though this method still remains the most protective malaria vaccine to date, it is likely impractical for widespread use. However, recent developments in sub-unit malaria vaccine platforms are bridging the gap between high levels of protection and feasibility. The current leading sub-unit vaccine, RTS,S (which consists of a fusion of a portion of the P. falciparum derived circumsporozoite protein to the Hepatitis B surface antigen), has demonstrated the ability to induce protection from malaria infection in up 56% of RTS,S vaccinees. Though encouraging, these results may fall short of protection levels generally considered to be required to achieve eradication of malaria. Therefore, the use of viral vectored vaccine platforms has recently been pursued to further improve the efficacy of malaria targeted vaccines. Adenovirus based vaccine platforms have demonstrated potent anti-malaria immune responses when used alone, as well when utilized in heterologous prime boost regimens. This review will provide an update as to the current advancements in malaria vaccine development, with a focus on the use of adenovirus vectored malaria vaccines.

Assessing potential introduction of universal or targeted hepatitis A vaccination: the Netherlands

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Regular Papers
Assessing potential introduction of universal or targeted hepatitis A vaccination in the Netherlands
Original Research Article
Pages 5199-5205
A.W.M. Suijkerbuijk, A.K. Lugnér, W. van Pelt, J. Wallinga, L.P.B. Verhoef, H.E. de Melker, G.A. de Wit

Abstract
In many industrialized countries, hepatitis A incidence rates have declined steadily in the past decades. Since future cohorts of non-vaccinated elderly will lack protection against disease and the burden of hepatitis A is higher with increasing age, this could be an argument in favour of taking preventive measures such as including hepatitis A vaccine into the National Immunisation Program, or offering hepatitis A vaccine to the elderly only. Using a vaccination evaluation scheme, we assessed the potential benefits and drawbacks of introducing hepatitis A vaccine in the National Immunisation Program in the Netherlands. The average number of annual hepatitis A notifications is declining, from 957 in the period 1991 to 1995 to 211 over the period 2006 to 2010. The direct health care costs and costs due to productivity losses per patient are rising, because the age at infection increases and older patients require a relatively higher number of hospitalizations. Initiating a vaccination program would most likely not be cost-effective yet. The annual costs of mass-vaccination are large: about €10 million for infants and €13 million for older people (and only in the first year €210 million), based on current retail prices. The annual effects of mass-vaccination are small: the cost-of-illness in recent years attributed to hepatitis A infection is estimated to be €650,000 per year, and the disease burden is on average 17 DALYs. Given the current low hepatitis A incidence, and the continuing decline in incidence, targeted preventive measures such as vaccinating travellers and other high-risk groups and timely vaccination of close contacts of hepatitis A patients are adequate. However, because susceptibility to hepatitis A is increasing in the group with the highest risk of developing severe complications upon infections, careful monitoring of the epidemiology of hepatitis A remains important.

Prevalence of type-specific HPV infection among women in France

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Regular Papers
Prevalence of type-specific human papillomavirus infection among women in France: Implications for screening, vaccination, and a future generation of multivalent HPV vaccines
Original Research Article
Pages 5215-5221
Joseph Monsonego, Laurent Zerat, Kari Syrjänen, Jean-Claude Zerat, Jennifer S. Smith, Philippe Halfon

Abstract
To assess human papillomavirus (HPV) prevalence and genotype distribution by age and cervical cytology/histology status among women undergoing routine gynecological examinations, and to discuss the possible impact on preventive strategies. Liquid-based cytology (LBC) samples were tested for HPV DNA, mRNA, and HPV genotypes. Women with atypical squamous cells of undetermined significance or greater (ASC-US+) and/or at least one positive HPV test were referred to colposcopy. Those with normal colposcopy results had biopsies taken at the 6 and 12 O’clock positions of the normal transformation zone. Of the 5002 women, 515 (10.3%) were <25 and 4487 (89.7%) were ≥25 years old. Overall HPV prevalence varied between 10.1% and 16.1% depending on the assay. Risk factors for HPV infection included greater number of recent sexual partners, history of abnormal cervical pathology, age <25 years, and smoking. HPV prevalence increased with the cytological and histological severity of cervical lesions. Prevalence of HPV 16/18 was 5.2% and 2.7% in women <25 and ≥25 years old, respectively. HPV 16 was the type most strongly associated with a diagnosis of cervical intraepithelial neoplasia grade 3 or higher (CIN3+) (odds ratio = 11.64 vs. HPV 16 absent, P < 0.001). A high proportion of high-grade cervical lesions (60.6% of genotyping assay-positive CIN2+) were associated with HPV types 31, 33, 45, 52, or 58. These data indicate that almost all young women could benefit from HPV prophylactic vaccination, but confirm the need for continued cervical screening and highlight the potential benefit of future vaccines targeting a wider range of HPV types.

Variation in adult vaccination policies across Europe

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Regular Papers
Variation in adult vaccination policies across Europe: An overview from VENICE network on vaccine recommendations, funding and coverage
Original Research Article
Pages 5222-5228
Elisabeth E. Kanitz, Lauren A. Wu, Cristina Giambi, Raymond A. Strikas, Daniel Levy-Bruhl, Pawel Stefanoff, Jolita Mereckiene, Eva Appelgren, Fortunato D’Ancona, VENICE (Vaccine European New Integrated Collaboration Effort) National Gatekeepers, Contact Points

Abstract
Background
In 2010–2011, in the framework of the VENICE project, we surveyed European Union (EU) and Economic Area (EEA) countries to fill the gap of information regarding vaccination policies in adults. This project was carried out in collaboration with the United States National Vaccine Program Office, who conducted a similar survey in all developed countries.

Methods
VENICE representatives of all 29 EU/EEA-countries received an online questionnaire including vaccination schedule, recommendations, funding and coverage in adults for 17 vaccine-preventable diseases.

Results
The response rate was 100%. The definition of age threshold for adulthood for the purpose of vaccination ranged from 15 to 19 years (median = 18 years). EU/EEA-countries recommend between 4 and 16 vaccines for adults (median = 11 vaccines). Tetanus and diphtheria vaccines are recommended to all adults in 22 and 21 countries respectively. The other vaccines are mostly recommended to specific risk groups; recommendations for seasonal influenza and hepatitis B exist in all surveyed countries. Six countries have a comprehensive summary document or schedule describing all vaccines which are recommended for adults. None of the surveyed countries was able to provide coverage estimates for all the recommended adult vaccines.

Conclusions
Vaccination policies for adults are not consistent across Europe, including the meaning of “recommended vaccine” which is not comparable among countries. Coverage data for adults should be collected routinely like for children vaccination.

Monitoring AEs for a new meningococcus conjugate vaccine, Niger, September 2010

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Regular Papers
Monitoring adverse events following immunization with a new conjugate vaccine against group A meningococcus in Niger, September 2010
Original Research Article
Pages 5229-5234
Maman S. Chaibou, Harouna Bako, Laouali Salisou, Téné M. Yaméogo, Mariama Sambo, Sung Hye Kim, Mamoudou H. Djingarey, Patrick L.F. Zuber, William A. Perea, Lorenzo Pezzoli

Abstract
Introduction
MenAfriVac is a new conjugate vaccine against Neisseria meningitidis serogroup A, the major cause of meningitis outbreaks in sub-Saharan Africa. In Niger, the MenAfriVac introduction campaign was conducted in the District of Filingue, during September 2010, targeting 392,211 individuals aged 1–29 years. We set up an enhanced spontaneous surveillance system to monitor adverse events following immunization (AEFI) during the campaign period and 42 days thereafter.

Methods
All the 33 health centres of the district have been designated as surveillance units, which reported AEFIs on a daily basis to the health district headquarters. Health care workers were instructed to screen patients presenting with predefined conditions of interest and patients spontaneously presenting at units or at vaccination posts with complaints after vaccination. Cases were classified as serious (resulting in death, hospitalization or long-term disability) or minor. A National Expert Committee was established to determine if serious cases were causally associated with the vaccine.

Results
In total, 356,532 vaccine doses were administered. During 61 days of monitoring, 82 suspected AEFIs were reported: 16 severe and 66 minor. The cumulative incidence was of 23.0 per 100,000 doses. Among severe cases, 14 were classified as coincidences, one urticaria complicated by respiratory distress was classified as a probable vaccine reaction, and one death was unclassifiable because post-mortem information was unavailable. The number of units that reported at least one case was 19/33 (57.6%).

Conclusions
Although these results are limited by underreporting of cases, we did not identify safety concerns with MenAfriVac. The lessons learned from this experience should be used to reinforce the national pharmacovigilance system in Niger to make it complaint with international standards. In order to do so, we recommend using a lighter system for routine; and conducting regular training and supervisory activities to increase its acceptance among local health workers.

Effects of influenza vaccine given to children in rural India

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 33  pp. 4897-5058 (13 July 2012)

Regular Papers
Design and initiation of a study to assess the direct and indirect effects of influenza vaccine given to children in rural India
Original Research Article
Pages 5235-5239
Wayne Sullender, Karen Fowler, Anand Krishnan, Vivek Gupta, Lawrence H. Moulton, Kathryn Lafond, Marc-Alain Widdowson, Renu B. Lal, Shobha Broor

Abstract
The burden of disease due to influenza is not well characterized for children in developing countries and the effectiveness of available influenza vaccines in lower resource settings has not been established. We initiated a prospective, longitudinal, phase IV, household-randomized, controlled, observer-blinded three year study (2009–2011) in a rural community of India to measure the total and indirect household protective effects of immunizing children ages 6 months through 10 years with seasonal inactivated trivalent influenza vaccine (TIV) or a control vaccine (n = 3697). Active weekly surveillance was conducted year round with home visits for identification of febrile acute respiratory illness (FARI) conducted for all vaccine recipients and household members (n = 18,220). Nasal and throat swabs were collected from each FARI episode for influenza detection by real-time reverse transcription polymerase chain reaction. The primary outcome was reduction in laboratory confirmed influenza infections in the influenza vaccine versus control vaccine group, with secondary outcome assessing indirect effects among the entire study population. This report describes the study site, cluster study design, choice of study and control vaccines, and the initial enrollment in the study.

Comment: BMGF and development action

Economist
http://www.economist.com/
Accessed 14 July 2012

Contraception and development: Opening the Gates
Jul 12th 2012, 13:53 by J.P. | LONDON

WHEN several heads of state, a dozen health ministers and hundreds of delegates piled into a conference centre in the middle of London on July 11th, there was a sound of broken barriers everywhere. The family-planning summit was the first big international meeting on birth control since a United Nations conference in Cairo in 1994, a sign that international attitudes seem to be changing towards a long-neglected subject. It was an indication that the British government, the joint sponsor of the meeting, is ploughing something of a lonely furrow in development at the moment. As Duncan Green, the head of research at Oxfam, has pointed out, this is a period of British exceptionalism. “The UK is pretty much alone among traditional donors,” he writes, “in sticking to its promises to increase aid despite deep public spending cuts, and is simultaneously pushing ahead in the multilateral arena.” In addition to the family-planning meeting, Britain will convene a “hunger summit” during the Olympic Games, and the prime minister, David Cameron, is one of three co-chairs of a UN panel to look at what comes after the millennium development goals. But in some ways the loudest sound of broken barriers comes from the summit’s other sponsor, the Bill and Melinda Gates Foundation.

When the foundation began in 1994, Mr Gates’s idea was that it would focus on areas neglected by others-vaccines not being financed by governments; complex crop research that was too long-term for governments or companies to contemplate. Where governments or the private sector were taking a lead, the idea was, the foundation would stay away.

But over time, that self-denying ordinance has proved hard to maintain. At first, the foundation concentrated mainly on diseases and health. But nutrition is one of the main determinants of health; agriculture is vital to nutrition-and the Gates foundation has ended up as one of the most important financiers of agricultural research today (especially into the crops of the poor, such as cassava and millet). Something similar seems to be happening with birth control. Family planning was part of the foundation’s health programmes from the start. But its programmes were small and now are being scaled up quickly. Perhaps more important, the summit shows that the modest “after-you-Claude” approach is hard to reconcile with an operation that paid out $2.4 billion in grants in 2010, making the Gates foundation the size of a medium-sized country donor, comparable to Australia or Belgium.

The family-planning summit was an example of the Gates foundation not merely filling in gaps left by others but acting to change the behaviour of countries. Donors have avoided or downplayed family planning for years, partly because of its former association with coercion, partly because of religious objections, especially to abortion, and partly because some developing-country governments have viewed it as white people coming to poor nations and telling them to have fewer children. But as evidence collected in the new edition of the Lancet, a medical journal, convincingly shows, family planning also has substantial, long-term health and economic benefits. The attitude of some developing countries has already started to change; Rwanda, Malawi, Tanzania and Nigeria have all launched or expanded family-planning programmes in the past few years. But it has taken the Gates foundation to team up with Britain to push western donors into a big expansion of official support: at the London summit, they promised $2.6 billion worth of aid, aiming to cut by more than half the number of women in developing countries without access to modern contraceptive methods.

http://www.economist.com/blogs/feastandfamine/2012/07/contraception-and-development

More on CIA, Vaccines, bin Laden

New Yorker
http://www.newyorker.com/
Accessed 14 July 2012
July 12, 2011
Blog: News Desk
The C.I.A., Vaccines, and bin Laden
Ahh—the old phony-vaccination ruse. How does the C.I.A. come up with this stuff? On Monday we learned, from a report in the Guardian, that our vaunted intelligence community decided to use a staged vaccination…
by Michael Specter
Read more http://www.newyorker.com/search?qt=dismax&sort=score+desc&query=vaccine&submit=#ixzz20dpHqDC0

New York Times
http://www.nytimes.com/
Accessed 14 July 2012
C.I.A. Vaccine Ruse May Have Harmed Pakistan’s War on Polio …
4 days ago … The team sent into Pakistan to obtain DNA from Osama bin Laden’s family had an unintended consequence.
July 10, 2012 – By THE NEW YORK TIMES – World – India Ink

Vaccines: The Week in Review 7 July 2012

Editor’s Notes:

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WHO: Global Alert and Response (GAR) – Undiagnosed illness in Cambodia – update

[Editor’s Note: We provide the full text of this GAR update below given the continuing identification of this presumably infectious syndrome]

WHO: Global Alert and Response (GAR) – Undiagnosed illness in Cambodia – update

6 July 2012 – The Ministry of Health of the Kingdom of Cambodia is conducting active investigation into the cause of a recent undiagnosed syndrome that has caused illness and deaths among children in the country.

Preliminary findings of the investigation identified a total of 74 cases who were hospitalised from April to 5 July 2012. Of these, 57 cases (including 56 deaths), presented a common syndrome of fever, respiratory and neurological signs, which is now the focus of the investigation.

The majority of the identified cases to date were under three years old. Most of them were from the southern and central parts of the country and received treatment at Kantha Bopha Children’s hospital, which is a reference paediatric hospital. Despite all efforts, many of the children died within 24 hours of admission.

Available samples have been tested at the Institut Pasteur in Cambodia. Although a causative agent remains to be formally identified, all these samples were found negative for H5N1 and other influenza viruses, SARS, and Nipah.

The Ministry of Health was first alerted to this by Kantha Bopha Children’s hospital in Phnom Penh, where the majority of the cases were hospitalised.

The Ministry of Health notified WHO about this event through the IHR notification mechanism as it met the criteria for notification of any event where the underlying agent or disease or mode of transmission is not formally identified.

WHO and partners are assisting the Ministry of Health with this event which focuses on hospitalised cases, early warning surveillance data, laboratory data and field investigations.

While this event is being actively investigated, the Government is also looking at other diseases occurring in the country, including dengue, hand-foot-mouth and Chikungunya.

Parents have been advised to take their children to hospital if they identify any signs of unusual illness. The Government is also reinforcing awareness of good hygiene practices to the public, which includes frequent washing of hands.

http://www.who.int/csr/don/2012_07_06a/en/index.html

GHI (Global Health Initiative) Office to close, Office of Global Health Diplomacy formed

Announcement: U.S. State Department Global Health Initiative Office (S/GHI) to close, Office of Global Health Diplomacy (S/GHD) formed

Global Health Initiative Next Steps – A Joint Message from Administrator Rajiv Shah, Ambassador Eric Goosby, Director Thomas Frieden, and GHI Executive Director Lois Quam

Extract

“…The Quadrennial Diplomacy and Development Review (QDDR) provided a forum for review of the structure of GHI. After careful consideration of evolving U.S. global health leadership needs, we have reached several key conclusions that will help guide the next phase of GHI:

First, we continue to recognize the capabilities of our global health agencies. Each has critical leadership responsibilities that must be maintained in the next phase of GHI as we seek greater impact and efficiency from our collective whole-of-government efforts to implement our health programs.

Second, we believe that a continued emphasis on country-level leadership of our global health activities will best achieve improved USG coordination of programs in the field, stronger country partnerships and ownership, and innovation for results.

Third, we recognize the critical role of health diplomacy to increase political will and resource commitments around global health among partner countries and increase external coordination among donors and stakeholders.

As a result of our analysis and conclusions, we have made a collective recommendation to close the QDDR benchmark process and shift our focus from leadership within the U.S. Government to global leadership by the U.S. Government. This recommendation has been accepted.

Our recommendation and the decision to move forward are a reflection of the strength and leadership of each agency.

–          The success of the recent Child Survival Call to Action, spearheaded by USAID, to launch a program to end preventable child death is a sterling example of our GHI principles at work, challenging countries with the greatest child mortality to take greater ownership and coordinating efforts from partners.

–          USAID is also assuming management responsibility for Saving Mothers, Giving Life, a public-private partnership to help reduce maternal mortality during labor, delivery, and the first 24 hours postpartum.

–          The Office of the Global AIDS Coordinator will continue to lead PEPFAR, ensuring that all Country Operational Plans reflect the principles of GHI in activities, thus improving programmatic integration and coordination, supporting country ownership and health systems strengthening, and focusing on gender equality. Through these activities, among others, PEPFAR is helping to create an AIDS free generation.

–          CDC is continuing its remarkable work implementing programs and leading the strengthening of public health systems across a diverse range of activities around the world.

What does this approach mean for the future of GHI work in country and at headquarters? The Global Health Initiative will continue as the priority global health initiative of the U.S. Government. GHI will continue to function with a collaborative leadership structure headed by the three core entities – USAID, CDC, OGAC – and with the enduring mandate of ensuring the GHI principles are implemented in the field to achieve our ambitious GHI goals. GHI country teams and GHI planning leads will continue to work to implement GHI strategies under the leadership of the U.S. Ambassador.

At the State Department, the GHI Office (S/GHI) will close and the Office of Global Health Diplomacy (S/GHD) will be stood up. Unlike S/GHI’s focus on interagency coordination, the S/GHD office’s mandate will be to champion the priorities and policies of GHI in the diplomatic arena. Success in the next phase will be measured by our ability to leverage our collective interagency leadership to influence global stakeholders, align donor investments with country resources and oversight and maintain and build country-focused technical support that expands capacity for global health priorities.

As we move into the next phase of GHI, we are committed to working together to achieve our ambitious GHI goals and to support and enhance our combined efforts to save lives.”

http://www.ghi.gov/newsroom/blogs/2012/194472.htm

Global Fund: “Outstanding Value for Money” and New Funding Model

Speech: General Manager Says Global Fund Offers Outstanding Value for Money
Gabriel Jaramillo, General Manager of the Global Fund to Fight AIDS, Tuberculosis and Malaria
5 July 2012, Tunis: Conference of Ministers of Finance and Health by Harmonization for Health in Africa (HHA)

Media Release – Extract
General Manager Jaramillo, told a gathering of finance and health ministers that the financing institution offers outstanding value for money by effectively treating and preventing the spread of disease. He said the changing economic climate had forced the Global Fund to change its operations to make grants more strategic, improve efficiency and become more effective overall.

The Global Fund will invest US$8 billion over the coming 20 months, US$5 billion of it in Africa. Mr. Jaramillo said that with productivity gains and more co-investment by countries that receive grants, there is a tremendous opportunity.

“As a former banker, I know a good deal when I see one,” said Mr. Jaramillo. “There is no better deal that investing to prevent these diseases.”

Mr. Jaramillo urged the ministers not to fear the investment necessary just because the up-front costs look high, because maintaining gains is less-expensive than the initial investments.

“Front-end these programs now, put your skin in the game now, because the out-years will be much cheaper as your number of cases goes down,” he said. “Sustaining your programs is much-less costly than you believe, and the return on investment is potentially huge.”
http://www.theglobalfund.org/en/mediacenter/newsreleases/2012-07-05_General_Manager_Says_Global_Fund_Offers_Outstanding_Value_for_Money/

 
Blog Post: Global Fund Consults on New Funding Model
[full text]
Strategic planners at the Global Fund are designing a new funding model, and have been seeking suggestions and comments from committee members and some outside partners. In an effort to modify the way countries apply for grants, the new funding model will replace the old ‘rounds-based’ system with a procedure that allows dialogue and early feedback, which should strengthen proposals and increase overall success rates. Early preparation for grant implementation, built-in to the system, is expected to speed up the entire process. Instructions from the Board are to make the funding model more flexible and more effective. Senior staff in the Global Fund’s Strategy Investment and Impact division have been reaching out to partners and committee members to canvass their views, gathering input for the designing the new funding model.

“It’s important that we hear views from different stakeholders,” said Ruwan de Mel, Head of Strategy and Access to Funding at the Global Fund. “We will be consulting broadly over the coming weeks.” A meeting of the Board’s Strategy and Investment and Impact Committee starting 9 July will consider aspects of the new funding model. The principles being followed in the design include a commitment to remaining global while focusing on interventions, countries and populations most in need, and simplifying the grant process while maintaining high standards of technical review. More flexibility on timing, and more predictability on available funding, are other improvements.

Consultations are expected to continue. The aim will also be to figure out how to best forecast true need or demand for support treating and preventing disease, and how other funding models or donor processes might improve the design of an allocation and application process.
Global Fund News Flash: Issue 05
Posted on Tuesday, 03 July 2012: http://www.theglobalfund.org/en/blog/29479/

Twitter Watch [accessed 7 July 2012 – 13:29]

Twitter Watch [accessed 7 July 2012 – 13:29]
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.

WHO @WHO
UPDATE: Cambodia unknown disease: Samples tested were found negative for #H5N1, other #influenza, SARS and Nipah http://goo.gl/N3rvS
1:24 PM – 6 Jul 12

UNDP Policy Centre ‏@UNDP_IPC
‘Looking beyond Rio+20’ – Special issue of the Inclusive Growth bulletin launched today: http://bit.ly/NbRKa2 @UNDPS @UNEP @UNDP
10:20 AM – 6 Jul 12

GAVI Alliance @GAVIAlliance
. @GAVISeth emphasises importance of long-term sustainable funding 4 vaccines at high-level Ministerial conference. http://ht.ly/c3z5u
9:30 AM – 6 Jul 12

Seth Berkley ‏@GAVISeth
Seismic change in vaccine market; Serum Institute buys Dutch vax co for production of inactivated polio & other vax http://bit.ly/L1Hty7
4:32 AM – 5 Jul 12

UN: 2012 Report on the Millennium Development Goals

Report: 2012 Report on the Millennium Development Goals
United Nations, 2 July 2012
Report: (pdf; 72 pages):2012 Report on the Millennium Development Goals
Chart: (pdf; 1 page) 2012 MDG Progress Chart

Press Release: extract
With three important targets on poverty, slums and water having been met, a new United Nations report stresses the need for a true global partnership to achieve the remaining Millennium Development Goals (MDGs) by the 2015 deadline. The 2012 MDG Report offers “the most comprehensive picture yet” on global progress towards the Goals, Secretary-General Ban Ki-moon said as he launched the report at the high-level segment of the annual session of the UN Economic and Social Council (ECOSOC). “The current economic crises besetting much of the developed world must not be allowed to decelerate or reverse the progress that has been made. Let us build on the successes we have achieved so far, and let us not relent until all the MDGs have been attained,” he said in the foreword.

[Full text from initial Overview section of report]
Overview
   Three years to the deadline, we can report broad progress on the MDGs
The Millennium Development Goals (MDGs) agreed to by world leaders over a decade ago have achieved important results. Working together, Governments, the United Nations family, the private sector and civil society have succeeded in saving many lives and improving conditions for many more.

The world has met some important targets—ahead of the deadline.

•• Extreme poverty is falling in every region
For the first time since poverty trends began to be monitored, the number of people living in extreme poverty and poverty rates fell in every developing region—including in sub-Saharan Africa, where rates are highest. The proportion of people living on less than $1.25 a day fell from 47 per cent in 1990 to 24 per cent in 2008—a reduction from over 2 billion to less than 1.4 billion.

•• The poverty reduction target was met
Preliminary estimates indicate that the global poverty rate at $1.25 a day fell in 2010 to less than half the 1990 rate. If these results are confirmed, the first target of the  MDGs—cutting the extreme poverty rate to half its 1990 level—will have been achieved at the global level well ahead of 2015.

•• The world has met the target of halving the proportion of people without access to improved sources of water
The target of halving the proportion of people without sustainable access to safe drinking water was also met by 2010, with the proportion of people using an improved water source rising from 76 per cent in 1990 to 89 per cent in 2010. Between 1990 and 2010, over two billion people gained access to improved drinking water sources, such as piped supplies and protected wells.

•• Improvements in the lives of 200 million slum dwellers exceeded the slum target
The share of urban residents in the developing world living in slums declined from 39 per cent in 2000 to 33 per cent in 2012. More than 200 million gained access to either improved water sources, improved sanitation facilities, or durable or less crowded housing. This achievement exceeds the target of significantly improving the lives of at least 100 million slum dwellers, well ahead of the 2020 deadline.

•• The world has achieved parity in primary education between girls and boys
Driven by national and international efforts and the MDG campaign, many more of the world’s children are enrolled in school at the primary level, especially since 2000. Girls have benefited the most. The ratio between the enrolment rate of girls and that of boys grew from 91 in 1999 to 97 in 2010 for all developing regions. The gender parity index value of 97 falls within the plus-or-minus 3-point margin of 100 per cent, the accepted measure for parity.

•• Many countries facing the greatest challenges have made significant progress towards universal primary education
Enrollment rates of children of primary school age increased markedly in sub-Saharan Africa, from 58 to 76 per cent between 1999 and 2010. Many countries in that region succeeded in reducing their relatively high out-of-school rates even as their primary school age populations were growing.

•• Child survival progress is gaining momentum
Despite population growth, the number of under-five deaths worldwide fell from more than 12.0 million in 1990 to 7.6 million in 2010. And progress in the developing world as a whole has accelerated. Sub-Saharan Africa—the region with the highest level of under-five mortality—has doubled its average rate of reduction, from 1.2 per cent a year over 1990-2000 to 2.4 per cent during 2000-2010.

•• Access to treatment for people living with HIV increased in all regions
At the end of 2010, 6.5 million people were receiving antiretroviral therapy for HIV or AIDS in developing regions. This total constitutes an increase of over 1.4 million people from December 2009, and the largest one-year increase ever. The 2010 target of universal access, however, was not reached.

•• The world is on track to achieve the target of halting and beginning to reverse the spread of tuberculosis
Globally, tuberculosis incidence rates have been falling since 2002, and current projections suggest that the 1990 death rate from the disease will be halved by 2015.

•• Global malaria deaths have declined
The estimated incidence of malaria has decreased globally, by 17 per cent since 2000. Over the same period, malaria-specific mortality rates have decreased by 25 per
cent. Reported malaria cases fell by more than 50 per cent between 2000 and 2010 in 43 of the 99 countries with ongoing malaria transmission.

  Inequality is detracting from these gains, and slowing advances in other key areas
Achievements were unequally distributed across and within regions and countries. Moreover, progress has slowed for some MDGs after the multiple crises of 2008-2009.

•• Vulnerable employment has decreased only marginally over twenty years
Vulnerable employment—defined as the share of unpaid family workers and own-account workers in total employment—accounted for an estimated 58 per cent of all employment in developing regions in 2011, down only moderately from 67 per cent two decades earlier. Women and youth are more likely to find themselves in such insecure and poorly remunerated positions than the rest of the employed population.

•• Decreases in maternal mortality are far from the 2015 target
There have been important improvements in maternal health and reduction in maternal deaths, but progress is still slow. Reductions in adolescent childbearing and expansion of contraceptive use have continued, but at a slower pace since 2000 than over the decade before.

•• Use of improved sources of water remains lower in rural areas
While 19 per cent of the rural population used unimproved sources of water in 2010, the rate in urban areas was only 4 per cent. And since dimensions of safety, reliability and sustainability are not reflected in the proxy indicator used to track progress towards the MDG target, it is likely that these figures overestimate the actual number of people using safe water supplies. Worse, nearly half of the population in developing regions—2.5 billion—still lacks access to improved sanitation facilities. By 2015, the world will have reached only 67 per cent coverage, well short of the 75 per cent needed to achieve the MDG target.

•• Hunger remains a global challenge
The most recent FAO estimates of undernourishment set the mark at 850 million living in hunger in the world in the 2006/2008 period—15.5 per cent of the world population. This continuing high level reflects the lack of progress on hunger in several regions, even as income poverty has decreased. Progress has also been slow in reducing child undernutrition. Close to one third of children in Southern Asia were underweight in 2010.

•• The number of people living in slums continues to grow
Despite a reduction in the share of urban populations living in slums, the absolute number has continued to grow from a 1990 baseline of 650 million. An estimated 863 million people now live in slum conditions.

   In the years ahead, we have the opportunity to achieve more and to shape the agenda for our future
The 2015 deadline is fast approaching. The contributions of national Governments, the international community, civil society and the private sector will need to intensify as we take on the longstanding and long-term challenge of inequality, and press forward on food security, gender equality, maternal health, rural development, infrastructure and environmental sustainability, and responses to climate change. A new agenda to continue our efforts beyond 2015 is taking shape. The MDG campaign, with its successes as well as setbacks, provides rich experience on which this discussion can draw, as well as confidence that further success is feasible.

•• Gender equality and women’s empowerment are key
Gender inequality persists and women continue to face discrimination in access to education, work and economic assets, and participation in government. Violence against women continues to undermine efforts to reach all goals. Further progress to 2015 and beyond will largely depend on success on these interrelated challenges.

•• MDG progress shows the power of global goals and a shared purpose
The MDGs have been a fundamental framework for global development. A clear agenda, with measurable goals and targets, and a common vision have been crucial for this
success. There is now an expectation around the world that sooner, rather than later, all these goals can and must be achieved. Leaders will be held to this high standard.

Sectors such as government, business, academia and civil society, often known for working at cross-purposes, are learning how to collaborate on shared aspirations. The comprehensive statistics and clear analysis in this year’s MDG Report give us all a good idea of where our efforts should be directed.
Sha Zukang
Under-Secretary-General for Economic and Social Affairs

Vaccine programmes must consider their effect on general resistance

British Medical Journal
07 July 2012 (Vol 345, Issue 7864)
http://www.bmj.com/content/345/7864

Analysis
Vaccine programmes must consider their effect on general resistance
BMJ 2012; 344 doi: 10.1136/bmj.e3769 (Published 14 June 2012)
Cite this as: BMJ 2012;344:e3769
Peter Aaby, Hilton Whittle, Christine Stabell Benn,

Extract
   Recent randomised trials have shown that live vaccines such as measles and BCG enhance general resistance, preventing other infections as well as the target infection.   However, current vaccination strategies assume a proportionate response. Peter Aaby, Hilton Whittle, and Christine Stabell Benn argue that we need to rethink our approach

Global health leaders have committed to making 2010-19 the decade of vaccines, with the aim of ensuring that lifesaving vaccines are available globally. The Bill and Melinda Gates Foundation pledged $10bn (£6.5bn; €8bn) to the new decade,1 which was established in recognition of the astonishing technological progress in developing new vaccines and our ethical obligation to make these vaccines available to all children in the poorest countries of the world.1 2 w1-8 The ultimate goal is to save lives, and vaccination programmes measure potential impact in terms of the lives saved.1 2 w1

Surprisingly, therefore, there are few observational studies and virtually no randomised clinical trials documenting the effect on child mortality of any of the existing vaccines. A notable exception is the high titre measles vaccine, which was withdrawn because an interaction with diphtheria-tetanus-pertussis (DTP) vaccine resulted in a 33% (95% confidence interval 2% to 73%) increase in mortality among children aged 4-60 months in several west African randomised trials.3 w9 Among the newer vaccines, conjugate pneumococcal vaccine has been found to be associated with an 11% (−1% to 21%) reduction in mortality in a meta-analysis.4

The lack of data on mortality is not considered a problem. If a vaccine is shown to produce immunity against a specific disease, the effect on survival is estimated using the burden of disease, and the efficacy and the coverage of the specific vaccine. For example, if rotavirus causes 527 000 annual deaths, 90% occurring in low income …

WHO essential medicines for children in Guatemala: availability, prices and affordability

Globalization and Health
[Accessed 7 July 2012]
http://www.globalizationandhealth.com/

Research
Availability, prices and affordability of the World Health Organization’s essential medicines for children in Guatemala
Angela Anson, Brooke Ramay, Antonio Ruiz de Esparza and Lisa Bero

Abstract (provisional)
Background
Several World Health Organization (WHO) initiatives aim to improve the accessibility of safe and effective medicines for children. A first step in achieving this goal is to obtain a baseline measure of access to essential medicines. The objective of this project was to measure the availability, prices, and affordability of children’s medicines in Guatemala.

Methods
An adaption of the standardized methodology developed by the World Health Organization and Health Action International (HAI) was used to conduct a cross sectional survey to collect data on availability and final patient prices of medicines in public and private sector medicine outlets during April and May of 2010.

Results
A subset of the public sector, Programa de Accesibilidad a los Medicamentos (PROAM), had the lowest average availability (25%) compared to the private sector (35%). In the private sector, highest and lowest priced medicines were 22.7 and 10.7 times more expensive than their international reference price comparison. Treatments were generally unaffordable, costing as much as 15 days wages for a course of ceftriaxone.

Conclusions
Analysis of the procurement, supply and distribution of specific medicines is needed to determine reasons for lack of availability. Improvements to accessibility could be made by developing an essential medicines list for children and including these medicines in national purchasing lists.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Health and Human Rights- Call for Submissions – Special Issue on Proposed Framework Convention on Global Health

Health and Human Rights
Vol 14, No 1 (2012)
http://hhrjournal.org/index.php/hhr
[Reviewed earlier]

Call for Submissions: Special Issue on Proposed Framework Convention on Global Health
Health and Human Rights, a peer-reviewed open access journal under the editorship of Partners in Health co-founder Paul Farmer, is published semi-annually, with new issues released in June and December. From 2012, selected papers in press are available prior to issue publication, thereby fast-tracking access to new research and enabling authors to cite their work. Submissions are welcomed at any time.

Health and Human Rights will be publishing a special issue in June 2013 on a proposed Framework Convention on Global Health (FCGH). An FCGH would be based in the right to health and aimed at reducing national and global health inequities. It would ensure universal health coverage, establish a framework for sufficient and sustained funding, improve accountability, raise the priority of health in other legal regimes, and meet major challenges in global governance for health, such as poor coordination. For more information, please see the website for the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI): http://www.jalihealth.org.

Human Vaccines: Special Focus – Meningococcal Vaccine Development

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 7  July 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/7/

Special Focus: Meningococcal Vaccine Development
RESEARCH PAPERS  [Open Access Articles]
The immunogenicity and safety of an investigational meningococcal serogroups A, C, W-135, Y tetanus toxoid conjugate vaccine (ACWY-TT) compared with a licensed meningococcal tetravalent polysaccharide vaccine: A randomized, controlled non-inferiority study
Ghassan Dbaibo, Noel Macalalad, Mari Rose Aplasca-De Los Reyes, Efren Dimaano, Veronique Bianco, Yaela Baine and Jacqueline Miller
http://dx.doi.org/10.4161/hv.20211
Abstract | Full Text | PDF

The investigational meningococcal serogroups A, C, W-135, Y tetanus toxoid conjugate vaccine (ACWY-TT) and the seasonal influenza virus vaccine are immunogenic and well-tolerated when co-administered in adults
Mari Rose Aplasca-De Los Reyes, Efren Dimaano, Noel Macalalad, Ghassan Dbaibo, Veronique Bianco, Yaela Baine and Jacqueline Miller
http://dx.doi.org/10.4161/hv.20212
Abstract | Full Text | PDF

A Phase 1, randomized, open-label, active-controlled trial to assess the safety of a meningococcal serogroup B bivalent rLP2086 vaccine in healthy adults
Eric Sheldon, Howard Schwartz, Qin Jiang, Peter Giardina and John Perez
Abstract | Full Text

Review: Effectiveness and harms of seasonal and pandemic influenza vaccines in children, adults and elderly

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 7  July 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/7/

REVIEW
Effectiveness and harms of seasonal and pandemic influenza vaccines in children, adults and elderly: A critical review and re-analysis of 15 meta-analyses
Lamberto Manzoli, John P.A. Ioannidis, Maria Elena Flacco, Corrado De Vito and Paolo Villari

Abstract:
Fifteen meta-analyses have been published between 1995 and 2011 to evaluate the efficacy/effectiveness and harms of diverse influenza vaccines—seasonal, H5N1 and 2009(H1N1) —in various age-classes (healthy children, adults or elderly). These meta-analyses have often adopted different analyses and study selection criteria. Because it is difficult to have a clear picture of vaccine benefits and harms examining single systematic reviews, we compiled the main findings and evaluated which could be the most reasonable explanations for some differences in findings (or their interpretation) across previously published meta-analyses. For each age group, we performed analyses that included all trials that had been included in at least one relevant meta-analysis, also exploring whether effect sizes changed over time. Although we identified several discrepancies among the meta-analyses on seasonal vaccines for children and elderly, overall most seasonal influenza vaccines showed statistically significant efficacy/effectiveness, which was acceptable or high for laboratory-confirmed cases and of modest magnitude for clinically-confirmed cases. The available evidence on parenteral inactivated vaccines for children aged < 2 y remains scarce. Pre-pandemic “avian” H5N1 and pandemic 2009 (H1N1) vaccines can achieve satisfactory immunogenicity, but no meta-analysis has addressed H1N1 vaccination impact on clinical outcomes. Data on harms are overall reassuring, but their value is diminished by inconsistent reporting.

Commentary: Inactivated Polio Vaccine – Time to introduce it in India’s national immunization schedu

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 7  July 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/7/

Commentary
Inactivated Polio Vaccine: Time to introduce it in India’s national immunization schedule
Ramesh Verma, Pardeep Khanna and Suraj Chawla
http://dx.doi.org/10.4161/hv.20089

Abstract:
Polio is a communicable disease caused by poliovirus that may attack nerve cells of the brain and spinal cord. The victims develop neurological complications, likes stiffness of the neck, muscular weakness, or paralysis of one or more limbs. In severe cases, it may be fatal due to respiratory paralysis. The world has seen tremendous gains in polio eradication over the past year. India and Nigeria saw a reduction in cases of almost 95% from 2009 to 2010, and cases of wild poliovirus type 3 (WPV3) fell by 92% globally over the same period. In fact, no case has been reported in India since February 2011, such that India may be on the verge of eradicating polio. Nevertheless, polio control experts are particularly worried about Vaccine-Derived Poliovirus (VDPV). Global surveillance efforts picked up 430 cases of VDPV from several countries between July 2009 and March 2011. In India, 7 cases of VDPV were reported during the year 2011. As long as OPV is used, virologists say that the world is at risk of VDPV causing polio in unprotected children. Achieving a polio-free world will require the “cessation of all OPV” and with it the elimination of the risk of vaccine-associated paralytic polio (VAPP) or VDPV infections. To this effect, in 2011 the Global Polio Eradication Initiative (GPEI) will produce and develop a new roadmap for VDPV Elimination. Several countries have shifted from all OPV to sequential OPV-IPV schedules and all-IPV schedules with elimination of live poliovirus. IPV will be indispensable in the post-eradication era when use of OPV has to stop but “vaccination against polio” cannot stop. IPV offers complete individual protection and has been considered as an additional tool at present for those who can afford the vaccine, and since we are nearing the eradication of polio, it is time to shift from OPV to sequential OPV-IPV schedule in India. Such a strategy will avoid inevitable problems with VAPP.

Report from the field: Fifth vaccine renaissance

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 7  July 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/7/

SPECIAL FOCUS COMMENTARIES
Report from the field: Fifth vaccine renaissance in Providence RI
Denice Spero, Nikolai Petrovsky and Annie De Groo

Abstract:
Emerging and re-emerging infectious diseases represent a major challenge to vaccine development since it involves two seemingly contradictory requirements. Rapid and flexible vaccine generation while using technologies and processes that can facilitate accelerated regulatory review. Development in the “-omics” in combination with advances in vaccinology offer novel opportunities to meet these requirements. Here we describe how a consortium of five different organizations from academia and industry is addressing these challenges. This novel approach has the potential to become the new standard in vaccine development allowing timely deployment to avert potential pandemics.

Lancet Comment: Mass gatherings medicine and global health security

The Lancet  
Jul 07, 2012  Volume 380  Number 9836  p1 – 74
http://www.thelancet.com/journals/lancet/issue/current

Comment
Mass gatherings medicine and global health security
Abdullah Al Rabeeah, Ziad A Memish, Alimuddin Zumla, Shuja Shafi, Brian McCloskey, Ahmad Moolla, Maurizio Barbeschi, David Heymann, Richard Horton

Preview
Mass gatherings continue to draw ever larger crowds from all corners of the globe.1 Although these events offer great potential for a health legacy through intense periods of unprecedented focus and funding for improvements in health systems, they pose several significant public health challenges to health and security authorities both within the host country and abroad.2,3 There is no existing global consensus or evidence base regarding the most effective public health measures that are required to be in place within the host country.

Disease outbreaks: Support for a cholera vaccine stockpile

Nature  
Volume 487 Number 7405 pp5-134  5 July 2012
http://www.nature.com/nature/current_issue.html

Correspondence
Disease outbreaks: Support for a cholera vaccine stockpile
Agnes Binagwaho, Thierry Nyatanyi, Cameron T. Nutt & Claire M. Wagner
doi:10.1038/487039c
Published online
04 July 2012

Extract
As researchers and policy-makers in Rwanda’s health sector, we congratulate Guinea and Haiti on integrating oral cholera vaccination into their regular control efforts during epidemics (see Nature http://doi.org/h2c; 2012). Rwanda has also learned valuable lessons about the costs of inaction from the world’s delayed response to cholera outbreaks in post-earthquake…

Nucleic acid sensing at the interface between innate and adaptive immunity in vaccination

Nature Reviews Immunology
July 2012 Vol 12 No 7
http://www.nature.com/nri/journal/v12/n7/index.html

Reviews
Nucleic acid sensing at the interface between innate and adaptive immunity in vaccination
Christophe J. Desmet & Ken J. Ishii
p479 | doi:10.1038/nri3247

Extract
It is becoming increasingly clear that the activation of the innate immune system by host or microbial nucleic acids contributes to the immunogenicity of many vaccines. This article describes the receptors and signalling pathways that are involved in sensing nucleic acids and discusses the implications for current and future vaccination strategies.

The demand is currently high for new vaccination strategies, particularly to help combat problematic intracellular pathogens, such as HIV and malarial parasites. In the past decade, the identification of host receptors that recognize pathogen-derived nucleic acids has revealed an essential role for nucleic acid sensing in the triggering of immunity to intracellular pathogens. This Review first addresses our current understanding of the nucleic acid-sensing immune machinery. We then explain how the study of nucleic acid-sensing mechanisms not only has revealed their central role in driving the responses mediated by many current vaccines, but is also revealing how they could be harnessed for the design of new vaccines.

Early Vaccinations Not Risk Factor for Celiac Disease

Pediatrics
July 2012, VOLUME 130 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Articles
Early Vaccinations Are Not Risk Factors for Celiac Disease
Anna Myléus, Hans Stenlund, Olle Hernell, Leif Gothefors, Marie-Louise Hammarström, Lars-Åke Persson, and Anneli Ivarsson
Pediatrics 2012; 130:e63-e70

Abstract
OBJECTIVES: To investigate if changes in the national Swedish vaccination program coincided with changes in the celiac disease (CD) incidence rate in infants (ie, the Swedish CD Epidemic), and to assess the potential association between these vaccinations and CD risk.

METHODS: All studies were based on the National Swedish Childhood Celiac Disease Register. Using an ecological approach, we plotted changes over time in the national vaccination program in the graph displaying CD incidence rate. A population-based incident case-referent study of invited infants was performed. Exposure information was received through a questionnaire and child health clinic records. Vaccines explored were diphtheria/tetanus, pertussis (acellular), polio (inactivated), Haemophilus influenzae type b (conjugated), measles/mumps/rubella, and live attenuated bacillus Calmette-Guérin (BCG) in children with increased tuberculosis risk. Findings were subjected to a birth cohort analysis.

RESULTS: Introduction of pertussis vaccine coincided in time with decreasing CD incidence rates. In the infant case-referent study, however, neither vaccination against pertussis (odds ratio 0.91; 95% confidence interval 0.60–1.4), nor against Haemophilus influenzae type b or measles/mumps/rubella was associated with CD. Coverage for the diphtheria/tetanus and polio vaccines was 99%. BCG was associated with reduced risk for CD (adjusted odds ratio 0.54; 95% confidence interval 0.31–0.94). Discontinuation of general BCG vaccination did not affect the cumulative incidence of CD at age 15 years.

CONCLUSIONS: Early vaccinations within the national Swedish program were not associated with CD risk, nor could changes in the program explain the Swedish epidemic. A protective effect by BCG was suggested, which could be subject to further studies.

Frequency of Alternative Immunization Schedule Use in a Metropolitan Area

Pediatrics
July 2012, VOLUME 130 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Articles
Frequency of Alternative Immunization Schedule Use in a Metropolitan Area
Steve G. Robison, Holly Groom, and Collette Young
Pediatrics 2012; 130:32-38

Abstract
OBJECTIVES: Recent studies have described an increase in parental hesitancy regarding vaccines as well as increases in parental adoption of vaccine schedules that delay or limit receipt of recommended vaccines. This study quantifies potential prevalence and trends in alternative schedule compliance by measuring consistent shot-limiting in a metropolitan area of Oregon.

METHODS: Retrospective cohort analysis using the Oregon ALERT Immunization Information System to track children born between 2003 and 2009 in the Portland metropolitan area. Joinpoint regression was used to analyze prevalence trends in consistent shot-limiting during that time period. The 2007–2009 Haemophilusinfluenzae type b vaccine shortage and increased availability of combination vaccines were also examined for their effects on shot-limiting rates.

RESULTS: A total of 4502 of 97 711 (4.6%) children met the definition of consistent shot-limiters. The proportion of consistent shot-limiters in the population increased from 2.5% to 9.5% between 2006 and 2009. Compared with those with no or episodic limiting, consistent shot-limiters by 9 months of age had fewer injections (6.4 vs 10.4) but more visits when immunizations were administered (4.2 vs 3.3). However, only a small minority of shot-limiters closely adhered to published alternative schedules.

CONCLUSIONS: The percentage of children consistently receiving 2 or fewer vaccine injections per visit between birth and age 9 months increased threefold within a 2-year period, suggesting an increase in acceptance of non–Advisory Committee on Immunization Practices vaccine schedules in this geographic

Participant Informed Consent in Cluster Randomized Trials: Review

PLoS One
[Accessed 7 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Participant Informed Consent in Cluster Randomized Trials: Review
Bruno Giraudeau, Agnès Caille, Amélie Le Gouge, Philippe Ravaud treatment
PLoS ONE: Research Article, published 06 Jul 2012 10.1371/journal.pone.0040436

Abstract 
Background
The Nuremberg code defines the general ethical framework of medical research with participant consent as its cornerstone. In cluster randomized trials (CRT), obtaining participant informed consent raises logistic and methodologic concerns. First, with randomization of large clusters such as geographical areas, obtaining individual informed consent may be impossible. Second, participants in randomized clusters cannot avoid certain interventions, which implies that participant informed consent refers only to data collection, not administration of an intervention. Third, complete participant information may be a source of selection bias, which then raises methodological concerns. We assessed whether participant informed consent was required in such trials, which type of consent was required, and whether the trial was at risk of selection bias because of the very nature of participant information.

Methods and Findings
We systematically reviewed all reports of CRT published in MEDLINE in 2008 and surveyed corresponding authors regarding the nature of the informed consent and the process of participant inclusion. We identified 173 reports and obtained an answer from 113 authors (65.3%). In total, 23.7% of the reports lacked information on ethics committee approval or participant consent, 53.1% of authors declared that participant consent was for data collection only and 58.5% that the group allocation was not specified for participants. The process of recruitment (chronology of participant recruitment with regard to cluster randomization) was rarely reported, and we estimated that only 56.6% of the trials were free of potential selection bias.

Conclusions
For CRTs, the reporting of ethics committee approval and participant informed consent is less than optimal. Reports should describe whether participants consented for administration of an intervention and/or data collection. Finally, the process of participant recruitment should be fully described (namely, whether participants were informed of the allocation group before being recruited) for a better appraisal of the risk of selection bias.