Editor’s Notes:

– Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_25 May 2013

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

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

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   UNICEF: Emergency measles vaccination campaign to protect 125,000 children in Central African Republic
UNICEF and its partners announced an emergency measles vaccination campaign in Bangui, the conflict-hit capital of the Central African Republic, after eight children tested positive for the disease in April. UNICEF said it is working with the Ministry of Health, WHO and NGO partners Merlin, IMC, ACF, PU-AMI and COOPI to reach 125, 000 children during the 22-26 May campaign. UNICEF noted that “recent fighting in the country has led to a breakdown of basic services and increased the risk of disease outbreaks in Bangui and across the country. This, along with poor living conditions, and a historically low vaccination rate for measles of 62 per cent, means that the lives of large numbers of children are now at risk from the disease.”

UNICEF also said the campaign faces considerable challenges. “Secure humanitarian access to those in need remains difficult in CAR. Following the coup on 24 March 2013, the security situation continues to be tenuous as law and order have yet to be fully restored in the capital. Many regions remain difficult to reach because of violence and insecurity and will be even harder to access as the rainy season sets in. Despite this, UNICEF is working with partners on the ground to respond to the emergency that is either directly or indirectly affecting the entire population of 4.6 million.” In preparation for the measles campaign, UNICEF said that 246,500 units of vaccine arrived in Bangui on 15 May, including 100,000 vaccines purchased by funds donated by the airline easyJet.

Full media release: http://www.unicef.org/media/media_69308.html

WHO: Global Alert and Response (GAR) – Disease Outbreak News
http://www.who.int/csr/don/2013_03_12/en/index.html

. Novel coronavirus infection – update (Middle East respiratory syndrome- coronavirus) – update 23 May 2013
Excerpt
23 May 2013 – The Ministry of Health in Saudi Arabia has notified WHO of an additional laboratory-confirmed case of infection with the Middle East respiratory syndrome coronavirus (MERS-CoV).
The fatal case was reported from Al-Qaseem region in the Central part of the country and is not related to the cluster of cases reported from Al-Ahsa region in the Eastern part of the country. The patient was a 63-year-old man with an underlying medical condition who was admitted to a hospital with acute respiratory distress on 15 May 2013 and died on 20 May 2013. Investigation into contacts of this case is ongoing.

The Saudi authorities are also continuing the investigation into the outbreak that began in a health care facility since the beginning of April 2013 in Al-Ahsa. To date, a total of 22 patients including 10 deaths have been reported from the outbreak.

Globally, from September 2012 to date, WHO has been informed of a total of 44 laboratory-confirmed cases of infection with MERS-CoV, including 22 deaths.

WHO has received reports of laboratory-confirmed cases from the following countries in the Middle East: Jordan, Qatar, Saudi Arabia, and the United Arab Emirates (UAE). France, Germany, Tunisia and the United Kingdom also reported laboratory-confirmed cases; they were either transferred for care of the disease or returned from Middle East and subsequently became ill. In France, Tunisia and the United Kingdom, there has been limited local transmission among close contacts who had not been to the Middle East but had been in close contact with the laboratory-confirmed or probable cases.

Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns.

Health care providers are advised to maintain vigilance. Recent travellers returning from the Middle East who develop SARI should be tested for MERS-CoV as advised in the current surveillance recommendations. Specimens from patients’ lower respiratory tracts should be obtained for diagnosis where possible. Clinicians are reminded that MERS-CoV infection should be considered even with atypical signs and symptoms, such as diarrhoea, in patients who are immunocompromised…
http://www.who.int/csr/don/2013_05_23_ncov/en/index.html
.

. Wild poliovirus in the Horn of Africa – 22 May 2013
Excerpt
22 May 2013 – The Horn of Africa is currently experiencing an outbreak of wild poliovirus type 1 (WPV1). A four-month-old girl near Dadaab, Kenya, developed symptoms of acute flaccid paralysis (AFP) on 30 April 2013. Two healthy contacts of the child tested positive for WPV1.    They are the first laboratory confirmed cases in Kenya since July 2011. Investigation into this outbreak is ongoing. In addition, a case of WPV1 in Banadir, Somalia was confirmed on 9 May 2013.

In response to the outbreak, the first vaccination campaign, reaching 440 000 children began on 14 May 2013 in Somalia and a second round of vaccination is planned for 26 May 2013 in synchronization with the affected parts of Kenya.

The risk to neighbouring countries is deemed as very high, due to large-scale population movements across the Horn of Africa and persistent immunity gaps in some areas. Dadaab hosts a major refugee camp, housing nearly 500 000 persons from across the Horn of Africa.

An alert for enhanced surveillance for polio has been issued to all countries across the Horn of Africa, highlighting the need to conduct active searches for any suspected cases. All countries are urged to rapidly identify sub-national surveillance gaps and to take measures to fill the gaps.

In 2005, polio spread east across the African continent, and into Yemen and the Horn of Africa, resulting in over 700 cases. Since then, international outbreak responses have been adopted and new monovalent and bivalent oral polio vaccines have been developed, which can significantly reduce the severity and length of polio outbreaks.

Some areas of Somalia (south-central) are also affected by an outbreak due to circulating vaccine-derived poliovirus type 2 (cVDPV2), which has resulted in 18 cases in Somalia since 2009. In 2012, this strain spread to Dadaab, causing three cases.

WHO’s International Travel and Health recommends that all travellers to and from polio-infected areas be fully vaccinated against polio…
http://www.who.int/csr/don/2013_05_22/en/index.html

Update: Polio this week – As of 22 May 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s extract and bolded text]
. A wild poliovirus type 1 (WPV1) case has been confirmed in Kenya, the first WPV in the country since July 2011, with onset of paralysis 30 April. The location is a refugee camp in the Dadaab area, close to the border with Somalia, where a child was paralysed by polio near the capital Mogadishu on 18 April. Outbreak response activities are being planned. See ‘Horn of Africa’ section for more.

Pakistan
. No new WPV cases were reported in the past week. The total number of WPV cases for 2013 remains eight. The most recent WPV case had onset of paralysis on 24 April (WPV1 from Federally Administered Tribal Areas – FATA).

. One new cVDPV2 case was reported in the past week (from North Waziristan, FATA), bringing the total number of cVDPV2 cases for 2013 to four. It is the most recent cVDPV2 case in the country and had onset of paralysis on 22 April.

. It is the second cVDPV2 case from North Waziristan, an area where immunizations have been suspended by local leaders since last June. To minimize the risk of a major outbreak in this area, it is critical that access to children is granted as quickly as possible. Immunizations in neighbouring high-risk areas are being intensified, to further boost population immunity levels in those areas and prevent further spread of this outbreak.

. Pakistan is also affected by transmission of WPV1, with eight cases this year (compared to 16 cases for the same period in 2012). Wild poliovirus type 3 (WPV3) has not been detected in the country in more than 12 months (since April 2012, from Khyber Agency, FATA).

. Confirmation of these latest cases underscores the risk which ongoing polio transmission (be it due to WPV or cVDPV) in the country continues to pose to children everywhere, and in particular to children living in areas where access has not been possible for extended periods of time.

. The security situation continues to be monitored closely, in consultation with law enforcement agencies. Immunization activities continue to be implemented, in some areas staggered or postponed, depending on the security situation at the local level.

Horn of Africa
. One new WPV case was reported in the past week (WPV1 from a refugee camp in Dadaab, north-eastern Kenya), with onset of paralysis on 30 April. It is the first WPV in Kenya since July 2011, and it follows last week’s confirmation of a WPV1 case from Somalia (onset of paralysis 18 April).

. The child is a four-month-old girl. Two healthy contacts of the child tested positive for WPV1. Dadaab hosts several large refugee camps, housing nearly 500,000 people from across the Horn of Africa, including from Somalia.

. An emergency outbreak response is being planned, to reach nearly 440,000 children aged less than 15 years across Dadaab, beginning on 26 May, using bivalent OPV. Further campaigns are planned across a wider area, including parts of Nairobi, on 9 June, followed by large-scale subnational immunization days (SNIDs) in late June.

. In Somalia, an outbreak response immunization activity was held last week (14-16 May), to reach 350,000 children across Banadir region (including Mogadishu), with further activities across Banadir and other regions planned for 26-29 May and again in early June.

. Immunization campaigns are also planned in other areas of the Horn of Africa, notably Ethiopia and Yemen, to urgently boost population immunity levels and minimize the risk of spread of the outbreak. Countries across the Horn of Africa are at significant risk, due to large-scale population movements and persistent immunity gaps in some areas. In 2005, polio spread across the African continent, and into Yemen and the Horn of Africa, resulting in over 700 cases. The adoption of international outbreak response guidelines and the development of new vaccines since then, have – when fully implemented – considerably reduced the severity and duration of such outbreaks.

Sixty-sixth World Health Assembly
20–28 May 2013
Geneva
Daily notes on proceedings – Editor’s Excerpts

66th WHA – Notes: Monday, 20 May 2013
World Health Assembly opens with focus on the Post Millennium Development Goals Agenda
The Sixty-sixth World Health Assembly opened this morning with the election of  Dr Shigeru Omi, Special Assistant for International Affairs, Ministry of Health, Labour and Welfare of Japan, as its new president. Five vice-presidents were also appointed from Angola, Haiti, Nepal, Oman, and Ukraine, representing their respective regions.

. Last 1,000 days for MDGs and the path forward
In his message, which was read by Mr Kassym-Jomart Tokayev, Director-General of the United Nations Office in Geneva, UN Secretary-General Ban Ki-moon drew attention to the positive effect the Millennium Development Goals (MDGs) have had on the global health agenda. He noted that the Health Assembly will discuss a number of MDG-related issues, such as implementation of the Global Vaccine Action Plan and recommendations from the UN Commission on life-saving commodities for women and children. He described the pressing challenge presented by the rise in noncommunicable diseases, highlighting the role of universal health coverage in ensuring equitable access to health services. He emphasized the continuing need for WHO to handle unforeseen global health events, such as newly emerging viruses.

Dr Omi observed that reform of WHO, the topic of tomorrow’s plenary discussion, aims to make the Organization more relevant, more effective and more dynamic.
Watch the President’s speech on video
Streaming wmv, 00:12:44

. Opening address of the WHO Director-General
In her opening address, WHO Director-General Dr Margaret Chan reiterated the importance of transparent reporting and vigilance in disease outbreaks, including recent cases of novel coronavirus and influenza H7N9, whilst at the same time maintaining the momentum made in addressing long-standing health issues such as tuberculosis, HIV, malaria; the emerging problem of noncommunicable diseases; and eradication of polio.

Dr Chan reiterated WHO’s refusal to work with the tobacco industry. However, she did not exclude the opportunity for cooperation with the food and beverage industry to address noncommunicable diseases, while supporting existing safeguards which ensure no conflicts of interest.

Read the Director-General’s address to the Sixty-sixth World Health Assembly

Watch the Director-General’s address
Streaming wmv, 00:31:48

66^th WHA – Notes: Wednesday, 22 May 2013
. Accelerating achievement of health-related MDGs: The Global Fund New Funding Model, implications for country level cooperation and WHO’s support
Technical briefing
Dr Margaret Chan, Director-General of WHO, applauded the contribution made by the Global Fund to Fight AIDS, Tuberculosis and Malaria to progress towards the MDGs at today’s lunchtime technical briefing on the Fund’s New Funding Model. Dr Mark Dybul, Executive Director of the Global Fund, explained that the new approach builds on three core principles: working as a financing institution that partners with others to serve countries; providing predictability around resource availability; and creating a platform for broader public health support.

Ministers of Health from El Salvador, Myanmar and Zimbabwe, all of whom have made proposals using the new funding model, welcomed the changes enthusiastically and commended support provided by WHO and other technical partners. Other speakers praised the Fund’s closer alignment with country plans and willingness to provide more support for health systems as well as its readiness to learn from experience and to increase transparency.
http://www.who.int/mediacentre/events/2013/wha66/journal/en/index3.html

66^th WHA – Notes: Thursday, 23 May 2013
. Implementation of the International Health Regulations (2005)
Item 15.1 – documents A66/16 and A66/16 Add.1
Before the item was undertaken, delegates requested an update from the WHO Secretariat and the Kingdom of Saudi Arabia on the recent emergence of MERS-CoV (previously known as Novel Coronavirus). The Secretariat and the Saudi Ministry of Health provided background information and a history of the emergence and response to the virus to date. The WHO presentation is attached. The discussion of the item will restart tomorrow.
Global overview of an emerging novel coronavirus
pdf, 741kb
Saudi Arabia’s response to novel coronavirus
pdf, 993kb
Implementation of the International Health Regulations (2005) (A66/16)
pdf, 178kb
Implementation of the International Health Regulations (2005) (A66/16 Add.1)
http://www.who.int/mediacentre/events/2013/wha66/journal/en/index2.html

66^th WHA – Notes: Friday, 24 May 2013
. Implementation of the International Health Regulations (2005)
Item 15.1 – document A66/16 and A66/16 Add.1
The newly identified H7N9 and MERS-CoV outbreaks lent even greater relevance to discussions on the International Health Regulations. Delegates voiced widespread support for the IHR and acknowledgement of WHO’s role in assisting countries. The Director-General told delegates that WHO was committed to supporting countries affected by MERS-CoV and to helping “unpack the barriers” standing in the way of the full implementation of the IHR. She added newly emerging diseases are not just a country problem but a global problem and WHO and the IHR can help bring together “the assets of the world” to fight such threats. The Secretariat stressed the need for countries to provide the necessary resources to ensure IHR work can continue in countries and at WHO. Delegates noted a report updating progress in taking forward 15 recommendations that seek to further improve the effectiveness of the regulations. Countries that have not yet met their IHR obligations and are requesting an extension to the deadline beyond 2014, will be required to inform the WHO Director-General and explain why they have not been able to put IHR in place.
Implementation of the International Health Regulations (2005) (A66/16)
pdf, 177kb
Addendum (A66/16 Add.1)
pdf, 81.8kb
. Pandemic influenza preparedness: sharing of influenza viruses and access to vaccine and other benefits
Item 15.2 – document A66/17
This is the first annual report of the pandemic influenza preparedness (PIP) framework which delegates were agreed to note. The report covers three main areas: virus sharing, benefit sharing, and governance.
It was noted that many countries still lack basic capacities. Laboratory and disease surveillance were highlighted by some countries. A similar concern was highlighted on the regulation and deployment of influenza vaccines during a pandemic.

Lengthy negotiations to conclude binding SMTA2s (Standard Material Transfer Agreement 2) are ongoing. Delegates called for an acceleration on the processes to enable agreements to be signed.

Delegates emphasized the need for transparency related to use of partnership contribution funds.
Pandemic Influenza Preparedness Framework 2013 biennial report (A66/17)
pdf, 204Kb

. Poliomyelitis: intensification of the global eradication initiative
Item 15.3 – document A66/18
The World Health Assembly acknowledged the progress achieved in the past year in bringing polio to its lowest ever levels, thanks to actions of Member States in placing polio eradication on an emergency footing. Delegates endorsed the new Polio Eradication and Endgame Strategic Plan 2013-2018 to secure a lasting polio-free world and urged for its full implementation and financing.

At the same time, the Assembly received stark warning of the ongoing risk the disease poses to children everywhere, with confirmation of a new polio outbreak in the Horn of Africa (Somalia and Kenya)

Noting the generous pledges made to support polio eradication at the Global Vaccine Summit, delegates urged donors to rapidly convert these pledges into contributions. The WHA pointed out that this funding was critical for accelerated implementation of the Plan, given the complexity and scale of introducing inactivated polio vaccine worldwide.

Delegates condemned the deadly attacks on health workers in Pakistan (in December 2012) and Nigeria (in February 2013), and called on all governments to ensure the safety and security of frontline health workers.
Poliomyelitis: intensification of the global eradication initiative (A66/18)
pdf, 146kb
http://www.who.int/mediacentre/events/2013/wha66/journal/en/index1.html

66^th WHA – Notes: Saturday, 25 May 2013
. Global Vaccine Action Plan
Item 16.1 – document A66/19
Member States reiterated their support to the Global Vaccine Action Plan (GVAP) to prevent millions of deaths by 2020 through more equitable access to vaccines for people in all communities, and for the proposed Framework for Monitoring, Evaluation and Accountability (which is linked to the Commission on Information and Accountability for Women’s and Children’s Health).

Delegates also supported the independent review process to assess and report progress and acknowledged the leadership demonstrated by the Strategic Advisory Group of Experts on immunization (SAGE) in this process. Speakers highlighted the need to mobilize greater resources to support low- and middle-income countries to implement the Plan and monitor impact; ensure that support to countries to implement the Plan includes a strong focus on strengthening routine immunization; and to facilitate vaccine technology transfer.
Global Vaccine Action Plan (A66/19)
pdf, 205kb
http://www.who.int/mediacentre/events/2013/wha66/journal/en/index.html

Speech and Response: Harnessing the power of science and the private sector: a 21st century model for international development
Dr Seth Berkley, CEO of the GAVI Alliance
Inaugural Lecture: Wellcome Trust – Cambridge Centre for Global Research University of Cambridge
2nd May 2013

Slides: http://www.thrive.cam.ac.uk/thrive/Seth%20Berkley%20GAVI%20Cambridge%20Final%20slides.pdf

Video: http://www.thrive.cam.ac.uk/thrive/GAVI%20CEO%20lecture%20in%20Cambridge%20(02052013)%20-%20%20540p.mp4

Video HD: http://www.thrive.cam.ac.uk/thrive/GAVI%20CEO%20lecture%20in%20Cambridge%20(02052013)%20-%20high%20definition%20720p.mp4

“The world-leading flu expert, Professor Derek Smith (Director of the WHO Collaborating Centre for Modelling, Evolution and Control of Emerging Infectious Diseases at the University of Cambridge, and Co-PI for the WT-CCGHR) gave a great presentation in response to Dr Berkley’s lecture, and that talk is also available on the video recording.”
http://www.thrive.cam.ac.uk/

GAVI Coverage: Excerpt
“…In the lecture Dr Berkley explained how GAVI operates and why this is critical to ensuring it has a lasting impact. As a 21st Century development organisation, GAVI is an inclusive and diverse partnership bringing together the World Health Organization, UNICEF, and recipient and donor countries together with NGOs, vaccine manufacturers, technical research institutes and individuals with skills and commitment to immunise children.

“In the GAVI model, developing countries lead vaccine uptake and co-finance the cost of the vaccines they receive to ensure immunisation programmes are sustainable after GAVI support ends. With a Board structure drawn from a diverse range of sectors, GAVI seeks to inject private sector innovation into public health issues…”

http://www.gavialliance.org/library/news/gavi-features/2013/gavi-as-a-model-of-21st-century-development/#sthash.i5vwCgxh.dpuf

PATH CEO Steve Davis announced a pledge “…to work with partners to save the lives of two million children affected by pneumonia and diarrhea by the end of 2015.”  Mr. Davis said “PATH is in the business of providing the world—particularly many of the poorest parts of the world—with a set of tools so good health can be in reach of everyone. And we’re here today to discuss these tools, and how PATH is thinking and acting differently to deploy them.”

Webcast of the event

http://www.path.org/news/an130524-breakfast-webcast.php

IVI: Strategic Plan 2013-2017 Chart
pdf

VISION: Developing countries free of suffering from infectious disease

MISSION: Discover, develop, and deliver safe, effective, and affordable vaccines for the world’s developing nations

GOALS: To ensure continued success in both vaccine sciences and public health, IVI’s new strategic plan for 2013-2017 will focus its efforts around the following four goals:
. Accelerate the development and introduction of safe and effective vaccines (cholera, typhoid, dengue and other EDD);
. Discover and pursue proof of concept for new vaccine candidates, with a particular focus on new vaccines against enteric and diarrheal diseases;
. Advance science driving new achievements in vaccinology, specifically through conducting further research in vaccine-enhancing technology and understanding how the immune system works in response to vaccination;
. Contribute to building vaccine technology and systems capacity in developing countries.

The chart includes specific goal level indictors.

The Weekly Epidemiological Record (WER) for 24 May 2013, vol. 88, 21 (pp. 217–224) includes:
– Building rotavirus laboratory capacity to support the Global Rotavirus Surveillance Network
– WHO Task Force on Immunization: call for nominations
http://www.who.int/entity/wer/2013/wer8821.pdf

Meeting: ACIP (ADVISORY COMMITTEE ON IMMUNIZATION PRACTICES)
June 19 – 20, 2013
Centers for Disease Control and Prevention
Atlanta, Georgia

Meeting Agenda/Draft at 21 May 2013: http://www.cdc.gov/vaccines/acip/meetings/downloads/agenda-archive/agenda-2013-06.pdf

Agenda topics:
–       Japanese Encephalitis Vaccine
–       General Recommendations on Immunization
–       Pertussis Vaccines
–       Human Papillomavirus (HPV) Vaccine
–       Rotavirus Vaccines: Update on Intussusception
–       The Role of Retail Pharmacies/Pharmacists in Vaccine Delivery in the United States
–       Vaccine Supply
–       Herpes Zoster Vaccine
–       Influenza

Meeting: “Cooperation Among First-to-Introduce Countries for Dengue Vaccines 2013 Meeting”
Dengue Vaccine Initiative (DVI); Hosted by the Ministry of Health of Brazil
April 9-11, 2013
Brasilia, Brazil

The meeting had three main objectives: 1) For developers to present status and timelines of dengue vaccine candidates under development; 2) For countries to present epidemiology data and points to consider for dengue vaccine introduction; and 3) For first-to-introduce countries to find mechanisms for collaboration in preparing introduction of dengue vaccines. Participating countries included Colombia, Indonesia, Mexico, Thailand, Malaysia and the Philippines, in addition to Brazil.
The meeting led to the identification of several areas for collaboration between countries and DVI: surveillance, regulatory pathways, modeling, strategic demand forecasting, financing, and communications.  Specific examples of follow-on collaborations were: 1) In collaboration with WHO and WHO regional offices, to standardize dengue surveillance; 2) To implement regulatory support activities such as access to knowledge and literature on dengue and dengue vaccines, facilitation of inter-agency collaborations for evaluation of dengue vaccines, National Regulatory Agency and National Immunization Technical Advisory Group coordination; 3) The application of a computer model to design the potentially most effective immunization strategies; 4) The preparation of demand forecasts that can take into account the potential limited supply; 5) The identification of resources to support the costs of the vaccine and its distribution; and 6) The development of accurate and informative communication messages to prepare communities for vaccine introduction.
The countries will meet again in October in Thailand to discuss collaborative activities to be undertaken in preparation for a dengue vaccine introduction.  The meeting will be held in conjunction with the Third International Conference on Dengue and Dengue Haemorrhagic Fever, “Global Dengue: Challenges and Promises”, which meets in Bangkok from the 21st to the 23rd of October.

Agenda and slide presentations: http://www.denguevaccines.org/news-events/cooperation-among-first-introduce-countries-dengue-vaccines-2013-meeting

BMC Public Health
(Accessed 25 May 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Using HPV vaccination for promotion of an adolescent package of care: opportunity and perspectives
Catherine MacPhail, Emilie Venables, Helen Rees and Sinead Delany-Moretlwe

Abstract (provisional)
Background
Adolescents are a difficult population to access for preventive health care, particularly in less resourced countries. Evidence from developed countries indicates that the HPV vaccine schedule may be a useful platform from which to deliver other adolescent health care services. We conducted a qualitative cross sectional study to assess the potential for using the HPV vaccine in the South African public health care system as an opportunity for integrated health care services for adolescents.

Methods
Parents, young adolescents, community members and key informants participated in interviews and focus group discussions about feasibility and acceptability, particularly the use of the HPV vaccination as the basis for an integrated adolescent package of care. Health care providers in both provinces participated in focus group discussions and completed a pairwise ranking exercise to compare and prioritise interventions for inclusion in an adolescent package of care.

Results
Participants were in favour of integration and showed preference for detailed information about the HPV vaccine, general health information and specific sexual and reproductive health information. Among health care workers, results differed markedly by location. In North West, prioritisation was given to information, screening and referral for tobacco and alcohol abuse, and screening for hearing and vision. In Gauteng integration with referral for male circumcision, and information, screening and referral for child abuse were ranked most highly.

Conclusions
There is generally support for the delivery of adolescent preventive health services. Despite national priorities to address adolescent health needs, our data suggest that national policies might not always be appropriate for vastly different local situations. While decisions about interventions to include have traditionally been made at country level, our results suggest that local context needs to be taken account of. We suggest low resource strategies for ensuring that national policies are introduced at local level in a manner that addresses local priorities, context and resource availability.
http://www.biomedcentral.com/1471-2458/13/493/abstract

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

Emerging Infectious Diseases
Volume 19, Number 6—June 2013
http://www.cdc.gov/ncidod/EID/index.htm

Letter
Wild Poliovirus Importation, Central African Republic
Excerpt
To the Editor: Since the Global Polio Eradication Initiative was launched in 1988, indigenous transmission of wild poliovirus (WPV) has been interrupted in all countries except Afghanistan, Pakistan, and Nigeria (1). However, during 2003–2011, outbreaks resulting from importation of WPV occurred in 29 previously polio-free countries in Africa, including Central African Republic (CAR) (1–3). In 2011, 350 WPV cases were reported from 12 countries in Africa, a 47% decrease from the 657 cases reported by 12 countries in Africa in 2010 (1).

In CAR, the last case of poliomyelitis caused by indigenous transmission of wild poliovirus was reported in 2000, but importation of WPV type 1 has been reported (4). We describe the importation of WPV1 and WPV3 into CAR during successive events in 2008, 2009, and 2011…

http://wwwnc.cdc.gov/eid/article/19/6/pdfs/12-1821.pdf

Emerging Infectious Diseases
Volume 19, Number 6—June 2013
http://www.cdc.gov/ncidod/EID/index.htm

Perspective
Prospects for Emerging Infections in East and Southeast Asia 10 Years after Severe Acute Respiratory Syndrome
P. Horby et al.
http://wwwnc.cdc.gov/eid/article/19/6/pdfs/12-1783.pdf

Abstract
It is 10 years since severe acute respiratory syndrome (SARS) emerged, and East and Southeast Asia retain a reputation as a hot spot of emerging infectious diseases. The region is certainly a hot spot of socioeconomic and environmental change, and although some changes (e.g., urbanization and agricultural intensification) may reduce the probability of emerging infectious diseases, the effect of any individual emergence event may be increased by the greater concentration and connectivity of livestock, persons, and products. The region is now better able to detect and respond to emerging infectious diseases than it was a decade ago, but the tools and methods to produce sufficiently refined assessments of the risks of disease emergence are still lacking. Given the continued scale and pace of change in East and Southeast Asia, it is vital that capabilities for predicting, identifying, and controlling biologic threats do not stagnate as the memory of SARS fades.

Perspective
Public Health Lessons from Severe Acute Respiratory Syndrome a Decade Later
J. P. Koplan et al.
http://wwwnc.cdc.gov/eid/article/19/6/pdfs/12-1426.pdf

Abstract
The outbreak of severe acute respiratory syndrome in 2002–2003 exacted considerable human and economic costs from countries involved. It also exposed major weaknesses in several of these countries in coping with an outbreak of a newly emerged infectious disease. In the 10 years since the outbreak, in addition to the increase in knowledge of the biology and epidemiology of this disease, a major lesson learned is the value of having a national public health institute that is prepared to control disease outbreaks and designed to coordinate a national response and assist localities in their responses.

Eurosurveillance
Volume 18, Issue 21, 23 May 2013
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Rapid communications
Ongoing outbreak of rubella among young male adults in Poland: increased risk of congenital rubella infections
by I Paradowska-Stankiewicz, MP Czarkowski, T Derrough, P Stefanoff

Journal of Medical Ethics
June 2013, Volume 39, Issue 6
http://jme.bmj.com/content/current

Brief report
Comprehension of a simplified assent form in a vaccine trial for adolescents
Sonia Lee, Bill G Kapogiannis, Patricia M Flynn, Bret J Rudy, James Bethel, Sushma Ahmad,    Diane Tucker, Sue Ellen Abdalian, Dannie Hoffman, Craig M Wilson, Coleen K  Cunningham,
Adolescent Medicine Trials Network for HIV/AIDS Interventions (ATN

Abstract
Introduction
Future HIV vaccine efficacy trials with adolescents will need to ensure that participants comprehend study concepts in order to confer true informed assent. A Hepatitis B vaccine trial with adolescents offers valuable opportunity to test youth understanding of vaccine trial requirements in general.

Methods
Youth reviewed a simplified assent form with study investigators and then completed a comprehension questionnaire. Once enrolled, all youth were tested for HIV and confirmed to be HIV-negative.

Results
123 youth completed the questionnaire (mean age=15 years; 63% male; 70% Hispanic). Overall, only 69 (56%) youth answered all six questions correctly.

Conclusions
Youth enrolled in a Hepatitis B vaccine trial demonstrated variable comprehension of the study design and various methodological concepts, such as treatment group masking.

http://jme.bmj.com/content/39/6/410.abstract

Journal of the Pediatric Infectious Diseases Society (JPIDS)
Volume 2 Issue 2 June 2013
http://jpids.oxfordjournals.org/content/current

Measles Outbreak Associated With International Travel, Indiana, 2011
J Ped Infect Dis (2013) 2(2): 110-118 doi:10.1093/jpids/pis132
Melissa G. Collier, Angela Cierzniewski, Thomas Duszynski, Cheryl Munson, Mona Wenger, Brad Beard, Ryan Gentry, Joan Duwve, Preeta K. Kutty, and Pamela Pontones

Abstract
Background
Endemic measles was declared eliminated in the United States in 2000, but imported measles cases continue to cause outbreaks. On June 20, 2011, 5 epidemiologically linked measles cases were reported to the Indiana State Department of Health. We investigated to identify additional cases and to prevent further spread.

Methods
Case findings and contact investigations during the June 3, 2011–August 13, 2011 outbreak identified measles cases, exposed persons, and exposure settings. Laboratory confirmation included measles serology and reverse-transcription polymerase chain reaction. Control measures included evaluating measles immune status and providing post-exposure prophylaxis, isolation, and quarantine.

Results
Fourteen confirmed measles illnesses were identified (10 [71%] females; median age, 11.5 years [range, 15 months–27 years]). The source patient was an unvaccinated US resident who recently traveled from Indonesia. Twelve patients were unvaccinated members of the source patient’s extended family. Two hospitalizations and no deaths were reported. Among 868 exposed persons identified through contact investigation, 644 (74%) had documented measles immunity, 153 (18%) were lost to follow-up, and 71 (8%) lacked evidence of immunity.

Conclusions
Misdiagnosis of measles in an unvaccinated patient with recent travel history to a measles-endemic region resulted in the second largest measles outbreak in the United States during 2011. Clinicians should consider measles among patients presenting with febrile rash illness and history of recent travel, and clinicians should promptly report suspected illnesses. Early identification of infectious patients, rapid public health investigation, and maintenance of high vaccine coverage are critical for the prevention and control of measles outbreaks.

http://jpids.oxfordjournals.org/content/2/2/110.abstract

Journal of Pediatrics
Vol 162 | No. 6 | June 2013 | Pages 1087-1298
http://www.jpeds.com/

Generalists’ role in vaccine safety reporting
Thomas R. Welch, MD
Every pediatrician involved in the day-to-day process of administering vaccines is aware of how fraught with complexity it has become. On one hand, many pediatricians have seen in their professional lifetimes the virtual disappearance of once-feared childhood disorders. On the other hand, unwarranted concerns about vaccine safety are leaving more and more children unprotected.

Journal of Pediatrics
Vol 162 | No. 6 | June 2013 | Pages 1087-1298
http://www.jpeds.com/

Comprehensive Assessment of Serious Adverse Events Following Immunization by Health Care Providers
S. Elizabeth Williams, Kathryn M. Edwards, MD, Roger P. Baxter, MD, Philip S. LaRussa, MD,     Neal A. Halsey, MD, Cornelia L. Dekker, MD, Claudia Vellozzi, MD, MPH, Colin D. Marchant, MD,    Peter D. Donofrio, MD, Tyler E. Reimschisel, MD, Melvin Berger, MD, Jane F. Gidudu, MD,     Nicola P. Klein, MD, PhD

Abstract
Many events occurring after vaccination have been attributed to vaccines, when in fact the association was often due to chance.1 However, as with any medical intervention, there are times when adverse events are caused by immunizations.2 Distinguishing which events are causally related to vaccine, rather than coincidental events, is a challenge for the pediatrician and a major focus of vaccine safety science. Consider a child who presents with aseptic meningitis after immunization. Because of the temporal relationship, one may suspect the immunizations as the cause, yet subsequent isolation of enterovirus from cerebrospinal fluid implicates the enteroviral infection instead.3 The term adverse event following immunization (AEFI) is defined as any untoward event that occurs after immunization, regardless of causal association.4 AEFI is the preferred notation to describe such clinical events because the term is free from implications regarding causal relationship and favors an open mind about the role of immunizations. AEFIs are a common part of routine clinical practice. The Clinical Immunization Safety Assessment (CISA) network has reviewed many individual cases of AEFIs and found that when a comprehensive investigation for alternative etiologies of the AEFI is completed, other causes for the event can often be identified. Yet, such comprehensive evaluations are rarely performed.8 We describe a stepwise approach to the comprehensive assessment of serious AEFIs by health care providers. The main objective is to highlight the important role that health care providers play in this effort by actively evaluating for the most likely causes of serious events when they occur after immunization.
http://www.jpeds.com/article/S0022-3476%2813%2900062-0/preview

The Lancet Infectious Diseases
Jun 2013   Volume 13  Number 6  p465 – 558
http://www.thelancet.com/journals/laninf/issue/current

Comment
AS03-adjuvanted influenza vaccine in elderly people
Julie E Ledgerwood

Preview
The best available method for prevention of influenza is vaccination. However, the effectiveness of inactivated trivalent influenza vaccine (TIV) is variable, generally reaching 60% in the overall population when vaccine strains and outbreak strains are well matched.1 Even with available licensed vaccines, up to 15% of the world’s population become infected with influenza every year, with as many as 5 million cases of severe illness and 500 000 deaths.2 In developed countries, most influenza deaths occur in elderly people, and, depending on the endpoint assessed, TIV effectiveness is as low as 9% in this population.

Articles
AS03-adjuvanted versus non-adjuvanted inactivated trivalent influenza vaccine against seasonal influenza in elderly people: a phase 3 randomised trial
Janet E McElhaney, Jiri Beran, Jeanne-Marie Devaster, Meral Esen, Odile Launay, Geert Leroux-Roels, Guillermo M Ruiz-Palacios, Gerrit A van Essen, Adrian Caplanusi, Carine Claeys, Christelle Durand, Xavier Duval, Mohamed El Idrissi, Ann R Falsey, Gregory Feldman, Sharon E Frey, Florence Galtier, Shinn-Jang Hwang, Bruce L Innis, Martina Kovac, Peter Kremsner, Shelly McNeil, Andrzej Nowakowski, Jan Hendrik Richardus, Andrew Trofa, Lidia Oostvogels, for the Influence65 study group
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2813%2970046-X/abstract

Summary
Background
We aimed to compare AS03-adjuvanted inactivated trivalent influenza vaccine (TIV) with non-adjuvanted TIV for seasonal influenza prevention in elderly people.

Methods
We did a randomised trial in 15 countries worldwide during the 2008—09 (year 1) and 2009—10 (year 2) influenza seasons. Eligible participants aged at least 65 years who were not in hospital or bedridden and were without acute illness were randomly assigned (1:1) to receive either AS03-adjuvanted TIV or non-adjuvanted TIV. Randomisation was done in an internet-based system, with a blocking scheme and stratification by age (65—74 years and 75 years or older). Participants were scheduled to receive one vaccine in each year, and remained in the same group in years 1 and 2. Unmasked personnel prepared and gave the vaccines, but participants and individuals assessing any study endpoint were masked. The coprimary objectives were to assess the relative efficacy of the vaccines and lot-to-lot consistency of the AS03-adjuvanted TIV (to be reported elsewhere). For the first objective, the primary endpoint was relative efficacy of the vaccines for prevention of influenza A (excluding A H1N1 pdm09) or B, or both, that was confirmed by PCR analysis in year 1 (lower limit of two-sided 95% CI had to be greater than zero to establish superiority). From Nov 15, to April 30, in both years, participants were monitored by telephone or site contact and home visits every week or 2 weeks to identify cases of influenza-like illness. After onset of suspected cases, we obtained nasal and throat swabs to identify influenza RNA with real-time PCR. Efficacy analyses were done per protocol. This trial is registered with ClinicalTrials.gov, number NCT00753272.

Findings
We enrolled 43 802 participants, of whom 21 893 were assigned to and received the AS03-adjuvanted TIV and 21 802 the non-adjuvanted TIV in year 1. In the year 1 efficacy cohort, fewer participants given AS03-adjuvanted than non-adjuvanted TIV were infected with influenza A or B, or both (274 [1·27%, 95% CI 1·12—1·43] of 21 573 vs 310 [1·44%, 1·29—1·61] of 21 482; relative efficacy 12·11%, 95% CI −3·40 to 25·29; superiority not established). Fewer participants in the year 1 efficacy cohort given AS03-adjuvanted TIV than non-adjuvanted TIV were infected with influenza A (224 [1·04%, 95% CI 0·91—1·18] vs 270 [1·26, 1·11—1·41]; relative efficacy 17·53%, 95% CI 1·55—30·92) and influenza A H3N2 (170 [0·79, 0·67—0·92] vs 205 [0·95, 0·83—1·09]; post-hoc analysis relative efficacy 22·0%, 95% CI 5·68—35·49).

Interpretation
AS03-adjuvanted TIV has a higher efficacy for prevention of some subtypes of influenza than does a non-adjuvanted TIV. Future influenza vaccine studies in elderly people should be based on subtype or lineage-specific endpoints.

Funding
GlaxoSmithKline Biologicals SA.

PLoS One
[Accessed 25 May 2013]
http://www.plosone.org/

Influenza Mortality in the United States, 2009 Pandemic: Burden, Timing and Age Distribution
Ann M. Nguyen, Andrew Noymer Research Article | published 22 May 2013 | PLOS ONE 10.1371/journal.pone.0064198

Abstract
Background
In April 2009, the most recent pandemic of influenza A began. We present the first estimates of pandemic mortality based on the newly-released final data on deaths in 2009 and 2010 in the United States.

Methods
We obtained data on influenza and pneumonia deaths from the National Center for Health Statistics (NCHS). Age- and sex-specific death rates, and age-standardized death rates, were calculated. Using negative binomial Serfling-type methods, excess mortality was calculated separately by sex and age groups.

Results
In many age groups, observed pneumonia and influenza cause-specific mortality rates in October and November 2009 broke month-specific records since 1959 when the current series of detailed US mortality data began. Compared to the typical pattern of seasonal flu deaths, the 2009 pandemic age-specific mortality, as well as influenza-attributable (excess) mortality, skewed much younger. We estimate 2,634 excess pneumonia and influenza deaths in 2009–10; the excess death rate in 2009 was 0.79 per 100,000.

Conclusions
Pandemic influenza mortality skews younger than seasonal influenza. This can be explained by a protective effect due to antigenic cycling. When older cohorts have been previously exposed to a similar antigen, immune memory results in lower death rates at older ages. Age-targeted vaccination of younger people should be considered in future pandemics.

PLoS Medicine
(Accessed  25 May 2013)
http://www.plosmedicine.org/

Integrating Global and National Knowledge to Select Medicines for Children: The Ghana National Drugs Programme
David Sinclair, Martha Gyansa-Lutterodt, Brian Asare, Augustina Koduah, Edith Andrews, Paul Garner

Summary Points
–    This paper reports the experience of the Ghana National Drugs Programme as they reviewed the international evidence base for five priority paediatric medicines.

–    Applying the global recommendations to Ghana was not straightforward for any of the five medicines, regardless of the presence of high quality evidence of important clinical benefits.

–    Four main factors generated debate and uncertainty in the committee: (1) effect unproven in African settings; (2) control group in trials not consistent with current practice; (3) little evidence on cost and cost effectiveness; and (4) limited supply chain.

–    This project demonstrates why global recommendations should be presented alongside transparent descriptions of the evidence base, allowing policy groups to identify where, when, and how the interventions have been evaluated, and any factors limiting applicability.

–    As many policy questions are relevant across sub-Saharan Africa, and policy makers are likely to encounter similar problems, we encourage regional collaboration on health technology assessment, and sharing of information and resources.

From Google Scholar & other sources: Selected Journal Articles, Dissertations, Theses, Commentary

Liability for Failure to Vaccinate
By Art Caplan
Bill of Health, Harvard Law Petrie-Flom Center
http://blogs.law.harvard.edu/billofhealth/2013/05/23/liability-for-failure-to-vaccinate/
Posted on May 23, 2013

Safety and Immunogenicity of a Recombinant Tetravalent Dengue Vaccine in 9-16-Year-Olds: A Randomized, Controlled, Phase II Trial in Latin America
LÁ Villar, DM Rivera-Medina, JL Arredondo-García… – The Pediatric Infectious …, 2013
Background. The dengue virus is a member of the Flavivirus (FV) genus, which also includes the yellow fever virus. Dengue disease is caused by any one of four dengue virus serotypesand is a serious public health concern in Latin America. This study evaluated the …

[HTML] In pursuit of an HIV vaccine: an interview with Andrew McMichael
AJ McMichael – BMC Biology, 2013
Andrew McMichael qualified in Medicine before doing a PhD in Immunology with Ita Askonas and Alan Williamson in the 1970s. His research during this time and later work done in his group has made a major contribution to our understanding of T-cell-mediated …

Vaccination Errors Reported to the Vaccine Adverse Event Reporting System 2000-2011
https://cste.confex.com/cste/2013/webprogram/Paper1777.html
2013 CSTE Annual Conference, 2013
Wednesday, June 12, 2013: 2:22 PM
Ballroom B (Pasadena Convention Center)
Beth Hibbs , Pedro Moro , Paige Lewis , Elaine Miller , Karen Broder , Claudia Vellozzi , Centers for Disease Control and Prevention, Atlanta, GA

BACKGROUND: Medication errors are an important public health problem and the subgroup of vaccination errors is relatively understudied. We characterized vaccination error reports to the Vaccine Adverse Event Reporting System (VAERS), a U.S. passive surveillance system for vaccine adverse events (AEs).

METHODS:  Signs and symptoms of AEs described in VAERS reports and reported medical errors are coded using the Medical Dictionary for Regulatory Activities (MedDRA).  We searched VAERS for U.S. reports of vaccination errors from 2000-2011 using 39 MedDRA medical error coding terms and categorized them into 11 error groups.  We performed manual review of selected reports and available medical records.

RESULTS:  Of the 255,528 reports received by VAERS from 2000-2011, we identified 13,137 (5.1% ) vaccination error reports.  The number of annual vaccination error reports increased from 10 reports in 2000 to 1,396 in 2011, peaking at 2,696 in 2008.  Of the vaccination error reports, 8813 (67%) reported the error without any AE while 4,324 (32.9%) documented an AE. Among these reports the most common AEs were injection site erythema (n=583, 13.5%), fever  (n=495, 11.4%) and  injection site pain (n=468, 10.8%).  The most common vaccination error reported was inappropriate schedule (i.e. wrong age, wrong schedule) (n=3,886, 29.6%), most often described for pediatric rotavirus vaccines (n=620, 16%).  The second most common vaccination error was wrong vaccine administered (n=2,693, 20.5%).  In a random sample of 100 reports of wrong vaccine administered, the most common mix-ups involved similar or related vaccines (i.e. Varicella and Zoster, pediatric DTaP and adult Tdap) in vaccination settings that served both children and adults.  We identified an unexpected vaccination error: 25 reports of rotavirus vaccine eye splashes affecting mainly healthcare providers (16 associated with ocular symptoms).  Cluster reports occurring in multiple individuals (range 2-500 persons) at the same vaccination location and date were noted 208 times; the most common error for clusters was expired drug administered.

CONCLUSIONS: Although VAERS data have limitations of passive surveillance, the data show that potentially preventable vaccination errors have occurred since 2000 in individuals and in clusters.   The most common vaccination errors, inappropriate schedule and wrong vaccine, as well as unexpected rotavirus eye splashes, may be prevented with education or packaging changes.  Even though most vaccination errors are not temporally associated with an adverse health event, errors potentially could cause adverse events, incur additional costs, inconvenience patients and impact confidence in vaccination programs.  Prevention strategies should be considered and evaluated.

Possible Factors Contributing to Vaccine Hesitancy Among Parents of Two Year Old Children in Georgia, 2010-2012
https://cste.confex.com/cste/2013/webprogram/Paper1613.html
2013 CSTE Annual Conference, 2013
Tuesday, June 11, 2013: 11:15 AM
Ballroom F (Pasadena Convention Center)
Rebecca M Willis , Georgia Department of Public Health, Atlanta, GA
Jessica Tuttle , Georgia Department of Public Health, Atlanta, GA

BACKGROUND:
Since 1997, the Georgia Immunization Office has conducted the annual Georgia Immunization Study (GIS) – a retrospective cohort study to determine the statewide and regional immunization coverage rates for 24 month old children born in the state of Georgia.  In 2010, data collection was expanded to include reasons for incomplete immunization. This study aims to assess the contribution of vaccine hesitancy to inadequate immunization in Georgia.

METHODS:
We analyzed data from the Georgia Registry of Immunization Transactions and Services (GRITS), which provided information on approximately 7,000 children who received immunizations during 2010-2012. We assessed the proportion of children who were inadequately immunized (4:3:1:3:3:1:4 level), analyzed the reasons listed for inadequate immunization, and used descriptive statistics to characterize demographic or other factors that may contribute to vaccine hesitancy –  measured as parent choosing delayed schedule or refusing any vaccines.

RESULTS:
During 2010-2012, a total of 462 (6.5%) two-year-olds were inadequately immunized by the end of the data collection period. During this time, there were a total of 261 (56.5%) reasons for inadequate immunization related to vaccine hesitancy, the most-frequently cited reason being “parent chose a delayed schedule” (141; 30.5%). The racial/ ethnic breakdown of the inadequately immunized subsample was: white, non-Hispanic (215; 46.5%), black, non-Hispanic (166; 35.9%) and Hispanic (28; 6.1%), similar to the overall eligible sample. The white, non-Hispanic children were inadequately immunized due primarily to a parent refusing one or more vaccines (48; 16.9%) versus children of black and Hispanic mothers (18; 5.0% and 5; 8.3%, respectively). Parents of children enrolled in WIC less often refused one or more vaccines when compared to parents of children not enrolled in WIC (10% versus 21%) (2011). Parents of children whose mother was 25-34 years old at the time of birth more often chose a delayed immunization schedule for their child than both the under 25 year and 35+ years age groups (79; 35.1% versus 51; 27.4% and 11; 21.6%, respectively).

CONCLUSIONS:
Inadequate immunization may be attributed, in part, to vaccine hesitancy in more than 2.5% of the cohort of two year olds in Georgia during 2010-2012. Inadequately immunized children differ by race/ethnicity, maternal age, and maternal WIC enrollment. Healthcare providers should take into account these differences to target vaccine education and improve vaccine coverage in Georgia.

New Yorker
http://www.newyorker.com/
Accessed 25 May 2013

Books
Resistant
Why a century-old battle over vaccination continues to rage.
by Michael Specter May 30, 2013
http://www.newyorker.com/arts/critics/books/2011/05/30/110530crbo_books_specter

BOOK review about the battle over vaccination. Smallpox claimed the lives of tens of thousands of French soldiers during the Franco-Prussian War, yet the Prussians lost fewer than five hundred men. That was because Prussia vaccinated its entire Army against the virus, and France did not. By the end…

Wall Street Journal
http://online.wsj.com/home-page
May 20, 2013, 4:02 a.m. ET

Polio-Vaccine Team Attacked in Pakistan
Associated Press
KHAR, Pakistan—Officials say gunmen have killed a policeman guarding a polio-vaccination team in northwestern Pakistan.

Local government administrator Faramosh Khan says the gunmen attacked on Monday in the town of Mamound in the Bajur tribal area, just as the team started a vaccination drive.

No one has claimed responsibility for the shooting, but suspicion will likely fall on Islamic militants suspected in similar attacks.

Jehanzeb Dawar, a senior regional health official, said a total of 624 teams are taking part in the latest push in Bajur to vaccinate more than 220,000 children. The teams relaunched the drive after taking a couple of months off because of past attacks on vaccination teams in the country.

It’s unclear whether the campaign will continue after Monday’s attack.

http://online.wsj.com/article/SB10001424127887324787004578494402823401718.html

Washington Post
http://www.washingtonpost.com/
Accessed 25 May 2013

WHO: Competition, rules dispute mar efforts to combat new Mideast virus that has killed 22
By Associated Press, Published: May 23
GENEVA — International efforts to combat a new pneumonia-like virus that has now killed 22 people are being slowed by unclear rules and competition for the potentially profitable rights to disease samples, the head of the World Health Organization warned Thursday.

Dr. Margaret Chan, in a blunt warning to the U.N. agency’s annual global assembly, portrayed a previously little-known flap over who owns a sample of the virus as a global game-changer that could put people’s lives at risk. The virus, which first emerged in Saudi Arabia where most cases have arisen, is called MERS for Middle East respiratory syndrome.

“Please, I’m very strong on this point, and I want you to excuse me,” she said. “Tell your scientists in your country, because you’re the boss. You’re the national authority. Why would your scientists send specimens out to other laboratories on a bilateral manner and allow other people to take intellectual property rights on a new disease?”

The controversy stems from a sample taken by Saudi microbiologist Ali Mohamed Zaki that he mailed last year to virologist Ron Fouchier at the Erasmus Medical Center in the Netherlands.

Fouchier tested, sequenced and identified it last September as a new virus. Then his private medical center patented how it synthesized the germ and required other researchers who wanted samples to first sign an agreement that could trigger a payment.

Saudi Arabia, which had the first case, said the patenting delayed its development of diagnostic kits and blood tests. “There was a lag of three months where we were not aware of the discovery of the virus,” Deputy Health Minister Ziad Memish told the Geneva assembly. He said the sample was sent to the Dutch lab without official permission.

So far there is no blood test for detecting infection in communities. Memish said that patients need to be isolated because in some cases, diarrhea or vomiting may help spread the germ.

Dr. Keiji Fukuda, WHO’s assistant director-general for health security, said his agency also has been “struggling with diagnostics” because of property rights concerns and ill-defined international rules for sharing such materials.

Chan railed against any arrangement that could prevent rapid sharing of information or that would enable individual scientists or private labs to profit.

WHO officials say the delays involve blood and other tests though a few other facilities in Canada, Britain and Germany have samples.

Fouchier, however, said the agreements between individual countries are similar to those within WHO’s networks.

“There are no restrictions to the use of the virus for research and public health purposes. There are only restrictions for commercial exploitation and forwarding virus to third parties,” he wrote in an email, responding to questions from The Associated Press.

Any delays claimed by WHO are a misconception, he said.

“After the first identification of the virus, diagnostic tests were developed in collaboration with several public health laboratories, and these tests were distributed free of charge to everyone around the world who asked for them,” Fouchier added. “We have not denied access to the virus to any research and public health laboratory with the appropriate facilities to handle this virus safely.”

The World Health Assembly, the decision-making body of WHO, meets from May 20-28.

Indonesia has previously refused to share samples of the bird flu virus that has been seen in Southeast Asia for several years. That country claimed vaccines made from those samples would be too expensive for developing countries to afford. That dispute led to a protracted series of negotiations with WHO and others to ensure poor nations would have access to vaccines in a global epidemic…

Copyright 2013 The Associated Press.

http://www.washingtonpost.com/world/europe/un-22-deaths-worldwide-from-44-cases-of-new-coronavirus/2013/05/23/6eb63bb6-c3b4-11e2-9642-a56177f1cdf7_story.html

Editor’s Notes:

– Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_18 May 2013_PDF

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

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

– 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…

WHO: Landmark reached with tetanus elimination achieved in over half of 59 priority countries
The Maternal and Neonatal Tetanus (MNT) Elimination Initiative announced that tetanus has been eliminated in over half of 59 priority countries. Since 1999, more than 118 million women of child-bearing age have been vaccinated against tetanus in 52 countries. Many of these women received their tetanus vaccine as part of an integrated campaign which included other life-saving interventions for children including immunization against measles, vitamin A supplements, deworming tablets and information on umbilical cord care. The MNT Elimination Initiative is an international private-public partnership that includes national governments, WHO, UNFPA, UNICEF, GAVI Alliance, USAID/Immunization Basics, CDC, UNICEF National Committees, the Government of Japan, Save the Children, PATH, RMHC, Bill & Melinda Gates Foundation, Kiwanis International, Pampers – a division of Procter & Gamble, and BD.

Countries that have eliminated MNT include: Bangladesh; Benin; Burkina Faso; Burundi; Cameroon; China; Comoros; Congo; Cote d’ Ivoire; Egypt; Eritrea; Ghana; Guinea Bissau; Iraq; Liberia; Malawi; Mozambique; Myanmar; Namibia; Nepal; Rwanda; Senegal; South Africa; Tanzania (United Republic of); Timor Leste; Togo; Turkey; Uganda; Viet Nam; Zambia and Zimbabwe.

Priority countries “still working toward elimination” include Afghanistan; Angola; Cambodia; Central African Republic; Chad; Congo (Democratic Republic of the); Equatorial Guinea; Ethiopia; Gabon; Guinea; Haiti; India; Indonesia; Kenya; Lao People’s Democratic Republic; Madagascar; Mali; Mauritania; Niger; Nigeria; Pakistan; Papua New Guinea; Philippines; Sierra Leone; Somalia; South Sudan; Sudan; and Yemen
http://www.who.int/immunization/newsroom/Landmark_reached_in_fight_against_tetanus/en/index.html

The Government of India’s Department of Biotechnology (DBT) and Bharat Biotech announced positive results from a Phase III clinical trial of a rotavirus vaccine developed and manufactured in India. The clinical study “demonstrates for the first time that the India-developed rotavirus vaccine is efficacious in preventing severe rotavirus diarrhoea in low-resource settings in India.”  DBT Secretary Dr K. Vijay Raghavan commented, “This is an important scientific breakthrough against rotavirus infections, the most severe and lethal cause of childhood diarrhoea, responsible for approximately 100,000 deaths of small children in India each year. The clinical results indicate that the vaccine, if licensed, could save the lives of thousands of children each year in India.”

The vaccine was developed through a unique social innovation partnership that brought together the experience and expertise of Indian and international researchers as well as the public and private sectors. The vaccine originated from an attenuated (weakened) strain of rotavirus that was isolated from an Indian child at the All India Institute of Medical Sciences in New Delhi in 1985-86. Since then, partners have included DBT, Bharat Biotech, the US National Institutes of Health (NIH), the US Centers for Disease Control and Prevention (CDC), Stanford University School of Medicine, and the nongovernmental organization, PATH.

The randomized, double-blind, placebo-controlled Phase III clinical trial enrolled 6,799 infants in India (aged six to seven weeks at the time of enrollment) at three sites—the Centre for Health Research and Development, Society for Applied Studies (SAS) in New Delhi; Shirdi Sai Baba Rural Hospital, KEM Hospital Research Centre in Vadu, Pune; and Christian Medical College (CMC) in Vellore…
Full announcement: http://www.defeatdd.org/sites/default/files/node-images/ROTAVAC%20press%20release_FINAL_0.pdf
.
   Results of the ROTAVAC Rotavirus Vaccine Study in India – Statement of Anthony S. Fauci, M.D.
Director, National Institute of Allergy and Infectious Diseases, National Institutes of Health
Excerpt
We congratulate the Program for Appropriate Technology in Health (PATH), Bharat Biotech International, Ltd., and the scientists, government and people of India on the important results from the ROTAVAC rotavirus vaccine study.

Highly contagious rotaviruses are the leading cause of severe diarrheal illnesses among infants and young children in both developed and resource-limited countries. Each year, rotavirus-induced diarrheal disease kills roughly 435,000 children younger than 5 years old and hospitalizes an estimated two million children worldwide, largely in developing countries. The youngest children — those between 6 months and 2 years of age — are most vulnerable.

Since 2006, two oral rotavirus vaccines have been licensed and available in North and South American, European and Eastern Mediterranean countries, where they have significantly reduced the burden of rotavirus-induced diarrhea. Based on that success, the World Health Organization recommended in 2009 the inclusion of rotavirus vaccine in all national immunization programs. However, access to vaccines can be slow and limited in the areas of the world where they are needed most.

ROTAVAC is a new rotavirus vaccine that consists of a strain of the virus that was isolated, manufactured and tested in India. The ROTAVAC trial represents a significant victory for India’s scientific community. Based on the study’s successful findings, infants in India will gain access to a licensed vaccine and its significant protection against severe rotavirus-induced gastroenteritis.

The National Institute of Allergy and Infectious Diseases (NIAID), part of the U.S. National Institutes of Health, was a partner in the public/private collaboration to develop and test this important vaccine. In the early 1990s, NIAID established an interagency agreement with the Centers for Disease Control and Prevention, and made several grant awards through the NIAID Indo-U.S. Vaccine Action Program….
Full media release: http://www.nih.gov/news/health/may2013/niaid-14.htm
.
PATH congratulates the government of India’s Department of Biotechnology and Bharat Biotech on their release of positive phase 3 clinical trial results for ROTAVAC®, the first efficacious rotavirus vaccine to be developed exclusively in India. Results demonstrate the vaccine successfully protects against rotavirus infections, one of the most lethal forms of diarrhea in young children.

“The clinical study results showing ROTAVAC to be safe and efficacious are tremendously exciting,” said Steve Davis, PATH president and CEO. “This unique social innovation partnership, which brought together a consortium of scientists and experts from a range of agencies and sectors in India and the United States, provides a great collaborative model for meeting a public health need—a more affordable rotavirus vaccine…PATH is pleased and honored to have played a role in reaching this incredible milestone, and we congratulate all of the partners involved on these positive clinical trial results.”

PATH provided technical assistance to Bharat Biotech and the consortium on issues such as vaccine stability, the development of special harvesting techniques, using cleaner preparation methods, and designing and implementing clinical trials that meet international standards…

Full announcement: http://www.path.org/news/an130514-rotavac-results.php

WHO SAGE: Yellow fever vaccination booster not needed
News release – Excerpt
Dr Helen Rees, chair of SAGE, commented, “The conventional guidance has been that the yellow fever vaccination has had to be boosted after ten years. Looking at really very good evidence, it was quite clear to SAGE that in fact a single dose of yellow fever vaccine is effective. This is extremely important for countries where yellow fever is endemic, because it will allow them to reconsider their vaccine scheduling. It is also important for travelers.” There are an estimated 200 000 cases of yellow fever worldwide each year. About 15% of people infected with yellow fever progress to a severe form of the illness, and up to half of those will die, as there is no cure for yellow fever. The treatment is “aimed simply at reducing patients’ discomfort”…
http://www.who.int/mediacentre/news/releases/2013/yellow_fever_20130517/en/index.html

    The Weekly Epidemiological Record (WER) for 17 May 2013, vol. 88, 20 (pp. 201–216) includes:
–       Meeting of the Strategic Advisory Group of Experts on immunization, April 2013 – conclusions and recommendations
http://www.who.int/entity/wer/2013/wer8820.pdf

Update: Polio this week – As of 15 May 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s extract and bolded text]
–       The Taliban in Afghanistan have released a statement supporting health programmes in the country, with particular reference to polio vaccination campaigns. The World Health Organization (WHO) welcomes this statement, notes the request to respect local conditions, and supports all efforts to protect the children of Afghanistan from polio and other diseases. [see below]
–       A wild poliovirus type 1 (WPV1) case has been confirmed in Somalia, the first in the country since 2007. Outbreak response activities have been launched. Please see ‘Horn of Africa’ section below for more.

Nigeria
–       Four new WPV cases were reported in the past week (WPV1s from Borno, Kano, Taraba and Yobe), bringing the total number of cases for 2013 to 22. The cases from Borno and Taraba are the most recent WPV cases in the country, both with onset of paralysis on 24 April.

Pakistan
–       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 2013 to eight. The case from FATA is the most recent WPV case in the country (and the first WPV from FATA in 2013), and had onset of paralysis on 24 April.
–       Two new positive environmental samples were confirmed this week, WPV1s from Gadap, Sindh (collected 11 April) and Peshawar, KP (collected 12 April). This year, 16 environmental samples positive for WPV1 have been reported (of which 11 were collected in Peshawar and Hyderabad, Sindh).
–       The security situation continues to be monitored closely, in consultation with law enforcement agencies. Immunization activities continue to be implemented, in some areas staggered or postponed, depending on the security situation at the local level.

Horn of Africa
–       One new WPV case was reported in the past week (WPV1 from Banadir, Somalia), with onset of paralysis on 18 April. It is the first WPV in Somalia since March 2007. It is the first outbreak outside of an endemic country in 2013.
–       The child is a 32-month-old girl from Banadir region.
–       In large areas of south-central Somalia, immunization campaigns have not been implemented since 2009 due to inaccessibility, affecting more than 500,000 children aged <5 years. Populations in this area are at particular risk of this polio outbreak. This is also the area affected by an ongoing cVDPV2 outbreak, which has resulted in 18 cases in the country since 2009 (most recent cVDPV2 case had onset of paralysis on 9 January 2013).

WHO: Afghanistan Taliban’s ‘Declaration regarding Polio Eradication’
13 May 2013
Supporting efforts which work “for the health care of the helpless people of our country”

“The Taliban in Afghanistan have released a statement supporting all health programs in the country, with particular reference to polio vaccination campaigns. WHO welcomes this statement, notes the request to respect local conditions, and supports all efforts to protect the children of Afghanistan from polio and other diseases.
Full text of the statement:

   According to the latest international medicine science, the polio disease can only be cured by preventive measures i.e. the anti-polio drops and the vaccination of children against this disease.
The Islamic Emirate of Afghanistan supports and lends a hand to all those programs which works for the health care of the helpless people of our country. The Islamic Emirate of Afghanistan advises in the existing war situation of the country to the campaigning organizations i.e. WHO and UNICEF to employ unbiased people in the region. The foreign employees should refrain from going to the region and similarly the campaign should be harmonized with the regional conditions, Islamic values and local cultural traditions. In case of compliance with these rudiments, all the associated workers (Mujahidin) of the Islamic Emirate of Afghanistan are directed, not to create any kind of trouble for them, rather they should be provided with all necessary support.
    Islamic Emirate of Afghanistan 

http://www.polioeradication.org/Mediaroom/Newsstories/Newsstories2013/tabid/488/iid/296/Default.aspx

WHO: Global Alert and Response (GAR) – Disease Outbreak News
http://www.who.int/csr/don/2013_03_12/en/index.html

Human infection with avian influenza A(H7N9) virus – update 17 May 2013
17 May 2013 – Since 8 May 2013, no new laboratory-confirmed cases of human infection with avian influenza A(H7N9) have been reported to WHO by the National Health and Family Planning Commission, China. However, four additional deaths have been reported from previously laboratory-confirmed cases.
To date, WHO has been informed of a total of 131 laboratory-confirmed cases, including 36 deaths…

Novel coronavirus infection – update 15 May 2013
15 May 2013 – The Ministry of Health in Saudi Arabia has informed WHO of an additional two laboratory-confirmed cases with infection of the novel coronavirus (nCoV).
The two patients are health care workers who were exposed to patients with confirmed nCoV. The first patient is a 45-year-old man who became ill on 2 May 2013 and is currently in a critical condition. The second patient is a 43-year-old woman with a coexisting health condition, who became ill on 8 May 2013 and is in a stable condition.
Although health care associated transmission has been observed before with nCoV (in Jordan in April 2012), this is the first time health care workers have been diagnosed with nCoV infection after exposure to patients. Health care facilities that provide care for patients with suspected nCoV infection should take appropriate measures to decrease the risk of transmission of the virus to other patients and health care workers. Health care facilities are reminded of the importance of systematic implementation of infection prevention and control (IPC)…

The Global Fund to Fight AIDS, Tuberculosis and Malaria said it agreed to participate in the Pledge Guarantee for Health, a new partnership “to leverage private sector funding to speed delivery and expand access to health supplies such as contraceptives, bed nets, and medicines.” The program is a “new financing mechanism that will help increase the impact of each dollar of donor funding and ultimately improve healthcare access and outcomes for millions of people.” Developed and incubated by the United Nations Foundation, The Pledge Guarantee for Health “facilitates innovative financing that expedites the disbursement of donor funds, making global health supplies more accessible and more affordable for developing countries.” The United States Agency for International Development and the Swedish International Agency for Development Cooperation are providing a 5-year partial guarantee to help speed up the procurement of essential medicines and health supplies by governments and civil society partners. In collaboration with commercial banking partners, this partial guarantee enables the Pledge Guarantee for Health to access $100 million in credit that, over 5 years, can mobilize tremendous lending capacity…
Full Release: 17 May 2013  http://www.theglobalfund.org/en/mediacenter/newsreleases/2013-05-17_Global_Fund_Joins_New_Innovative_Financing_Partnership/

   The Global Fund published a report on preventing and detecting possible misuse of funds in countries where it makes grants. The report, prepared by Chief Risk Officer Cees Klumper, “outlines actions that the Global Fund has taken over the past year to reduce risk and improve oversight.” Mr. Klumper pointed out that “investing in developing countries means taking calculated risks. In order to manage those risks, significant measures are in place with a particular focus on fraud prevention and detection.” While 1.9 percent of Global Fund grants have been determined to have been misspent, fraudulently misappropriated or inadequately accounted for, the Global Fund “does not tolerate any misuse of funds, no matter how minor.” The proportion of the grant portfolio accounted for by fraudulent misappropriation is 0.3 percent. Starting in 2012, the Fund “has begun to apply a systematic approach to grant risk management that can be considered leading practice. All risks that determine a grant’s success are captured, documented and assessed on a regular basis. These risk assessments inform specific risk mitigation measures, including for fraud risks, grant-by-grant…”
http://www.theglobalfund.org/en/mediacenter/announcements/2013-05-17_Global_Fund_Report_on_Preventing_and_Detecting_Possible_Misuse_of_Funds/

Sixty-sixth World Health Assembly (WHA)
20–28 May 2013
Geneva, Switzerland

Provisional Agenda: http://apps.who.int/gb/ebwha/pdf_files/WHA66/A66_1-en.pdf

WHA 66 Documentation
Editor’s Excerpt
A66/8 – Draft comprehensive global monitoring framework and targets for the prevention and control of noncommunicable diseases
Formal Meeting of Member States to conclude the work on the comprehensive global monitoring framework, including indicators, and a set of voluntary global targets for the prevention and control of noncommunicable diseases

A66/13 – Monitoring the achievement of the health-related Millennium Development Goals

A66/14 – Follow-up actions to recommendations of the high-level commissions convened to advance women’s and children’s health

A66/15 – Social determinants of health

A66/16 – Implementation of the International Health Regulations (2005)

A66/17 – Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other benefits/Pandemic Influenza Preparedness Framework 2013 biennial report

A66/17 Add.1 – Pandemic influenza preparedness: sharing of influenza viruses and access to vaccines and other benefits/Report of the meeting of the Pandemic Influenza Preparedness Framework Advisory Group

A66/18 – Poliomyelitis: intensification of the global eradication initiative

A66/19 – Global vaccine action plan

A66/20 – Neglected tropical diseases; Prevention, control, elimination and eradication

A66/21 – Malaria

WHO: World Health Statistics 2013
Contains WHO’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.
This year, it also includes highlight summaries on the topics of reducing the gaps between the world’s most-advantaged and least-advantaged countries, and on current trends in official development assistance (ODA) for health.

http://who.int/gho/publications/world_health_statistics/2013/en/index.html

Report: PUTTING PROGRESS AT RISK? MDG spending in developing countries
Government Spending Watch report
May 2013
Development Finance International (DFI) and Oxfam International
http://www.governmentspendingwatch.org/images/pdfs/GSW-Report-Progress-at-risk-MDG_160513.pdf

Excerpt from Executive Summary
Thirty-two months remain until the 2015 deadline set by world leaders for reaching the Millennium Development Goals (MDGs). This Government Spending Watch (GSW) report is the first ever to track how much developing countries are spending on the MDGs. It is based on data compiled by Development Finance International (DFI) and Oxfam, covering 52 low- and

lower-middle income countries… Future reports will extend the analysis to 34 more countries. The data, research, and information on current campaigns on MDG spending, are available from the GSW website:

www.governmentspendingwatch.org

Report: Progress on sanitation and drinking-water
2013 update: Joint Monitoring Programme for Water Supply and Sanitation
WHO, UNICEF
JMP 2013 update: Progress on sanitation and drinking-water
Overview
JMP 2013 update presents country, regional and global estimates for the year 2011. Drinking-water coverage in 2011 remains at 89% – which is 1% above the MDG drinking-water target. In 2011, 768 million people relied on unimproved drinking-water sources.
http://www.who.int/water_sanitation_health/publications/2013/jmp_report/en/index.html

2.4 billion people will lack improved sanitation in 2015; World will miss MDG target
13 May 2013 | GENEVA/NEW YORK – Some 2.4 billion people – one-third of the world’s population – will remain without access to improved sanitation in 2015, according to a joint WHO/UNICEF report issued today.

The report, entitled Progress on sanitation and drinking-water 2013 update, warns that, at the current rate of progress, the 2015 Millennium Development Goal (MDG) target of halving the proportion of the 1990 population without sanitation will be missed by 8% – or half a billion people.

While UNICEF and WHO announced last year that the MDG drinking water target had been met and surpassed by 2010, the challenge to improve sanitation and reach those in need has led to a consolidated call for action to accelerate progress.

http://www.who.int/mediacentre/news/notes/2013/sanitation_mdg_20130513/en/index.html

Report: Capital for the Future: Saving and Investment in an Interdependent World
World Bank – Global Development Horizons (GDH)
http://siteresources.worldbank.org/EXTDECPROSPECTS/Resources/476882-1368197310537/CapitalForTheFuture.pdf

Announcement Excerpt
Capital for the Future, the second edition of the series, explores saving, investment, and capital flows through 2030. It finds that developing economies are fast becoming major investors in the world economy, and by 2030 will account for more than 60 cents of every dollar invested. This represents a fundamental shift with respect to historical performance: for 4 decades (through the 1990s), developing countries had been accounting for just about 20 cents for every dollar of global saving and investment. Before 2020, total investment in the developing world is expected to overtake that in high income countries. Developing countries will—for the first time in history—become major sources, destinations, and potentially also intermediaries of global gross capital flows.

Future trends in investment, saving, and capital flows will affect economic conditions from the household level to the global macroeconomic level, with implications not only for national governments but also for international institutions and policy coordination. Without timely efforts, some countries will be left behind. And, more importantly, even within otherwise successful countries, some people will be left behind. Policy makers preparing for this change will thus benefit from a better understanding of the unfolding dynamics of global capital and wealth in the future…

Full overview: http://econ.worldbank.org/WBSITE/EXTERNAL/EXTDEC/EXTDECPROSPECTS/0,,contentMDK:23413150~pagePK:64165401~piPK:64165026~theSitePK:476883,00.html

Global Assessment Report on Disaster Risk Reduction 2013
From Shared Risk to Shared Value: the Business Case for Disaster Risk Reduction
United Nations Office for Disaster Risk Reduction
May 2013
http://www.preventionweb.net/english/hyogo/gar/2013/en/home/index.html

The third edition of this biennial publication highlights how the transformation of the global economy over the last forty years has led to rapid increases in disaster risk in low, medium and high income countries, affecting businesses and societies.

Download Full Report and Sections: http://www.preventionweb.net/english/hyogo/gar/2013/en/home/download.html

Globalization and Health
[Accessed 18 May 2013]
http://www.globalizationandhealth.com/

Research
Ownership and use of mobile phones among health workers, caregivers of sick children and adult patients in Kenya: cross-sectional national survey
Zurovac D, Otieno G, Kigen S, Mbithi AM, Muturi A, Snow RW and Nyandigisi A Globalization and Health 2013, 9:20 (14 May 2013)

Abstract (provisional)
Background
The rapid growth in mobile phone penetration and use of Short Message Service (SMS) has been seen as a potential solution to improve medical and public health practice in Africa. Several studies have shown effectiveness of SMS interventions to improve health workers? practices, patients? adherence to medications and availability of health facility commodities. To inform policy makers about the feasibility of facility-based SMS interventions, the coverage data on mobile phone ownership and SMS use among health workers and patients are needed.

Methods
In 2012, a national, cross-sectional, cluster sample survey was undertaken at 172 public health facilities in Kenya. Outpatient health workers and caregivers of sick children and adult patients were interviewed. The main outcomes were personal ownership of mobile phones and use of SMS among phone owners. The predictors analysis examined factors influencing phone ownership and SMS use.

Results
The analysis included 219 health workers and 1,177 patients? respondents (767 caregivers and 410 adult patients). All health workers possessed personal mobile phones and 98.6% used SMS. Among patients? respondents, 61.2% owned phones and 71.4% of phone owners used SMS. The phone ownership and SMS use was similar between caregivers of sick children and adult patients. The respondents who were male, more educated, literate and living in urban area were significantly more likely to own the phone and use SMS. The youngest respondents were less likely to own phones, however when the phones were owned, younger age groups were more likely to use SMS. Respondents living in wealthier areas were more likely to own phones; however when phones are owned no significant association between the poverty and SMS use was observed.

Conclusions
Mobile phone ownership and SMS use is ubiquitous among Kenyan health workers in the public sector. Among patients they serve the coverage in phone ownership and SMS use is lower and disparities exist with respect to gender, age, education, literacy, urbanization and poverty. Some of the disparities on SMS use can be addressed through the modalities of mHealth interventions and enhanced implementation processes while further growth in mobile phone penetration is needed to reduce the ownership gap.

http://www.globalizationandhealth.com/content/9/1/20/abstract

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

International Journal of Infectious Diseases
Vol 17 | No. 7 | July 2013
http://www.ijidonline.com/current

Latest outbreak news from ProMED-mail. Yellow fever outbreak—Darfur Sudan and Chad
Thomas M. Yuill, John P. Woodall, Susan Baekeland
Received 14 March 2013; accepted 16 March 2013. published online 02 May 2013.

Summary
The recent yellow fever outbreak in Darfur has been the worst in Africa in 20 years. It began on 2 September 2012. However, it was not until 30 October that samples were sent to a reference laboratory in Senegal for confirmation of the disease. On 9 November 2012, the World Health Organization (WHO) Sudan reported 266 suspected cases and 85 fatalities in 20 localities for a case fatality rate of 32%, with Central Darfur state the area hardest hit. The yellow fever vaccination plan to cover 3.5 million persons was finalized. On 13 November 2012 the WHO reported laboratory confirmation of yellow fever in two samples. Mass vaccination began in the region on 20 November. On 10 January 2013 a report was jointly released by the Ministry of Health and the WHO that stated that 171 people had died of the disease as of 9 January 2013 and that there had been 849 suspected cases in Darfur since 2 September 2012. It was estimated that 35 out of the 64 localities of Darfur had been affected by the disease. On 14 February 2013, the WHO reported two confirmed yellow fever cases in Chad in December 2012, an apparent spill-over from Darfur. The Ministry of Health of Chad launched an emergency mass vaccination campaign against yellow fever starting 22 February 2013.

http://www.ijidonline.com/article/S1201-9712%2813%2900138-0/abstract

International Journal of Infectious Diseases
Vol 17 | No. 7 | July 2013
http://www.ijidonline.com/current

Don’t forget how severe varicella can be—complications of varicella in children in a defined Polish population
Ewelina Gowinemail, Jacek Wysocki, Michał Michalak

Summary 
Background
This study aimed to analyze the causes of hospitalization in children with varicella, based on a defined Polish population.

Methods
This was a retrospective analysis of causes of hospitalization in children under 18 years of age with varicella, treated on the Infectious Diseases Ward of the Children’s Hospital in Poznan, Poland from January 2007 to June 2012. The ward serves almost the entire child population of the Greater Poland region (10% of the Polish population – almost 600 000 children). The analysis was based on hospital records. Patients were identified using the International Classification of Diseases Tenth Revision (ICD-10) codes. The case definition consisted of physical evidence of varicella.

Results
A total of 224 children were hospitalized for varicella complications. The median age of admitted patients was 37.5 months (range 6 days to 17 years). Rates of hospitalization decreased with age. The highest rates were among children during their first year. Ninety-two percent of children were healthy prior to hospitalization (no chronic diseases). The most common complications were respiratory tract infections (26%), followed by skin infections (21%) and neurological symptoms (18%). Twenty-five patients (11%) had more than one complication. The most common coexisting conditions were dehydration and otitis media.

Conclusions
The results presented here serve to remind us that varicella may to lead to severe complications in unvaccinated children and adolescents, and demonstrate the benefits of varicella vaccination. Most children hospitalized with varicella were immunologically healthy. Meningitis was more common in older children (>6 years of age). Streptococcus pyogenes was the most commonly identified bacterial pathogen.

http://www.ijidonline.com/article/S1201-9712%2812%2901317-3/abstract

The Lancet  
May 18, 2013  Volume 381  Number 9879  p1687 – 1788  e12 – 15
http://www.thelancet.com/journals/lancet/issue/current

Effect of women’s groups and volunteer peer counselling on rates of mortality, morbidity, and health behaviours in mothers and children in rural Malawi (MaiMwana): a factorial, cluster-randomised controlled trial
Sonia Lewycka, Charles Mwansambo, Mikey Rosato, Peter Kazembe, Tambosi Phiri, Andrew Mganga, Hilda Chapota, Florida Malamba, Esther Kainja, Marie-Louise Newell, Giulia Greco, Anni-Maria Pulkki-Brännström, Jolene Skordis-Worrall, Stefania Vergnano, David Osrin, Anthony Costello
Summary
Background
Women’s groups and health education by peer counsellors can improve the health of mothers and children. We assessed their effects on mortality and breastfeeding rates in rural Malawi.
Methods
We did a 2×2 factorial, cluster-randomised trial in 185 888 people in Mchinji district. 48 equal-sized clusters were randomly allocated to four groups with a computer-generated number sequence. 24 facilitators guided groups through a community action cycle to tackle maternal and child health problems. 72 trained volunteer peer counsellors made home visits at five timepoints during pregnancy and after birth to support breastfeeding and infant care. Primary outcomes for the women’s group intervention were maternal, perinatal, neonatal, and infant mortality rates (MMR, PMR, NMR, and IMR, respectively); and for the peer counselling were IMR and exclusive breastfeeding (EBF) rates. Analysis was by intention to treat. The trial is registered as ISRCTN06477126.
Findings
We monitored outcomes of 26 262 births between 2005 and 2009. In a factorial model adjusted only for clustering and the volunteer peer counselling intervention, in women’s group areas, for years 2 and 3, we noted non-significant decreases in NMR (odds ratio 0·93, 0·64—1·35) and MMR (0·54, 0·28—1·04). After adjustment for parity, socioeconomic quintile, and baseline measures, effects were larger for NMR (0·85, 0·59—1·22) and MMR (0·48, 0·26—0·91). Because of the interaction between the two interventions, a stratified analysis was done. For women’s groups, in adjusted analyses, MMR fell by 74% (0·26, 0·10—0·70), and NMR by 41% (0·59, 0·40—0·86) in areas with no peer counsellors, but there was no effect in areas with counsellors (1·09, 0·40—2·98, and 1·38, 0·75—2·54). Factorial analysis for the peer counselling intervention for years 1—3 showed a fall in IMR of 18% (0·82, 0·67—1·00) and an improvement in EBF rates (2·42, 1·48—3·96). The results of the stratified, adjusted analysis showed a 36% reduction in IMR (0·64, 0·48—0·85) but no effect on EBF (1·18, 0·63—2·25) in areas without women’s groups, and in areas with women’s groups there was no effect on IMR (1·05, 0·82—1·36) and an increase in EBF (5·02, 2·67—9·44). The cost of women’s groups was US$114 per year of life lost (YLL) averted and that of peer counsellors was $33 per YLL averted, using stratified data from single intervention comparisons.
Interpretation
Community mobilisation through women’s groups and volunteer peer counsellor health education are methods to improve maternal and child health outcomes in poor rural populations in Africa.
Funding
Saving Newborn Lives, UK Department for International Development, and Wellcome Trust.
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961959-X/abstract

Women’s groups practising participatory learning and action to improve maternal and newborn health in low-resource settings: a systematic review and meta-analysis
Audrey Prost, Tim Colbourn, Nadine Seward, Kishwar Azad, Arri Coomarasamy, Andrew Copas, Tanja A J Houweling, Edward Fottrell, Abdul Kuddus, Sonia Lewycka, Christine MacArthur, Dharma Manandhar, Joanna Morrison, Charles Mwansambo, Nirmala Nair, Bejoy Nambiar, David Osrin, Christina Pagel, Tambosi Phiri, Anni-Maria Pulkki-Brännström, Mikey Rosato, Jolene Skordis-Worrall, Naomi Saville, Neena Shah More, Bhim Shrestha, Prasanta Tripathy, Amie Wilson, Anthony Costello
Preview | Summary | Full Text | PDF

Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study
João Paulo Souza, Ahmet Metin Gülmezoglu, Joshua Vogel, Guillermo Carroli, Pisake Lumbiganon, Zahida Qureshi, Maria José Costa, Bukola Fawole, Yvonne Mugerwa, Idi Nafiou, Isilda Neves, Jean-José Wolomby-Molondo, Hoang Thi Bang, Kannitha Cheang, Kang Chuyun, Kapila Jayaratne, Chandani Anoma Jayathilaka, Syeda Batool Mazhar, Rintaro Mori, Mir Lais Mustafa, Laxmi Raj Pathak, Deepthi Perera, Tung Rathavy, Zenaida Recidoro, Malabika Roy, Pang Ruyan, Naveen Shrestha, Surasak Taneepanichsku, Nguyen Viet Tien, Togoobaatar Ganchimeg, Mira Wehbe, Buyanjargal Yadamsuren, Wang Yan, Khalid Yunis, Vicente Bataglia, José Guilherme Cecatti, Bernardo Hernandez-Prado, Juan Manuel Nardin, Alberto Narváez, Eduardo Ortiz-Panozo, Ricardo Pérez-Cuevas, Eliette Valladares, Nelly Zavaleta, Anthony Armson, Caroline Crowther, Carol Hogue, Gunilla Lindmark, Suneeta Mittal, Robert Pattinson, Mary Ellen Stanton, Liana Campodonico, Cristina Cuesta, Daniel Giordano, Nirun Intarut, Malinee Laopaiboon, Rajiv Bahl, Jose Martines, Matthews Mathai, Mario Merialdi, Lale Say
Preview | Summary | Full Text | PDF

Trends in contraceptive need and use in developing countries in 2003, 2008, and 2012: an analysis of national surveys
Jacqueline E Darroch, Susheela Singh
Preview | Summary | Full Text | PDF

Effect of HIV infection on pregnancy-related mortality in sub-Saharan Africa: secondary analyses of pooled community-based data from the network for Analysing Longitudinal Population-based HIV/AIDS data on Africa (ALPHA)
Basia Zaba, Clara Calvert, Milly Marston, Raphael Isingo, Jessica Nakiyingi-Miiro, Tom Lutalo, Amelia Crampin, Laura Robertson, Kobus Herbst, Marie-Louise Newell, Jim Todd, Peter Byass, Ties Boerma, Carine Ronsmans
Preview | Summary | Full Text | PDF

Reproductive health priorities: evidence from a resource tracking analysis of official development assistance in 2009 and 2010
Justine Hsu, Peter Berman, Anne Mills

The Lancet Infectious Diseases
May 2013 Volume 13  Number 5  p377 – 464
http://www.thelancet.com/journals/laninf/issue/current

Online First
Comment
May 13, 2013
Inoculating communities against vaccine scare stories
Natasha Sarah Crowcroft, Kwame Julius McKenzie
Preview
The biggest threat facing the success of immunisation might be public lack of confidence in vaccines, repeatedly undermined by safety concerns promulgated in social and news media.1 In The Lancet Infectious Diseases, Heidi Larson and colleagues’ study examines how a typology of concerns can be applied within an established global surveillance system, HealthMap, to track and characterise vaccine news stories.2,3 The usefulness of systematically tracking online media stories was first established for disease surveillance through a Canadian project, the Global Public Health Information Network,4 followed by several other systems including HealthMap.

The Lancet Infectious Diseases
May 2013 Volume 13  Number 5  p377 – 464
http://www.thelancet.com/journals/laninf/issue/current

Online First
Articles
May 13, 2013
Measuring vaccine confidence: analysis of data obtained by a media surveillance system used to analyse public concerns about vaccines
Heidi J Larson, David MD Smith, Pauline Paterson, Melissa Cumming, Elisabeth Eckersberger, Clark C Freifeld, Isaac Ghinai, Caitlin Jarrett, Louisa Paushter, John S Brownstein, Lawrence C Madoff

Summary
Background
The intensity, spread, and effects of public opinion about vaccines are growing as new modes of communication speed up information sharing, contributing to vaccine hesitancy, refusals, and disease outbreaks. We aimed to develop a new application of existing surveillance systems to detect and characterise early signs of vaccine issues. We also aimed to develop a typology of concerns and a way to assess the priority of each concern.

Methods
Following preliminary research by The Vaccine Confidence Project, media reports (eg, online articles, blogs, government reports) were obtained using the HealthMap automated data collection system, adapted to monitor online reports about vaccines, vaccination programmes, and vaccine-preventable diseases. Any reports that did not meet the inclusion criteria—any reference to a human vaccine or vaccination campaign or programme that was accessible online—were removed from analysis. Reports were manually analysed for content and categorised by concerns, vaccine, disease, location, and source of report, and overall positive or negative sentiment towards vaccines. They were then given a priority level depending on the seriousness of the reported event and time of event occurrence. We used descriptive statistics to analyse the data collected during a period of 1 year, after refinements to the search terms and processes had been made.

Findings
We analysed data from 10 380 reports (from 144 countries) obtained between May 1, 2011, and April 30, 2012. 7171 (69%) contained positive or neutral content and 3209 (31%) contained negative content. Of the negative reports, 1977 (24%) were associated with impacts on vaccine programmes and disease outbreaks; 1726 (21%) with beliefs, awareness, and perceptions; 1371 (16%) with vaccine safety; and 1336 (16%) with vaccine delivery programmes. We were able to disaggregate the data by country and vaccine type, and monitor evolution of events over time and location in specific regions where vaccine concerns were high.

Interpretation
Real-time monitoring and analysis of vaccine concerns over time and location could help immunisation programmes to tailor more effective and timely strategies to address specific public concerns.

Funding
Bill & Melinda Gates Foundation.

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099%2813%2970108-7/abstract

Nature   
Volume 497 Number 7449 pp287-402  16 May 2013
http://www.nature.com/nature/current_issue.html

Comment
Philanthropy: The difficult art of giving
William H. Schneider reflects on the centenary of the Rockefeller Foundation, which began the postdoc and the grant, and led to the World Health Organization.

http://www.nature.com/nature/journal/v497/n7449/full/497311a.html

New England Journal of Medicine
May 16, 2013  Vol. 368 No. 20
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Government’s Role in Protecting Health and Safety
Thomas R. Frieden, M.D., M.P.H.
N Engl J Med 2013; 368:1857-1859May 16, 2013DOI: 10.1056/NEJMp1303819

What is the appropriate role of governmental public health action? Law and public opinion recognize protection of health and safety as a core government function, but public health actions are sometimes characterized as inappropriately intrusive. Such criticism has a long history, but today we accept many public health measures that were once considered misguided, intrusive, or controversial. Public health initiatives include efforts to promote free and open information to facilitate informed decision making, protect individuals from being harmed by other individuals and groups, and facilitate societal action to promote and protect health (see tablePotential Public Health Actions of a Responsive Government.).

Free and open information empowers people to make informed choices and reduces the likelihood that misinformation or hidden information will endanger health. Laws may require disclosure of factual information (e.g., product content), provide for government transparency (freedom of information), or prevent dissemination of inaccurate or misleading information. Newer applications of this principle include calorie labeling in restaurants, which appears to encourage some companies to offer and some people to choose more healthful food options.1 The initial costs to restaurants to perform nutritional analyses and reprint menus and menu boards are the focus of most objections, but these costs may be counterbalanced by lower health care costs and increased productivity. Some people value the transparency that such laws require, regardless of the health effects.

Another example of the power of information is the graphic warnings on tobacco packages and antitobacco advertising to encourage smoking cessation.2 Pack warnings convey clear information about the health effects of tobacco use, creating a visual and visceral counter to the aggressive and often misleading information spread by tobacco companies, which have been convicted of deliberately deceiving the public about the health effects of tobacco. Antitobacco advertising helps counteract the industry’s efforts to undermine science and its massive marketing expenditures. Opposition to such government efforts may have financial as well as philosophical or legal bases.

A second key role of government is to protect individuals from preventable harm caused by other individuals or groups. An individual’s right to engage in particular conduct may affect others (“your right to swing your fist ends at my nose”). Government has a responsibility to protect individuals from unhealthy environments, whether the sources of health risks are natural (e.g., mosquito infestation) or created by people or organizations. Few Americans now question government’s role in preventing sales of contaminated food, water, and medications; reducing alcohol-impaired driving; or protecting workers and communities from industrial toxins.

For some issues, government may be the only entity capable of promoting the greater good by reconciling social and economic interests. Limiting promotion of tobacco and alcohol helps individuals by reducing consumption and benefits business by increasing workforce productivity and reducing health care costs. Although increased use of their products benefits tobacco and alcohol companies’ employees and shareholders, other companies and society bear increased medical, economic, and social costs, as well as the illness and deaths caused by use of these products.

Opinions vary about whether a given behavior’s risk to others is sufficient to warrant governmental action. But where there are clear ways to prevent substantial harms, government may have a responsibility to act. Smokefree laws illustrate the growing acceptance of actions that protect people from others’ behavior. Such laws are often controversial when introduced, with opponents predicting reduced hospitality-industry profits and decrying infringement of personal freedoms, but they gain acceptance as people see their health benefits — and no economic harm to businesses. Smoke-free laws cost little to implement, improve health, reduce health care costs, increase productivity, save lives, and do not reduce overall business revenues or tax receipts.3 A large majority of the U.S. public now favors such laws.4

Newer examples of actions that prevent harm by others are the elimination of artificial trans fats from the food supply, which protects people against a contributor to cardiovascular disease, and ignition interlock devices in vehicles, which can protect the public from convicted drunk drivers.

A third key role of government is to protect and promote health through population-wide action. Governmental action is often a more effective and efficient means of protecting public health than the actions of individuals. Immunization mandates, fluoridation of water, iodization of salt, and micronutrient fortification of flour are all classic examples of this type of action; many were controversial initially but are widely accepted today because they save money and reduce illness, disability, and death.

More recent and controversial examples of societal action include zoning laws that require or provide incentives to create bicycling and walking paths or that reduce the neighborhood density of liquor stores. These actions serve entire communities, and individuals cannot feasibly implement them on their own — characteristics that also apply to efforts to reduce sodium in processed and restaurant foods. Objections to such actions usually focus on their costs, effectiveness, or importance, but the appropriate role of government and the relative costs and benefits are also debated. Controversy can be reduced by providing data documenting the health burden and building consensus about the problem and the action’s efficacy. Government action need not consist solely of mandates: micronutrient fortification of food has often been accomplished through voluntary industry actions coordinated through public–private partnerships.

The most controversial public health actions seek to regulate the behavior of adults in such a way as to improve their own health. Public health agencies operate on the belief that government has a valid interest in a healthier populace, but many argue that people have the right to knowingly make decisions that may result in harm to their health. Taxing, decreasing access to, or limiting portion sizes of sugar-sweetened beverages is one example of recent controversial proposals of this type. Seatbelt and motorcycle-helmet laws exemplify the balancing act between health benefits and individual rights: these laws have financial costs for enforcement and the purchase of helmets and perceived societal costs in loss of personal freedom, but they prevent traffic injuries and deaths and reduce societal costs, including health care costs and lost productivity. Such measures may be best enacted at the local or state level, where government’s proper role can be debated; deliberations will be fairest if there are no major vested financial interests, as is generally the case with helmet laws.

Beyond the societal costs in health care and lost productivity, actions to protect health are supported by the recognition that although many people express remorse over past behavior, we tend to assign limited weight to future events or conditions — a pattern behavioral economists call “hyperbolic discounting.” Action by democratically elected leaders may therefore be needed to protect public health over the long term.

Opponents of specific public health actions may believe that the health burden is low, the intervention is too costly or is likely to be ineffective, and that therefore the expected benefits don’t warrant the costs. The costs cited may include financial costs to government, industry, and the economy and to individuals who might not benefit personally. There may also be philosophical objections, such as perceived loss of personal autonomy or the belief that these actions will undermine self-reliance or individual choice. Some opponents fear a slippery slope toward “sabotaging our rights on all fronts.”5

The potential benefits of public health action include economic, health care, and productivity gains, as well as the intrinsic benefit of longer, healthier lives. The dissemination of accurate information on costs and benefits may be the best way to reduce opposition and implement effective public health actions. When government fails to protect and improve people’s health, society suffers. Opponents of public health action often fail to acknowledge the degree to which individual actions are influenced by marketing, promotion, and other external factors. They also may underestimate the health costs of inaction and overestimate the financial or other costs of action. For-profit corporations have a fiduciary responsibility to increase return on investment; some (e.g., tobacco companies) have incentives to oppose actions that may harm their business, even if these actions would promote overall economic development and benefit other businesses. And in some cases, current judicial philosophies may limit possibilities for public health action in the United States.

Government has a responsibility to implement effective public health measures that increase the information available to the public and decision makers, protect people from harm, promote health, and create environments that support healthy behaviors. The health, financial, and productivity gains from public health actions benefit individuals and society as a whole.

http://www.nejm.org/doi/full/10.1056/NEJMp1303819

New England Journal of Medicine
May 16, 2013  Vol. 368 No. 20
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Global Concerns Regarding Novel Influenza A (H7N9) Virus Infections
Timothy M. Uyeki, M.D., M.P.H., M.P.P., and Nancy J. Cox, Ph.D.
N Engl J Med 2013; 368:1862-1864May 16, 2013DOI: 10.1056/NEJMp1304661

Severe disease in humans caused by a novel influenza A virus that is distinct from circulating human influenza A viruses is a seminal event. It might herald sporadic human infections from an animal source — e.g., highly pathogenic avian influenza (HPAI) A (H5N1) virus; or it might signal the start of an influenza pandemic — e.g., influenza A(H1N1)pdm09 virus. Therefore, the discovery of novel influenza A (H7N9) virus infections in three critically ill patients reported in the Journal by Gao and colleagues (pages 1888–1897) is of major public health significance. Chinese scientists are to be congratulated for the apparent speed with which the H7N9 virus was identified, and whole viral genome sequences were made publicly available in relatively short order. Because this H7N9 virus has not been detected in humans or animals previously, the situation raises many urgent questions and global public health concerns.

The key question for pandemic risk assessment is whether there is evidence of either limited or, more important, sustained human-to-human transmission — the latter being indicative of an emerging pandemic. If human-to-human transmission occurs, transmission dynamics, modes of transmission, basic reproductive number, and incubation period must all be determined. It is possible that these severely ill patients represent the tip of the iceberg and that there are many more as-yet-undetected mild and asymptomatic infections. Determining the spectrum of illness will help us understand the scope of the problem and assess severity. Enhanced surveillance for H7N9 virus infection is therefore urgently needed among hospitalized patients and outpatients of all ages with less severe respiratory illness. Other useful information can be derived from monitoring close contacts of patients with confirmed H7N9 cases to assess whether family members or health care personnel who provided care for patients with H7N9 virus infection have respiratory illness and laboratory-confirmed H7N9 virus infection. Such investigations will clarify whether H7N9 virus transmission in people appears efficient, or whether limited, nonsustained human-to-human transmission is occurring in persons with prolonged unprotected exposures, such as in clusters of HPAI H5N1 cases in blood-related family members. So far, the information provided by Chinese health officials provides reassurance that sustained human-to-human transmission is not occurring.

In addition to causing severe illness and deaths, the novel H7N9 viruses reported by Gao and colleagues have genetic characteristics that are of concern for public health. The hemagglutinin (HA) sequence data suggest that these H7N9 viruses are a low-pathogenic avian influenza A virus and that infection of wild birds and domestic poultry would therefore result in asymptomatic or mild avian disease, potentially leading to a “silent” widespread epizootic in China and neighboring countries. If H7N9 virus infection is primarily zoonotic, as reports currently suggest, transmission is expected to occur through exposure to clinically normal but infected poultry, in contrast to HPAI H5N1 virus infection, which typically causes rapid death in infected chickens.

The gene sequences also indicate that these viruses may be better adapted than other avian influenza viruses to infecting mammals. For example, the presence of Q226L in the HA protein has been associated with reduced binding to avian-like receptors bearing sialic acids linked to galactose by α-2,3 linkages found in the human lower respiratory tract,1 and potentially an enhanced ability to bind to mammalian-like receptors bearing sialic acids linked to galactose by α-2,6 linkages located in the human upper airway.1 Equally troubling is that Q226L in HA has been shown to be associated with transmission of HPAI H5N1 viruses by respiratory droplets in ferrets, one of the animal models for assessing pathogenicity and transmissibility of influenza viruses.2,3 These H7N9 viruses also possess the E627K substitution in the PB2 protein, which has also been associated with mammalian adaptation and respiratory-droplet transmission of HPAI H5N1 virus in ferrets.3 This H7N9 virus is a novel reassortant with HA and neuraminidase (NA) genes from an ancestral avian H7N9 virus and the six other genes from an avian H9N2 virus. The animal reservoir now appears to be birds, but many experts are asking whether these viruses might also be able to infect pigs, another common reservoir for zoonotic infections. The viral sequence data indicate antiviral resistance to the adamantanes and susceptibility to neuraminidase inhibitors, except for an R292K mutation in the NA protein of the A/Shanghai/1/2013 virus. Because this mutation has been associated with in vitro resistance to neuraminidase inhibitors in another N9 NA subtype virus, additional analyses must be undertaken to understand its significance. It is not known whether this mutation arose de novo in the host or is associated with oseltamivir treatment. Ongoing surveillance is crucial to assessing the emergence and prevalence of H7N9 viruses resistant to available antivirals.

Since available diagnostic assays used in clinical care (e.g., rapid influenza diagnostic tests) may lack sensitivity to identify H7N9 virus and since existing molecular assays will identify H7N9 virus as a nonsubtypeable influenza A virus, a critical public health issue is the rapid development, validation, and deployment of molecular diagnostic assays that can specifically detect H7N9 viral RNA. Such assays have been developed in China and are in development in many countries including the United States, and they will be deployed as they were for the 2009 H1N1 pandemic.4 Having available H7-specific assays will facilitate surveillance of H7N9 virus infections and help address key questions such as the duration of viral shedding, the infectious period, the optimal clinical specimens for laboratory confirmation, and the spectrum of clinical illness.

The clinical features described in the three patients with H7N9 virus infection, including fulminant pneumonia, respiratory failure, acute respiratory distress syndrome (ARDS), septic shock, multiorgan failure, rhabdomyolysis, and encephalopathy, are very troubling. Clinical care of severely ill patients should be focused on evidence-based supportive management of complications such as ARDS. Adherence to recommended infection-control measures in clinical settings to reduce the risk of nosocomial transmission cannot be overemphasized.

All three patients with H7N9 virus infection reported by Gao and colleagues received late treatment with oseltamivir starting on day 7 or 8 of illness while critically ill. Data related to human infections with seasonal, pandemic, and HPAI H5N1 viruses indicate that the earlier antiviral treatment is initiated, the greater the clinical benefit. Therefore, oral oseltamivir or inhaled zanamivir should be administered to patients with suspected or confirmed H7N9 virus infection as soon as possible. Secondary invasive bacterial infections associated with influenza can cause severe and fatal complications, and appropriate empirical antibiotic treatment for community-acquired bacterial infections may be indicated for initial management of severe H7N9 pneumonia. Caution should be exercised regarding the use of glucocorticoids, which are not indicated for routine treatment of influenza. Clinical research, including randomized, controlled trials and observational studies, is urgently needed on new antiviral agents, including parenteral neuraminidase inhibitors and drugs with different mechanisms of action, combination antiviral treatment, and immunotherapy. To inform clinical management, rapid clinical data collection, data sharing, analysis, and timely feedback are needed worldwide.5

Because H7N9 virus infections have not occurred in humans before, it is expected that persons of all ages might be susceptible worldwide. Serologic assays must be developed so that studies can be conducted to determine whether some people have cross-reactive antibodies to these viruses from prior influenza A virus infections. Existing H7-vaccine viruses are not well matched to this novel H7N9 virus, and extensive efforts are under way to develop potential H7N9 vaccines as quickly as possible. These efforts have started worldwide using the H7N9 sequence data obtained from these early cases, and sharing of H7N9 viruses will further facilitate vaccine development. There are many challenges to making H7N9 vaccines available. Previously studied H7 vaccines were poorly immunogenic in humans, and clinical trials to assess the safety and immunogenicity of H7N9 vaccine candidates will be needed. But even if new vaccine manufacturing technologies, such as tissue-cell-culture–derived vaccine antigens, are utilized, the process from vaccine development to availability will probably take many months.

The 2009 H1N1 pandemic taught us many lessons, including that a pandemic virus can emerge from an animal reservoir in an unexpected location and be spread rapidly through air travel. The focus on critically ill adults early in the pandemic led to elevated public concern about pandemic severity. Clear communication of key messages to the public and the clinical community is critical in implementing successful prevention and control activities. The detection of human H7N9 virus infections is yet another reminder that we must continue to prepare for the next influenza pandemic. The coming weeks will reveal whether the epidemiology reflects only a widespread zoonosis, whether an H7N9 pandemic is beginning, or something in between.

The key is intensified surveillance for H7N9 virus in humans and animals to help answer important questions. We cannot rest our guard.

http://www.nejm.org/doi/full/10.1056/NEJMp1304661

Human Infection with a Novel Avian-Origin Influenza A (H7N9) Virus

R. Gao and Others

Free Full Text: http://www.nejm.org/toc/nejm/medical-journal