Progress toward Global Reduction in Under-Five Mortality: A Bootstrap Analysis of Uncertainty in Millennium Development Goal 4 Estimates

PLoS Medicine
(Accessed 15 December 2012)

Progress toward Global Reduction in Under-Five Mortality: A Bootstrap Analysis of Uncertainty in Millennium Development Goal 4 Estimates
Leontine Alkema, Jin Rou
New Research Article, published 11 Dec 2012

Millennium Development Goal 4 calls for an annual rate of reduction (ARR) of the under-five mortality rate (U5MR) of 4.4% between 1990 and 2015. Progress is measured through the point estimates of the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). To facilitate evidence-based conclusions about progress toward the goal, we assessed the uncertainty in the estimates arising from sampling errors and biases in data series and the inferior quality of specific data series.

Methods and Findings
We implemented a bootstrap procedure to construct 90% uncertainty intervals (UIs) for the U5MR and ARR to complement the UN IGME estimates. We constructed the bounds for all countries without a generalized HIV epidemic, where a standard estimation approach is carried out (174 countries). In the bootstrap procedure, potential biases in levels and trends of data series of different source types were accounted for. There is considerable uncertainty about the U5MR, particularly for high mortality countries and in recent years. Among 86 countries with a U5MR of at least 40 deaths per 1,000 live births in 1990, the median width of the UI, relative to the U5MR level, was 19% for 1990 and 48% for 2011, with the increase in uncertainty due to more limited data availability. The median absolute width of the 90% UI for the ARR from 1990 to 2011 was 2.2%. Although the ARR point estimate for all high mortality countries was greater than zero, for eight of them uncertainty included the possibility of no improvement between 1990 and 2011. For 13 countries, it is deemed likely that the ARR from 1990 to 2011 exceeded 4.4%.

In light of the upcoming evaluation of Millennium Development Goal 4 in 2015, uncertainty assessments need to be taken into account to avoid unwarranted conclusions about countries’ progress based on limited data.

Editors’ Summary 
In September 2000, world leaders adopted the United Nations Millennium Declaration, committing member states (countries) to a new global partnership to reduce extreme poverty and improve global health by setting out a series of time-bound targets with a deadline of 2015—the Millennium Development Goals (MDGs). There are eight MDGs and the fourth, MDG 4, focuses on reducing the number of deaths in children aged under five years by two-thirds from the 1990 level. Monitoring progress towards meeting all of the MDG targets is of vital importance to measure the effectiveness of interventions and to prioritize slow progress areas. MDG 4 has three specific indicators, and every year, the United Nations Inter-agency Group for Child Mortality Estimation (the UN IGME, which includes the key agencies the United Nations Children’s Fund, the World Health Organization, the World Bank, and the United Nations Population Division) produces and publishes estimates of child death rates for all countries.

Why Was This Study Done?
Many poorer countries do not have the infrastructure and the functioning vital registration systems in place to record the number of child deaths. Therefore, it is difficult to accurately assess levels and trends in the rate of child deaths because there is limited information (data) or because the data that exists may be inaccurate or of poor quality. In order to deal with this situation, analyzing trends in under-five child death rates (to show progress towards MDG 4) currently focuses on the “best” estimates from countries, a process that relies on “point” estimates. But this practice can lead to inaccurate results and comparisons. It is therefore important to identify a framework for calculating the uncertainty surrounding these estimates. In this study, the researchers use a statistical method to calculate plausible uncertainty intervals for the estimates of death rates in children aged under five years and the yearly reduction in those rates.

What Did the Researchers Do and Find?
The researchers used the publicly available information from the UN IGME 2012 database, which collates data from a variety of sources, and a statistical method called bootstrapping to construct uncertainty levels for 174 countries out of 195 countries for which the UN IGME published estimates in 2012. This new method improves current practice for estimating the extent of data errors, as it takes into account the structure and (potentially poor) quality of the data. The researchers used 90% as the uncertainty level and categorized countries according to the likelihood of meeting the MDG 4 target.

Using these methods, the researchers found that in countries with high child mortality rates (40 or more deaths per 1,000 children in 1990), there was a lot of uncertainty (wide uncertainty intervals) about the levels and trends of death rates in children aged under five years, especially more recently, because of the limited availability of data. Overall, in 2011 the median width of the uncertainty interval for the child death rate was 48% among the 86 countries with high death rates, compared to 19% in 1990. Using their new method, the researchers found that for eight countries, it is not clear whether any progress had been made in reducing child mortality, but for 13 countries, it is deemed likely that progress exceeded the MDG 4 target.

What Do These Findings Mean?
These findings suggest that new uncertainty assessments constructed by a statistical method called bootstrapping can provide more insights into countries’ progress in reducing child mortality and meeting the MDG 4 target. As demonstrated in this study, when data are limited, uncertainty intervals should to be taken into account when estimating progress towards MDG 4 in order to give more accurate assessments on a country’ progress, thus allowing for more realistic comparisons and conclusions.

Additional Information
Please access these websites via the online version of this summary at​001355.

The UN website has more information about the Millennium Development Goals, including country-specific data

More information is available from UNICEF’s ChildInfo website about the UN IGME and child mortality

All UN IGME child mortality estimates and data are available via CME Info

Countdown to 2015 tracks coverage levels for health interventions proven to reduce child mortality and proposes new actions to reach MDG 4

Preventing Pandemics Via International Development: A Systems Approach

PLoS Medicine
(Accessed 15 December 2012)

Preventing Pandemics Via International Development: A Systems Approach
Tiffany L. Bogich, Rumi Chunara, David Scales, Emily Chan, Laura C. Pinheiro, Aleksei A. Chmura, Dennis Carroll, Peter Daszak, John S. Brownstein
Policy Forum, published 11 Dec 2012

Summary Points
The way in which public health programs are designed and funded has changed significantly; however, the trend toward establishing vertical, disease-specific global health programs may be at the cost of strengthening basic public health infrastructure and development in the long term.

In a review of nearly 400 public health events of international concern, we found that a breakdown or absence of public health infrastructure was the driving factor in the largest fraction of outbreaks (39.5%). No single other driving factor accounted for more than 10% of outbreaks.

The relative roles of emergency response versus long-term development strategies to mitigate infectious disease threats are being debated within bilateral and intergovernmental aid agencies.

We propose a systems approach within development agencies to address pandemic prevention at the intersection of people and their environment where the risk of disease emergence is highest. To achieve this goal, mainstream development funding, rather than emergency funding, is required.

Factors Predicting Completion of the Human Papillomavirus Vaccine Series

Journal of Adolescent Health
Article in Press

Factors Predicting Completion of the Human Papillomavirus Vaccine Series
Rachel Gold, Allison Naleway, Karen Riedlinger,
Received 16 May 2012; accepted 14 September 2012. published online 11 December 2012.
Corrected Proof

This study identified factors associated with completion of the three dose quadrivalent human papillomavirus vaccine (HPV4) series by female adolescents.

Between February and September 2008, we prospectively surveyed 11- to 26-year-old female members of an integrated managed care organization shortly after their first HPV4 dose to identify factors that predicted series completion. We used regression analyses to assess whether self-reported experiences at the index visit, knowledge/attitudes about HPV and HPV4, and medical record data on adverse events, demographic characteristics, care-utilization frequency, and visit characteristics, were associated with vaccine series completion within one year of the first HPV4 dose.

Of 899 survey respondents (27% of 3347 survey recipients), 786 (87%) maintained continuous enrollment in the health plan in the year following the first HPV4 dose. Fifty percent (n = 393) completed the vaccine series within that year. In multivariate analyses of survey respondents, only respondents’ ability to correctly identify the number of shots required for series completion was significantly associated with series completion. Reported bruising was associated with decreased likelihood of completion, and the clinician stating that future shots were required was associated with increased likelihood, but both were of borderline significance. Females ages 16–20 had the lowest series completion.


Improving HPV4 completion will require targeted efforts. Our results suggest that providers may help by stressing the need for additional doses of vaccine, and confirming that patients understand this information. Special attention should be given to females ages 16–20. Future randomized trials should assess the effect on vaccine completion of these simple, low-cost interventions.

Twitter Watch [accessed 15 December 2012 – 18:54]

Twitter Watch [accessed 15 December 2012 – 18:54]
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.

CVEP @VaxEthicsPolicy
@MSF_USA @dndi_hq Center for Vaccine Ethics & Policy applauds the extraordinary #fatalneglect conference: compelling, alarming, energizing.
11:28 AM – 14 Dec 12

Doctors w/o Borders @MSF_USA
Thank you for following our #fatalneglect conference. See highlights from our discussion here:  #globalhealth #ntds
By Doctors w/o Borders @MSF_USA
A two-day conference in New York City on delivering medical innovations for neglected patients and populations. Hosted by Doctors Without Borders/Médecins Sans Frontières (MSF) and the Drugs for…
10:26 AM – 14 Dec 12

PAHO/WHO @pahowho
Rt @TheLancet: The Lancet publishes largest ever study on global burden of disease. Freely available online  #GBD2010
6:43 AM – 14 Dec 12

PAHO/WHO @pahowho
Rt @WHO: 10 facts on the state of #globalhealth: the loss of health from all causes of illness and deaths worldwide 
5:31 AM – 14 Dec 12

Global Health Observatory – free access to world’s largest and most comprehensive collection of up-to-date health data 
3:52 AM – 14 Dec 12

The Global Fund @globalfundnews
Japan’s 2012 Contribution to the Global Fund is the Highest it Has Ever Made 
3:29 AM – 14 Dec 12

M&R Initiative ‏@MeaslesRubella
Nepal: > 5.5 million children will be #immunized in 3rd phase of #measles & #rubella #vaccination drive starting today. 
11:35 PM – 13 Dec 12

M&R Initiative ‏@MeaslesRubella
#Pakistan: 20 children die with more 100 undergoing treatment after outbreak of #measles in rain-affected #Khanpur. 
11:32 PM – 13 Dec 12

Only 34 countries produce high-quality data on causes of #death; WHO works closely w/ developing countries to improve health info systems
9:22 AM – 13 Dec 12

Vaccines: The Week in Review – 8 December 2012

Editor’s Notes:

Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to

pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_8 December 2012

Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

Support: If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary. Thank you…

Measles and polio vaccination campaign targets 2.5 million children in the Syrian Arab Republic

Media Release: Measles and polio vaccination campaign targets 2.5 million children in the Syrian Arab Republic

A vaccination campaign is under way in the Syrian Arab Republic to immunize children under 5 against polio and measles.

The campaign is being implemented by the Ministry of Health with support from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). In addition to the vaccines provided by the Ministry of Health, UNICEF procured 1.5 million doses of measles vaccine and WHO provided doses of infant paracetamol and multivitamin syrup. The Ministry of Health has increased its advocacy messages in the media to create awareness about the campaign throughout the country.

The total under-five population in the Syrian Arab Republic is almost 2.5 million children and the aim of the campaign is to reach every child, vaccinating all children below the age of five against polio and 2 million children against measles.

Due to escalations in the conflict, the national vaccination coverage for the first quarter of 2012 dropped from 95% to 80%, and it is expected to have dropped even further since then.    Challenges in implementing the national immunization programme include difficulties in maintaining the cold chain (leading to destroyed vaccines) and reaching children in areas where access is limited due to blocked roads and security issues. Many vaccination and supply vehicles have been damaged or affected, resulting in critical shortages of transportation for the vaccines.

An estimated 4000 health workers and volunteers are participating in the campaign taking place across 13 of the country’s 14 governorates from 26 November to 10 December. The governorate of Deir El Zor was not included in the campaign as the majority of its residents have relocated to other areas in the country.

Field staff working on the campaign have reported that some areas where children live are inaccessible due to the ongoing conflict. Othman Mohamed, field worker and supervisor of the Damascus field teams, said that despite restrictions in accessibility, the teams have so far managed to reach all children targeted to date. Eight mobile teams are responsible for vaccinations in Damascus, including one team dedicated to reaching internally displaced persons living in shelters. Mohamed reports that an average of 12 000 children are being vaccinated daily by the mobile teams, as well as in health centres and preschools in the city.

The Ministry of Health has requested assistance from WHO in delivering vaccines to heavily affected areas. WHO has distributed 650 000 vaccine doses to areas in Aleppo, Homs and Rural Damascus where the Ministry has restricted access.

Three days after the launch of the campaign, WHO visited two health centres and a medical point located in Adraa, Rural Damascus, an area hosting 200 000 internally displaced persons. WHO reported that despite health staff being overburdened with an extremely high workload, the campaign at the facilities was well managed and vaccines were available and well stored. Almost 500 children were visiting the facilities every day, including many who had not been previously vaccinated.


UNICEF: Amid conflict and displacement, Syrian children receive lifesaving vaccinations  Mobile teams reach displaced children in shelters
DAMASCUS, 7 December 2012 – An emergency vaccination campaign is under way in Syria to protect young children against measles and polio, diseases that can spread rapidly – and sometimes with fatal results – in times of conflict and displacement.

The campaign – targeting 1.4 million children in all – has faced unusual challenges: With key roads blocked and fighting in many parts of the country, getting vital vaccine supplies to towns where they were needed has been both dangerous and difficult.

“The toughest job has been for the drivers who have had to collect supplies in Damascus and then deliver them, often by circuitous routes, to campaign workers across the country,” said Iman Bahnasi, Child Survival and Development specialist with UNICEF Syria. “But thanks to their determination and courage, all governorates have received the supplies they need.”

Data received from 11 of Syria’s 14 governorates show that since the campaign started on 26 November, more than 630,000 children aged under five have already received polio drops, while over 510,000 children aged 1 to 5 years have been vaccinated against measles.

Children over one year of age are also receiving a dose of Vitamin A, which contributes to reducing morbidity due to acute respiratory infections and diarrhoea…

[Editor’s Note: The most recent SAGE meeting (Geneva, 6-8 November 2012) session titled  “Vaccination in humanitarian emergencies session” may be of interest to readers. The draft document discussed at the session is posted on the WHO SAGE site and available here:
Vaccination in acute emergencies: A framework for decision-making, 23 October 2012
pdf, 1.66Mb

GAVI: Alliance Partners Forum 2012 – Documentation

GAVI: Alliance Partners Forum
5-7 December 2012, Dar es Salaam, Tanzania
More than 650 global health and government leaders exploring ways to accelerate Results, Innovation, Sustainability and Equity [RISE] in the field of immunisation.

This page – – provides a single, integrated source of content associated with the Forum. Please see Seth Berkley’s opening plenary excerpts just below and, further below, media releases issued by GAVI during the week.

Speech: GAVI Past, Present and Future – GAVI CEO Seth Berkley
Excerpts from GAVI

About the Baobab tree, the Forum’s symbol: “the baobab tree has a special significance in Africa. It’s revered. People gather under its branches to discuss important issues and talk to their ancestors. This Forum is a time for us to come together and discuss. We should start with our founders and the question is how are we doing. I think we are living up to their vision. As of 2014, every single GAVI country will be using the DTP3 vaccine. It is a routine vaccine and that is what we are trying to do.”

Rollout of pneumococcal vaccine: it‘s an extraordinary story that this vaccine (pneumococcal) was made available in developing countries about a year and a half after it became available in high-income countries. The ultimate goal would be simultaneous introduction in north and south. That’s what we want. Never again will a company have a life-saving vaccine and ask ‘when’ will it reach a developing country. The question should only be ‘how’.

On the heroic efforts of health workers in developing countries: health workers do whatever it takes to get the vaccines out there … camels, donkeys .. It’s heroic. It’s getting the vaccine into her hands so she can vaccinate and it’s going to lead to healthy children in school.”

The fully immunised child: WHO recommends that every child has 11 antigens: BCG, DTP3 (diphtheria-tetanus-pertussis), measles, polio, hepatitis B, Haemophilus influenzae type b, pneumococcal, rotavirus, rubella and human papillomavirus.

So should we be looking at DTP3 or the fully immunised child as an indicator of immunisation coverage? What we want is every child, everywhere protected by the full number of antigens.     Conceptually, this is where we want to go. If we want to do this, current estimates predict that by 2030, only 50 percent of children will be fully immunised. This is not good enough; we need to reset our aspirations.

Technology: we also need to use technology. Every village household has one cell phone in it and often two or more. Why is it that we are not looking at vaccine stock using GPS, so a flashing red light on an interactive map tells us immediately there is a stock problem in a local health clinic. This is not far fetched. This is what is happening in most of the world for supply chains. We just haven’t used it in immunisation.

Inconsistency in immunisation data: can we measure immunisation rates? Our numbers really aren’t very tight. We’re shooting in the dark against a target, because we don’t have the tools to really allow us to understand what is happening. This is a critical goal going forward.

Flowering of our effort: when we think about the field of immunisation, we’re back to the (baobab) tree. We need to bring together all the critical parts of immunisation, to become part of routine immunisation. Something extraordinary will happen, we will see the flowering of this effort, and we will see something extraordinary happen.

Watch the video of GAVI CEO, Seth Berkley presenting his visionary speech:

Media Releases during the week of the Alliance Partners’ Forum:
06 December 2012
More than 30 million girls to be immunised with HPV vaccines by 2020 with GAVI support
The GAVI Alliance plans to work with countries to prepare them for nationwide roll outs of the vaccine against the human papillomavirus (HPV), the leading cause of cervical cancer.

05 December 2012
Immunisation protecting 370 million additional children through successful global partnership
Progress is accelerating in the global effort to protect children from infectious diseases and spread the benefits of immunisation around the world.

04 December 2012
GAVI Board reappoints Dagfinn Høybråten as chair
The GAVI Alliance Board unanimously reappointed Dagfinn Høybråten to serve a second-year term as the GAVI Board Chair.

03 December 2012
100 millionth person receives lifesaving meningitis vaccine
A revolutionary meningitis vaccine will reach the 100 millionth person this week in a region of Africa that has been plagued by deadly epidemics for more than a century. The milestone will take place in northern Nigeria, part of Africa’s “meningitis belt’, where the country is conducting its second seasonal immunisation campaign against the disease

MSF at the GAVI Alliance “Partners’ Forum” Vaccination Conference, Tanzania, December 5–7, 2012

MSF at the GAVI Alliance “Partners’ Forum” Vaccination Conference, Tanzania, December 5–7, 2012

Three new issue briefs outlining Doctors Without Borders/Médecins Sans Frontières (MSF)’s main concerns regarding the need for adapted vaccines, the need to bring vaccine prices down, and the need to address vaccine supply problems can be accessed at:

Global Fund names Norbert Hauser as Interim Inspector General

The Global Fund to Fight AIDS, Tuberculosis and Malaria named Norbert Hauser as Interim Inspector General. The announcement described Mr. Hauser as “a highly-respected lawyer and international auditor who recently retired after a distinguished 35-year career in government and financial supervision” with “extensive experience supervising financial and legal matters, (who) served until 2011 as Vice President of Germany’s Supreme Audit Institution.  His reputation for independence, integrity and honesty is unsurpassed.” Simon Bland, Chair of the Global Fund Board, said, “We could not wish for a better person than Norbert Hauser to fill this interim role.  We are delighted that he is able to provide this support to the Global Fund at the current time.”

WHO – Call for nominations: SAGE Working Group on the Decade of Vaccines Global Vaccine Action Plan (GVAP)

WHO – Call for nominations: SAGE Working Group on the Decade of Vaccines Global Vaccine Action Plan (GVAP)

Terms of reference
pdf, 99kb
Proposals for nominations should be sent by email to with Curriculum Vitae, declaration of interests and indication of expertise and no later than Friday, 25 January 2013.

WHO: Human Rights Day – 10 December 2012

WHO: Human Rights Day
10 December 2012

On 10 December 1948, the UN General Assembly adopted the Universal Declaration of Human Rights, which has become a universal standard for the promotion and protection of human rights worldwide. This year on 10 December, the international community celebrates Human Rights Day to mark the adoption of the Universal Declaration.

Related links
Human Rights Day web site

More on human rights and health

GPEI – Update: Polio this week – As of 4 Dec 2012

Update: Polio this week – As of 4 Dec 2012
Global Polio Eradication Initiative

[Editor’s Extract]
– The Regional Certification Commission of the Western Pacific met in Beijing, China, last week and confirmed the WHO Western Pacific Region’s polio-free certified status following China’s successful control of the outbreak last year in the Xinjiang Uyghur Autonomous Region. In a press release from 29 November, Dr. Shin Young-soo, WHO Regional Director for the Western Pacific, said “China’s all-out response to the polio outbreak is an inspiration to all countries in the Western Pacific to redouble efforts to have high-quality surveillance and immunization in place. It is encouraging to those places that still have polio that the right commitment, coordination and accountability

– Two new WPV cases were reported in the past week (one WPV1 from Kandahar and one WPV1 from Uruzgan), bringing the total number of WPV cases for 2012 to 33. The most recent is a WPV1 with onset of paralysis on 9 November (from Khost).
– Additionally, two circulating vaccine-derived poliovirus type 2 (cVDPV2) cases were reported (from Kandahar). Genetic sequencing is ongoing to determine their origin, and to determine if they are linked to the cVDPV2 outbreak in neighbouring Pakistan (greater Quetta, Balochistan)…

– One new WPV case was reported in the past week (WPV1 from Nasarawa), bringing the total number of WPV cases for 2012 to 111. The WPV1 from Nasarawa is the most recent in the country and had onset of paralysis on 11 November.
– The new WPV1 case from Nasarawa occurred in the new district of Doma. The state had not reported a WPV case since June 2009, indicating continuation of localized WPV transmission in infected areas and polio-free Local Government Area (LGA)…

– No new WPV cases were reported in the past week. The most recently reported WPV case occurred in Federally Administered Tribal Areas (WPV1) with onset of paralysis on 10 November. The total number of WPV cases for 2012 remains 56.
– However, 3 new cVDPV2 cases were reported in the past week from Balochistan, bringing the total number of cVDPV2 cases to 10 (all from the greater Quetta area of Balochistan). Response vaccination activities are being planned for Killa Abdullah, Pishin and Quetta for second week of December…

Horn of Africa
– Efforts are continuing to stop an ongoing cVDPV2 outbreak in Kenya and parts of Somalia (in a Somali refugee camp in Dadaab, Kenya, and Kismayo, south-central Somalia).
– Immunizations of older age groups have taken place in Dadaab. In Somalia, campaigns have been conducted in border areas with Kenya and Ethiopia, and in some areas of central Somalia (access allowing).

– Across the region, OPV continues to be added to broader humanitarian response activities.

New tactics are being explored to further boost immunity levels in and around inaccessible areas of south-central Somalia. Potential activities include focusing on people in transit to/from inaccessible areas, using local negotiators to allow safe passage of vaccination teams to inaccessible areas, and immunizing populations bordering inaccessible areas…

Project: Global Burden of Disease – Launch

Global Burden of Disease Launch
December 14, 2012

About the launch
On December 14, 2012 The Lancet together with the Institute for Health Metrics and Evaluation (IHME) will host an event to present the findings of the 2010 GBD study. The launch of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 results will feature discussion of comparable estimates of mortality, causes of death, years lived with disability (YLDs), and disability-adjusted life years (DALYs) for 291 conditions and 67 risk factors, for 21 regions and three time periods – 1990, 2005, and 2010. The results reveal substantial shifts in the burden of disease from children to younger adults, from premature mortality to morbidity and disability, from communicable, maternal, neonatal and nutritional conditions to noncommunicable diseases. Overlaid on these major shifts are important regional variations and the ongoing challenge in sub-Saharan Africa of conditions related to Millennium Development Goals 4, 5, and 6.

Details of the event
This free one-day event is open to the public and will feature five panel sessions with the opportunity for open discussion of key findings and implications. The event will occur from 9:00am to 5:30pm at the Royal Society 6-9 Carlton House Terrace, London SW1Y 5AG, with coffee and tea available at 8:30am, and a reception following at the same location, from 5:30pm to 7:00pm. No registration is required.
If you are unable to attend the event, a live webcast of each session can be viewed by clicking on the link. Choose which sessions you would like to attend from the preliminary agenda below. Full agenda available here.

HHS Conference: 2012 Science of Eliminating Health Disparities Summit

Conference: 2012 Science of Eliminating Health Disparities Summit
December 17 to Wednesday, December 19, 2012
Gaylord National Resort and Convention Center
201 Waterfront Street, National Harbor, MD 20745

The U.S. Department of Health and Human Services (HHS) under the leadership of the National Institutes of Health (NIH) through the National Institute on Minority Health and Health Disparities (NIMHD), in partnership with:

   HHS agencies and offices: Food and Drug Administration, Agency for Healthcare Quality and Research, Centers for Disease Control and Prevention, Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration; Indian Health Service, Centers for Medicare and Medicaid Services, Administration for Children and Families, Office of the Assistant Secretary for Health, Office of Minority Health, Office of the Surgeon General, Office of Global Affairs, and

   Other federal agencies: The Environmental Protection Agency, the U.S. Departments of State, Defense, Agriculture, Housing and Urban Development, Transportation, Veterans Affairs, Education, Labor, and Justice, and their many grantees, constituents, and partners in the public and private sector. The 2012 Science of Eliminating Health Disparities Summit is the leading scientific gathering on health disparities. Thousands of participants will attend approximately 100 sessions to exchange new knowledge, and learn about progress, successes, challenges, and opportunities in implementing innovative research. Sessions will also feature practice and policy interventions to inform health disparities science, and highlight the power and impact of multi-sector partnerships in tackling the social, behavioral, environmental, economic, and biological factors that cause health disparities. The theme is Building a Healthier Society: Integrating Science, Practice, and Policy.

Health Care Provider Recommendation, HPV Vaccination, and Race/Ethnicity in the US National Immunization Survey

American Journal of Public Health
Volume 103, Issue 1 (January 2013)

Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/Ethnicity in the US National Immunization Survey
Kelly R. Ylitalo, Hedwig Lee, Neil K. Mehta
American Journal of Public Health: January 2013, Vol. 103, No. 1: 164–169.

Objectives. Human papillomavirus (HPV) is a common sexually transmitted infection in the United States, yet HPV vaccination rates remain relatively low. We examined racial/ethnic differences in the prevalence of health care provider recommendations for HPV vaccination and the association between recommendation and vaccination.

Methods. We used the 2009 National Immunization Survey–Teen, a nationally representative cross-section of female adolescents aged 13 to 17 years, to assess provider-verified HPV vaccination (≥ 1 dose) and participant-reported health care provider recommendation for the HPV vaccine.

Results. More than half (56.9%) of female adolescents received a recommendation for the HPV vaccine, and adolescents with a recommendation were almost 5 times as likely to receive a vaccine (odds ratio = 4.81; 95% confidence interval = 4.01, 5.77) as those without a recommendation. Racial/ethnic minorities were less likely to receive a recommendation, but the association between recommendation and vaccination appeared strong for all racial/ethnic groups.

Conclusions. Provider recommendations were strongly associated with HPV vaccination. Racial/ethnic minorities and non-Hispanic Whites were equally likely to obtain an HPV vaccine after receiving a recommendation. Vaccine education efforts should target health care providers to increase recommendations, particularly among racial/ethnic minority populations.

Childhood immunization rates in rural Intibuca, Honduras: assessing and improving vaccine coverage

BMC Public Health
(Accessed 8 December 2012)

Research article
Childhood immunization rates in rural Intibuca, Honduras: An analysis of a local database tool and community health center records for assessing and improving vaccine coverage
Yuan He, Alan Zarychta, Joseph B Ranz, Mary Carroll, Lori M Singleton, Paria M Wilson, Elizabeth P Schlaudecker BMC Public Health 2012, 12:1056 (7 December 2012)

Abstract (provisional)
Vaccines are highly effective at preventing infectious diseases in children, and prevention is especially important in resource-limited countries where treatment is difficult to access. In Honduras, the World Health Organization (WHO) reports very high immunization rates in children. To determine whether or not these estimates accurately depict the immunization coverage in non-urban regions of the country, we compared the WHO data to immunization rates obtained from a local database tool and community health center records in rural Intibuca, Honduras.

We used data from two sources to comprehensively evaluate immunization rates in the area: 1) census data from a local database and 2) immunization data collected at health centers. We compared these rates using logistic regression, and we compared them to publicly available WHO-reported estimates using confidence interval inclusion.

We found that mean immunization rates for each vaccine were high (range 84.4 to 98.8 percent), but rates recorded at the health centers were significantly higher than those reported from the census data (p<=0.001). Combining the results from both databases, the mean rates of four out of five vaccines were less than WHO-reported rates (p<0.05). Overall immunization rates were significantly different between townships (p=0.03). The rates by individual vaccine were similar across townships (p>0.05), except for diphtheria/tetanus/pertussis vaccine (p=0.02) and oral polio vaccine (p<0.01).

Immunization rates in Honduras are high across data sources, though most of the rates recorded in rural Honduras were less than WHO-reported rates. Despite geographical difficulties and barriers to access, the local database and Honduran community health workers have developed a thorough system for ensuring that children receive their immunizations on time. The successful integration of community health workers and a database within the Honduran decentralized health system may serve as a model for other immunization programs in resource-limited countries where health care is less accessible.

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

Study Protocol: Efficacy and safety of a nicotine conjugate vaccine (NicVAX)

BMC Public Health
(Accessed 8 December 2012)

Study protocol
The efficacy and safety of a nicotine conjugate vaccine (NicVAX(R)) or placebo co-administered with varenicline (Champix(R)) for smoking cessation: study protocol of a phase IIb, double blind, randomized, placebo controlled trial
Philippe Hoogsteder, Daniel Kotz, Wolfgang Viechtbauer, Ruth Brauer, Paul Kessler, Matthew Kalnik, Raafat Fahim, Paul van Spiegel, Onno van Schayck BMC Public Health 2012, 12:1052 (6 December 2012)

Abstract (provisional)
A potential new treatment in smoking cessation and relapse prevention is nicotine vaccination which is based on active immunization against the nicotine molecule. This immunization will elicit the immune system to produce nicotine-specific antibodies that sequester nicotine in the blood stream, after inhaling tobacco products. The resulting antibody-antigen is too large to cross the blood–brain barrier and is therefore postulated to attenuate the rewarding effect of nicotine by preventing the latter from reaching its receptors in the brain and causing the release of dopamine. The aim of this paper is to describe the design of a phase IIb, multi-center, double blind, randomized, placebo controlled trial to assess the efficacy of the nicotine vaccine NicVAX(R) co-administered with varenicline (Champix(R)) and intensive counseling as an aid in smoking cessation and relapse prevention.

Two centers will include a total of 600 smokers who are motivated to quit smoking. At week -2 these smokers will be randomized, in a 1:1 ratio, to either 6 injections of NicVAX(R) or placebo, both co-administered with 12-weeks of varenicline treatment, starting at week 0. The target quit day will be set after 7 days of varenicline treatment at week 1. Smokers will be followed up for 54 weeks. The primary outcome is defined as biochemically validated prolonged smoking abstinence from week 9 to 52. Secondary outcomes include safety, immunogenicity, smoking abstinence from week 37 to 52, abstinence from week 9 to 24, abstinence in the subset of subjects with the highest antibody response, and lapse/relapse rate.

This is the first study to assess the efficacy of a nicotine conjugate vaccine in combination with an evidence-based smoking cessation pharmacotherapy (varenicline) to quit smoking. Although NicVAX(R) is primarily designed as an aid to smoking cessation, our study is designed to explore its potential to maintain abstinence and prevent relapse. The results of this trial will give a unique insight in the potential of nicotine vaccination for relapse prevention. (NCT00995033)

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

Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011

Volume 17, Issue 49, 06 December 2012

Surveillance and outbreak reports
Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011
by G Fitzpatrick, M Ward, O Ennis, H Johnson, S Cotter, MJ Carr, B O’Riordan, A Waters, J Hassan, J Connell, W Hall, A Clarke, H Murphy, M Fitzgerald

In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

GAVI, the Global Fund and World Bank support for human resources for health in developing countries

Health Policy and Planning
Volume 27 Issue 8   December 2012

Original Articles
Editor’s Choice: An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries
Marko Vujicic, Stephanie E Weber, Irina A Nikolic, Rifat Atun, and Ranjana Kumar
Health Policy Plan. (2012) 27(8): 649-657 doi:10.1093/heapol/czs012

Shortages, geographic imbalances and poor performance of health workers pose major challenges for improving health service delivery in developing countries. In response, multilateral agencies have increasingly recognized the need to invest in human resources for health (HRH) to assist countries in achieving their health system goals. In this paper we analyse the HRH-related activities of three agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World Bank. First, we reviewed the type of HRH-related activities that are eligible for financing within each agency. Second, we reviewed the HRH-related activities that each agency is actually financing. Third, we reviewed the literature to understand the impact that GAVI, Global Fund and World Bank investments in HRH have had on the health workforce in developing countries. Our analysis found that by far the most common activity supported across all agencies is short-term, in-service training. There is relatively little investment in expanding pre-service training capacity, despite large health worker shortages in developing countries. We also found that the majority of GAVI and the Global Fund grants finance health worker remuneration, largely through supplemental allowances, with little information available on how payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be sustained at the end of the grant period. Based on the analysis, we argue there is an opportunity for improved co-ordination between the three agencies at the country level in supporting HRH-related activities. Existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, could present viable and timely vehicles for the three agencies to implement this improved co-ordination.

Free full-text:

Acceptance and rejection of influenza vaccination by pregnant women in southern Iran: Physicians’ role and barriers

Human Vaccines & Immunotherapeutics(formerly Human Vaccines)
Volume 8, Issue 12  December 2012

Acceptance and rejection of influenza vaccination by pregnant women in southern Iran: Physicians’ role and barriers
Behnam Honarvar, Neda Odoomi, Mojtaba Mahmoodi, Golnar Kashkoli, Fatemeh Khavandegaran, Kamran Bagheri Lankarani and Mohsen Moghadami

Objective: Vaccination provides the most effective protection against maternal, fetal and neonatal complications of influenza infection. This study aimed to determine the uptake rate of influenza vaccination including 2009 pandemic H1N1 influenza and seasonal influenza vaccination and the reasons for acceptance or rejection among pregnant women.

Method: This questionnaire based study was conducted at obstetrics and maternity hospitals affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Pregnant women were interviewed individually and privately. SPSS was used for data analysis.

Result: Mean age of the 416 pregnant women enrolled in this study was 27.06 ± 5.27 y. Only 25 (6%) of 397 women had history of vaccination. Of 383 (92.06%) pregnant women who had rejected vaccination, 116 (30.28%) declared that they lacked information about influenza vaccination and 44 (11.48%) felt that they did not need vaccination. Concerns about the safety of influenza vaccination were reported by only 2 women (0.52%). Of the 25 (6%) pregnant women who were vaccinated against influenza, 15 (60%) accepted because of advice they received from persons other than physicians, 5 (20%) believed that influenza vaccination is necessary for everyone, and 3 (12%) accepted because of a history of frequent influenza virus infections in previous years.

Conclusion: Most of the unvaccinated and vaccinated pregnant women lacked sufficient knowledge about influenza. Education of pregnant women about influenza vaccination and encouragement from physicians may have a remarkable effect on turning poor compliance into high flu vaccination uptake among pregnant women.

COMMENTARY – Meningococcal vaccine: A new vaccine to combat meningococcal disease in India

Human Vaccines & Immunotherapeutics(formerly Human Vaccines)
Volume 8, Issue 12  December 2012

Meningococcal vaccine: A new vaccine to combat meningococcal disease in India
Ramesh Verma and Pardeep Khanna

Meningococcal meningitis is caused by Neisseria meningitidis, a gram-negative, aerobic, encapsulated diplococcus. Meningococci are divided into numerous serogroups based on the composition of their capsular polysaccharide (Ps) antigens. At least 13 serogroups have been described: A, B, C, D, 29E, H, I, K, L, W-135, X, Y and Z. Out of these 13, six (A, B, C, W135, X and Y) can cause epidemics. The incubation period averages 3–4 d (range 1–10 d), which is the period of communicability. Bacteria can be found for 2–4 d in the nose and pharynx, and for up to 24 h after starting antibiotics. N. meningitidis is a leading cause of meningitis worldwide and a significant public health problem and dreaded disease in most countries. Morbidity and mortality rates from the disease remain high. Apart from epidemics, at least 1.2 million cases of bacterial meningitis are estimated to occur every year, 135,000 of which are fatal – of these, ~500,000 and ~50,000 respectively are caused by meningococci. Many outbreaks of meningococcal meningitis have been documented, with major outbreaks mainly seen in large cities of northern, western and eastern India like New Delhi, Mumbai, Kolkata and northeastern states. In 2011, 245 people died in India, the vast majority (179) in West Bengal, while 467 and 341 people in 2009 and 2010 respectively died of this disease. The meningococcal conjugate vaccines (MCV) are preferred for reasons of immunogenicity and persistence of immunity but are unavailable in India. Only the quadrivalent and bivalent meningococcal Ps vaccines (MPV) are available in India. The quadrivalent MPV is preferred for Haj pilgrims, international travelers and students in that it provides protection against emerging W-135 and Y disease in these areas. A single-dose 0.5mL injection is recommended.

Innovative financing for health: what is truly innovative?

The Lancet  
Dec 08, 2012   Volume 380  Number 9858  p1967 – 2052

Health Policy
Innovative financing for health: what is truly innovative?
Rifat Atun, Felicia Marie Knaul, Yoko Akachi, Julio Frenk

Development assistance for health has increased every year between 2000 and 2010, particularly for HIV/AIDS, tuberculosis, and malaria, to reach US$26·66 billion in 2010. The continued global economic crisis means that increased external financing from traditional donors is unlikely in the near term. Hence, new funding has to be sought from innovative financing sources to sustain the gains made in global health, to achieve the health Millennium Development Goals, and to address the emerging burden from non-communicable diseases.

The Lancet – Offline: The struggle for leadership (global health governance and impact)

The Lancet  
Dec 08, 2012   Volume 380  Number 9858  p1967 – 2052

Offline: The struggle for leadership
Richard Horton

Shortly after the UN General Assembly concluded its September meeting, the Director-General of WHO, Margaret Chan, wrote to, among others, heads of UN agencies, the World Bank, USAID, GAVI, and the Gates Foundation—Anthony Lake, Michel Sidibé, Babatunde Osotimehin, Jim Kim, Rajiv Shah, Seth Berkley, and Chris Elias. Her message was candid: “You will recall that we discussed what we can do to step up our collective action and collaboration to accelerate progress on the health MDGs before the 2015 deadline. There was agreement on the following points: the urgent need to stop competition and fragmentation among global health agencies, and improving harmonisation and alignment at the country level with a focus on results.” Her note went on to make specific recommendations for revitalising the International Health Partnership (IHP+). But her general intention was clear: a sharp warning to colleagues for pursuing agendas that were more about their own interests than the needs of countries. She was expressing the frustration of someone who sees the global health architecture as failing those it is supposed to defend and protect. She knows that the competition for influence and authority between WHO, UNICEF, UNAIDS, UNFPA, the World Bank, the Gates Foundation, and other Global Health Initiatives is leading her and other leaders to overpromise and underdeliver.

Two weeks after Dr Chan sent her email, Michel Sidibé replied (during the annual University College London/Lancet Lecture). Sidibé began by recalling the fear that AIDS once instilled in nations. That sense of crisis created an utterly new social compact between countries. In 2000, there were few signs of real or lasting success in the battle against AIDS. Now 8 million people have access to antiretrovirals and there is “a serious belief in ending the epidemic”. But Sidibé also offered a warning. None of these achievements are sustainable if the global community continues to work in the same way. There is not only a financial crisis afflicting countries. There is also an “ethical crisis…a crisis of trust”. If there is no trust between countries it is impossible to inspire global solidarity around any notion of justice. Sidibé argued that global health was at a “moment of transition”. It was moving away from a disease-centred to a people-centred vision of development. Yet just as this transition was upon us, “multilateralism is more and more in crisis”. Perhaps the ideal of achieving global consensus has passed forever. The world is multipolar. The idea of one central authority of knowledge or power is no longer credible.    China and India are already strong voices. Africa is rising. Governance mechanisms are slowly giving space to these emerging nations. In this “new world”, five key issues will demand our attention. First, the architecture of global health, although changing, is still “not good enough”. Second, better ways have to be devised to engage new actors, especially new country voices. Third, despite billions of dollars of aid pouring into countries, delivery systems for health have to be rethought. Fourth, technology will be a much bigger determinant of success. Finally, none of this manifesto can be delivered without applying principles of human rights to health…

The Use of Cost-Effectiveness Analysis for Pediatric Immunization in Developing Countries

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
December 2012  Volume 90, Issue 4  Pages 631–807

Original Articles
The Use of Cost-Effectiveness Analysis for Pediatric Immunization in Developing Countries (pages 762–790)
Article first published online: 6 DEC 2012 | DOI: 10.1111/j.1468-0009.2012.00682.x

Context: Developing countries face critical choices for introducing needed, effective, but expensive new vaccines, especially given the accelerated need to decrease the mortality of children under age five and the increased immunization resources available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision makers can use for efficiently allocating expanding resources. Its use in developing countries, however, lags behind that in industrialized countries.

Methods: We explored how CEA could be made more relevant to immunization policymaking in developing countries by identifying the limitations for using CEA in developing countries and the impact of donor funding on the CEA estimation. We conducted a comprehensive literature search using formal search protocols and hand searching indexed and gray literature sources. We then systematically summarized the application of CEA in industrialized and developing countries through thematic analysis, focusing on pediatric immunization and methodological and contextual issues relevant to developing countries.

Findings: Industrialized and developing countries use CEA differently. The use of the Disability-Adjusted Life Year (DALY) outcome measure and an alternative generalized cost-effectiveness analysis approach is restricted to developing countries. In pediatric CEAs, the paucity of evaluations and the lack of attention to overcoming the methodological limitations pertinent to children’s cognitive and development distinctiveness, such as discounting and preference characterization, means that pediatric interventions may be systematically understudied and undervalued. The ability to generate high-quality CEA evidence in child health is further threatened by an inadequate consideration of the impact of donor funding (such as GAVI immunization funding) on measurement uncertainty and the determination of opportunity cost.

Conclusions:  Greater attention to pediatric interventions and donor funding in the conduct of CEA could lead to better policies and thus more worthwhile and good-value programs to benefit children’s health in developing countries.

Editorial: Lessons from vaccine history

Nature Medicine
December 2012, Volume 18 No 12 pp1717-1857

Nature Medicine | Editorial
Lessons from vaccine history
Nature Medicine
18, 1717 (2012)
Published online 06 December 2012

In spite of years of effort, we still lack highly efficacious vaccines against HIV, tuberculosis, malaria and numerous other widespread pathogens. Two recent setbacks in vaccine trials suggest that it’s time to rethink how new vaccines are developed and to investigate what can be learned from the existing armament of childhood vaccines.

In November, a phase 3 trial of the malaria vaccine RTS,S/AS01 in African infants showed only 31% protection against clinical malaria compared with a control nonmalaria vaccine (N. Engl. J. Med. doi:10.1056/NEJMoa1208394). The results were disappointing to many, given the initial clinical experience with RTS,S.

In 1997, in a trial of 22 adults, one formulation of RTS,S protected six out of seven individuals from infection, whereas two other formulations of the same antigen did not. Subsequent phase 2 trials of two different formulations of RTS,S in young children also showed protective efficacy. And in early results of the phase 3 trial reported in 2011, the vaccine was 55.8% efficacious at protecting against a first episode of clinical malaria in young children aged 5 to 17 months at trial enrollment in the first 12 months after vaccination. The new results show that in infants aged 6 to 12 weeks at enrollment, which is a population at high risk of developing severe malaria, the protective efficacy of RTS,S/AS01 is substantially lower (see News story page 1723).

Similarly disappointing were the recent results of a phase 2b trial of a vaccine candidate against dengue fever, which is caused by four serotypes of dengue virus (Lancet 380, 1559–1567, 2012). Although the vaccine showed 30% overall efficacy against infection, protection was limited to three of the four serotypes of dengue, and the vaccine did not confer protection against the most prevalent serotype (serotype 2) in the region where the trial was conducted. As antibodies to one serotype have been associated with enhancement of disease after infection with another serotype, the lack of complete protection could increase the risk of developing severe disease, although this was not observed in the trial.

Still, some remain optimistic about both the malaria and the dengue vaccine candidates, arguing that modest protection may be better than none, particularly in view of the hundreds of millions of individuals who are infected with these pathogens each year. But the suboptimal results of these trials are emblematic of the problems with vaccine development in general—we don’t even understand how effective vaccines work, making it very difficult to identify the reasons why new candidates fail. The dengue vaccine induced an antibody response against serotype 2, yet did not protect against it. And in the initial trial of RTS,S in adults, all three formulations induced similar antibody and T cell responses, but only one formulation was protective against malaria. The fact that we don’t know what kind and what quality of immune response is necessary to prevent infection greatly challenges attempts to rationally approach vaccine design.

We do, in theory, have a starting point to try to better understand the mechanisms of vaccine efficacy. In the US, within the first six years of life, children receive ten different vaccines that provide protection against 14 different viral and bacterial diseases. All but one are delivered intramuscularly. Several contain attenuated or inactivated viruses, whereas others are composed of bacterial sugars, virus-like particles or purified proteins. Some contain aluminum-based adjuvants, some do not. In spite of their differences, when primarily injected into an arm or a leg, they all succeed in inducing protective immunity against an array of pathogens that target different tissues and use different strategies of immune evasion. If there is strength in numbers, surely there are commonalities to the induction of protection by these distinct vaccines that can be understood and applied to the development of future vaccines.

The trouble is that there are limited information and data from the original trials of approved childhood vaccines and no investment—and therefore no incentive—to analyze anew the protection that they confer in humans. Nevertheless, there is impetus to rationally develop vaccines: systems biology approaches have identified molecular signatures of the immune responses to influenza and yellow fever vaccines, albeit not correlates of the protection the vaccines confer. Preclinical studies of new adjuvants have provided fresh insight into their stimulatory effects on innate immune cells, although the key pathways by which they induce protective immunity remain unclear. And improved tools exist to predict T and B cell receptor epitopes and their immunogenicity, although the present accuracy of these methods is not sufficient for routine application. Moreover, as the recent experiences with the dengue and malaria vaccines show, predicting immunogenicity is not equivalent to predicting protection.    Therefore, it is incumbent on the vaccine field to increase investment into identifying the mechanisms of protection of successful vaccines in humans in order to fine-tune the application of these new tools to contribute to future vaccine success.

Different pathogens have different degrees of antigenicity, mutation rates and mechanisms to subvert protective immunity. Yet even the wiliest infection might be blocked if the right magnitude, breadth and potency of immune response were rapidly recruited upon initial infection. Understanding what those parameters should be, whether they are common to all infectious agents and how they can be induced by a vaccine will require both empirical and rational design, as well as a systematic approach to understanding the past to help guide the future.

Opinion: Global health needs to fill the innovation gap

Nature Medicine
December 2012, Volume 18 No 12 pp1717-1857

Global health needs to fill the innovation gap – p1735
Trevor Mundel

In recent years, the pharmaceutical industry has struggled to deliver new therapies, especially for diseases that affect the most vulnerable in developing countries. The global health community can fill this vacuum by catalyzing innovative partnerships across academia, government and the private sector, fostering a more rigorous environment for scientific decision making and creating the tools and infrastructure to conduct effective translational research.

Willingness to Participate in HIV Vaccine Trials among Men Who Have Sex with Men in Chennai and Mumbai, India: A Social Ecological Approach

PLoS One
[Accessed 8 December 2012];jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Willingness to Participate in HIV Vaccine Trials among Men Who Have Sex with Men in Chennai and Mumbai, India: A Social Ecological Approach
Venkatesan Chakrapani, Peter A. Newman, Neeti Singhal, Jhalak Jerajani, Murali Shunmugam
PLoS ONE: Research Article, published 04 Dec 2012 10.1371/journal.pone.0051080

Recruitment of low- and middle-income country volunteers from most-at-risk populations in HIV vaccine trials is essential to vaccine development. In India, men who have sex with men (MSM) are at disproportionately high risk for HIV infection and an important population for trial recruitment. Investigations of willingness to participate (WTP) in HIV vaccine trials have focused predominantly on individual-level determinants. We explored multi-level factors associated with WTP among MSM in India.

We conducted 12 focus groups (n = 68) with low socioeconomic MSM in Chennai and Mumbai, and 14 key informant interviews with MSM community leaders and service providers. Focus groups/interviews were recorded, transcribed and translated into English. Two bilingual investigators conducted thematic analysis using line-by-line coding and a constant comparative method, with member-checking by community representatives.

Factors associated with WTP were evidenced across the social ecology of MSM–social-structural: poverty, HIV-, sexual- and gender non-conformity stigma, institutionalized discrimination and government sponsorship of trials; community-level: endorsement by MSM community leaders and organizations, and fear of within-group discrimination; interpersonal: anticipated family discord, partner rejection, having financially-dependent family members and disclosure of same-sex sexuality; and individual-level: HIV vaccine trial knowledge and misconceptions, safety concerns, altruism and preventive misconception.

Pervasive familial, community and social-structural factors characteristic of the Indian sociocultural context may complicate individual-focused approaches to WTP and thereby constrain the effectiveness of interventions to support recruitment and retention in HIV vaccine trials. Interventions to reduce stigma and discrimination against MSM and people living with HIV, capacity-building of MSM community organizations and transparent communications tailored to the knowledge and educational level of local communities may support meaningful engagement of MSM in HIV vaccine trials. Vigilance in providing fair but not excessive compensation and healthcare benefits and in mitigating preventive misconception are warranted to support ethical conduct of trials among MSM in India.

Editorial: Risk, Risk Groups and Population Health

Public Health Ethics
Volume 5 Issue 3 November 2012

Risk, Risk Groups and Population Health
Marcel Verweij and Angus Dawson
Public Health Ethics (2012) 5(3): 213-215 doi:10.1093/phe/phs032

A central issue in public health is whether preventive activities are best aimed at groups held to be at high risk or at the population as a whole. Such a decision is often an issue in discussions about policies relating to vaccinations, health promotion, infectious disease control as well as protection from risks relating to toxic agents or radiation, etc. There are a number of interesting conceptual issues that can be explored such as what we mean by risk, how we define a ‘risk group’, and how subgroups relate to each other and to a larger population. For example, how do we determine what level of risk is sufficient for calling some subpopulation a ‘high-risk’ group? Suppose we can identify a group of children who run a risk of developing complications from varicella that is 10 times higher than the average, but it is also possible to identify even smaller subgroups that run a 50- or even 100-fold risk of developing severe complications if infected? Which group is ‘high risk’? How do we decide what our priorities ought to be? Judgements in this case would be influenced, perhaps, by what the options are for preventive care. Clearly, the identification of risk groups is just as much a normative judgement as decision making about the content of any policies relating to a high-risk group. This suggests that policy decisions are, and ought, to be not only dependent on which strategy is most efficient or cost-effective, but equally require consideration of ethical issues relating to justice, equity and solidarity.

Twenty years ago, Rose (1992) published his book The Strategy of Preventive Medicine, offering an in-depth exploration of these issues in relation to public health. Rose argued that in many cases a population strategy, focused on reducing average risk within the whole…

Conceptualizing a Human Right to Prevention in Global HIV/AIDS Policy

Public Health Ethics
Volume 5 Issue 3 November 2012

Original Articles
Conceptualizing a Human Right to Prevention in Global HIV/AIDS Policy
Public Health Ethics (2012) 5(3): 263-282 doi:10.1093/phe/phs034
Benjamin Mason Meier, Kristen Nichole Brugh, and Yasmin Halima

Given current constraints on universal treatment campaigns, recent advances in public health prevention initiatives have revitalized efforts to stem the tide of HIV transmission. Yet, despite a growing imperative for prevention—supported by the promise of behavioral, structural and biomedical approaches to lower the incidence of HIV—human rights frameworks remain limited in addressing collective prevention policy through global health governance. Assessing the evolution of rights-based approaches to global HIV/AIDS policy, this review finds that human rights have shifted from collective public health to individual treatment access. While the advent of the HIV/AIDS pandemic gave meaning to rights in framing global health policy, the application of rights in treatment access litigation came at the expense of public health prevention efforts. Where the human rights framework remains limited to individual rights enforced against a state duty bearer, such rights have faced constrained application in framing population-level policy to realize the public good of HIV prevention. Concluding that human rights frameworks must be developed to reflect the complementarity of individual treatment and collective prevention, this article conceptualizes collective rights to public health, structuring collective combination prevention to alleviate limitations on individual rights frameworks and frame rights-based global HIV/AIDS policy to assure research expansion, prevention access and health system integration.

Prioritizing Vaccine Access for Vulnerable but Stigmatized Groups

Public Health Ethics
Volume 5 Issue 3 November 2012

Prioritizing Vaccine Access for Vulnerable but Stigmatized Groups
Public Health Ethics (2012) 5(3): 283-295 doi:10.1093/phe/phs010
Chris Kaposy and Natalie Bandrauk

This article discusses the prioritization of scarce and in-demand influenza vaccines during a pandemic. The mass vaccination campaign in Canada against H1N1 influenza in 2009 illustrated that some groups considered vulnerable may also be stigmatized. In 2009, prisoners and people with severe obesity were given priority of H1N1 vaccination in some Canadian jurisdictions. Assigning priority for vaccination to such groups may be socially unpopular. This article examines a number of possible arguments that might motivate opposition to prioritizing stigmatized groups. We find these arguments flawed. They rely on a suspect ‘social worth’ rationale for the prioritization of scarce resources. Furthermore, human rights concerns support the prioritization of vulnerable but stigmatized groups for vaccination during a pandemic. We also argue that it is necessary to prioritize vulnerable but stigmatized groups to promote the common good in its various forms. The article concludes with an analysis of an objection that no vulnerable groups—stigmatized or otherwise—should be given priority for influenza vaccination in a pandemic. We argue that the objection is based on a confusion.

Proposed H5N1 Research Reviews Raise Concerns

7 December 2012 vol 338, issue 6112, pages 1249-1384

News & Analysis – Avian Influenza
Proposed H5N1 Research Reviews Raise Concerns
David Malakoff

Researchers are giving a mixed reception to a draft U.S. government plan to do more stringent funding reviews of certain kinds of H5N1 avian influenza research—and perhaps even require some studies to be kept secret. The proposal, presented last week at a meeting of the National Science Advisory Board for Biosecurity, is the latest fallout from the controversy surrounding two studies in which scientists engineered the H5N1 virus and led to a voluntary moratorium on such potentially risky “gain-of-function” studies. The new proposal seeks to help biosecurity experts for funding agencies identify problematic experiments before they begin.

Effect of falsely balanced reporting of the autism–vaccine controversy on vaccine safety perceptions

The effect of falsely balanced reporting of the autism–vaccine controversy on vaccine safety perceptions and behavioral intentions

G Dixon, C Clarke – Health Education Research, 2012

Abstract Controversy surrounding an autism–vaccine link has elicited considerable news
media attention. Despite being widely discredited, research suggests that journalists report
this controversy by presenting claims both for and against a link in a relatively ‘balanced’ …

Yellow fever outbreak kills 164 in Sudan’s Darfur: WHO

Accessed 8 December 2012

Yellow fever outbreak kills 164 in Sudan’s Darfur: WHO
KHARTOUM | Mon Dec 3, 2012 10:11am EST

(Reuters) – Yellow fever has killed 164 people over the last three months in Sudan’s Darfur, the World Health Organization (WHO) said on Monday, an arid region the size of Spain where fighting and banditry makes access particularly difficult.

Healthcare is provided almost entirely by aid agencies in parts of Darfur, where rebels took up arms in 2003 complaining of neglect by the central government hundreds of miles away in Khartoum.

The latest outbreak of mosquito-borne yellow fever has been concentrated in central Darfur, the WHO and Sudan’s health ministry said in a joint statement.

“Between 2 September and 29 November, the total number of suspected yellow fever cases has reached 677, including 164 deaths,” the statement said.

Nearly half the yellow fever cases were in people between the ages of 15 and 30, it said, and about a quarter were children aged five to 15.

There is no effective treatment for the hemorrhagic fever, but there is a vaccine. The WHO said last month that some 3.6 million people would be vaccinated in affected areas of Darfur.

Monday’s statement said more than half of the targeted population had been vaccinated by November 30.

Twitter Watch [accessed 8 December 2012 – 17:21

Twitter Watch [accessed 8 December 2012 – 17:21]
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.

GAVI Alliance ‏@GAVIAlliance
The “best ever” #GAVIPartners closed after 3 days of discussion about Results, Innovation, Sustainability & Equity. 
2:53 AM – 8 Dec 12

PAHO/WHO ‏@pahowho
Bolivia, Haiti, Honduras & Nicaragua honored by @gavialliance for their achievements in #immunization #gavipartners …
3:13 PM – 7 Dec 12

As leaders talk at #GAVIpartners, #Tanzania introduces new vaccines for #pneumonia and #diarrhoea  #Promise4Children
2:05 PM – 7 Dec 12

GAVI Alliance ‏@GAVIAlliance
The 5th #GAVIPartners Forum is officially over. Here’s what the leading voices in global immunisation were saying: 
1:23 PM – 7 Dec 12

Doctors w/o Borders ‏@MSF_USA
“There’s no reason children should still be dying of vaccine-preventable diseases.” 
11:15 AM – 7 Dec 12

The Global Fund ‏@globalfundnews
Video: the Global Fund’s 2012 end-year results. #progress #thebigpush 
3:25 AM – 6 Dec 12

Vaccines: The Week in Review 1 December 2012

Editor’s Notes:

Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to

pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_1 December 2012

Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

Support: If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary. Thank you…

World AIDS Day 2012: Getting to Zero

WHO: 1 December 2012 – World AIDS Day 2012: Getting to Zero
Getting to Zero: Zero new HIV infections. Zero deaths from AIDS-related illness. Zero discrimination is the theme of World AIDS Day 2012. Given the spread of the epidemic today, getting to zero may sound difficult but significant progress is underway.
In 2011, 2.5 million people were newly infected with HIV. An estimated 1.7 million people died. That is 700,000 fewer new infections worldwide than ten years ago, and 600,000 fewer deaths than in 2005…

PEPFAR Blueprint: Creating an AIDS-Free Generation
U.S. Secretary of State Hillary Rodham Clinton unveiled the new PEPFAR Blueprint to correspond to this year’s World AIDS Day on December 1. The document’s vision statement notes:  Scientific advances and their successful implementation have brought the world to a tipping point in the fight against AIDS. The United States believes that by making smart investments based on sound science, and a shared global responsibility, we can save millions of lives and achieve an AIDS-free generation.

NIH Statement: World AIDS Day 2012
December 1, 2012
Anthony S. Fauci, M.D., Director, National Institute of Allergy and Infectious Diseases; Jack Whitescarver, Ph.D., Director, NIH Office of AIDS Research; Francis S. Collins, M.D., Ph.D., NIH Director

The International AIDS Conference in Washington, D.C., this past summer energized HIV/AIDS researchers and focused on the potential benefits of broadly implementing scientifically proven HIV prevention and treatment tools. On World AIDS Day, the National Institutes of Health joins with our global partners to maintain this momentum toward a world without AIDS. As the world’s leading funder of HIV/AIDS research, NIH is vigorously pursuing promising research in therapeutics, prevention (including efforts to develop a vaccine), and work toward a cure, while also studying how best to deliver these interventions to people who need them.

NIH-funded researchers have contributed to the development of the more than 30 antiretroviral drugs and drug combinations currently available, which have saved millions of lives. Additionally, NIH partners with pharmaceutical companies to identify optimal treatment regimens. We continue to pursue the development of new antiretroviral drugs that are longer acting, simpler to use, and less toxic than currently available therapies.

NIH also supports studies on how to improve HIV treatment outcomes and how to manage and reduce the incidence of diseases and complications associated with long-term HIV disease and antiretroviral therapy…


Media Release: China and Global Fund Signal Strong Partnership
30 November 2012

China and the Global Fund to Fight AIDS, Tuberculosis and Malaria marked a new stage in their partnership today by drawing senior leaders together with health workers and civil society partners to celebrate the achievements and identify the challenges of joint action to prevent and treat HIV and AIDS.

On the occasion of World AIDS Day, Premier Wen Jiabao led the special gathering inside the headquarters of the central government in downtown Beijing and welcomed Gabriel Jaramillo, General Manager of the Global Fund, as a special guest.

“China and the Global Fund have been cooperating well in the fight against HIV and AIDS,” said Premier Wen. He pledged that China do more to fight the spread of AIDS, both by working with international organizations and by investing in anti-AIDS efforts within China.

Mr. Jaramillo praised China’s leadership in fighting HIV, as the country assumes a more prominent role in global health efforts. He cited China’s generosity and its willingness to help other countries, as well as its growing commitment to domestic initiatives, as an example for all nations to follow.

WHO Europe: Recommendation to Resume BCG vaccination programme against tuberculosis in Romania

WHO Europe: Recommendation to Resume BCG vaccination programme against tuberculosis in Romania
30 November 2012

“A joint mission of WHO/Europe and the European Centre for Disease Prevention and Control (ECDC) to Romania has recommended immediate resumption of bacille Calmette–Guérin (BCG) vaccination against tuberculosis (TB) in the country.

“The Ministry of Health temporarily suspended BCG vaccination on 22 November as a precautionary measure, following increased reports of enlarged lymph nodes in children after administration of the vaccine produced by the State Serum Institute (SSI) of Denmark.

“The BCG vaccination programme will resume with additional elements, taking account of the mission’s findings. These include:
– strengthening the risk management plan, including guidelines for vaccine administration, follow-up and treatment of adverse events;
– reinforcing close monitoring of adverse events to detect them early and enable rapid and appropriate action; and
– developing a communication plan for health care workers and the public.

In the last decade, BCG vaccination has halved the number of TB cases in children under 14 years in Romania. For every million children aged under 5 years with BCG vaccination, over 350 severe TB cases are avoided…

Report: “Polio’s Last Stand” Independent Monitoring Board – Global Polio Eradication Initiative

Report: Polio’s Last Stand 
Independent Monitoring Board of the Global Polio Eradication Initiative
November 2012

The full report is available as a 50-page pdf here:

[Editor’s Note: We present the final section of the report titled “Conclusions and Recommendations” in full text below. We draw reader attention to the first recommendation (our bolding which suggests that “the International Health Regulations Expert Review Committee urgently issue a standing recommendation by May 2013 that will introduce pre-travel vaccination or vaccination checks in Afghanistan, Nigeria and Pakistan until national transmission is stopped. No country should allow a citizen from any endemic polio state to cross their border without a valid vaccination certificate.”

With just weeks remaining, the Programme is certain to fail in its main 2010-2012 Strategic Plan target of interrupting polio transmission globally by the end of 2012. The impact of this failure has been mitigated by a final strategic plan phase of high achievement: India and Angola polio-free for over a year; DR Congo close behind; numbers of cases in Afghanistan, Chad and Pakistan down on last year; globally the number of polio cases at their lowest level in history. Only Nigeria has clouded the picture but there are encouraging signs here with strong new policies in place and actions in train. The IMB is heartened that global and country programmes have acted on its guidance set out in five reports.

To all appearances the polio virus is making its last stand, in 0.2% of the world’s land surface.

The uninformed observer might conclude that it had no chance of survival. But those who have targeted the polio viruses for three decades to make it extinct know what a formidable foe it is. It survives for reasons that are well known. The polio virus finds friends amongst missed children, badly managed campaigns, weak data, ill-informed parents, poor political and public health leadership and resistance in adopting best practice.

There is one ingredient, a magic formula for transformation, that is still missing in the affected countries – absolute ownership. Ownership means parents demanding the vaccine, making it their mission to protect their children. Ownership means local leaders grasping the challenge of wiping polio from their area. Ownership means a critical mass in the population believing that their children can, must and will be protected through the eradication of polio. Most of all ownership is about national pride: a country determined to be a vibrant, respected 21st century nation, not one that is looked down on because it remains tainted by a disease that almost everywhere else in the world survives only in the memory of grandparents.

A new strategic plan is being prepared. It needs to be very different to its predecessors. It needs to be built on a foundation of knowledge and understanding about what the remaining barriers to polio eradication are – not just the technical elements, but the ever-important, ever-challenging ‘human factors’ too. It needs to be rigorous in establishing the case for why polio must and can be eradicated, and how this will be achieved. It needs to be deeply compelling, to draw in everybody in the world who can help the Programme to overcome polio’s last stand.

This report makes ten recommendations:

    1. We recommend that the International Health Regulations Expert Review Committee urgently issue a standing recommendation by May 2013 that will introduce pre-travel vaccination or vaccination checks in Afghanistan, Nigeria and Pakistan until national transmission is stopped. No country should allow a citizen from any endemic polio state to cross their border without a valid vaccination certificate.

2. We recommend that within the next fortnight, programme leaders in Afghanistan, Nigeria, Pakistan and Chad discuss their country’s plan and best practice elsewhere to write, with their partners, a list of no more than five priority goals that they will achieve by the end of April 2013, circulate these goals to all programme staff, and maintain the focus and pace necessary to achieve them.

3. We recommend that an analysis be urgently commissioned to examine the relationship

between the frequency and quality of vaccination campaigns, to guide programmatic decisions about the optimum interval between campaigns.

4. We recommend that every endemic country district-level task force (or equivalent) should be constituted to include a parent, representing parents of the district.

5. We recommend that every opportunity be taken to ‘pair’ other health and neighbourhood benefits with the polio vaccine.

6. The IMB requests a report on vaccine supply at each of its future meetings.

7. We recommend that the Programme accelerate planning to set out how the learning from polio eradication can be captured rigorously and comprehensively, overseen and funded with minimal distraction to current work.

8. We recommend that an intensive ‘Polio Watch’ be established in the countries at highest risk of a polio outbreak. We further recommend that the responsible WHO Regional Offices should issue within the next month an action plan for strengthening vaccination coverage and surveillance in these areas.

9. We recommend that India plans for a simulation exercise to test the readiness of its emergency response plans. We recommend that the exercise should begin, on an unannounced date in mid-2013, by selecting a sample of districts at random and carrying out real-time simulation-based scrutiny of their emergency response capability

10. We recommend that a continual live audiovisual feed should be broadcast online from the Nigerian Emergency Operations Centre, with a facility for the world’s polio experts and the IMB to observe and provide input at any time.

Global Polio Eradication Initiative – Update: Polio this week [As of 27 Nov 2012]

Update: Polio this week As of 27 Nov 2012
Global Polio Eradication Initiative

[Editor’s Extract]
– The Independent Monitoring Board (IMB) has published the report of its end-October meeting. Entitled ‘Polio’s Last Stand’, the report highlights that polio is ‘more tightly confined than ever’ and that the global eradication effort is ‘enjoying an unprecedented level of priority and commitment’. While the report notes that the programme ‘will now clearly not achieve its goal of stopping all transmission by end-2012’, the IMB points out that despite this, prospects for success ‘are more positive than ever’. [
– The Kano State Government, the Bill & Melinda Gates Foundation and the Dangote Foundation – funded by Nigerian business magnate Alhaji Aliko Dangote – launched this week a collaboration to improve routine immunization and primary health care in Kano, with a goal of reaching 80% coverage with basic vaccines by 2015. Kano has one of the lowest routine immunization coverage rates in Nigeria, with less than 40% of children vaccinated.

– One new WPV case was reported in the past week (one WPV1 from Khost), bringing the total number of WPV cases for 2012 to 31. It is the most recent case in the country and had onset of paralysis on 9 November.
– Khost province is on the country’s eastern border with Pakistan. Though Khost is not an endemic area, a case was reported in September as well. Both cases are linked to virus circulating in Quetta, capital of Balochistan province in Pakistan.
– The Independent Monitoring Board has stated that Afghanistan has made progress, but too slowly, and that too many children in southern Afghanistan are missed not just due to insecurity but also due to remaining managerial challenges. As with each of the three endemic countries, the IMB recommends ‘absolute ownership’ by leaders at all levels…

– Six new WPV cases were reported in the past week (five WPV1s from Katsina and one WPV1 from Borno), bringing the total number of WPV cases for 2012 to 110. A WPV1 from Katsina is the most recent in the country and had onset of paralysis on 4 November.
– Katsina has now had 32 cases, and represents nearly one-third of all of Nigeria’s cases this year. The state has the most intense transmission of wild poliovirus in the world at the moment, accounting for more than 15% of all polio cases globally this year.
– The new case in Borno is the first since August. Insecurity in Borno continues to complicate operations, and the state’s proximity to Chad is cause for concern. Historically, polio from Borno has spread east into Chad and from there onwards…

– Two new WPV cases were reported in the past week (WPV1s from Khyber Pakhtunkhwa – KP, and Federally Administered Tribal Areas – FATA), bringing the total number of WPV cases for 2012 to 56. The WPV1 from FATA is the most recent case in the country and had onset of paralysis on 10 November.
– Additionally, two new cVDPV2 cases were reported in the past week, bringing the total number of cVDPV2 cases to seven (all from the greater Quetta area of Balochistan)…

PATH names Amie Batson as new chief strategy officer

PATH announced the appointment of Amie Batson to the newly created position of chief strategy officer. Ms. Batson is currently senior deputy assistant administrator for global health with the US Agency for International Development (USAID) in Washington, DC. Her 20-year career in global health includes positions with the World Bank, the World Health Organization, and UNICEF. Ms. Batson will have responsibility for helping guide PATH’s strategy, strengthening its partnerships and business relationships in the global health community, and contributing to PATH’s advocacy and policy priorities. She will join PATH in mid-April 2013 and report to Steve Davis, PATH’s president and CEO.

Weekly Epidemiological Record (WER) for 30 November 2012

The Weekly Epidemiological Record (WER) for 30 November 2012, vol. 87, 47 (pp. 477–492) includes:
– Outbreak news: Yellow fever, Sudan – update
– Transmission assessment surveys in the Global Programme to Eliminate Lymphatic Filariasis: WHO position statement
– Validation of maternal and neonatal tetanus elimination in Timor-Leste, 2012

French women’s knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination

BMC Public Health
(Accessed 1 December 2012)

Research article
French women’s knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination among those with 14 — 18 year old daughters: a quantitative-qualitative study
Julie Haesebaert, Delphine Lutringer-Magnin, Julie Kalecinski, Giovanna Barone, Anne-Carole Jacquard, Véronique Régnier, Yann Leocmach, Philippe Vanhems, Franck Chauvin, Christine Lasset BMC Public Health 2012, 12:1034 (27 November 2012)

Abstract (provisional)
In France, it is recommended that girls and women aged 14–23 are vaccinated against the human papillomavirus (HPV). However, French women’s knowledge of and attitude towards the vaccine has been little studied.

Thirty-nine general practitioners, representative of those working in the large Rhone-Alpes region, offered a self-administered questionnaire on cervical cancer (CC) prevention to all 18–65 year-old women who came for consultation during June and July 2008. In addition, semi-structured interviews were undertaken with a sample of those who had daughters aged 14–18.

Of the 1,478 women who completed the questionnaire, only 16.9% mentioned HPV as the cause of CC, even though 76.2% knew of the vaccine. 210 women had daughters aged 14–18, and 32 were interviewed. Compared with the wider group, more of these women were aware of the HPV vaccine (91.4%). 44.8% knew the target population and 17.1% the recommended ages for vaccination. 54.3% favoured HPV vaccination; 37.2% were undecided and only 0.9% were opposed. The main barrier to acceptance was the recency of the vaccine’s introduction and concern about possible side effects (54.9%); 14.1% preferred to rely on their GP’s decision. Factors associated with acceptance of the HPV vaccine were having previously vaccinated a child against pneumococcus (OR=3.28 [1.32-8.11]) and knowing the target population for HPV vaccination (OR=2.12 [1.15-3.90]). Knowing the recommended frequency of Papanicolaou smear testing (Pap test) screening was associated with lower acceptance (OR=0.32 [0.13-0.82]).

Few mothers are opposed to HPV vaccination. Factors associated with acceptability were knowledge about the vaccine, acceptance of other vaccines and, unexpectedly, lack of knowledge about the recommended frequency of Pap testing. On multivariate analysis, compliance with recommendations for Pap test screening and socioeconomic factors had no effect on views about HPV vaccination. Given that concern about possible side effects is the major barrier to wider acceptance of the HPV vaccine in France, GPs have a key role in providing information.

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

BMJ Head to Head – Should India launch a national immunisation programme against rotavirus?

British Medical Journal
01 December 2012 (Vol 345, Issue 7885)

Head to Head
Should India launch a national immunisation programme against rotavirus? Yes
BMJ 2012; 345 doi: (Published 30 November 2012)
Cite this as: BMJ 2012;345:e7818
Johnie Rose, senior instructor 1; Umesh D Parashar, medical epidemiologist2

India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar support the move, but Jacob Puliyel and Joseph Mathew (doi:10.1136/bmj.e7832) question the evidence used to support vaccination

The World Health Organization recommends inclusion of rotavirus vaccination of infants into all national immunisation programmes, with a strong recommendation for introduction of vaccine in countries like India where diarrhoeal deaths account for ≥10% of child mortality.1    The health burden of rotavirus in India is well established. WHO estimated that 98 621 Indian children died from rotavirus gastroenteritis in 2008, representing about one third of deaths from diarrhoeal disease and 4% of all child deaths in India.2 More recent data from the Million Death  Study, a nationally representative survey of 1.1 million Indian households, estimated that the virus causes 113 000 deaths a year.3 Both of these figures are conservative compared with an estimate of 147 000 annual rotavirus deaths obtained by directly extrapolating rates of laboratory confirmed rotavirus mortality from a contemporary community based birth cohort study in India.4

Non-fatal rotavirus gastroenteritis results in around 880 000 hospital admissions and 1.26 million …

Head to Head
Should India launch a national immunisation programme against rotavirus? No
BMJ 2012; 345 doi: (Published 30 November 2012)
Jacob M Puliyel, consultant paediatrician1,
Joseph L Mathew, associate professor2

India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar (doi:10.1136/bmj.e7818) support the move, but Jacob Puliyel and Joseph Mathew question the evidence used to support vaccination

The programme to immunise all the world’s children with the rotavirus vaccine is based on mistaken assumptions. Careful evaluation of available evidence does not support the launch of the programme in India. It will divert funds from more life saving interventions and could cause harm.

Inappropriate extrapolations
The World Health Organization recommended universal rotavirus vaccination well before regional evidence of its effectiveness was collected. This is a distortion of the standard procedure whereby recommendations are made based on local evidence. The distortion came about in two stages. In 2007, the WHO committee looking at rotavirus vaccination for developing countries decided that efficacy data from one population can be extrapolated to other populations that are in an “equivalent child mortality strata.”1 This presumes that the prevalent virus strains are the same in different regions with similar socioeconomic status and mortality rates. There is no scientific evidence to support this assumption. Following this in 2009, using data from Malawi (one of the poorest regions in the world),2 Nicaragua, and a handful of developed countries, WHO recommended rotavirus vaccine for all regions of the world.3


According to the GAVI Alliance, which funds vaccination for children in poor countries, rotavirus…

Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?

Bulletin of the World Health Organization
Volume 90, Number 12, December 2012, 869-944

Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?
Tom L Drake, Zaid Chalabi & Richard Coker
doi: 10.2471/BLT.12.109025
Article [HTML]

The evidence base for the cost–effectiveness of pandemic influenza preparedness policy options is small but growing rapidly. Modelling methods vary considerably between studies and the literature is limited in scope. To contribute to improving quality and consistency in this emerging study area, we recommend: (i) greater focus on low-resource settings; (ii) inclusion of non-pharmaceutical interventions; (iii) incorporation of health system capacity; and (iv) more robust analysis and presentation of pandemic event uncertainty. So, what’s missing from pandemic influenza preparedness cost–effectiveness analysis? Answer: poor countries, non-pharmaceutical interventions, health system capacity and pandemic uncertainty.

HIV and AIDS in the European Union, 2011

Volume 17, Issue 48, 29 November 2012

Rapid communications
HIV and AIDS in the European Union, 2011
G Likatavicius, M Van de Laar

European Economic Area countries. The annual rate of HIV diagnoses does not show clear signs of decrease and HIV continues to be concentrated in selected populations such as men who have sex with men and injecting drug users, and a high proportion reported as late presenters. Despite effective and available antiretroviral treatment, the number of AIDS cases increased in a few countries.

Commentary: Zeroing in on AIDS and global health Post-2015

Globalization and Health
[Accessed 1 December 2012]

Zeroing in on AIDS and global health Post-2015
Buse K, Blackshaw R and Harakeye Ndayisaba MG Globalization and Health 2012, 8:42 (30 November 2012)

Abstract (provisional)  Open Access
December 1st marks World AIDS Day with the theme ‘Getting to zero’. Three years ago, UNAIDS articulated what was then considered to be an ambitious vision, the aspiration for zero new HIV infections and zero-AIDS related deaths underpinned by zero discrimination. As we imagine the Post-2015 development agenda, we can and should reconceptualise this vision as a set of concrete goals.

This Viewpoint argues that today’s rapidly changing world, including its shifting geo-political and economic landscape, requires policy responses that are context-sensitive. We highlight the Shared Responsibility-Global Solidarity agenda, as pioneered by the African Union in its recent Roadmap on AIDS, tuberculosis, and malaria, to illustrate ways in which global health can be re-thought to tackle twenty-first century challenges. In light of the emerging debate on what a Post-2015 development agenda and accountability framework should look like, we argue that the AIDS response offers lessons as a pathfinder which can pave the way for global health responses in which the most marginalised are at the centre of the debate, human rights are protected under the rule of law, strong accountability is in place for results for people and community and participatory processes are the norm. These hard-learned and -won principles of the AIDS response are critical if we are to realize a world in which there is zero inequality and health justice for all.

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

Childhood Pertussis

November 28, 2012, Vol 308, No. 20

Original Contribution
Association of Childhood Pertussis With Receipt of 5 Doses of Pertussis Vaccine by Time Since Last Vaccine Dose, California, 2010
Lara K. Misegades, PhD, MS; Kathleen Winter, MPH; Kathleen Harriman, PhD, MPH, RN; John Talarico, DO, MPH; Nancy E. Messonnier, MD; Thomas A. Clark, MD, MPH; Stacey W. Martin, MSc
JAMA. 2012;308(20):2126-2132. doi:10.1001/jama.2012.14939.

Context  In 2010, California experienced its largest pertussis epidemic in more than 60 years; a substantial burden of disease was noted in the 7- to 10-year-old age group despite high diphtheria, tetanus, and acellular pertussis vaccine (DTaP) coverage, indicating the possibility of waning protection.

Objective  To evaluate the association between pertussis and receipt of 5 DTaP doses by time since fifth DTaP dose.

Design, Setting, and Participants  Case-control evaluation conducted in 15 California counties. Cases (n = 682) were all suspected, probable, and confirmed pertussis cases among children aged 4 to 10 years reported from January through December 14, 2010; controls (n = 2016) were children in the same age group who received care from the clinicians reporting the cases. Three controls were selected per case. Vaccination histories were obtained from medical records and immunization registries.

Main Outcome Measures  Primary outcomes were (1) odds ratios (ORs) for the association between pertussis and receipt of the 5-dose DTaP series and (2) ORs for the association between pertussis and time since completion (<12, 12-23, 24-35, 36-47, 48-59, or ≥60 months) of the 5-dose DTaP series. Logistic regression was used to calculate ORs, accounting for clustering by county and clinician, and vaccine effectiveness (VE) was estimated as (1 − OR) × 100%.

Results  Among cases and controls, 53 (7.8%) and 19 (0.9%) had not received any pertussis-containing vaccines, respectively. Compared with controls, children with pertussis had a lower odds of having received all 5 doses of DTaP (OR, 0.11; 95% CI, 0.06-0.21 [estimated VE, 88.7%; 95% CI, 79.4%-93.8%]). When children were categorized by time since completion of the DTaP series, using an unvaccinated reference group, children with pertussis compared with controls were less likely to have received their fifth dose within the prior 12 months (19 [2.8%] vs 354 [17.6%], respectively; OR, 0.02; 95% CI, 0.01-0.04 [estimated VE, 98.1%; 95% CI, 96.1%-99.1%]). This association was evident with longer time since vaccination, with ORs increasing with time since the fifth dose. At 60 months or longer (n = 231 cases [33.9%] and n = 288 controls [14.3%]), the OR was 0.29 (95% CI, 0.15-0.54 [estimated VE, 71.2%; 95% CI, 45.8%-84.8%]). Accordingly, the estimated VE declined each year after receipt of the fifth dose of DTaP.

Conclusion  Among children in 15 California counties, children with pertussis, compared with controls, had lower odds of having received the 5-dose DTaP series; as time since last DTaP dose increased, the odds increased, which is consistent with a progressive decrease in estimated vaccine effectiveness each year after the final dose of pertussis vaccine.

Pertussis remains a poorly controlled vaccine-preventable disease in the United States, despite a well-established childhood vaccination program and high coverage.1 Although infants have substantially higher rates of pertussis compared with other age groups, data from the National Notifiable Diseases Surveillance System reflect a recent increase in the number of reported pertussis cases among children aged 7 to 10 years. In 2010, this age group had the second highest incidence of pertussis in the United States.2 The changing epidemiology raises important questions about possible waning protection from the childhood acellular pertussis vaccine series.

After the diphtheria, tetanus, and whole-cell pertussis (DTwP) vaccine was introduced in the late 1940s, a dramatic decline occurred in the number of reported pertussis cases. However, whole-cell vaccine was commonly associated with local adverse events (eg, redness, swelling, and pain at the injection site) and less commonly with more serious adverse events.3– 4 These safety concerns prompted development and licensure of diphtheria, tetanus, and acellular pertussis (DTaP) vaccines, which were recommended by the Advisory Committee on Immunization Practices in 1992 for childhood booster doses at 15 to 18 months and 4 to 6 years of age and in 1997 for the complete 5-dose series, including the primary doses at 2, 4, and 6 months of age.5 In 2006, an adolescent booster dose (Tdap) was recommended at age 11 to 12 years.6 Recent studies have demonstrated waning protection following the current 5-dose DTaP schedule, but no study, to our knowledge, has compared fully vaccinated with unvaccinated children to estimate the durability of protection afforded by the childhood series.7– 8

In 2010, California experienced its largest pertussis epidemic in more than 60 years; more than 9000 pertussis cases were reported and 10 infants died.9 Concordant with national trends, a substantial burden of disease (67.9 cases per 100 000) occurred in 7- to 10-year-olds despite high DTaP coverage.2 Concern about the number of cases in California and the increasing burden of pertussis among 7-to 10-year-olds prompted a large-scale assessment of the long-standing pertussis childhood vaccination program. The objectives of the investigation were to evaluate the association between pertussis and receipt of 5 DTaP doses by time since the fifth DTaP dose.

Acellular Vaccines and Resurgence of Pertussis
Eugene D. Shapiro, MD
JAMA. 2012;308(20):2149-2150. doi:10.1001/jama.2012.65031.

Pertussis is a highly contagious, vaccine-preventable disease for which a whole-cell vaccine (killed bacteria), in combination with toxoids against diphtheria and tetanus (DTwP), was introduced for immunization of children in the United States in the 1940s. With the eventual widespread use of DTwP vaccine, the national annual incidence of reported cases of pertussis decreased at least 150- to 200-fold, with only 1010 reported cases in 1976.1 Because of high rates of both local and systemic adverse events associated with DTwP vaccine, acellular pertussis vaccines (DTaP) that contain a small number of purified antigens of Bordetella pertussis and have far fewer adverse effects replaced DTwP vaccine in the 1990s. The DTaP vaccine is currently recommended for both primary (3 doses administered at 2, 4, and 6 months of age) and booster (2 doses administered at 15 to 18 months and 4 to 6 years of age) immunizations.2 In 2005, formulations suitable for adolescents and adults (Tdap vaccine) were approved, and an additional 1-time booster dose is recommended…