Forbes Interview: Delivering Vaccines To Where They’re Needed Most

Accessed 10 August 2013

Delivering Vaccines To Where They’re Needed Most
Editor’s Note: In advance of the many health-related discussions to take place in September at the Clinton Global Initiative, the Social Good Summit, UN week and other such events, the Skoll World Forum asked some of the world’s leading voices in global health to paint a comprehensive picture of key trends, challenges and opportunities to realizing healthcare access and treatment around the world. A new piece will be posted everyday through Friday, and you can view the entire series here.
   Kevin Reilly is a senior business executive with more than 30 years’ experience in the pharmaceutical and vaccine industries. During his 20 years with Wyeth Pharmaceuticals, he served in several positions covering responsibilities in Canada, Asia, and the Pacific region. From 1999 until his retirement in 2003, he was president of Wyeth’s $2 billion Vaccine and Nutrition Division.

Rahim Kanani: You bring a unique perspective to global health work, coming from a long career in the pharmaceutical and vaccine industries. What are some of the lessons you’ve learned or “aha” moments you’ve experienced in your work on broader global health and development issues?
Kevin Reilly: Personally, I’ve developed a deeper appreciation for the complexity involved in running successful immunization programs. From the point of view of the vaccine manufacturer, you focus on the specific activities needed to move a vaccine successfully through the stages of development, but the many challenges involved in delivering and distributing that vaccine in developing countries may be less obvious. Getting a vaccine successfully from the factory door to the arms of millions of children in low-resource settings—that’s an enormously complicated task. Increasingly, I see pharmaceutical and vaccine manufacturers engaging in the dialogue about strengthening immunization and distribution systems to ensure vaccines get to where they are needed. Vaccine manufacturers were among the key partners involved in the early conversations that led to the formation of the GAVI Alliance, for example. They could see that global immunization rates were stagnating and that something needed to be done.

Similarly, I see growing awareness among global health organizations about the difficult, multiyear process required to develop vaccines and how that process influences the price. Where some organizations may once have advocated for a flat price of, say, less than $1 per dose for developing countries, now I think there is greater appreciation for the fact that new vaccines are extremely complex and expensive to develop. There are more efforts now to create a productive dialogue between manufacturers and global health organizations and to think creatively about funding structures and other mechanisms that may expand access to vaccines while also recognizing the need of manufacturers to ensure the financial health and well-being of their own corporations.

Rahim Kanani: What makes public-private partnerships between business, government, and civil society an effective way to tackle global health challenges? And what are some examples of big pharmaceutical companies partnering with other sectors?
Kevin Reilly: Vaccine manufacturers have a long history of providing vaccines at heavily discounted prices for use in the developing world, a practice that stretches back over half a century. For example, early in my career, I was involved in helping to provide polio vaccine to UNICEF for 2 cents per dose. While the prices have gone up for various reasons, this practice is still active today and is a critical factor in many vaccines reaching millions of children in the developing world.

From the standpoint of business, one of the keys to success for public-private partnerships is recognition that vaccine and pharmaceutical manufacturers have an important contribution to make but also have corporate interests that they must protect as well. So companies are striving to find that balance between using their discoveries to maximize the good they can do for people around the world and achieving a reasonable return on their investment.

I was also involved in helping bring Prevnar, the first pneumococcal conjugate vaccine, to market as president of Wyeth Pharmaceuticals’ Vaccine and Nutrition Division. Wyeth and GAVI entered into a discussion early on about how the vaccine could help meet the needs of developing countries, where pneumonia is the leading cause of death in young children. Through those conversations and GAVI’s innovative financing mechanism, Wyeth was able to make special arrangements for the supply of the vaccine, thus accelerating the availability of a new, complex vaccine in low-income countries.

Rahim Kanani: Is developing a vaccine the hardest part, or is it the delivery and distribution of that vaccine to the developing world?
Kevin Reilly: Both are essential for successful health outcomes—and both are immensely challenging. Developing a vaccine involves a relatively narrow set of activities driven by scientific and clinical research work. Since 2000, barely a handful of new vaccines have been developed. That’s because this is complicated work dotted with setbacks and failures along the way. You try things in the lab that fail, or things don’t work out clinically the way you predicted they would based on results in the lab. Prevnar was 17 years in development and went through ownership by three different corporate entities on its way to market.

On the other hand, vaccine delivery is a broad-based, multidimensional, and cross-sector activity involving many different systems and stakeholders. Ideally, you aim to bridge the two sides of this process, to develop a vaccine that is safe and effective while also being suited for efficient distribution and delivery. Sometimes, the complex biological and scientific factors involved in vaccine development limit your ability to optimize design for the distribution and delivery of the vaccine —for example, it may have special cold chain requirements that make it difficult to reach remote areas.

PATH’s work on the MenAfriVac® vaccine is a good example of how vaccine development, distribution, and delivery are inextricably linked. PATH and the World Health Organization worked with dozens of global collaborators over a decade to develop the vaccine against deadly meningitis A. Simultaneously, they worked with countries across Africa’s “meningitis belt” to build their capacity to integrate the vaccine into their health programs by strengthening disease surveillance, enhancing lab capacity, and reaching out to policymakers, health workers, and journalists with information and training. Recently, the vaccine became the first in Africa approved for transport and storage outside the traditional cold chain. To date, more than 100 million Africans across ten countries have received this new vaccine.

Rahim Kanani: It’s clear that businesses do a tremendous amount of work in researching and developing new drugs and vaccines to fight disease and illness. What role should governments and educational institutions play in terms of investment and research, and how can they complement each other?
Kevin Reilly: Businesses primarily focus on developing products directed at specific disease targets. In many cases, they are building on the broad base of knowledge created by academic and government research facilities. A lot of this early, upstream research may not be highly visible, but it provides a crucial foundation for the specific products coming out of pharmaceutical and biotech companies. This base of knowledge is a critical asset for the progress of health and medicine, and because this approach has been most successfully applied in the US, I believe it also gives the US a significant competitive advantage. This allows business to focus on the specific development work needed to deliver a product—work that usually involves large investments and significant risk-taking associated with the success or failure of the project. I think that matching of risk capital with high-risk activity seems appropriate.

Increasingly, we are seeing drug and vaccine manufacturers coming together with global health organizations to reduce the lag time between product launches in the developed world and the developing world. This is a relatively new trend, and a welcome one. With Prevnar, for example, Wyeth was in dialogue with GAVI soon after the vaccine launched in 2000 in the US and Europe about how to accelerate the launch of the vaccine in developing countries.

Rahim Kanani: Finally, as someone with more than 30 years of experience in this space, what are some of the leadership lessons you’ve learned along the way when it comes to advancing global health?
Kevin Reilly: Patience and persistence. These are essential elements of success in improving health around the world. The development of drugs and vaccines is an extremely long and high-risk process. Maintaining momentum requires an unwavering faith in the final objective and an unrelenting focus on doing what it takes to get there. The same is true in other kinds of global health initiatives. Some of these programs take decades to reach fruition. Polio eradication, for example, has been a global health priority for more than 50 years. In the case of polio, it’s not a matter of developing a vaccine. We’ve had the vaccine since the 1950s. It’s overcoming the challenges of delivering the vaccine to every child in every village in every country around the world. The global health community has been pushing on this for years, knowing what a powerful payoff there will be if we are successful.

Vaccines: The Week in Review 3 August 2013

Vaccines: The Week in Review is a weekly digest — summarizing news, events, announcements, peer-reviewed articles and research in the global vaccine ethics and policy space. Content is aggregated from key governmental, NGO, international organization and industry sources, key peer-reviewed journals, and other media channels. This summary proceeds from the broad base of themes and issues monitored by the Center for Vaccine Ethics & Policy in its work: it is not intended to be exhaustive in its coverage. You are viewing the blog version of our weekly digest, typically comprised of between 30 and 40 posts below all dated “29 June 2013″
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pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_3 August 2013
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
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– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

GAVI announces price cits for pneumococcal vaccines via new agreements among GAVI, UNICEF, The World Bank, GlaxoSmithKline and Pfizer

GAVI said that the price it pays pneumococcal vaccines will be reduced under new agreements among GAVI, UNICEF, The World Bank, GlaxoSmithKline and Pfizer. GAVI said that under previous agreements both manufacturers offered pneumococcal vaccine at US$3.50 per dose, but that under new pricing arrangements Pfizer will provide the vaccine at $3.40 per dose with a further reduction to $3.30 per dose from 2014 onwards. The new prices will apply to all doses to be purchased from Pfizer under current contracts, including those awarded under two previous agreements. GSK will lower its price to $3.40 per dose for this new contract covering the period 2014-2024. GAVI purchases pneumococcal vaccines through UNICEF as part of an Advance Market Commitment (AMC) which “aims to accelerate the development of new products, bring forward supply availability and increase the introduction of appropriate and affordable vaccines to tackle pneumococcal disease.” The AMC involved is supported by the governments of Italy, the United Kingdom, Canada, the Russian Federation and Norway, and the Bill & Melinda Gates Foundation, which have committed a total of US$1.5 billion to the initiative. The AMC was launched in 2009 and is being implemented by GAVI, The World Bank and UNICEF.

GAVI approves US$21 million “to help improve vaccine supply chains in Nigeria”

GAVI said it approved US$21 million “to help improve vaccine supply chains in Nigeria as part of a partnership aimed at scaling up routine immunisation.” The funds will be used by Nigeria’s National Primary Health Care Development Agency “to procure vital equipment for storing vaccines and to improve data collection, both of which have been identified as key pillars in protecting children’s lives as enshrined in the government’s Saving One Million Lives Initiative.” As part of this initiative, Nigeria has set a target to increase routine immunisation coverage to 87% through 2015. The GAVI support “…comes as part of a broader partnership on health system strengthening including vaccine supply chain improvement, that is expected to be complemented with support from other partners including the European Union, UNICEF, the Bill & Melinda Gates Foundation, the Clinton Health Access Initiative, the Japan International Cooperation Agency, the UK’s Department of International Development and the Canadian International Development Agency.”

PATH announces five-year, US$19.5 million Gated Fdn grant to strengthen national immunization management systems

PATH announced a five-year, US$19.5 million grant from the Bill & Melinda Gates Foundation to “help countries strengthen their immunization management systems” through the Better Immunization Data (BID) Initiative. The BID Initiative is described as “one of the first and largest data management projects of its kind, bringing together on-the-ground knowledge of immunization programs with a focus on eHealth and data quality and use issues. It recognizes that to improve immunization management, information technology is only part of the solution—and that it may not always be the right solution for all levels of the health system. The BID Initiative will invest in supporting existing and new national health information systems and help address the operational challenges health workers face in delivering immunization services.”  PATH noted that it will work with John Snow, Inc. and partner with countries and global stakeholders “to solve these data collection, quality, and use issues. While the initial focus will be on ensuring that the most accurate information is made available for the best decision-making around immunization programs, the BID Initiative inherently recognizes that point-of-care service delivery collects information beyond immunizations.”

PATH said that as a first step in the initiative, the Bill & Melinda Gates Foundation will invite a number of African countries to a country consultation meeting to outline the concept, collect feedback, and identify partners interested in working with the BID Initiative. The BID Initiative will partner with lead countries to “develop and deploy scalable solution components involving products, practices, people, and packaging these components into a replicable solution that can be easily and cost-effectively adopted by other countries interested in using the solution to improve their immunization management.”

Chinese CDC and Aeras sign MOU to develop new tuberculosis vaccines

The Chinese Center for Disease Control and Prevention and Aeras said they signed a memorandum of understanding “to advance research and development of new tuberculosis vaccines.” The new collaboration “will accelerate research efforts for new vaccines by supporting studies that determine the incidence of TB infection, and will aim to strengthen the capacity within China to conduct future vaccine clinical trials.” The announcement noted that “while China has achieved significant reductions in TB illness and death over the past 30 years, TB remains a major public threat, with over one million new cases in China each year. A study published in the New England Journal of Medicine last year found that one in 10 cases of TB in China are resistant to the most commonly-used drugs. Based on the World Health Organization’s estimates of global multidrug-resistant TB (MDR-TB), China has the highest annual number of cases of MDR-TB in the world—a quarter of the cases worldwide.” Dr. Wang Yu, China CDC Director General, said, ”…we have embraced innovation in our TB control efforts in China. We have adopted the latest technologies to diagnose TB. We have advanced innovative approaches to address TB and drug-resistant TB, and to promote the research that is necessary to urgently develop needed new tools to prevent, diagnose and treat it. We have made TB a high priority on our public health agenda, and will continue to seek out new and better ways to prevent and treat TB in communities across our country. But we know that this will not be enough. We will not defeat TB in our country or in the world without new, more effective vaccines. There is a coordinated, global effort underway to develop these urgently needed vaccines, and China must be a partner in this endeavor. With that goal in mind, we are excited to announce a new collaboration with Aeras to advance the research and development of new, more effective vaccines.”…

FDA approves Menveo for use in infants and toddlers from 2 months of age

Novartis said that the US Food and Drug Administration (FDA) approved its Menveo for use in infants and toddlers from 2 months of age. Menveo (Meningococcal [Groups A, C, Y and W-135] Oligosaccharide Diphtheria CRM197 Conjugate Vaccine) helps prevent meningococcal disease caused by four strains of the bacterium Neisseria meningitidis (N. meningitidis). Novartis said that with this expanded indication, “pediatricians in the US can now offer a single vaccine to help protect infants, children and adolescents against four of the five most common serogroups that cause meningococcal disease.” This FDA approval was based on data from three randomized multicenter studies involving more than 8,700 infants, conducted in Australia, Canada, Latin America, Taiwan and the US. The studies demonstrated that Menveo “generated a robust protective immune response and a demonstrated safety profile when co-administered with routine pediatric vaccines1.”

MMWR: Vaccination Coverage Among Children in Kindergarten — United States, 2012–13 School Year

CDC/MMWR Watch [to 3 August 2013]
MMWR August 2, 2013 / Vol. 62 / No. 30
Vaccination Coverage Among Children in Kindergarten — United States, 2012–13 School Year
August 2, 2013 / 62(30);607-612
Excerpt – Editor’s Text Bolding
State and local school vaccination requirements are implemented to maintain high vaccination coverage and minimize the risk from vaccine preventable diseases (1). To assess school vaccination coverage and exemptions, CDC annually analyzes school vaccination coverage data from federally funded immunization programs. These awardees include 50 states and the District of Columbia (DC), five cities, and eight U.S.-affiliated jurisdictions.* This report summarizes vaccination coverage from 48 states and DC and exemption rates from 49 states and DC for children entering kindergarten for the 2012–13 school year. Forty-eight states and DC reported vaccination coverage, with medians of 94.5% for 2 doses of measles, mumps, and rubella (MMR) vaccine; 95.1% for local requirements for diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccination; and 93.8% for 2 doses of varicella vaccine among awardees with a 2-dose requirement. Forty-nine states and DC reported exemption rates, with the median total of 1.8%. Although school entry coverage for most awardees was at or near national Healthy People 2020 targets of maintaining 95% vaccination coverage levels for 2 doses of MMR vaccine, 4 doses of DTaP† vaccine, and 2 doses of varicella vaccine (2), low vaccination and high exemption levels can cluster within communities, increasing the risk for disease. Reports to CDC are aggregated at the state level; however, local reporting of school vaccination coverage might be accessible by awardees. These local-level data can be used to create evidence-based health communication strategies to help parents understand the risks for vaccine-preventable diseases and the benefits of vaccinations to the health of their children and other kindergarteners.

Vaccination coverage among children entering kindergarten is assessed annually by awardees. Each school year, the health department, school nurse, or other school personnel assess the vaccination and exemption status of a census or sample of kindergarteners enrolled in public and private schools to determine vaccination coverage, as defined by state and local school requirements established to protect children from vaccine-preventable diseases. Among the 50 states and DC, 43 awardees used an immunization information system (IIS) as at least one source of data for some of their school assessment. To collect data, 33 awardees used a census of kindergarteners; 11 a sample of schools, kindergarteners, or both; two a voluntary response of schools; and five a mix of methods. Results of the school-level assessments are reported to the health department. Aggregated data are reported to CDC for public and private schools. Data for homeschooled students were not reported to CDC. All estimates of coverage and exemption were weighted based on each awardee’s response rates and sampling methodology, unless otherwise noted. Of the 50 states and DC, 12 awardees met CDC standards for school assessment methods in 2012–13.

Kindergarteners were considered up-to-date for each vaccination if they had received all of the doses required for school entry in their jurisdiction. School entry requirements varied by awardee: all reporting awardees required 2 doses of MMR vaccine; for DTaP vaccine, two awardees required 3 doses, 35 required 4 doses, and 20 required 5 doses; and for varicella vaccine, 13 required 1 dose, 41 required 2 doses, and three did not require varicella vaccination.

   The types of exemptions allowed varied by awardee. All reporting awardees allowed medical exemptions, 46 allowed religious exemptions, 18 allowed philosophic exemptions, and two (Mississippi and West Virginia) did not allow exemptions for religious or philosophic reasons. Medical, religious, and philosophic exemptions were reported as the percentage of kindergarteners with each type of exemption. Total exemptions were reported as the percentage of kindergarteners with any exemption.

Overall, among the 48 states and DC that reported 2012–13 school vaccination coverage, median 2-dose MMR vaccination coverage was 94.5% (range: 85.7% in Colorado to ≥99.9% in Mississippi); 20 reported coverage ≥95% (Table 1). Median DTaP vaccination coverage was 95.1% (range: 82.9% in Colorado and Arkansas to ≥99.9% in Mississippi); 25 reported coverage ≥95%. Median 2-dose varicella vaccination coverage among the 36 states and DC requiring and reporting 2 doses was 93.8% (range: 84.6% in Colorado to ≥99.9% in Mississippi); 14 reported coverage ≥95%.

    An estimated 91,453 exemptions were reported among a total estimated population of 4,242,558 kindergarteners. Overall, among the 49 states and DC that reported 2012–13 school vaccination exemptions, the percentage of kindergarteners with an exemption was <1% for nine awardees and >4% for 11 awardees (range: <0.1% in Mississippi to 6.5% in Oregon), with a median of 1.8% (Figure; Table 2). The largest increases in total exemptions between 2011–12 and 2012–13 were reported by Georgia and West Virginia, each with an increase of 1.0 percentage point; four states reported decreases of >1.0 percentage points (range: -1.3 in Colorado to -1.6 in New Mexico). Where reported separately, the median medical exemption level was 0.3% (range: <0.1% in five states [Arkansas, Minnesota, Mississippi, North Dakota, and Virginia] to 1.6% in Alaska). Where allowed and reported separately, the median nonmedical exemption level was 1.5% (range: 0.2% in New Mexico to 6.4% in Oregon).

Reported by

Ranee Seither, MPH, Lauren Shaw, MS, Cynthia L. Knighton, Stacie M. Greby, DVM, Shannon Stokley, MPH, Immunization Svcs Div, National Center for Immunization and Respiratory Diseases, CDC. Corresponding contributor: Ranee Seither,, 404-639-8693.

WHO GAR – Middle East respiratory syndrome coronavirus (MERS-CoV) – update 1 August 2013

WHO: Global Alert and Response (GAR) – Disease Outbreak News

Middle East respiratory syndrome coronavirus (MERS-CoV) – update 1 August 2013
1 August 2013 – WHO has been informed of an additional three laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Saudi Arabia.
The first patient is a 67-year-old woman from Riyadh with underlying medical conditions. She became ill on 25 July 2013. She has no known exposure to animals or to a case confirmed with MERS-CoV infection. She is currently hospitalized.

The other two patients are health care workers, both women, from Assir and Riyadh regions . Both of them have mild symptoms and were exposed to patients who were laboratory-confirmed cases.

Globally, from September 2012 to date, WHO has been informed of a total of 94 laboratory-confirmed cases of infection with MERS-CoV, including 46 deaths.

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…

GPEI Update: Polio this week – As of 31 July 2013

Update: Polio this week – As of 24 July 2013
Global Polio Eradication Initiative

[Editor’s extract and bolded text]
:: In Nigeria, the Presidential Task Force has reviewed the latest epidemiology of poliovirus transmission and strategies to overcome remaining challenges. A new risk-classification system of low-performing areas aims to focus resources where they are most needed. See ‘Nigeria’ section for more.
:: In Pakistan, the outbreak in Federally Administered Tribal Areas (FATA) is continuing, with a new case reported from Khyber Agency. The current outbreak is threatening progress achieved elsewhere in the country, as well as efforts in neighbouring Afghanistan. See ‘Pakistan’ section

:: Five new WPV cases were reported in the past week (four WPV1s from Kano state and one WPV1 from Yobe state), bringing the total number of WPV1 cases for 2013 to 40. The most recent WPV1 case had onset of paralysis on 9 July (WPV1 from Kano)…
:: The latest epidemiology and strategies were discussed at last week’s Presidential Task Force meeting on 23 July in Abuja. The meeting underscored that more than half of this year’s cases are from two states: Borno and Yobe.
:: Performance during Immunization Plus Days (IPDs) continues to improve in all high-risk states. However, vaccination coverage gaps persist in low-performing Local Government Areas (LGAs), particularly in Kano, Borno and Yobe.
:: Although Borno and Yobe are affected by insecurity, polio eradication activities are continuing in most LGAs of Borno and all LGAs of Yobe. Special strategies are being evaluated for these areas, including conducting ‘wall fencing’ immunizations around insecure areas, use of permanent health teams and increased use of Short Interval Additional Dose (SIADs) campaigns, as and when opportunities arise. Social mobilization activities are being targeted, to increase community demand for polio vaccination.
:: Efforts must continue to improve micro planning, reaching ‘absent’ children, and further engaging communities and traditional leaders to address non-compliance.
:: At the same time, more needs to be done to foster subnational political engagement – the involvement of LGA Chairpersons remains inconsistent across high-risk states. Engagement at state-level is also inconsistent, as measured by the Abuja Commitments.
:: A new risk classification system will improve the delivery of resources to areas where they are most needed. Across the high-risk states, 129 LGAs have now been classified as ‘very very high risk’, ‘very high risk’, or ‘special situation’ (security-affected LGAs in Borno and Yobe).
:: The next subnational IPD in northern states is planned for early September using bivalent OPV. Measles vaccine will also be offered during this round.

:: One new WPV1 case was reported in the past week (WPV1 from Khyber Agency, Federally Administered Tribal Area – FATA), bringing the total number of WPV1 cases for 2013 to 22. It is the most recent WPV1 case in the country and had onset of paralysis on 3 July…
:: Federally Administered Tribal Areas (FATA) is the major WPV1 reservoir in Pakistan at the moment, accounting for 13 of this year’s 22 cases in the country. Khyber Agency is particularly affected, with nine cases, and in particular Bara tehsil of Khyber. This outbreak is threatening progress achieved elsewhere in the country and in neighbouring Afghanistan. In 2011 and 2012, Bara was the epicentre of a major outbreak which also spread to other areas.

Horn of Africa
:: 24 new WPV1 cases were reported in the past week (23 from Somalia and one from Kenya), bringing the total number of WPV1 cases in the region to 105 (95 from Somalia and ten from Kenya). The most recent case in the region had onset of paralysis on 10 July (from Somalia).
:: Eleven of the newly-reported cases are from Banadir, which remains the epicentre of the outbreak, accounting for more than half of all cases associated with this outbreak.
:: Four of the newly-reported cases are from Lower Shabelle, areas of which are inaccessible due to insecurity. Special strategies continue to be implemented for these areas, including increased local-level access negotiations, immunizing older age groups and setting up vaccination posts at entry/exit points of inaccessible areas.
:: In Somalia, nationwide campaigns were conducted last week, targeting children under the age of five years. In Kenya, SIAs are currently ongoing (27-30 July), aiming to reach host communities around the Dadaab camps…

Report: A rapid survey of Global Vaccine Action Plan implementation

Report: A rapid survey of Global Vaccine Action Plan implementation
25 July 2013
Sabin Vaccine Institute
Mariya Savchuk*, Senior Program Officer; Mike McQuestion, Director, Sustainable Immunization Financing Program

Summary (excerpt)
An online survey of the global immunization community was carried out to measure knowledge and practices relating to the Global Vaccine Action Plan (GVAP). Of 62 respondents, 58% live in a GVAP target country and 29% are government or elected officials. Respondents were knowledgeable about GVAP goals and strategic objectives. Two-thirds reported they were working to make immunization a national priority and/or to strengthen immunization as an integral part of health systems. Respondents most often associated country ownership with self reliance, government prioritizing immunization or government control…

A sample of immunization practitioners and supporters from all six WHO Regions responded to the survey. At just 4%, the response rate was low. Results are thus not generalizable to the entire global immunization community.

The sample results showed GVAP exposure and knowledge to be relatively high. GVAP information appears to have reached English speakers sooner than the French speakers.

Respondents are working across the range of GVAP strategic objectives. All are devoting the most effort to high-level immunization advocacy (SO1). French speakers appear to be more mindful of sustainability issues (SO5).

An open-ended question about the meaning of country ownership ownership- a guiding GVAP principle- elicited varied responses. Respondents most frequently associated country ownership with the ability of a country to fully finance its immunization program.

These results must be interpreted with caution. The sample is small, nonrandom and self-selected. A random, population-based sample would likely be less engaged in immunization and less familiar with GVAP. What can be said is that GVAP messages have effectively reached the subgroups most engaged in global immunization. Further research will reveal more about variations in how countries are pursuing the GVAP objectives.

IOM: International Regulatory Harmonization Amid Globalization of Drug Development – Workshop Sum

IOM: International Regulatory Harmonization Amid Globalization of Drug Development – Workshop Summary
Released: August 1, 2013

The past several decades have been a time of rapid globalization in the development, manufacture, marketing, and distribution of medical products and technologies. Increasingly, research on the safety and effectiveness of new drugs is being conducted in countries with little experience in regulation of medical product development. Demand has been increasing for globally harmonized, science-based standards for the development and evaluation of the safety, quality, and efficacy of medical products. Consistency of such standards could improve the efficiency and clarity of the drug development and evaluation process and, ultimately, promote and enhance product quality and the public health.

To explore the need and prospects for greater international regulatory harmonization for drug development, the IOM Forum on Drug Discovery, Development, and Translation hosted a workshop on February 13-14, 2013. Discussions at the workshop helped identify principles, potential approaches, and strategies to advance the development or evolution of more harmonized regulatory standards. This document summarizes the workshop.

American Journal of Infection Control: HCP/HCW Immunization, Coverage, Uptake

American Journal of Infection Control
Vol 41 | No. 8 | August 2013 | Pages 667-758

Evaluating influenza vaccination campaigns beyond coverage: A before-after study among health care workers
Anna Llupià, Guillermo Mena, Victòria Olivé, Sebastiana Quesada, et al.

Influenza vaccination campaigns based on educational interventions do not seem to increase coverage in the hospital setting, and their impact on educational goals is not usually evaluated. This study describes the campaign implemented in a university hospital and assesses the achievement of the strategic objectives, which were to increase health care workers (HCW) perceptions of the risk of influenza and of their role as promoters of influenza vaccination among their colleagues and to increase knowledge about influenza.

A before-after study was conducted using a self-administered survey in a randomized sample of HCW during the 2010-2011 influenza vaccination campaign. The Wilcoxon paired measures test was used to assess attainment of the strategic objectives.

The campaign had a positive impact on the strategic objectives (Wilcoxon test, P value <.05 in all cases). The reach of the campaign was high (91.9%), and HCW rated it as positive (7.19 [standard deviation, 2.3] out of 10) but did not achieve increased coverage (34%; 95% confidence interval: 33.8-36.4).

Evaluation of the campaign shows that its effect responded to the strategic objectives. However, it seems that increasing the information provided to HCW and heightening their risk perception do not necessarily lead to greater acceptance of influenza vaccination.


Predicting influenza vaccination uptake among health care workers: What are the key motivators?
Kimberly Corace, Chatura Prematunge, Anne McCarthy, Rama C. Nair, et al.
Health care worker (HCW) vaccination was critical to protecting HCW during the H1N1 pandemic. However, vaccine uptake rates fell below recommended targets. This study examined motivators and barriers influencing HCW pH1N1 vaccination to identify modifiable factors that can improve influenza vaccine uptake.

A cross-sectional survey was conducted at a large Canadian tertiary care hospital. HCW (N = 3,275) completed measures of demographics, vaccination history, influenza risk factors, and attitudes toward pH1N1 vaccination. Self-reported vaccination was verified with staff vaccination records. Of the total sample, 2,862 (87.4%) HCW received the pH1N1 vaccine. Multiple logistic regression analyses were used to predict HCW vaccination.

HCW attitudes toward vaccination significantly predicted vaccination, even after adjusting for demographics, vaccine history, and influenza risk factors. This model correctly predicted 95% (confidence interval [CI]: 0.93-0.96) of HCW vaccination. Key modifiable factors driving HCW vaccination include (1) desire to protect family members and patients, (2) belief that vaccination is important even if one is healthy, (3) confidence in vaccine safety, and (4) supervisor and physician encouragement.

This research identified fundamental reasons why HCW get vaccinated and provides direction for future influenza vaccination programs. To enhance vaccine uptake, it is important to target HCW attitudes in influenza vaccine campaigns and create a culture of vaccine promotion in the workplace, including strong messaging from supervisors and physicians


Health care worker influenza immunization rates: The missing pieces of the puzzle
Susan Quach, Jennifer A. Pereira, Christine L. Heidebrecht, Jeffrey C. Kwong, et al.
Immunization rates are used to assess the level of protection against influenza, but limited data exist on how such rates are measured in health care organizations. We conducted key informant interviews with campaign planners to learn about processes for collecting immunization data, including barriers and facilitating factors for measuring and reporting rates.

We conducted telephone interviews with 23 influenza immunization program planners across Canada working in 7 acute care hospitals, 6 continuing care facilities, and 8 public health organizations in 2012. We used content analysis to examine the interview data.

The methods used to collect immunization data varied by the size and type of health care organization. Immunization data from different personnel groups were included in immunization rate calculations depending on the local public health reporting requirements and the organization’s size. Challenges associated with collecting immunization data and calculating rates included lack of resources for identifying personnel immunized off-site, tracking personnel who declined immunization, identifying non-payroll staff, and interpreting unclear public health reporting requirements.

Support from other vaccine providers, public health, employers, and professional and external bodies is needed to provide the necessary information and resources to calculate accurate and complete rates. Further work is needed to refine and standardize the collection of HCW influenza immunization data so that it may be used for surveillance and quality assessment purposes.


Using a validated health promotion tool to improve patient safety and increase health care personnel influenza vaccination rates
Kevin Real, Sujin Kim, Joseph Conigliaro
This study employed the risk perception attitude (RPA) framework to determine whether health care personnel (HCP) influenza-related risk perceptions and efficacy beliefs could be used to segment individuals into meaningful groups related to vaccination uptake, absenteeism, and patient safety beliefs.
After pilot interviews, a questionnaire was administered to 318 hospital-based HCP (80%) and nonclinical support staff (20%) in Lexington, KY, in 2011. Follow-up interviews were conducted with 29 respondents.
Cluster analysis was used to create 4 groups that correspond to the RPA framework: responsive (high risk, strong efficacy), avoidance (high risk, weak efficacy), proactive (low risk, strong efficacy), and indifference (low risk, weak efficacy). A significant association was found between membership in 1 or more of the 4 RPA groups and the 3 study variables of interest: influenza vaccination uptake (F7,299 = 2.51, P < .05), influenza-related absenteeism (F7,269=3.6, P<.001), and perceptions of patient safety climate (F7,304=6.21, P<.001). A subset of respondents indicated the principal reasons for not getting vaccinated were “had one before and got sick anyway,” “concerned about vaccine safety,” and “no convenient time.” In follow-up interviews, HCP indicated that employee vaccinations were altruistic, increased herd immunity, and important for patient safety.
The RPA framework is a valid health promotion tool for improving patient safety, targeting specific groups for interventions, and improving HCP influenza vaccination rates.


Impact of hospital policies on health care workers’ influenza vaccination rates
Mary Patricia Nowalk, Chyongchiou Jeng Lin, Mahlon Raymund, Jamie Bialor, et al.
Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%.
To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ2 or Fisher exact tests for categorical variables and t tests for continuous variables.
One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P=.002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences.
Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.


Influenza vaccination knowledge and perceptions among Veterans Affairs nurses
Andrea R. Jennings, Christopher J. Burant
Flu vaccination among nurses in the Veterans Health Administration system is crucial in the prevention of influenza. Nurses working at a Veterans Administration Medical Center completed the Influenza Vaccination Knowledge and Perceptions Survey. The findings from this survey suggest the need for additional education for nurses as it relates to flu vaccination.


A mandatory campaign to vaccinate health care workers against pertussis
Lisa M. Esolen, Kimberly L. Kilheeney
Pertussis is a highly contagious respiratory infection that has dramatically increased in recent decades and has caused outbreaks in health care facilities. Because of these trends, we implemented a mandatory pertussis (Tdap) employee vaccination program. Final vaccination compliance was 97.8% across all clinical campuses.


Influenza immunization coverage of residents and employees of long-term care facilities in New York State, 2000-2010
Cara J. Person, Jessica A. Nadeau, Joshua K. Schaffzin, Lynn Pollock, et al.
We describe influenza immunization coverage trends from the New York State (NYS) Department of Health long-term care facility (LTCF) reports. Overall median immunization coverage levels for NYS LTCF residents and employees were 84.0% (range: 81.6%-86.0%) and 37.7% (range: 32.7%-50.0%), respectively. LTCF resident immunization coverage levels in NYS have neared the Healthy People 2020 target of 90% but have not achieved high LTCF employee coverage, suggesting a need for more regulatory interventions

BMJ Head to Head: Should Europe have a universal hepatitis B vaccination programme?

British Medical Journal
03 August 2013 (Vol 347, Issue 7919)

Head to Head
Should Europe have a universal hepatitis B vaccination programme?
BMJ 2013; 347 doi: (Published 10 July 2013)
Cite this as: BMJ 2013;347:f4057

WHO recommends that hepatitis B virus should be included in childhood vaccination programmes. Pierre Van Damme and colleagues argue that universal immunisation is essential to stop people becoming carriers but Tuija Leino and colleagues think that a targeted approach is a better use of resources in countries with low endemicity

Yes—Pierre Van Damme, Elke Leuridan, Greet Hendrickx, Alex Vorsters, Heidi Theeten
Hepatitis B occurs worldwide, with more than two billion people having been infected with the virus.1 Of these, about 240 million are living with chronic infection and at risk of cirrhosis and hepatocellular carcinoma, diseases that are estimated to cause 500 000-700 000 deaths a year.2 The risk of developing chronic infection decreases with age, occurring in up to 90% of infants infected during first year of life versus 5% of those infected as adults.1 Globally, newborns and infants are therefore the main target of hepatitis B immunisation programmes. In 1991 the World Health Organization set 1997 as the target for integrating hepatitis B vaccine into national immunisation programmes worldwide,3 and in 2010 the World Health Assembly adopted a resolution calling for a comprehensive prevention and control strategy, including universal hepatitis B vaccination and development of time specific immunisation goals.4 By the end of 2012, 179 countries—93% of WHO member states—had added hepatitis B vaccine to their national newborn, infant, or adolescent immunisation programmes.2 It is time that all European countries followed suit.

Infection in Europe
About 14 million people are chronically infected with hepatitis B virus (HBV) in the WHO European region (53 countries), and 36 000 die each year from HBV related causes.2 Forty seven European countries have a universal HBV immunisation programme as well as strategies for immunising high risk groups. Routine immunisation has created a generation of children and young adults with virtually no markers of HBV infection. Surveillance data from Italy, where universal infant…

Editorial: Universal health coverage and universal access

Bulletin of the World Health Organization
Volume 91, Number 8, August 2013, 545-620

Universal health coverage and universal access
David B Evans a, Justine Hsu a & Ties Boerma a
a. World Health Organization, 20 avenue Appia, CH-1211 Geneva 27, Switzerland.
Bulletin of the World Health Organization 2013;91:546-546A. doi: [PDF]

Universal health coverage has been set as a possible umbrella goal for health in the post-2015 development agenda.1 Whether it is a means to an end or an end in itself and whether it is measureable are subjects of heated debate.2 In this issue of the Bulletin, Kutzin argues that universal health coverage not only leads to better health and to financial protection for households, but that it is valuable for its own sake.3 More recently, attention has shifted to just what the goal should be: whether universal coverage or universal access. This editorial focuses on this question.

Universal health coverage is the goal that all people obtain the health services they need without risking financial hardship from unaffordable out-of-pocket payments.4 It involves coverage with good health services – from health promotion to prevention, treatment, rehabilitation and palliation – as well as coverage with a form of financial risk protection. A third feature is universality – coverage should be for everyone. Although many countries are far from attaining universal health coverage, all countries can take steps in this direction.3,4 Improving access is one such step.

Universal health coverage is attained when people actually obtain the health services they need and benefit from financial risk protection. Access, on the other hand, is the opportunity or ability to do both of these things. Hence, universal health coverage is not possible without universal access, but the two are not the same…

Delivery cost of human papillomavirus vaccination of young adolescent girls in Peru, Uganda and Viet Nam

Bulletin of the World Health Organization
Volume 91, Number 8, August 2013, 545-620

Delivery cost of human papillomavirus vaccination of young adolescent girls in Peru, Uganda and Viet Nam
Carol E Levin, Hoang Van Minh, John Odaga, Swampa Sarit Rout, Diep Nguyen Thi Ngoc, Lysander Menezes, Maria Ana Mendoza Araujo & D Scott LaMontagne

To estimate the incremental delivery cost of human papillomavirus (HPV) vaccination of young adolescent girls in Peru, Uganda and Viet Nam.

Data were collected from a sample of facilities that participated in five demonstration projects for HPV vaccine delivery: school-based delivery was used in Peru, Uganda and Viet Nam; health-centre-based delivery was also used in Viet Nam; and integrated delivery, which involved existing health services, was also used in Uganda. Microcosting methods were used to guide data collection on the use of resources (i.e. staff, supplies and equipment) and data were obtained from government, demonstration project and health centre administrative records. Delivery costs were expressed in 2009 United States dollars (US$). Exclusively project-related expenses and the cost of the vaccine were excluded.

The economic delivery cost per vaccine dose ranged from US$ 1.44 for integrated outreach in Uganda to US$ 3.88 for school-based delivery in Peru. In Viet Nam, the lowest cost per dose was US$ 1.92 for health-centre-based delivery. Cost profiles revealed that, in general, the largest contributing factors were project start-up costs and recurrent personnel costs. The delivery cost of HPV vaccine was higher than published costs for traditional vaccines recommended by the Expanded Programme on Immunization (EPI).

The cost of delivering HPV vaccine to young adolescent girls in Peru, Uganda and Viet Nam was higher than that for vaccines currently in the EPI schedule. The cost per vaccine dose was lower when delivery was integrated into existing health services.

Impact of rotavirus vaccination in Australian children below 5 years of age: A database study

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
August 2013  Volume 9, Issue 8

Special Focus: Vaccine Acceptance
Research Paper
Impact of rotavirus vaccination in Australian children below 5 years of age: A database study
Annmarie Pendleton, Maja Galic, Christopher Clarke, Su Peing Ng, Emilio Ledesma, Gunasekaran Ramakrishnan and Yanfang Liu

This study was conducted to assess the impact of administration of two-dose rotavirus (RV) vaccine (RIX4414; GlaxoSmithKline Vaccines) among children aged less than 5 y in three states/territories of Australia. Aggregated and de-identified data on rotavirus gastroenteritis (RVGE) and all-cause gastroenteritis (AGE) from July 1998–June 2009 were obtained from the Australian Institute of Health and Welfare database. The baseline incidence (July 1998–June 2006) of RVGE hospitalizations before RV vaccine introduction in New South Wales (NSW), the Australian Capital Territory (ACT) and the Northern Territory (NT) were 33.75, 42.93 and 288.67 per 10 000 child-years, respectively among children aged 0–11 mo. Following RV vaccine introduction in NSW, the ACT and the NT, incidence of RVGE hospitalizations reduced to 13.06, 17.35 and 47.52 per 10,000 child-years, respectively, during July 2007–June 2008 and 3.87, 8.40 and 122.79 per 10,000 child-years, respectively, during July 2008–June 2009 among children aged 0–11 mo. Reductions in RVGE and AGE were also observed in all children below 5 y of age in NSW and the ACT. Overall reduction in hospitalizations due to RVGE and AGE was observed following RV vaccine introduction into the NIP in Australia

HPV vaccination coverage among women aged 18–20 years in Germany three years after recommendation of HPV vaccination for adolescent girls: Results from a cross-sectional sur

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
August 2013  Volume 9, Issue 8

Short Report
HPV vaccination coverage among women aged 18–20 years in Germany three years after recommendation of HPV vaccination for adolescent girls: Results from a cross-sectional survey
Yvonne Deleré, Merle M. Böhmer, Dietmar Walter and Ole Wichmann

Routine immunization of adolescent girls aged 12–17 y against human papillomavirus (HPV) was recommended in Germany in March 2007. We aimed to assess HPV-vaccine uptake and knowledge about post-vaccination cervical cancer screening and condom use in women aged 18–20 years, three years after adoption of HPV-vaccination into the routine vaccination schedule.

Overall 2,001 females participated in our study. Of these, 49% reported receipt of a complete three-dose course of HPV-vaccines; 11% received 1 or 2 doses. Living in East Germany, high educational status, and interest in health-related issues were independently associated with HPV-vaccination. Misconceptions among survey-participants were rare: Only 8% believed that HPV-vaccination would obviate the need for cervical screening and 1% that condom use would be dispensible after vaccination.

In 2010, a nationwide cross-sectional telephone-survey was performed among randomly-selected women aged 18–20 years living in Germany. Telephone interviews were conducted by a large professional market research institute as part of a daily omnibus survey.

HPV-vaccination coverage is low in Germany. The results indicate that there is an urgent need for the implementation of a coordinated adolescent vaccination program to facilitate access to vaccination, including balanced information tailored to this age group. Otherwise, the HPV-vaccination effort will fall short of reaching its maximum public health benefit.

Human Vaccines & Immunotherapeutics: Special Focus Issue – Vaccine Acceptance

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
August 2013  Volume 9, Issue 8
Special Focus: Vaccine Acceptance

Special Focus Review
The rise (and fall?) of parental vaccine hesitancy
Charitha Gowda and Amanda F. Dempsey
View Article Abstract

Special Focus Review
Utilizing health information technology to improve vaccine communication and coverage
Melissa S. Stockwell and Alexander G. Fiks
View Article Abstract Keywords

Special Focus Review
Public trust and vaccine acceptance-international perspectives
Sachiko Ozawa and Meghan L. Stack
View Article Abstract

Special Focus Review
Addressing heterogeneous parental concerns about vaccination with a multiple-source model: A parent and educator perspective
Allison Hagood and Stacy Mintzer Herlihy
View Article Abstract

Special Focus Review
Story and science: How providers and parents can utilize storytelling to combat anti-vaccine misinformation
Ashley Shelby and Karen Ernst
View Article Abstract

Special Focus Review
Vaccine hesitancy: An overview
Eve Dubé, Caroline Laberge, Maryse Guay, Paul Bramadat, Réal Roy and Julie A Bettinger
View Article Abstract

Special Focus Review
Professionalism, fidelity and relationship-preservation: Navigating disagreement and frustration in clinical encounters
Christy A. Rentmeester
View Article Abstract

Special Focus Review
How society should respond to the risk of vaccine rejection
David Ropeik
View Article Abstract

Special Focus Research Paper
Provider dismissal policies and clustering of vaccine-hesitant families: An agent-based modeling approach
Alison M. Buttenheim, Sarah T. Cherng and David A. Asch
View Article Abstract

Negotiating vaccine acceptance in an era of reluctance
Heidi J Larson
View Article Abstract

Research Paper
Parental vaccine concerns, information source, and choice of alternative immunization schedules
Marissa Wheeler and Alison M Buttenheim
View Article Abstract

Research gaps for three main tropical diseases in the People’s Republic of China

Infectious Diseases of Poverty
[Accessed 3 August 2013]

Scoping Review
Research gaps for three main tropical diseases in the People’s Republic of China
Qi Zheng, Samantha Vanderslott, Bin Jiang, Li-Li Xu, Cong-Shan Liu, Le-Le Huo, Li-Ping Duan, Ning-Bo Wu, Shi-Zhu Li, Zhi-Gui Xia, Wei-Ping Wu, Wei Hu and Hao-Bing Zhang
Infectious Diseases of Poverty 2013, 2:15 doi:10.1186/2049-9957-2-15
Published: 29 July 2013

Abstract (provisional)
This scoping review analyzes the research gaps of three diseases: schistosomiasis japonica, malaria and echinococcosis. Based on available data in the P.R. China, we highlight the gaps between control capacity and prevalence levels, and between diagnostic/drug development and population need for treatment at different stages of the national control programme. After reviewing the literature from 848 original studies and consultations with experts in the field, the gaps were identified as follows. Firstly, the malaria research gaps include (i) deficiency of active testing in the public community and no appropriate technique to evaluate elimination, (ii) lack of sensitive diagnostic tools for asymptomatic patients, (iii) lack of safe drugs for mass administration. Secondly, gaps in research of schistosomiasis include (i) incongruent policy in the implementation of integrated control strategy for schistosomiasis, (ii) lack of effective tools for Oncomelania sp. snail control, (iii) lack of a more sensitive and cheaper diagnostic test for large population samples, (iv) lack of new drugs in addition to praziquantel. Thirdly, gaps in research of echinococcosis include: (i) low capacity in field epidemiology studies, (ii) lack of sanitation improvement studies in epidemic areas, (iii) lack of a sensitivity test for early diagnosis, (iv) lack of more effective drugs for short-term treatment. We believe these three diseases can eventually be eliminated in mainland China if all the research gaps are abridged in a short period of time.

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

Inequalities in the uptake of Human Papillomavirus Vaccination: a systematic review and meta-analysis

International Journal of Epidemiology
Volume 42 Issue 3 June 2013

Inequalities in the uptake of Human Papillomavirus Vaccination: a systematic review and meta-analysis
Harriet Fisher*, Caroline L Trotter, Suzanne Audrey, Kyle MacDonald-Wallis and Matthew Hickman
School of Social and Community Medicine, University of Bristol, Bristol, UK
Accepted February 28, 2013.

Background The human papillomavirus (HPV) vaccine offers an opportunity to reduce health inequalities associated with cervical cancer provided the vaccine is delivered equitably at population level.

Method We reviewed evidence of inequalities in HPV vaccine uptake in young women after undertaking a comprehensive search of databases from inception to March 2012. Studies that compared HPV vaccination initiation and/or completion by at least one ethnicity or socioeconomic-related variable in adolescent young women were included. There were no language restrictions. Data were extracted by two reviewers and pooled in a meta-analysis using a random-effects model; sub-analyses and meta-regression were undertaken to investigate sources of heterogeneity.

Results In all, 29 publications related to 27 studies were included in the review. Black young women were less likely to initiate HPV vaccination compared with White young women (combined OR: 0.89, 95% CI: 0.82–0.97). In the USA, young women without healthcare insurance were less likely to initiate (combined OR: 0.56, 95% CI: 0.40–0.78). There was no strong evidence that lower family income (combined OR: 1.16, 95% CI: 1.00–1.34) or lower parental education (combined OR 1.06, 95% CI: 0.92–1.22) influenced HPV vaccination initiation.

Conclusions We found strong evidence for differences in HPV vaccination initiation by ethnicity and healthcare coverage, but did not find a strong association with parental education or family income variables. The majority of studies originated from the USA. Population-based studies reporting both initiation and completion of the HPV vaccination programme are required to establish patterns of uptake in different healthcare contexts.

Commentary: The uptake of human papillomavirus vaccination: the power of belief

International Journal of Epidemiology
Volume 42 Issue 3 June 2013

Commentary: The uptake of human papillomavirus vaccination: the power of belief
Heidi J Larson
Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:
Accepted April 29, 2013.

The systematic review and meta-analysis of ‘Inequalities in the uptake of human papillomavirus vaccination’ in this issue of IJE reveals the complexities of identifying the diverse factors which determine HPV vaccination uptake. The authors note ‘the factors affecting HPV vaccination in Black young women are not yet fully understood’.1

Although the review particularly focuses on socio-economic and ethnic disparities in HPV vaccine uptake among young women in the USA, it acknowledges additional underlying factors—beyond economic and ethnic determinants—which also affect the uptake of HPV vaccines confirmed in studies globally.1–4

The determinants of HPV acceptance are very different from those around childhood vaccines. Firstly, the vaccine prevents a sexually transmitted infection (STI)—evoking the moral judgements and religious and cultural taboos that come with discussing and addressing sexual behaviour. In some settings, the vaccine is being promoted largely as a vaccine for cancer prevention, making it more culturally acceptable than an STI vaccine, particularly for adolescents.1,3 Secondly, and linked to the issue …

No association between the number of vaccine antigens and risk of autism spectrum disorder

Journal of Pediatrics
Vol 163 | No. 2 | August 2013 | Pages 309-612

No association between the number of vaccine antigens and risk of autism spectrum disorder
Sarah S. Long, MD

Many well-meaning parents have unfounded fears that their young children are exposed to too much immunologic stimulation through vaccines. Some then take real risks of underimmunizing their children or insisting on schedules that are unstudied for efficacy or safety. In this issue of The Journal, DeStefano et al performed a secondary analysis of the robust database from a case-control study evaluating potential risks of thimerosal exposure from vaccines. They sought to test the hypothesis that increasing exposure to antibody-stimulating proteins and polysaccharides in vaccines was associated with risk of autism spectrum disorder (ASD). They repeatedly found aORs of 0.999 (with narrow CIs) for association of ASD diagnosed by 6-13 years of age with incremental increases in total antigens received, as well as with decreasing ages at receipt. The authors also found no association between the maximum number of antigens that a child was exposed to on a single day and ASD.

The Lancet Editorial – Meningitis B

The Lancet  
Aug 03, 2013  Volume 382  Number 9890  p367 – 478  e2

Meningitis B
The Lancet
Preview |
Invasive meningococcal disease is a serious global health threat that kills about one in 20 infected individuals. Meningitis B accounts for about 80% of cases of invasive meningococcal disease in high-income countries, 50% of whom are children younger than 2 years; it is the foremost cause of infant bacterial meningitis and severe sepsis in Europe.

The price of prevention: what now for immunisation against meningococcus B?
Richard Moxon, Matthew D Snape
Preview |
Meningococcal sepsis is one of the most dreaded bacterial infections: the death rate remains at about 5% and the effects for survivors include neurological damage, limb amputation, and widespread skin necrosis.1 There is a compelling case for prevention of meningococcal disease by immunisation. On July 24, 2013, in an interim position statement,2 the UK Joint Committee on Vaccination and Immunisation (JCVI) concluded that it cannot currently recommend a vaccine (4CMenB, licensed as Bexsero, Novartis Vaccines and Diagnostics, Siena, Italy) for use in the UK routine immunisation programme.

Influenza A (H7N9) and the Importance of Digital Epidemiology

New England Journal of Medicine
August 1, 2013  Vol. 369 No. 5

Influenza A (H7N9) and the Importance of Digital Epidemiology
Marcel Salathé, Ph.D., Clark C. Freifeld, M.S., Sumiko R. Mekaru, D.V.M., Anna F. Tomasulo, M.P.H., and John S. Brownstein, Ph.D.
N Engl J Med 2013; 369:401-404August 1, 2013DOI: 10.1056/NEJMp1307752

In recent outbreaks including that of novel H7N9 influenza, digital disease surveillance has supplemented laboratory studies and work by public health officials and epidemiologists, by leveraging widespread use of the Internet, mobile phones, and social media.

Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus

New England Journal of Medicine
August 1, 2013  Vol. 369 No. 5

Original Article
Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus
Abdullah Assiri, M.D., Allison McGeer, M.D., Trish M. Perl, M.D., Connie S. Price, M.D., Abdullah A. Al Rabeeah, M.D., Derek A.T. Cummings, Ph.D., Zaki N. Alabdullatif, M.D., Maher Assad, M.D., Abdulmohsen Almulhim, M.D., Hatem Makhdoom, Ph.D., Hossam Madani, Ph.D., Rafat Alhakeem, M.D., Jaffar A. Al-Tawfiq, M.D., Matthew Cotten, Ph.D., Simon J. Watson, Ph.D., Paul Kellam, Ph.D., Alimuddin I. Zumla, M.D., and Ziad A. Memish, M.D. for the KSA MERS-CoV Investigation Team
N Engl J Med 2013; 369:407-416August 1, 2013DOI: 10.1056/NEJMoa1306742

In September 2012, the World Health Organization reported the first cases of pneumonia caused by the novel Middle East respiratory syndrome coronavirus (MERS-CoV). We describe a cluster of health care–acquired MERS-CoV infections.
Full Text of Background…

Medical records were reviewed for clinical and demographic information and determination of potential contacts and exposures. Case patients and contacts were interviewed. The incubation period and serial interval (the time between the successive onset of symptoms in a chain of transmission) were estimated. Viral RNA was sequenced.
Full Text of Methods…

Between April 1 and May 23, 2013, a total of 23 cases of MERS-CoV infection were reported in the eastern province of Saudi Arabia. Symptoms included fever in 20 patients (87%), cough in 20 (87%), shortness of breath in 11 (48%), and gastrointestinal symptoms in 8 (35%); 20 patients (87%) presented with abnormal chest radiographs. As of June 12, a total of 15 patients (65%) had died, 6 (26%) had recovered, and 2 (9%) remained hospitalized. The median incubation period was 5.2 days (95% confidence interval [CI], 1.9 to 14.7), and the serial interval was 7.6 days (95% CI, 2.5 to 23.1). A total of 21 of the 23 cases were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units in three different health care facilities. Sequencing data from four isolates revealed a single monophyletic clade. Among 217 household contacts and more than 200 health care worker contacts whom we identified, MERS-CoV infection developed in 5 family members (3 with laboratory-confirmed cases) and in 2 health care workers (both with laboratory-confirmed cases).
Full Text of Results…

Person-to-person transmission of MERS-CoV can occur in health care settings and may be associated with considerable morbidity. Surveillance and infection-control measures are critical to a global public health response.

Measuring the Global Burden of Disease

New England Journal of Medicine
August 1, 2013  Vol. 369 No. 5

Review Article
Global Health
Measuring the Global Burden of Disease
Christopher J.L. Murray, M.D., D.Phil., and Alan D. Lopez, Ph.D.
N Engl J Med 2013; 369:448-457August 1, 2013DOI: 10.1056/NEJMra1201534

It is difficult to deliver effective and high-quality care to patients without knowing their diagnoses; likewise, for health systems to be effective, it is necessary to understand the key challenges in efforts to improve population health and how these challenges are changing. Before the early 1990s, there was no comprehensive and internally consistent source of information on the global burden of diseases, injuries, and risk factors. To close this gap, the World Bank and the World Health Organization launched the Global Burden of Disease (GBD) Study in 1991.1 Although assessments of selected diseases, injuries, and risk factors in selected populations are published each year (e.g., the annual assessments of the human immunodeficiency virus [HIV] epidemic2), the only comprehensive assessments of the state of health in the world have been the various revisions of the GBD Study for 1990, 1999–2002, and 2004.1,3-10 The advantage of the GBD approach is that consistent methods are applied to critically appraise available information on each condition, make this information comparable and systematic, estimate results from countries with incomplete data, and report on the burden of disease with the use of standardized metrics.

The most recent assessment of the global burden of disease is the 2010 study (GBD 2010), which provides results for 1990, 2005, and 2010. Several hundred investigators collaborated to report summary results for the world and 21 epidemiologic regions in December 2012.11-18 Regions based on levels of adult mortality, child mortality, and geographic contiguity were defined. GBD 2010 addressed a number of major limitations of previous analyses, including the need to strengthen the statistical methods used for estimation.11 The list of causes of the disease burden was broadened to cover 291 diseases and injuries. Data on 1160 sequelae of these causes (e.g., diabetic retinopathy, diabetic neuropathy, amputations due to diabetes, and chronic kidney disease due to diabetes) have been evaluated separately. The mortality and burden attributable to 67 risk factors or clusters of risk factors were also assessed.

GBD 2010, which provides critical information for guiding prevention efforts, was based on data from 187 countries for the period from 1990 through 2010. It includes a complete reassessment of the burden of disease for 1990 as well as an estimation for 2005 and 2010 based on the same definitions and methods; this facilitated meaningful comparisons of trends. The prevalence of coexisting conditions was also estimated according to the year, age, sex, and country. Detailed results from global and regional data have been published previously.11-18

The internal validity of the results is an important aspect of the GBD approach. For example, demographic data on all-cause mortality according to the year, country, age, and sex were combined with data on cause-specific mortality to ensure that the sum of the number of deaths due to each disease and injury equaled the number of deaths from all causes. Similar internal-validity checks were used for cause-specific estimates related to impairments such as hearing loss and vision loss, anemia, heart failure, intellectual disability, infertility, and epilepsy when there were substantial data on the overall levels of the impairment.

Although GBD 2010 provides the most comprehensive and consistent assessment of global data on descriptive epidemiology, there remain many limitations. There were insufficient data on many diseases, injuries, and risk factors from many countries. Estimates depended on sophisticated statistical modeling to address sparse and often inconsistent data.13,16,19,20 All outcomes were measured with 95% uncertainty intervals, which captured uncertainty from sampling, nonsampling error from the study designs or diagnostic methods, model parameter uncertainty, and uncertainty regarding model specification. This combined assessment of uncertainty was meant to communicate the strength of the evidence available for a particular condition in a particular place…

Editorial and Special Report: Clinical Trial Data and Transparency/GSK data-access plan

New England Journal of Medicine
August 1, 2013  Vol. 369 No. 5

Participant-Level Data and the New Frontier in Trial Transparency
Deborah A. Zarin, M.D.
N Engl J Med 2013; 369:468-469August 1, 2013DOI: 10.1056/NEJMe1307268
Medical progress is possible only because altruistic volunteers put themselves at risk in clinical trials. The results of those trials are then used to inform medical decisions. The traditional system of relying on investigators, sponsors, and journal editors to decide whether, when, and how to report trial results was based on trust. There was no way to know what trials had been conducted, what data were collected, how they were analyzed, and whether the reported data were complete and accurate. Policies mandating the registration of trials and the reporting of summary results were instituted to provide greater transparency. In turn…

Special Report
Access to Patient-Level Data from GlaxoSmithKline Clinical Trials
Perry Nisen, M.D., Ph.D., and Frank Rockhold, Ph.D.
N Engl J Med 2013; 369:475-478August 1, 2013DOI: 10.1056/NEJMsr1302541

GlaxoSmithKline is providing access to patient-level clinical trial data under a new policy. This article reviews the data-access plan

Understanding the Cost-Effectiveness of Influenza Vaccination in Children: Methodological Choices and Seasonal Variability

Volume 31, Issue 8, August 2013

Understanding the Cost-Effectiveness of Influenza Vaccination in Children: Methodological Choices and Seasonal Variability
Anthony T. Newall, Juan Pablo Dehollain, Prudence Creighton, Philippe Beutels, James G. Wood

The universal vaccination of children for influenza has recently been recommended in the UK and is being considered in other developed countries.

The aim of this study was to explore the potential costs and benefits of childhood influenza vaccination to gain a better understanding of the key drivers of cost-effectiveness.

As our case study we examined the cost-effectiveness of vaccination in Australian schoolchildren using an age-stratified Susceptible Exposed Infectious Recovered model.

The results of this study highlight the critical role that methodological choices play in determining the cost-effectiveness of influenza vaccination. These choices include decisions about the structure of the model (including/excluding herd immunity) and what costs and benefits to include in the analysis. In scenarios where herd protection was included we estimated that the program was likely to be cost-effective. The study also illustrates the importance of the inherent seasonal variability of influenza, which can produce counter-intuitive results, with low transmission seasons being easier to control by vaccination but resulting in fewer benefits.

Universal childhood influenza vaccination is likely to be cost-effective if a substantial herd protection effect can be achieved by the program. However, it is important that decision makers understand the role of seasonal variability and the impact of alternative methodological choices in economic evaluations of influenza vaccination.

Risk Map of Cholera Infection for Vaccine Deployment: The Eastern Kolkata Case

PLoS One
[Accessed 3 August 2013]

Research Article
Risk Map of Cholera Infection for Vaccine Deployment: The Eastern Kolkata Case
Young Ae You, Mohammad Ali, Suman Kanungo, Binod Sah, Byomkesh Manna, Mahesh Puri, G. Balakrish Nair, Sujit Kumar Bhattacharya, Matteo Convertino, Jacqueline L. Deen, Anna Lena Lopez, Thomas F. Wierzba, John Clemens, Dipika Sur

Despite advancement of our knowledge, cholera remains a public health concern. During March-April 2010, a large cholera outbreak afflicted the eastern part of Kolkata, India. The quantification of importance of socio-environmental factors in the risk of cholera, and the calculation of the risk is fundamental for deploying vaccination strategies. Here we investigate socio-environmental characteristics between high and low risk areas as well as the potential impact of vaccination on the spatial occurrence of the disease.

Methods and Findings
The study area comprised three wards of Kolkata Municipal Corporation. A mass cholera vaccination campaign was conducted in mid-2006 as the part of a clinical trial. Cholera cases and data of the trial to identify high risk areas for cholera were analyzed. We used a generalized additive model (GAM) to detect risk areas, and to evaluate the importance of socio-environmental characteristics between high and low risk areas. During the one-year pre-vaccination and two-year post-vaccination periods, 95 and 183 cholera cases were detected in 111,882 and 121,827 study participants, respectively. The GAM model predicts that high risk areas in the west part of the study area where the outbreak largely occurred. High risk areas in both periods were characterized by poor people, use of unsafe water, and proximity to canals used as the main drainage for rain and waste water. Cholera vaccine uptake was significantly lower in the high risk areas compared to low risk areas.

The study shows that even a parsimonious model like GAM predicts high risk areas where cholera outbreaks largely occurred. This is useful for indicating where interventions would be effective in controlling the disease risk. Data showed that vaccination decreased the risk of infection. Overall, the GAM-based risk map is useful for policymakers, especially those from countries where cholera remains to be endemic with periodic outbreaks.

Citation: You YA, Ali M, Kanungo S, Sah B, Manna B, et al. (2013) Risk Map of Cholera Infection for Vaccine Deployment: The Eastern Kolkata Case. PLoS ONE 8(8): e71173. doi:10.1371/journal.pone.0071173

Editor: Matteo Convertino, University of Florida, United States of America

Received: April 11, 2013; Accepted: June 25, 2013; Published: August 2, 2013

Funding: This study is supported by the Bill & Melinda Gates Foundation through the Diseases of the Most Impoverished Program and the Cholera Vaccine Initiative. Additional funding is provided by the Swedish International Development Cooperation Agency and the Governments of South Korea, Sweden, and Kuwait. No funding bodies had any role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Physicians Infrequently Adhere to Hepatitis Vaccination Guidelines for Chronic Liver Disease

PLoS One
[Accessed 3 August 2013]

Research Article
Physicians Infrequently Adhere to Hepatitis Vaccination Guidelines for Chronic Liver Disease
Kavitha Thudi, Dhiraj Yadav, Kaitlyn Sweeney, Jaideep Behari mail

Background and Goals
Hepatitis A (HAV) and hepatitis B (HBV) vaccination in patients with chronic liver disease is an accepted standard of care. We determined HAV and HBV vaccination rates in a tertiary care referral hepatology clinic and the impact of electronic health record (EHR)-based reminders on adherence to vaccination guidelines.

We reviewed the records of 705 patients with chronic liver disease referred to our liver clinic in 2008 with at least two follow-up visits during the subsequent year. Demographics, referral source, etiology, and hepatitis serology were recorded. We determined whether eligible patients were offered vaccination and whether patients received vaccination. Barriers to vaccination were determined by a follow-up telephone interview.

HAV and HBV serologic testing prior to referral and at the liver clinic were performed in 14.5% and 17.7%; and 76.7% and 74% patients, respectively. Hepatologists recommended vaccination for HAV in 63% and for HBV in 59.7% of eligible patients. Patient demographics or disease etiology did not influence recommendation rates. Significant variability was observed in vaccination recommendation amongst individual providers (30–98.6%), which did not correlate with the number of patients seen by each physician. Vaccination recommendation rates were not different for Medicare patients with hepatitis C infection for whom a vaccination reminder was automatically generated by the EHR. Most patients who failed to get vaccination after recommendation offered no specific reason for noncompliance; insurance was a barrier in a minority.

Hepatitis vaccination rates were suboptimal even in an academic, sub-speciality setting, with wide-variability in provider adherence to vaccination guidelines.

From Google Scholar & other sources [to 3 August 2013]

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

SY Kim – The 35th Annual Meeting of the Society for Medical …, 2013
Purpose: In low-and middle-income countries, cost-effectiveness analyses of new vaccine
introduction have typically compared vaccine against doing nothing. We illustrate the impact
of competing new vaccines against other realistic prevention alternatives, using maternal …

Carbon nanotubes as vaccine scaffolds
DA Scheinberg, MR McDevitt, T Dao, JJ Mulvey… – Advanced Drug Delivery …, 2013
Abstract Carbon nanotubes display characteristics that are potentially useful in their
development as scaffolds for vaccine compositions. These features include stability in vivo,
lack of intrinsic immunogenicity, low toxicity, and the ability to be appended with multiple …

[PDF] Selection of an adjuvant for seasonal influenza vaccine in elderly people: modelling immunogenicity from a randomized trial
HC Rümke, JH Richardus, L Rombo, K Pauksens… – BMC Infectious Diseases, 2013
Background Improved influenza vaccines are needed to reduce influenza-associated
complications in older adults. The aim of this study was to identify the optimal formulation of
adjuvanted seasonal influenza vaccine for use in elderly people. Methods This observer- …

[PDF] Factors influencing women’s intentions to obtain the Human Papillomavirus (HPV) vaccine
B Ebertz, M Sjöberg, AT Bengtsson – 2013
Abstract Background: Cervical cancer is second most common cancer in women. The 15%
incidence of cervical cancer in women worldwide can potentially be reduced by the vaccine
against human papillomavirus (HPV). It is therefore important for all healthcare …

The Private Sector in the New Global Development Agenda

Accessed 3 August 2013

The Private Sector in the New Global Development Agenda
Kemal Derviş, Strobe Talbott and Richard C. Blum | July 31, 2013 10:33am

This weekend, global leaders, entrepreneurs, practitioners and public intellectuals will come together at the Brookings Blum Roundtable to discuss innovative ideas and advance groundbreaking initiatives to alleviate global poverty. This year marks the roundtable’s 10th anniversary and a time when the prospects for eradicating extreme poverty are arguably the best they have ever been…

Can collaboration resuscitate global health funding?

The Guardian
Accessed 3 August 2013

Can collaboration resuscitate global health funding?, 31 Jul 2013
Anurag Mairal

  As support for global health projects declines, governments, NGOs and the private sector will have to be creative and commit to collaboration, argues Anurag Mairal
A golden era of funding for global health has ended. After rising threefold during the first decade of the twenty-first century, development assistance for health has plateaued.

Although funding from international donors has catalysed remarkable improvements in health in many countries, the gap between rich and poor remains wide. To further reduce health inequities, we need new approaches that make the most of available resources and I believe public-private partnerships across international borders are key to providing the highest value for money and achieving sustainable impact.

Others share the same view. In an open letter to G8 leaders who met in Northern Ireland in June, global health groups noted that “public-private partnership models supported by our governments have accelerated progress towards the millennium development goals and will have a critical role in the post-2015 development agenda.”

At Path, the US-based nongovernmental organisation where I work, our mantra is to always begin with the end in mind. In 35 years of developing and delivering high-impact, cost-effective health technologies for developing countries, we have found that both public- and private-sector partners are essential to effectively and efficiently drive lifesaving innovations to scale…

Washington Post Editorial: A setback on polio [Somalia, Kenya]

Washington Post
Accessed 3 August 2013

The Post’s View
A setback on polio
By Editorial Board, Published: July 29

ONLY A few months ago, there was great optimism that polio was on the verge of eradication. The world saw only 223 cases in 2012, the lowest level in history, and the Global Polio Eradication Initiative, an umbrella group, unveiled a major strategy to wipe out the disease over the next five years.

Those hopes now seem clouded by a poliovirus outbreak in Somalia and Kenya. This year, there have been 81 cases in these two countries, more than the 59 cases in the three countries where polio remains endemic: Afghanistan, Pakistan and Nigeria. The first case in this outbreak, on April 30, was a 4-month-old girl who developed symptoms of acute paralysis in Dadaab, Kenya — the site of a major refugee camp, with 500,000 people, near the Somali border; within days, a case was confirmed in neighboring Somalia, according to the World Health Organization (WHO).

Polio is a highly contagious disease that affects the nervous system and can lead to paralysis, largely among children age 5 and younger. It spreads rapidly.

The WHO has warned that the “risk to neighboring countries is deemed very high, due to large-scale population movements across the Horn of Africa and persistent immunity gaps in some areas.” The worry about immunity gaps is serious. Vaccination is the most critical tool in the battle against polio, and oral vaccines are much improved, but some 500,000 children in Somalia have not been vaccinated in several years, if at all. These vulnerable children are in areas largely outside the control of Somalia’s weak central government, and the fear is these regions could become a cauldron for poliovirus, fueling the outbreak for a long time. Health workers simply can’t reach them.

In hopes of containing the virus, road posts are being set up along major corridors to vaccinate those going and coming from the remote areas, while fresh vaccination campaigns are targeting Mogadishu, the Somali capital.

The latest outbreak underscores how armed conflicts threaten populations not only with bullets but also with disease. In Pakistan, polio has maintained a stubborn foothold in areas roiled by violence, including the assassination of polio vaccination workers by militants. Fortunately, in Somalia there does not appear to be resistance to vaccination, just an inability to extend it to those in need.

This is not the first outbreak of its kind. When vaccination was suspended in Nigeria in 2003, the virus spread across the continent, including into the Horn of Africa, and eventually into Yemen, resulting in some 700 cases. Lessons learned from that experience are being deployed in battling the current outbreak, and it is not likely to derail the global campaign for eradication. But the virus is demonstrating a dogged resilience, and it will take enormous determination and hard work to extinguish the latest scourge.