Gates Foundation names Keith Klugman as Director, Pneumonia Program

   The Bill & Melinda Gates Foundation announced that Keith Klugman has been named director of its Pneumonia program. Dr. Klugman was previously the William H. Foege Professor of Global Health and Professor of Epidemiology in the Rollins School of Public Health at Emory University, as well as Professor of Medicine in the Division of Infectious Diseases at the Emory School of Medicine. He will continue to serve as Honorary Professor in the Respiratory and Meningeal Pathogens Research Unit at the University of the Witwatersrand in South Africa. Klugman has chaired or served on numerous expert committees for the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC). He trained in South Africa and completed his post-doctoral research at Rockefeller University in New York.

http://www.gatesfoundation.org/Media-Center/Press-Releases/2013/08/Klugman

IAVI announces appointment of Dr. Robin Weiss as Chair, Scientific Advisory Committee

   The International AIDS Vaccine Initiative (IAVI) announced the appointment of Dr. Robin Weiss as Chair of its Scientific Advisory Committee (SAC) effective July 1, 2013, to June 30, 2016. In this capacity, Dr. Weiss will also serve as the SAC representative to the IAVI Board of Directors. Dr. Weiss is Emeritus Professor of Viral Oncology at University College London (UCL) and will be the fourth SAC Chair since IAVI was established in 1996. Margaret McGlynn, President and CEO of IAVI, commented, “We are delighted that Dr. Weiss, a pioneer in HIV research whose laboratory made seminal findings on the pathogenesis of HIV infection, is rejoining IAVI’s Scientific Advisory Committee to serve as its Chairman. In this capacity, Dr. Weiss will lead a newly reconstituted SAC to provide scientific and strategic advice and counsel to IAVI’s research and development efforts aimed at accelerating global efforts in HIV vaccine development.”

Full media release: July 09, 2013 – http://www.iavi.org/Information-Center/Press-Releases/Pages/HIV-Research-Pioneer-Dr-Robin-Weiss-Appointed-Chair-of-IAVI-Scientific-Advisory-Committee.aspx

GPEI Update: Polio this week – As of 10 July 2013

Update: Polio this week – As of 10 July 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s extract and bolded text]
:: In the Horn of Africa, an outbreak of WPV1 is continuing, centred around Banadir, Somalia. The majority of cases associated with this outbreak developed paralysis before the start of the comprehensive emergency outbreak response activities.
:: WPV3 continues to be at the lowest ever recorded levels. Globally, WPV3 has not been detected anywhere since November 2012, from Yobe state, Nigeria. In Asia, the strain the strain has not been detected in over a year (since April 2012, from Khyber Agency in Pakistan)… For more, please click here: http://www.polioeradication.org/Mediaroom/Newsstories/Newsstories2013/tabid/488/iid/290/Default.aspx

Nigeria
:: Nine new WPV cases were reported in the past week, bringing the total number of WPV cases for 2013 to 35. The most recent WPV case had onset of paralysis on 18 June (WPV1 from Bauchi).

Pakistan
:: FATA is the major WPV1 reservoir in Pakistan at the moment. Of 18 WPV1 cases reported in the country in 2013, more than half are from FATA. Bara in Khyber Agency is particularly affected. 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
:: Four new WPV cases were reported in the past week (all from Banadir, Somalia), bringing the total number of WPV1 cases in the region to 52 (45 WPV1s from Somalia and seven WPV1s from Kenya). The most recent case in the region had onset of paralysis on 8 June (from Banadir).

:: Banadir remains the epicentre of the outbreak.

:: Outbreak response across the Horn of Africa continues to be implemented. In Somalia, campaigns were held on 1-6 July. In Kenya, activities were conducted on 3-7 July. In Ethiopia on 5-8 July, and in Yemen the next campaigns are planned for late August.

IOM Report: Health Literacy – Improving Health, Health Systems, and Health Policy Around the World – Workshop Summary

Report: Health Literacy – Improving Health, Health Systems, and Health Policy Around the World – Workshop Summary
July 12, 2013
IOM: Board on Population Health and Public Health Practice

“From the first use of the term health literacy in 1974 – described as “health education meeting minimal standards for all school grade levels” – the definition of health literacy has evolved into a common idea that involves both the need for people to understand information that helps them maintain good health and the need for health systems to reduce their complexity. Since the 1990s, health literacy has taken two different approaches; one oriented to clinical care and the other to public health. The public health approach is more prominent in developing nations, where organizations not only work to improve health for large groups of people but also provide educational opportunities. There are many opportunities for international research collaboration between the United States, European countries, and developing nations.

“In September 2012, the IOM Roundtable on Health Literacy hosted a workshop focused on international health literacy efforts. The workshop featured presentations and discussions about health literacy interventions from various countries as well as other topics related to international health literacy. This document summarizes the workshop.”

http://iom.edu/Reports/2013/Health-Literacy-Improving-Health-Health-Systems-and-Health-Policy-Around-the-World.aspx?utm_medium=etmail&utm_source=Institute%20of%20Medicine&utm_campaign=07.12.13+New+Report+-+Health+Literacy&utm_content=&utm_term

Measles Vaccination Before the Measles-Mumps-Rubella Vaccine

American Journal of Public Health
Volume 103, Issue 8 (August 2013)
http://ajph.aphapublications.org/toc/ajph/current

Measles Vaccination Before the Measles-Mumps-Rubella Vaccine
Jan Hendriks, MSc, and Stuart Blume, PhD, M
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301075

ABSTRACT
At the beginning of the 1960s, it was clear that a vaccine against measles would soon be available. Although measles was (and remains) a killer disease in the developing world, in the United States and Western Europe this was no longer so. Many parents and many medical practitioners considered measles an inevitable stage of a child’s development. Debating the desirability of measles immunization, public health experts reasoned differently. In the United States, introduction of the vaccine fit well with Kennedy’s and Johnson’s administrations’ political commitments. European policymakers proceeded cautiously, concerned about the acceptability of existing vaccination programs. In Sweden and the Netherlands, recent experience in controlling polio led researchers to prefer an inactivated virus vaccine. Although in the early 1970s attempts to develop a sufficiently potent inactivated vaccine were abandoned, we have argued that the debates and initiatives of the time during the vaccine’s early history merit reflection in today’s era of standardization and global markets.

Policies to Reduce Influenza in the Workplace: Impact Assessments Using an Agent-Based Model

American Journal of Public Health
Volume 103, Issue 8 (August 2013)
http://ajph.aphapublications.org/toc/ajph/current

Policies to Reduce Influenza in the Workplace: Impact Assessments Using an Agent-Based Model
Supriya Kumar, PhD, MPH, John J. Grefenstette, PhD, David Galloway, MS, Steven M. Albert, PhD, and Donald S. Burke, MD
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2013.301269

Abstract
Objectives. We examined the impact of access to paid sick days (PSDs) and stay-at-home behavior on the influenza attack rate in workplaces.

Methods. We used an agent-based model of Allegheny County, Pennsylvania, with PSD data from the US Bureau of Labor Statistics, standard influenza epidemic parameters, and the probability of staying home when ill. We compared the influenza attack rate among employees resulting from workplace transmission, focusing on the effects of presenteeism (going to work when ill).

Results. In a simulated influenza epidemic (R0  = 1.4), the attack rate among employees owing to workplace transmission was 11.54%. A large proportion (72.00%) of this attack rate resulted from exposure to employees engaging in presenteeism. Universal PSDs reduced workplace infections by 5.86%. Providing 1 or 2 “flu days”—allowing employees with influenza to stay home—reduced workplace infections by 25.33% and 39.22%, respectively.

Conclusions. PSDs reduce influenza transmission owing to presenteeism and, hence, the burden of influenza illness in workplaces.

Effectiveness of Border Screening for Detecting Influenza in Arriving Airline Travelers

American Journal of Public Health
Volume 103, Issue 8 (August 2013)
http://ajph.aphapublications.org/toc/ajph/current

Effectiveness of Border Screening for Detecting Influenza in Arriving Airline Travelers
Patricia C. Priest, DPhil, MPH, MBChB, Lance C. Jennings, PhD, MSc, BSc, Alasdair R. Duncan, MPH, BSc, Cheryl R. Brunton, MBChB, DipComH, and Michael G. Baker, MBChB, DPH
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.300761

Abstract
Objectives. We measured symptom and influenza prevalence, and the effectiveness of symptom and temperature screening for identifying influenza, in arriving international airline travelers.

Methods. This cross-sectional study collected data from travelers to Christchurch International Airport, New Zealand, in winter 2008, via a health questionnaire, temperature testing, and respiratory sampling.

Results. Forms were returned by 15 976 (68%) travelers. Of these, 17% reported at least 1 influenza symptom, with runny or blocked nose (10%) and cough (8%) most common. Respiratory specimens were obtained from 3769 travelers. Estimated prevalence of influenza was 1.1% (4% among symptomatic, 0.2% among asymptomatic). The sensitivity of screening criteria ranged from 84% for “any symptom” to 3% for a fever of 37.8 °C or greater. The positive predictive value was low for all criteria.

Conclusions. Border screening using self-reported symptoms and temperature testing has limitations for preventing pandemic influenza from entering a country. Using “any symptom” or cough would lead to many uninfected people being investigated, yet some infected people would remain undetected. If more specific criteria such as fever were used, most infected people would enter the country despite screening.

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males

American Journal of Public Health
Volume 103, Issue 8 (August 2013)
http://ajph.aphapublications.org/toc/ajph/current

Longitudinal Predictors of Human Papillomavirus Vaccination Among a National Sample of Adolescent Males
Paul L. Reiter, PhD, Annie-Laurie McRee, DrPH, Jessica K. Pepper, MPH, Melissa B. Gilkey, PhD, Kayoll V. Galbraith, BSN, BA, and Noel T. Brewer, PhD
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301189

Abstract
Objectives. We conducted a longitudinal study to examine human papillomavirus (HPV) vaccine uptake among male adolescents and to identify vaccination predictors.

Methods. In fall 2010 and 2011, a national sample of parents with sons aged 11 to 17 years (n = 327) and their sons (n = 228) completed online surveys. We used logistic regression to identify predictors of HPV vaccination that occurred between baseline and follow-up.

Results. Only 2% of sons had received any doses of HPV vaccine at baseline, with an increase to 8% by follow-up. About 55% of parents who had ever received a doctor’s recommendation to get their sons HPV vaccine did vaccinate between baseline and follow-up, compared with only 1% of parents without a recommendation. Fathers (odds ratio = 0.29; 95% confidence interval = 0.09, 0.80) and non-Hispanic White parents (odds ratio = 0.29; 95% confidence interval = 0.11, 0.76) were less likely to have vaccinated sons. Willingness to get sons HPV vaccine decreased from baseline to follow-up among parents (P < .001) and sons (P = .003).

Conclusions. Vaccination against HPV remained low in our study and willingness to vaccinate may be decreasing. Physician recommendation and education about HPV vaccine for males may be key strategies for improving vaccination.

Prevalence of Anogenital Warts Among Participants in Private Health Plans in the United States, 2003–2010: Potential Impact of Human Papillomavirus Vaccination

American Journal of Public Health
Volume 103, Issue 8 (August 2013)
http://ajph.aphapublications.org/toc/ajph/current

Prevalence of Anogenital Warts Among Participants in Private Health Plans in the United States, 2003–2010: Potential Impact of Human Papillomavirus Vaccination
Elaine W. Flagg, PhD, MS, Robert Schwartz, BS, and Hillard Weinstock, MD, MPH
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2012.301182

Abstract
Objectives. We estimated anogenital wart prevalence from 2003 to 2010 by gender and age group in a large US cohort with private insurance to detect potential decreases among people most likely to be affected by human papillomavirus (HPV) vaccination.

Methods. We restricted health care claims to those from individuals aged 10 to 39 years with continuous insurance within a given year. We derived anogenital wart diagnoses from a diagnosis of condyloma acuminata, or either a less specific viral wart diagnosis or genital wart medication combined with either a benign anogenital neoplasm or destruction or excision of a noncervical anogenital lesion.

Results. Prevalence increased slightly in 2003 to 2006, then significantly declined in 2007 to 2010 among girls aged 15 to 19 years; increased in 2003 to 2007, remained level through 2009, and declined in 2010 among women aged 20 to 24 years; and increased through 2009 but not in 2010 for women aged 25 to 39 years. For males aged 15 to 39 years, prevalence for each 5-year age group increased in 2003 to 2009, but no increases were observed for 2010.

Conclusions. These data indicate reductions in anogenital warts among US females aged 15 to 24 years, the age group most likely to be affected by introduction of the HPV vaccine.

Reasons for and against receiving influenza vaccination in a working age population in Japan: a national cross-sectional study

BMC Public Health
(Accessed 13 July 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Reasons for and against receiving influenza vaccination in a working age population in Japan: a national cross-sectional study
Tsubasa Iwasa and Koji Wada
http://www.biomedcentral.com/1471-2458/13/647/abstract

Abstract (provisional)
Background
To improve influenza vaccination coverage in the working age population, it is necessary to understand the current status and awareness of influenza vaccination. This study aimed to determine influenza vaccination coverage in Japan and reasons for receiving the vaccine or not.

Methods
An anonymous internet-based survey was performed in September 2011. Our target study size was 3,000 participants between 20 and 69 years of age, with approximately 300 men and 300 women in each of five age groups (20–29, 30–39, 40–49, 50–59, and 60–69). We asked the history of influenza vaccine uptake in the previous year, and reasons for having vaccination or not.

Results
There were 3,129 respondents, of whom 24.2% of males and 27.6% of females received influenza vaccination between October 2010 and March 2011. Among those who were vaccinated, the main reasons for receiving the influenza vaccine were “Wanted to avoid becoming infected with influenza virus” (males: 84.0%; females: 82.6%) and “Even if infected with influenza, wanted to prevent the symptoms from becoming serious” (males: 60.7%; females: 66.4%). Among those not vaccinated, the most frequent reasons for not receiving the influenza vaccine included “No time to visit a medical institution” (males: 32.0%; females: 22.4%) and “Unlikely to become infected with influenza” (males: 25.1%; females: 22.7%).

Conclusions
The reasons for receiving the influenza vaccine varied between age groups and between sexes. To heighten awareness of influenza vaccination among unvaccinated working age participants, different intervention approaches according to sex and age group may be necessary.

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

Debate: Towards the eradication of HPV infection through universal specific vaccination

BMC Public Health
(Accessed 13 July 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Debate
Towards the eradication of HPV infection through universal specific vaccination
Piergiorgio Crosignani, Antonella De Stefani, Gaetano Maria Fara, Andrea M Isidori, Andrea Lenzi, Carlo Antonio Liverani, Alberto Lombardi, Francesco Saverio Mennini, Giorgio Palu¿, Sergio Pecorelli, Andrea P Peracino, Carlo Signorelli and Gian Vincenzo Zuccotti
http://www.biomedcentral.com/1471-2458/13/642/abstract

Abstract (provisional)
Background
The Human Papillomavirus (HPV) is generally recognized to be the direct cause of cervical cancer. The development of effective anti-HPV vaccines, included in the portfolio of recommended vaccinations for any given community, led to the consolidation in many countries of immunization programs to prevent HPV-related cervical cancers. In recent years, increasing evidence in epidemiology and molecular biology have supported the oncogenic role of HPV in the development of other neoplasm including condylomas and penile, anal, vulvar, vaginal, and oro-pharyngeal cancers. Men play a key role in the paradigm of HPV infection: both as patients and as part of the mechanisms of transmission. Data show they are affected almost as often as women. Moreover, no screening procedures for HPV-related disease prevention are applied in men, who fail to undergo routine medical testing by any medical specialist at all. They also do not benefit from government prevention strategies.

Discussion
A panel of experts convened to focus on scientific, medical, and economic studies, and on the achievements from health organizations’ intervention programs on the matter. One of the goals was to discuss on the critical issues emerging from the ongoing global implementation of HPV vaccination. A second goal was to identify contributions which could overcome the barriers that impede or delay effective vaccination programs whose purpose is to eradicate the HPV infection both in women and men.

Summary
The reviewed studies on the natural history of HPV infection and related diseases in women and men, the increasing experience of HPV vaccination in women, the analysis of clinical effectiveness vs economic efficacy of HPV vaccination, are even more supportive of the economic sustainability of vaccination programs both in women and men. Those achievements address increasing and needed attention to the issue of social equity in healthcare for both genders.

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

Social equity in Human Papillomavirus vaccination: a natural experiment in Calgary Canada

BMC Public Health
(Accessed 13 July 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Social equity in Human Papillomavirus vaccination: a natural experiment in Calgary Canada
Richard Musto1,2*, Jodi E Siever1, J C Johnston1,2, Judy Seidel1,2, M S Rose3 and Deborah A McNeil1,4
http://www.biomedcentral.com/1471-2458/13/640/abstract

Abstract
Background
The Alberta Immunization Program offers a vaccine against the Human Papillomavirus (HPV) free of charge to all girls in Grades 5 and 9. The vaccine is provided in two different service delivery models depending upon the acceptance of the program by the local school board. Vaccinations may be provided “in-school” or in “community” through appointments at Public Health Clinics. The purpose of this study was to determine whether there was a difference in vaccine uptake in Calgary between the two service delivery models, “in-school” and “community”, and to examine if socioeconomic status (SES) was a contributing factor.

Methods
Individual data from the Calgary Zone Public Health vaccination database for all grade 5 and 9 girls in Calgary for school years 2008–2011 were analyzed using descriptive statistics. These data included vaccination records for 35,592 girls. Logistic regression was used to examine the effect of delivery system and SES status on being vaccinated, controlling for school type.

Results
HPV vaccination completion rates were 75% (95% confidence interval = 74.7%, 75.8%) for girls with an “in-school” compared to 36% (95% confidence interval = 35.3%, 37.2%) for girls in schools with a “community” service delivery model. A girl’s neighbourhood SES was related to the likelihood of being HPV vaccinated depending on the service delivery model available to her. For girls attending a Public school with an “in-school” delivery model, the proportion completing vaccination increased as SES decreased (high SES = 79%; medium SES = 79%; low SES = 83%; p-value<0.001). For girls attending Calgary Catholic School District schools with the “community” delivery model there was a decrease in immunization rates from high and mid to low SES (high SES = 41%; medium SES = 42%; low SES = 34%; p-value<0.001). These results show that those with lower SES were differentially disadvantaged by not having access to an “in-school” vaccination delivery model.

Conclusion
Service delivery models make a difference in HPV vaccination completion rates and create inequities for health protection and disease prevention based on socioeconomic status.

Detection of mild to moderate influenza A/H7N9 infection by China’s national sentinel surveillance system for influenza-like illness: case series

British Medical Journal
13 July 2013 (Vol 347, Issue 7916)
http://www.bmj.com/content/347/7916

Research
Detection of mild to moderate influenza A/H7N9 infection by China’s national sentinel surveillance system for influenza-like illness: case series
Dennis KM Ip, clinical assistant professor1, Qiaohong Liao, public health officer 2, Peng Wu, post doctorate fellow1, Zhancheng Gao, professor and respiratory physician3, Bin Cao, professor and infectious disease physician4, Luzhao Feng, public health officer2, Xiaoling Xu, respiratory physician5, Hui Jiang, public health officer2, Ming Li, public health officer2, Jing Bao, respiratory physician3, Jiandong Zheng, public health officer2, Qian Zhang, public health officer2, Zhaorui Chang, public health officer2, Yu Li, public health officer2, Jianxing Yu, public health officer2, Fengfeng Liu, public health officer2, Michael Y Ni, clinical assistant professor1, Joseph T Wu, associate professor1, Benjamin J Cowling, associate professor1, Weizhong Yang, medical epidemiologist and deputy director6, Gabriel M Leung, professor1, Hongjie Yu, medical epidemiologist and director2
http://www.bmj.com/content/346/bmj.f3693

Abstract
Objective  To characterise the complete case series of influenza A/H7N9 infections as of 27 May 2013, detected by China’s national sentinel surveillance system for influenza-like illness.

Design  Case series.

Setting  Outpatient clinics and emergency departments of 554 sentinel hospitals across 31 provinces in mainland China.

Cases  Infected individuals were identified through cross-referencing people who had laboratory confirmed A/H7N9 infection with people detected by the sentinel surveillance system for influenza-like illness, where patients meeting the World Health Organization’s definition of influenza-like illness undergo weekly surveillance, and 10-15 nasopharyngeal swabs are collected each week from a subset of patients with influenza-like illness in each hospital for virological testing. We extracted relevant epidemiological data from public health investigations by the Centers for Disease Control and Prevention at the local, provincial, and national level; and clinical and laboratory data from chart review.

Main outcome measure  Epidemiological, clinical, and laboratory profiles of the case series.

Results  Of 130 people with laboratory confirmed A/H7N9 infection as of 27 May 2013, five (4%) were detected through the sentinel surveillance system for influenza-like illness. Mean age was 13 years (range 2-26), and none had any underlying medical conditions. Exposure history, geographical location, and timing of symptom onset of these five patients were otherwise similar to the general cohort of laboratory confirmed cases so far. Only two of the five patients needed hospitalisation, and all five had mild or moderate disease with an uneventful course of recovery.

Conclusion  Our findings support the existence of a “clinical iceberg” phenomenon in influenza A/H7N9 infections, and reinforce the need for vigilance to the diverse presentation that can be associated with A/H7N9 infection. At the public health level, indirect evidence suggests a substantial proportion of mild disease in A/H7N9 infections.

Brazil’s Conditional Cash Transfer Program Associated With Declines In Infant Mortality Rates

Health Affairs
July 2013; Volume 32, Issue 7
http://content.healthaffairs.org/content/current
Theme: States, Medicaid & Countdown To Reform

Brazil’s Conditional Cash Transfer Program Associated With Declines In Infant Mortality Rates
Amie Shei1]
http://content.healthaffairs.org/content/32/7/1274.abstract

Abstract
Conditional cash transfer programs are innovative social safety-net programs that aim to relieve poverty. They provide a regular source of income to poor families and are “conditional” in that they require poor families to invest in the health and education of their children through greater use of educational and preventive health services. Brazil’s Bolsa Família conditional cash transfer program, created in 2003, is the world’s largest program of its kind. During the first five years of the program, it was associated with a significant 9.3 percent reduction in overall infant mortality rates, with greater declines in postneonatal mortality rates than in mortality rates at an earlier age and in municipalities with many users of Brazil’s Family Health Program than in those with lower use rates. There were also larger effects in municipalities with higher infant mortality rates at baseline. Programs like Bolsa Família can improve child health and reduce long-standing health inequalities. Policy makers should review the adequacy of basic health services to ensure that the services can respond to the increased demand created by such programs. Programs should also target vulnerable groups at greatest risk and include careful monitoring and evaluation.

Exempting Schoolchildren From Immunizations: States With Few Barriers Had Highest Rates Of Nonmedical Exemptions

Health Affairs
July 2013; Volume 32, Issue 7
http://content.healthaffairs.org/content/current
Theme: States, Medicaid & Countdown To Reform

Exempting Schoolchildren From Immunizations: States With Few Barriers Had Highest Rates Of Nonmedical Exemptions
Nina R. Blank1,*, Arthur L. Caplan2 and Catherine Constable3
http://content.healthaffairs.org/content/32/7/1282.abstract

Abstract
Rates of nonmedical exemptions from school immunizations are increasing and have been associated with resurfacing clusters of vaccine-preventable diseases, such as measles. Historically, state-level school immunization policies successfully suppressed such diseases. We examined state immunization exemption regulations across the United States. We assessed procedures for exempting schoolchildren and whether exemption rates were associated with the complexity of the procedures. We also analyzed legal definitions of religious objections and state legislatures’ recent modifications to exemption policies. We found that states with simpler immunization exemption procedures had nonmedical exemption rates that were more than twice as high as those in states with more-complex procedures. We also found that the stringency of legal definitions of religious exemptions was not associated with exemption procedure complexity. Finally, we found that although there were more attempts by state legislatures to broaden exemptions than to tighten them in 2011–13, only bills tightening exemptions passed. Policy makers seeking to control exemption rates to achieve public health goals should consider tightening nonmedical exemption procedures and should add vaccine education components to the procedures by either mandating or encouraging yearly educational sessions in schools for parents reluctant to have their children vaccinated.

In Memoriam: Hilary Koprowski, 1916–2013 [by Stanley Plotkin]

Journal of Virology
August 2013, volume 87, issue 15
http://jvi.asm.org/content/current

In Memoriam: Hilary Koprowski, 1916–2013
Stanley A. Plotkin
+ Author Affiliations
University of Pennsylvania, Philadelphia, Pennsylvania, USA

Koprowski, who died this year at the age of 96, was an extraordinary person. He excelled as an innovative scientist, a director of a research institute, a classical pianist, a composer of music, a connoisseur of art, and a polyglot world traveler. Born in Warsaw, Poland, where he obtained a medical degree, the Nazi invasion forced him and his wife, Irena, to flee to Italy, where he studied piano at the Accademia Nazionale di Santa Cecilia in Rome. During the Second World War, he managed to emigrate to Brazil, where he became a research assistant in the Rockefeller Foundation Laboratories. There, his work on yellow fever and several arboviruses so impressed the senior staff that a position was found for him at the Lederle Laboratories in Pearl River, New York. At Lederle, he began work leading to improved rabies vaccines and on attenuation of polio virus, the work for which he will be most remembered.

In the early 1950s, there was pessimism about the development of a polio vaccine subsequent to disastrous clinical trials of two experimental vaccines. Koprowski set out to attenuate the virus through adaptation to mouse brain. Starting with what later was identified as a type 2 strain, he achieved attenuation of neurovirulence in monkeys. After ingesting the orally administered vaccine himself, he arranged to vaccinate 20 mentally disabled children in collaboration with the physician in charge of the institution in which they resided, although it is said that his superiors at Lederle were unaware of this step. The ethical justification was the fear of poliovirus entering the institution, a common occurrence at the time. Although this first trial showed safety and immunogenicity of the strain, the presentation of the results at a later scientific meeting was greeted with shock because of the audacity of the work (1).

In the mid-1950s, cell culture became available, and Koprowski and Albert Sabin separately began to attenuate polioviruses by passage in monkey kidney cells. Both succeeded, and the Koprowski strains were tested extensively in the former Belgian Congo, his native Poland, and elsewhere (2). Nevertheless, because the Sabin strains were less neurovirulent in monkeys and were given successfully to millions of children in the former Soviet Union, they achieved licensure in the United States and adoption by the WHO for use throughout the world. During the battle between the oral polio vaccines, the atmosphere between Sabin and Koprowski became quite heated, with many colorful exchanges of insults, but afterwards they reestablished a friendship.

In 1957, Koprowski left Lederle to become Director of the Wistar Institute on the campus of the University of Pennsylvania in Philadelphia, a position he held for 35 years. The Wistar, established in 1892, was somewhat sleepy when he arrived, but he proceeded to convert it into a flourishing institution where there were no departments or walls between laboratories and where both fundamental and applied biology were at the leading edge. I also arrived in 1957, and like many others, I consider him to be my scientific father. Although the emphasis at Wistar was on virology and cancer, other areas, such as atherosclerosis, were investigated. The Wistar was a marvelous place to work in those years because of the international scientists Koprowski recruited and the stimulating atmosphere that he fostered. The lingua franca of Wistar was said to be broken English.

After losing the battle with Sabin over the polio vaccine, Koprowski switched to studies of fusion between somatic cells and eggs, subacute sclerosing encephalitis caused by measles, and “slow” viruses in the central nervous system (3, 4, 5). In that period, his laboratory also adapted rabies virus to human diploid cell culture, leading to a new and highly immunogenic rabies vaccine for humans (6). The gene for the rabies glycoprotein was also inserted into poxvirus vectors for immunization of wild animals, a technique that has successfully controlled wildlife rabies in parts of the world. It is no exaggeration to say that not since Pasteur had one person made more progress in preventing rabies than Koprowski. In addition, while Koprowski was director of Wistar, vaccines were also developed against rubella and rotaviruses.

A curious late sequel of polio vaccination in the Belgian Congo between 1957 and 1960 was the accusation in the late 1990s by certain journalists that Koprowski’s experimental vaccine had been made in chimpanzee cells contaminated by a simian immunodeficiency virus (SIV) that mutated to human immunodeficiency virus (HIV) and thus had introduced the virus into humans. Characteristically, Koprowski rejected the accusation with disdain, but in any case the accusation was refuted by a search of historical records, PCR of the supposed contaminated lot, and studies of SIV and HIV sequences and evolution which showed that HIV entered humans from wild chimpanzees early in the 20th century (7). Nevertheless, setting the matter to rest required international meetings and considerable work by his colleagues (8).

Koprowski’s scope in virology was breathtaking: his bibliography includes articles on at least 25 different viruses, including polio virus, rabies virus, simian virus 40 (SV40), parainfluenza virus type 1, herpes simplex virus, and many flaviviruses. His publication record includes over 900 articles.

When the technology to make monoclonal antibodies became available in the late 1970s, Koprowski founded the Centocor biotechnology company to make antibodies that could be used practically to treat viral infections and cancer. Late in his career, Koprowski set up the Biomedical Foundation to channel research toward making vaccine antigens in plants. Despite his age, he was actively promoting this field until the last year of his life.

Naturally, Koprowski received many awards in his lifetime, locally in the United States but also from Poland, France, Belgium, and Finland. He was a member of the National Academy of Sciences.

However, this recounting of his life does not fully convey the combination of charm, brilliance, and roguishness that struck anyone who came into contact with Hilary. He could converse in many languages about science, art, or music and had a sense of humor that included playing practical jokes. His piano concerts at Wistar and compositions, including short stories, plays, and an opera, were legendary. For his 70th birthday party, he came disguised as a disgruntled gentleman who was angry at the director of the Wistar Institute. Hilary could be an enfant terrible, but he was never boring, always full of ideas, and always stimulating. He left no one who met him unmoved, and none of us, friend or critic, will see his like again.

References available here: http://jvi.asm.org/content/87/15/8270.full

Comment: Timely estimates of influenza A H7N9 infection severity [Articles]

The Lancet  
Jul 13, 2013  Volume 382  Number 9887  p101 – 180
http://www.thelancet.com/journals/lancet/issue/current

Comment
Timely estimates of influenza A H7N9 infection severity
Cécile Viboud, Lone Simonsen
Preview |
WHO guidance, released in May, 2013, established that estimates of disease severity are key for risk assessment of novel influenza viruses.1 Unfortunately, epidemiological assessment of severity is difficult in the context of an emerging disease, when estimates are most needed to guide pandemic response. The case fatality risk is an estimate of the proportion of patients with a specific disease who have died; however, both the numerator and denominator of this estimator are elusive.2–4 Case detection is typically skewed towards patients with severe disease; laboratory-based case ascertainment can vary geographically and temporally; and there are delays between onset, death, and reporting, potentially leading to overestimation or underestimation of fatality risk.

Comparative epidemiology of human infections with avian influenza A H7N9 and H5N1 viruses in China: a population-based study of laboratory-confirmed cases
Benjamin J Cowling, Lianmei Jin, Eric HY Lau, Qiaohong Liao, Peng Wu, Hui Jiang, Tim K Tsang, Jiandong Zheng, Vicky J Fang, Zhaorui Chang, Michael Y Ni, Qian Zhang, Dennis KM Ip, Jianxing Yu, Yu Li, Liping Wang, Wenxiao Tu, Ling Meng, Joseph T Wu, Huiming Luo, Qun Li, Yuelong Shu, Zhongjie Li, Zijian Feng, Weizhong Yang, Yu Wang, Gabriel M Leung, Hongjie Yu
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961171-X/abstract
Preview |
The sex ratios in urban compared with rural cases are consistent with exposure to poultry driving the risk of infection—a higher risk in men was only recorded in urban areas but not in rural areas, and the increased risk for men was of a similar magnitude for H7N9 and H5N1. However, the difference in susceptibility to serious illness with the two different viruses remains unexplained, since most cases of H7N9 were in older adults whereas most cases of H5N1 were in younger people. A limitation of our study is that we compared laboratory-confirmed cases of H7N9 and H5N1 infection, and some infections might not have been ascertained.

Human infection with avian influenza A H7N9 virus: an assessment of clinical severity
Hongjie Yu, Benjamin J Cowling, Luzhao Feng, Eric HY Lau, Qiaohong Liao, Tim K Tsang, Zhibin Peng, Peng Wu, Fengfeng Liu, Vicky J Fang, Honglong Zhang, Ming Li, Lingjia Zeng, Zhen Xu, Zhongjie Li, Huiming Luo, Qun Li, Zijian Feng, Bin Cao, Weizhong Yang, Joseph T Wu, Yu Wang, Gabriel M Leung
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961207-6/abstract
Preview |
Human infections with avian influenza A H7N9 virus seem to be less serious than has been previously reported. Many mild cases might already have occurred. Continued vigilance and sustained intensive control efforts are needed to minimise the risk of human infection.

Editorial: A brighter future in the fight against hepatitis Article: Current progress in development of hepatitis C virus vaccines

Nature Medicine
July 2013, Volume 19 No 7 pp791-945
http://www.nature.com/nm/journal/v19/n7/index.html

Editorial
A brighter future in the fight against hepatitis
doi:10.1038/nm.3269

Public health and research efforts directed at managing and targeting viral hepatitis have borne fruit in recent decades. However, more work is necessary to meet the goals of preventing transmission and treating infection to eliminate the enormous burden of hepatitis worldwide.

In 2012, the World Health Organization (WHO) established a Global Hepatitis Program with the goal of fully preventing and treating viral hepatitis. This month, the WHO hopes to increase public awareness through the official World Hepatitis Day, on 28 July. In this issue, Nature Medicine features a series of Review and Perspective articles that discuss promising research and clinical efforts and continuing challenges in viral hepatitis.

Hepatitis B virus (HBV) and HCV are primarily responsible for the high global prevalence of hepatitis disease and for the morbidity and mortality associated with chronic infection. A key challenge for the management of hepatitis is its silent progression, as acute hepatic failure rarely occurs. Infection is often asymptomatic, causing liver scarring and damage decades later in up to 30% of people infected with HCV, and the proportion is even higher in those infected with HBV at birth or during early childhood. Inadequate recognition of infection and region-specific variation in prevalence and risk groups hinders diagnosis and precludes timely treatment. The lack of sufficiently widespread antibody screening to identify all exposed individuals and of follow up with RNA testing, a technique not yet available for routine medical use, to distinguish people with active virus, results in incorrect estimates of infection and increased transmission. In the case of hepatitis C, recent human studies showed that less than half of the infected people in the United States knew they carried the virus (Hepatology 55, 1652–1661, 2012), a number that may be higher in areas with limited disease-control tools. Moreover, the harsh side effects of pegylated interferon-α and ribavirin force many infected people to opt out of this standard therapy, contributing to viral persistence in the community and prevalence of chronic disease.

The advent of effective antivirals is changing the therapeutic landscape, and the goal for eradicating hepatitis viruses may not be as distant as it seemed five years ago, high treatment costs notwithstanding. Current antiviral therapies do not cure chronic hepatitis B, which affects about 210 million people worldwide. At the 2013 International Liver Congress, new approaches to eliminate the HBV replication template, which persists inside liver cells, by modulating host processes such as epigenetic mechanisms and hepatocyte regeneration showed promise and may offer the potential of a cure in the future. For HCV, which affects about 150 million individuals worldwide, there have been rapid advances in drugs. Two protease inhibitors approved in 2011 greatly improved responses in patients infected with the predominant genotype 1; however, host genetic variability affecting antiviral efficacy, evolving drug resistance and the lack of coverage to inhibit all existing HCV genotypes are major drawbacks. Also, these new drugs must be given with the standard therapy, which exacerbates side effects. Second-generation antivirals with different viral targets are under development, and combination strategies should improve efficacy and may even eradicate the virus. Although these therapies are promising, resistance may still develop, and monitoring the emergence of resistant variants will be necessary for guiding treatment choices.

An interferon-free therapy for hepatitis C may also soon exist. In April, a triple combination of direct-acting antivirals without interferon showed efficacy in treatment-naive individuals and in nonresponders to standard of care. And in May, four clinical trials tested an inhibitor of viral polymerase, sofosbuvir, in patients infected with HCV (N. Engl. J. Med. 368, 1867–1887, 2013). In combination with ribavirin, sofosbuvir showed increased efficacy against genotypes 2 and 3 compared to both standard of care and placebo, and adding pegylated interferon alpha-2a to the combination achieved broad genotype coverage. Patients with unacceptable side effects to standard therapy or who were unresponsive to previous therapies may therefore benefit from these new approaches. Research on host factors required for the HCV life cycle has also yielded targets that may overcome virus-acquired resistance and circumvent side effects. A recent example is the targeting of microRNA-122, which is liver specific and necessary for viral replication (N. Engl. J. Med. 368, 1685–1694, 2013) Although long-term studies are necessary to address their safety and toxicity in the long run, interferon-free strategies may become the future of hepatitis C therapy.

But the holy grail for eradicating and decreasing the burden of any infectious disease is a prophylactic vaccine. Prevention of infection with the effective HBV vaccines and with improved medical and lifestyle practices has reached impressive levels in developed countries, and continuing efforts to improve testing and implement mass vaccination programs in low-income countries should achieve similar results in these regions. A working vaccine for HCV, however, still remains elusive, in part because of the lack of experimental systems to study the virus and the lack of animal models to test vaccine candidates. Moreover, because this virus has developed mechanisms of persistence and has an enormous genetic diversity, vaccines will need to induce both neutralizing antibodies and T cell–mediated responses to achieve broad, lasting cross-protection. Unraveling how the host immune response clears the virus during the course of natural infection and prevents persistence will help us understand what constitutes protective immunity and provide a rationale to develop an effective pan-genotype vaccine.

The goals of preventing infection, slowing disease progression and curing chronic hepatitis will undoubtedly require continuing research and clinical efforts. Pharmaceutical companies should be encouraged to keep investigating future compounds to overcome the existing therapeutic barriers, and public awareness efforts should be intensified to underscore to funding and public health agencies that, although we are closer, we are still far from achieving the goals proposed to tackle these silent elusive killers.
http://www.nature.com/nm/journal/v19/n7/full/nm.3269.html

Current progress in development of hepatitis C virus vaccines – pp869 – 878
T Jake Liang
doi:10.1038/nm.3183
Ongoing investigational studies aim to uncover new strategies to develop an effective vaccine to prevent hepatitis C infection. Advances have moved forward vaccine candidates, but technical and biological barriers posed by the virus still exist. This Review discusses how to better design vaccine trials and evaluate key components of protective immunity to achieve a working preventive vaccine.
Abstract – | Full Text – Current progress in development of hepatitis C virus vaccines | PDF (1,514 KB)

U.S. Hospitalizations for Pneumonia after a Decade of Pneumococcal Vaccination

New England Journal of Medicine
July 11, 2013  Vol. 369 No. 2
http://www.nejm.org/toc/nejm/medical-journal

Original Article
U.S. Hospitalizations for Pneumonia after a Decade of Pneumococcal Vaccination
Marie R. Griffin, M.D., M.P.H., Yuwei Zhu, M.D., Matthew R. Moore, M.D., M.P.H., Cynthia G. Whitney, M.D., M.P.H., and Carlos G. Grijalva, M.D., M.P.H.
N Engl J Med 2013; 369:155-163July 11, 2013DOI: 10.1056/NEJMoa1209165
http://www.nejm.org/doi/full/10.1056/NEJMoa1209165

Background
The introduction of 7-valent pneumococcal conjugate vaccine (PCV7) into the U.S. childhood immunization schedule in 2000 has substantially reduced the incidence of vaccine-serotype invasive pneumococcal disease in young children and in unvaccinated older children and adults. By 2004, hospitalizations associated with pneumonia from any cause had also declined markedly among young children. Because of concerns about increases in disease caused by nonvaccine serotypes, we wanted to determine whether the reduction in pneumonia-related hospitalizations among young children had been sustained through 2009 and whether such hospitalizations in older age groups had also declined.

Methods
We estimated annual rates of hospitalization for pneumonia from any cause using the Nationwide Inpatient Sample database. The reason for hospitalization was classified as pneumonia if pneumonia was the first listed diagnosis or if it was listed after a first diagnosis of sepsis, meningitis, or empyema. Average annual rates of pneumonia-related hospitalizations from 1997 through 1999 (before the introduction of PCV7) and from 2007 through 2009 (well after its introduction) were used to estimate annual declines in hospitalizations due to pneumonia.

Results
The annual rate of hospitalization for pneumonia among children younger than 2 years of age declined by 551.1 per 100,000 children (95% confidence interval [CI], 445.1 to 657.1), which translates to 47,000 fewer hospitalizations annually than expected on the basis of the rates before PCV7 was introduced. The rate for adults 85 years of age or older declined by 1300.8 per 100,000 (95% CI, 984.0 to 1617.6), which translates to 73,000 fewer hospitalizations annually. For the three age groups of 18 to 39 years, 65 to 74 years, and 75 to 84 years, the annual rate of hospitalization for pneumonia declined by 8.4 per 100,000 (95% CI, 0.6 to 16.2), 85.3 per 100,000 (95% CI, 7.0 to 163.6), and 359.8 per 100,000 (95% CI, 199.6 to 520.0), respectively. Overall, we estimated an age-adjusted annual reduction of 54.8 per 100,000 (95% CI, 41.0 to 68.5), or 168,000 fewer hospitalizations for pneumonia annually.

Conclusions
Declines in hospitalizations for childhood pneumonia were sustained during the decade after the introduction of PCV7. Substantial reductions in hospitalizations for pneumonia among adults were also observed. (Funded by the Centers for Disease Control and Prevention.)

Policy Forum: A Comparison of Frameworks Evaluating Evidence for Global Health Interventions

PLoS Medicine
(Accessed 13 July 2013)
http://www.plosmedicine.org/

Policy Forum
A Comparison of Frameworks Evaluating Evidence for Global Health Interventions
Jill Luoto, Margaret A. Maglione, Breanne Johnsen, Christine Chang, Elizabeth S. Higgs, Tanja Perry, Paul G. Shekelle
PLoS Med 10(7): e1001469. doi:10.1371/journal.pmed.1001469
Published: July 9, 2013

Summary Points
:: Evidence-based decision-making is critical to informing policy in global health interventions and programs.

:: Existing frameworks for evaluating evidence that were developed or recommended for community or public health decision-making vary in their criteria and application.

:: We compared how different community or public health evidence frameworks assessed the same body of evidence for three advocated global health interventions and find there can be substantial differences in the rating of evidence, which could contribute to differences in policy recommendations.

:: All current frameworks emphasize effectiveness, and have shortcomings on other important factors into policy decision-making such as costs, implementation issues, context, and sustainability.

:: As global health policymakers move towards evidence-based approaches, we find a gap between what is currently available and the needs for an evidence framework appropriate for application to a global health setting in a low- and middle-income country context. More work is needed to either adapt one or more existing frameworks, or to develop an entirely new framework to meet the needs of policymakers and others responsible for implementing global health interventions.

Introduction
A major movement in global health and development in the past 10 years has been the enthusiastic adoption by many of randomized controlled trials (RCTs) from the field of medicine to represent the most rigorous method to evaluate a program’s causal impact [1][4]. More recently, this movement has brought about a conceptual debate in global health and development about the proper role for RCTs in informing policy, with increasing efforts to “mind the gap” [5] between the evidence generated by RCTs (which focus on internal consistency) and the larger policy questions at the level of communities or populations (which require, among other things, generalizability) [4],[6][10]. The field of medicine that developed the RCT also developed the concept of “evidence-based” medicine that aims to improve health policy decision making by encouraging policymakers to base their policies on the best available evidence. Large international policy-making bodies appear set on applying a similar concept to global health and health systems research [4],[11]. In order to be evidence-based, decisions about global health interventions must consider the available evidence in terms of its quantity, quality, and relevance. Rather than use implicit judgment or other ad hoc methods, in evidence-based medicine it is now advocated and common practice to use a formal framework for considering the evidence as part of a systematic review, the advantages of which include increased transparency and better decision-making. Formal frameworks for evaluating evidence about community-level public health interventions have been proposed and advocated for similar reasons [12][17]. These frameworks differ in the degree to which they weight the importance of data from RCTs as compared to data from other study designs, the magnitude of potential benefits and harms, the role of context and implementation, and other factors. At present, there are no commonly accepted guidelines within global public health for how to evaluate evidence, and there is scant evidence to guide policymakers when selecting a framework to use for assessing a body of evidence about a global health intervention. We sought to assess how summary conclusions about the evidence for interventions or programs currently in use or proposed for wide adoption could be influenced by the choice of framework. Consistent results across frameworks would increase policymakers’ confidence in using and applying evidence frameworks, and may thereby help to narrow the gap between the questions asked by global health researchers and policymakers. Inconsistent results would call for a re-examination of current frameworks in terms of the domains they assess and the ways in which they are applied.

From Google Scholar+ [to 13 July 2013]

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

H7N9 Avian Influenza A Virus and the Perpetual Challenge of Potential Human Pandemicity
David M. Morensa, Jeffery K. Taubenbergerb, Anthony S. Faucia
mBio 4(4):e00445-13. doi:10.1128/mBio.00445-13.
Published 9 July 2013
http://mbio.asm.org/content/4/4/e00445-13
ABSTRACT
The ongoing H7N9 influenza epizootic in China once again presents us questions about the origin of pandemics and how to recognize them in early stages of development. Over the past ~135 years, H7 influenza viruses have neither caused pandemics nor been recognized as having undergone human adaptation. Yet several unusual properties of these viruses, including their poultry epizootic potential, mammalian adaptation, and atypical clinical syndromes in rarely infected humans, suggest that they may be different from other avian influenza viruses, thus questioning any assurance that the likelihood of human adaptation is low. At the same time, the H7N9 epizootic provides an opportunity to learn more about the mammalian/human adaptational capabilities of avian influenza viruses and challenges us to integrate virologic and public health research and surveillance at the animal-human interface.

A Comprehensive, Model-Based Review of Vaccine and Repeat Infection Trials for Filariasis
CP Morris, H Evans, SE Larsen, E Mitre – Clinical Microbiology Reviews, 2013
SUMMARY Filarial worms cause highly morbid diseases such as elephantiasis and river blindness. Since the 1940s, researchers have conducted vaccine trials in 27 different animal models of filariasis. Although no vaccine trial in a permissive model of filariasis has …

Vaccine adjuvants: the future is bright
R Rappuoli – Expert Review of Vaccines, 2013
Interview by Jenaid Rees, Commissioning Editor Rino Rappuoli is the Global Head of Vaccines Research at Novartis Vaccines & Diagnostics (Siena, Italy). Previously, he was Head of R&D (Sclavo, Italy), and then Head of Vaccine Research and Chief Scientific …

[PDF] Should acellular pertussis vaccine be recommended to healthcare professionals? A vacina pertússis acelular deve ser recomendada a profissionais de saúde?¿ La …
JC de Moraes, T Carvalhanas, LF Bricks – Cad. Saúde Pública, 2013
Page 1. Cad. Saúde Pública, Rio de Janeiro, 29(7):1277-1290, jul, 2013 Should acellular
pertussis vaccine be recommended to healthcare professionals? A vacina pertússis
acelular deve ser recomendada a profissionais de saúde? …

CURRENT OPINION Immunization in transplantation: review of the recent literature
LF Pittet, KM Posfay-Barbe – Curr Opin Organ Transplant, 2013
… CONCLUSION Despite an increasing number of interesting studies evaluating immunization in SOT patients, many questions remain unanswered and research should continue, aiming at elaborating the best immunization strategies in this vulnerable population. …

Sanofi starts dengue vaccine production to keep lead over riva

Reuters
http://www.reuters.com/
Accessed 13 July 2013

Sanofi starts dengue vaccine production to keep lead over rivals
By Catherine Lagrange
NEUVILLE-SUR-SAONE, France, July 12 | Fri Jul 12, 2013 7:26am EDT
Sanofi SA has started producing its experimental dengue vaccine, the most advanced against the tropical disease, in a move to keep its lead over competitors ahead of the product’s likely launch in 2015…

http://www.reuters.com/article/2013/07/12/sanofi-dengue-vaccine-idUSL6N0FI1O320130712

Opinion: An AIDS-free generation is closer than we might think

Washington Post
http://www.washingtonpost.com/
Accessed 13 July 2013

Opinion
An AIDS-free generation is closer than we might think
By Anthony S. Fauci, Published: July 11
Anthony S. Fauci is director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health.

Because of the extraordinary progress in the fight against HIV/AIDS, we can now consider a question that just a few years ago seemed far-fetched. No longer is it whether we can achieve an AIDS-free generation. Now, the question is: How long will it take and will it be sustained?        Vaccines historically have played an important role in the control and even elimination of global health scourges such as smallpox, polio and measles. So two important questions regarding an AIDS-free generation are: Is an HIV vaccine needed to reach this goal, and if so, what role will it play?

An AIDS-free generation would mean that virtually no child is born with HIV; that, as those children grow up, their risk of becoming infected is far lower than it is today; and that those who become infected can access treatment to help prevent them from developing AIDS and from passing the virus on to others.

While the road to an AIDS-free generation will be long and arduous, recent progress in HIV/AIDS prevention and treatment has been encouraging. Initiatives such as the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria are channeling antiretroviral treatment to millions of people in hard-hit countries. Of the estimated 34 million people worldwide infected with HIV, more than 10 million have access to antiretroviral drugs. Treatment reduces the levels of virus in infected individuals, benefiting their health and lessening the chances that they will transmit the virus to others.

Thirteen countries receiving PEPFAR funds have reached a key “tipping point” at which the annual increase in new patients on antiretroviral treatment exceeds the annual number of new HIV infections. The curve of new HIV infections in many countries is trending downward.

Mathematical models suggest that, by implementing existing HIV/AIDS treatment and prevention tools much more broadly worldwide, we can reach an AIDS-free generation. But without an effective HIV vaccine, reaching that goal will take much longer and will be more difficult, and along the way more people will become infected and more lives will be lost.

So while it may be possible, and even likely, to achieve an AIDS-free generation without it, an effective HIV vaccine would get us to an AIDS-free generation faster and, more important, help sustain that accomplishment.

Reaching our goal depends on expanding antiretroviral treatment and proven HIV/AIDS-prevention tools to all people who need them. In this regard, success or failure rests heavily on human behavior. To attain and sustain an AIDS-free generation, those who are already infected or at risk of infection must faithfully practice recommended treatment and/or prevention strategies: taking antiretroviral drugs daily as prescribed; using a condom every time they have sex; and, for those who inject drugs, always using a clean needle and syringe.

In clinical trials, adherence to an intervention regimen has been shown time and again to be the make-or-break variable in whether that strategy proved effective. Less-than-optimal adherence to a particular regimen reduces the effectiveness of most non-vaccine prevention tools. The chance of acquiring or transmitting HIV increases proportionately the less one sticks to the regimen in question.

Contrast this to an HIV vaccine. For it to be effective, a person probably would need to receive a small number of recommended immunizations, possibly just one. Beyond that, human behavior does not affect the intrinsic effectiveness. Furthermore, unlike with polio, measles or other life-saving vaccines, which are sufficient in themselves to control the spread of the respective disease, an HIV vaccine would stand together with other HIV/AIDS prevention modalities in a new model for infectious diseases. It would be one component, rather than the only component, of a prevention tool kit. We aspire to create a highly effective HIV vaccine. But to be useful, an HIV vaccine need only hit that sweet spot — perhaps 50 percent to 70 percent effective — that, when combined with other prevention tools, provides a highly effective prevention strategy.

Research continues to yield clues to how we might rationally design an effective HIV vaccine, yet many scientific challenges remain. When we do succeed, an HIV vaccine will be the main driver to not only accelerate the decline of new HIV infections — and to do so more efficiently and cost-effectively — but also to maintain an AIDS-free generation once we get there. While an HIV vaccine will be integral to achieving an AIDS-free generation, it also will be essential to realizing our ultimate goal: a world permanently without HIV/AIDS.

http://www.washingtonpost.com/opinions/anthony-fauci-an-aids-free-generation-is-closer-than-we-might-think/2013/07/11/80ab000c-e70b-11e2-a301-ea5a8116d211_story.html

Vaccines: The Week in Review 6 July 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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Email Summary: Vaccines: The Week in Review is published as a single email summary, scheduled for release each Saturday eveningbefore midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.
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pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_6 July 2013
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Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.
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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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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…
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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
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School
– mobile:  [US] 267.251.2305
– skype:    davidrcurry1

– email: david.r.curry@centerforvaccineethicsandpolicy.org
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WHO convenes IHR Emergency Committee on MERS-CoV

WHO: Emergency Committee to convene on MERS-CoV
WHO said it is convening an Emergency Committee under the International Health Regulations (IHR) for Middle East respiratory syndrome coronavirus (MERS-CoV). The Emergency Committee will meet 9 to 11 July.
http://www.who.int/en/

WHO sets up emergency committee on MERS virus
GENEVA | Fri Jul 5, 2013 8:18am EDT
(Reuters) – The World Health Organization is forming an emergency committee of international experts to prepare for a possible worsening of the Middle East coronavirus (MERS), which has killed 40 people, WHO flu expert Keiji Fukuda said on Friday.

Fukuda said there was currently no emergency or pandemic but the experts would advise on how to tackle the disease if the number of cases suddenly grows. Most of the cases of MERS so far have been in Saudi Arabia, which hosts millions of Muslim visitors every year for the annual haj pilgrimage.

“We want to make sure we can move as quickly as possible if we need to,” Fukuda told a news conference.

“If in the future we do see some kind of explosion or if there is some big outbreak or we think the situation has really changed, we will already have a group of emergency committee experts who are already up to speed so we don’t have to go through a steep learning curve.”

The emergency committee is the second to be set up under WHO rules that came into force in 2007, years after the 2002 SARS outbreak. The previous emergency committee was set up to respond to the 2009 H1N1 pandemic.

Fukuda said MERS (Middle East Respiratory Syndrome) remained a patchwork of infections that had not yet swept through countries or communities as influenza can. The committee was partly being formed to consider big gaps in knowledge about the disease, he added.

(Reporting by Tom Miles; Editing by Gareth Jones)
http://www.reuters.com/article/2013/07/05/us-coronavirus-emergency-committee-idUSBRE9640B320130705

WHO: Global Alert and Response (GAR) – Disease Outbreak News: MERS-CoV; A(H7N9)

WHO: Global Alert and Response (GAR) – Disease Outbreak News
http://www.who.int/csr/don/2013_03_12/en/index.html
Middle East respiratory syndrome coronavirus (MERS-CoV) – update 5 July 2013
Excerpt
The Ministry of Health (MoH) in Saudi Arabia has announced two additional laboratory-confirmed cases and two deaths in previously confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection in Saudi Arabia.

The new cases are a 69 year-old male and a 66 year-old male from Riyadh. Both were admitted to hospital on the 28 June 2013 and are currently in critical condition in an intensive care unit.

In addition, the two deaths in previously confirmed cases are a 63 year-old female from Riyadh and a 75 year-old male from Al Ahsa.

Globally, from September 2012 to date, WHO has been informed of a total of 79 laboratory-confirmed cases of infection with MERS-CoV, including 42 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…
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Human infection with avian influenza A(H7N9) virus – update 4 July 2013
Excerpt
The National Health and Family Planning Commission, China notified WHO of an additional retrospectively detected laboratory-confirmed case of human infection with avian influenza A(H7N9) virus.

The patient is a 15-year-old boy reported from Jiangsu who became ill on 25 April 2013 and hospitalized on 26 April 2013. He recovered and was discharged on 2 May 2013. The results of molecular diagnostics were positive for H3N2 seasonal influenza virus and H7N9 avian influenza virus. On 1 July, Jiangsu Provincial Health Department consulted national and provincial experts for diagnosis.

To date, WHO has been informed of a total of 133 laboratory-confirmed cases, including 43 deaths.

Authorities in affected locations continue to maintain surveillance, epidemiological investigations, close contact tracing, clinical management, laboratory testing and sharing of samples as well as prevention and control measures.

So far, there is no evidence of sustained human-to-human transmission…

GPEI: Update: Polio this week – As of 3 July 2013 [plus additional reports]

Update: Polio this week – As of 3 July 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s extract and bolded text]
:: In Pakistan, a WPV1 outbreak centred in Federally Administered Tribal Areas (FATA) is continuing. The epicentre of the outbreak is in areas where immunizations are limited due to access challenges. See ‘Pakistan’ section for more.

Pakistan
:: One new WPV case was reported in the past week (WPV1 from North Waziristan, Federally Administered Tribal Areas – FATA), bringing the total number of WPV cases for 2013 to 18. The most recent WPV case in the country had onset of paralysis on 6 June (WPV1 from Bara in Khyber Agency, FATA).

:: In addition to this latest WPV1 case, North Waziristan is also affected by an ongoing cVDPV2 outbreak. It is an area where immunization campaigns have been suspended by local leaders since last June. To minimize the risk of a major WPV1 and/or cVDPV2 outbreak in this area, it is critical that access to children is granted as quickly as possible. Immunization campaigns in neighbouring high-risk areas are being intensified, to further boost population immunity levels in those areas and minimize the risk of further spread.

:: FATA is the major WPV1 reservoir in Pakistan at the moment. Of 18 WPV1 cases reported in the country in 2013, more than half are from FATA. Khyber Agency is particularly affected, with seven cases confirmed since end-April. 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.

Central Africa: Chad and Cameroon
:: In Chad, no new WPV cases were reported in the past week. The most recent WPV case had onset of paralysis on 14 June 2012 (WPV1 from Lac).

:: However, one new cVDPV2 case was reported in the country, with onset of paralysis on 12 May (from Ennedi in northern Chad), bringing the total number of cVDPV2 cases for 2013 to three. The virus is linked to the ongoing cVDPV2 outbreak affecting Chad.

Horn of Africa
:: 17 new WPV cases were reported in the past week (16 WPV1s from Somalia and one WPV1 from Kenya), bringing the total number of WPV1 cases in the region to 48 (41 WPV1s from Somalia and seven WPV1s from Kenya). The most recent cases in the region had onset of paralysis on 3 June (WPV1s from Somalia and Kenya).

:: The bulk of the newly-reported cases are from Somalia’s Banadir province, which remains the epicentre of the outbreak. However, two of the new cases are from Lower Shabelle region, in south-central Somalia, where access for supplementary immunization activities (SIAs) has been compromised for the past three years. As many as 500,000 children in this area are at particular risk of polio at the moment. Efforts are ongoing to operate in this area, and vaccinations are continuing at entry and exit points to build up immunity levels.

:: Outbreak response continues across the Horn of Africa, including in Ethiopia and Yemen.

.

WHO Europe: Mission sent to Israel following detection of wild poliovirus in sewage
1 July 2013
As requested by Israeli health authorities, a team of international poliomyelitis (polio) experts, coordinated by WHO, completed a five-day mission to Israel on 26 June 2013. The team assessed the risks and recommended action following the detection of wild poliovirus type 1 (wPV1) in sewage in the Southern District of the country. No cases of paralytic polio have been detected.

Following the mission, a supplementary immunization campaign with oral polio vaccine is planned, even though Israel continues to maintain high vaccination coverage and polio immunity in the population. The decision to launch the campaign reflects both the estimated extent of circulation of the virus and the Israeli authorities’ commitment to interrupt transmission as rapidly as possible.
The virus was originally isolated from sewage samples collected in Beersheva in February 2013. Since then it has been isolated in further samples from different locations, most recently in early June. Genetic sequencing and epidemiological investigations have established that it is of the South Asian genotype and not related to the virus currently affecting the Horn of Africa. WHO experts are working with scientists from Israel’s national polio laboratory to gain further understanding of the origins of the virus…

…Israel has been free of indigenous wPV transmission for 25 years, the last cases of paralytic polio having occurred in 1988. At that time the authorities launched a mass vaccination campaign immunizing the population aged 0–40 years with oral polio vaccine.
http://www.euro.who.int/en/what-we-do/health-topics/communicable-diseases/poliomyelitis/news/news/2013/07/who-sends-mission-to-israel-following-detection-of-wild-poliovirus-in-sewage

.

Female polio aid worker killed in northwest Pakistan
Thu, 04 Jul 2013 03:00:29 GMT
Peshawar, Jul 3 (PTI) A woman polio worker was today shot dead by suspected militants in northwest Pakistan during an anti-immunisation drive, the latest in a series of attacks targeting the government’s vaccination campaign.
Other members of the team managed to escape unhurt in the incident that took place in Swabi District of Khyber-Pakthunkhwa province, which last month witnessed two polio workers being killed by militants, police said…
http://news.in.msn.com/international/article.aspx?cp-documentid=253320000

New WHO position paper on vaccines and vaccination against yellow fever

WHO position paper on vaccines and vaccination against yellow fever
An updated position paper on yellow fever vaccines and vaccination has been published in today’s edition of the WHO Weekly Epidemiological record. The updated position paper replaces the previous 2003 WHO position paper and summarizes recent developments in the field.

Yellow fever is a mosquito-borne viral disease of humans and other primates, and is currently endemic in 44 countries in the tropical regions of Africa and South America.

Yellow fever vaccination is carried out for three reasons:
:: To protect populations living in areas subject to endemic and epidemic disease;
:: To protect travellers visiting these areas; and
:: To prevent international spread by minimizing the risk of importation of the virus by infected travellers.

A single dose of yellow fever vaccine is sufficient to sustain life-long protective immunity against yellow fever disease; hence a booster dose is not necessary.

In view of the ongoing transmission of yellow fever virus, and the proven efficacy and safety of yellow fever vaccination, WHO recommends that all endemic countries should introduce yellow fever vaccine into their routine immunization programmes.

Related links
:: WHO position paper on vaccines and vaccination against yellow fever – June 2013
pdf, 1.24Mb

:: Accompanying materials for the WHO position paper on vaccines and vaccination against yellow fever
:: WHO news release: Yellow fever vaccination booster not needed
http://www.who.int/immunization/newsroom/news_WHO_position_paper_yellow_fever/en/index.html

The Weekly Epidemiological Record (WER) for 5 July 2013, vol. 88, 27 (pp. 269–284) includes:
– Vaccines and vaccination against yellow fever WHO Position Paper – June 2013
http://www.who.int/entity/wer/2013/wer8827.pdf

Sabin Vaccine Institute survey: current awareness of GVAP (Global Vaccine Action Plan)

The Sabin Vaccine Institute issued a survey “to gather information about current awareness of the GVAP (Global Vaccine Action Plan) and how the GVAP is being implemented throughout the global immunization community. Results will be compiled and reported to the WHO Strategic Advisory Group of Experts (SAGE) Decade of Vaccines Working Group in late July as part of the GVAP Monitoring and Evaluation/Accountability Framework.” Click here to take the survey.

BRICS and global health: a call for papers [Bulletin of the WHO]

Bulletin of the World Health Organization
Volume 91, Number 7, July 2013, 465-544
http://www.who.int/bulletin/volumes/91/7/en/index.html

BRICS and global health: a call for papers
Pascal Zurn a, Marie-Andrée Romisch-Diouf a, Shambhu Acharya a, Sarah Louise Barber b, Natela Menabde c, Luigi Migliorini d, Joaquin Molina e & Michael J O’Leary f
http://www.who.int/bulletin/volumes/91/7/13-125344/en/index.html

Excerpt
…The Bulletin plans to publish a theme issue on BRICS and global health to enhance people’s understanding of the dynamics of health and development in BRICS countries and of how these countries contribute to global health, both by improving health outcomes in their own territories and by engaging in mutual cooperation. This issue will cover these countries’ key health policy achievements and their most important health challenges, as well as their rising influence on international health cooperation.

We welcome papers for all sections of the Bulletin and encourage authors to consider contributions on any of the following topics as they pertain to BRICS countries: universal health coverage; universal access to medicines or vaccines; emerging and existing public health challenges, notably health inequities and the double burden of disease; South–South cooperation and inter-BRICS cooperation.

The deadline for submissions is October 2013. Manuscripts should be prepared in accordance with the Bulletin’s Guidelines for contributors and authors should mention this call for papers in a covering letter. All submissions will go through the Bulletin’s peer review process. Please submit to: http://submit.bwho.org

Placing populations’ health at the heart of the post-2015 agenda

Bulletin of the World Health Organization
Volume 91, Number 7, July 2013, 465-544
http://www.who.int/bulletin/volumes/91/7/en/index.html

Placing populations’ health at the heart of the post-2015 agenda
Carole Presern a & for the Post-2015 Working Group of the Partnership for Maternal, Newborn & Child Health
a. Partnership for Maternal, Newborn & Child Health, World Health Organization, 20 Rue Appia 27, Geneva 1211, Switzerland.
Correspondence to Andres de Francisco (e-mail: defranciscoa@who.int)
Bulletin of the World Health Organization 2013;91:467-467A. doi: http://dx.doi.org/10.2471/BLT.13.125146
http://www.who.int/bulletin/volumes/91/7/13-125146/en/index.html

Excerpt
The Millennium Development Goals (MDGs) have shaped global health and development priorities and have catalysed major improvements in women’s and children’s health. The post-2015 development agenda, currently under debate, must capitalize on these achievements. To this end, in 2012 the United Nations System Task Team on the Post-2015 Sustainable Development Agenda proposed a framework with four core dimensions: inclusive economic development, environmental sustainability, inclusive social development and peace and security.1 Based on this framework, the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda has proposed 12 goals and 54 targets as part of a transformative, people-centred agenda for development. We wish to reinforce the direction of this work by stressing the need to put populations’ health at the heart of the post-2015 agenda. This can be accomplished by moving health and development efforts beyond sectoral silos and focusing on the world’s most disadvantaged groups.1

Equity resonates throughout current discussions and consensus towards prioritizing the most disadvantaged members of society is emerging. We therefore propose a focus on the poorest populations in every country, with special attention to women of reproductive age, children and adolescents. These groups are especially vulnerable in several domains, yet they are also vital “human capital” for any society wishing to progress in the four dimensions of sustainable development.

In the economic sphere, women are major players. Over 500 million women in the world have joined the workforce in the past 30 years thanks to strides in female education, access to contraception and gender equity.2 Lower fertility rates resulting from access to contraception have reduced pressure on the environment. In fact, lower fertility rates and better child survival explain from 30 to 50% of south-eastern Asia’s dramatic economic growth between 1965 and 1990.3 Children and adolescents, on the other hand, are tomorrow’s workforce. Those who are healthy will grow up to be more productive citizens and will have higher lifetime earning potential than those who are not…

Vaccinations for healthcare personnel: update on influenza, hepatitis B, and pertussis

Current Opinion in Infectious Diseases.
August 2013 – Volume 26 – Issue 4  pp: v-vi,295-398
http://journals.lww.com/co-infectiousdiseases/pages/currenttoc.aspx
Vaccinations for healthcare personnel: update on influenza, hepatitis B, and pertussis
Kaltsas, Anna; Sepkowitz, Kent
Current Opinion in Infectious Diseases. 26(4):366-377, August 2013.
doi: 10.1097/QCO.0b013e3283630ee5

Abstract:
Purpose of review: Healthcare personnel (HCP) are at risk for exposure to and transmission of potentially life-threatening vaccine preventable diseases to patients and colleagues. The Centers for Disease Control and Advisory Committee on Immunization Practices (ACIP) recommend routine influenza immunization and maintenance of immunity to hepatitis B and pertussis, among others. In this article, we aim to review recently approved influenza vaccines, as well as address some of the issues regarding hepatitis B and pertussis vaccinations in HCP.

Recent findings: Several new formulations of influenza vaccines are now available, including quadrivalent vaccines and non-egg-based vaccines; their use in HCP requires further study. An alarming rise in pertussis rates has led to a revision of ACIP guidelines recommending vaccination for women during each pregnancy. Persistent lack of immunity to hepatitis B after vaccine series remains a problem for many HCP.

Summary: Inactivated trivalent influenza vaccines remain the safest and most widely studied influenza vaccinations for healthcare workers. A pertussis booster in the form of Tdap is now recommended for most HCP. More studies are needed regarding the issue of nonresponders in HCP who receive the three-dose hepatitis B vaccine series, as there are some promising strategies available that may boost immune responses.

Race, ethnicity and income as factors for HPV vaccine acceptance and use

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 7   July 2013
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/7/

Review
Race, ethnicity and income as factors for HPV vaccine acceptance and use
Patricia Jeudin, Elizabeth Liveright, Marcela G. del Carmen and Rebecca B. Perkins
http://dx.doi.org/10.4161/hv.24422
Abstract:
If distributed equitably, Human Papillomavirus (HPV) vaccines have the potential to reduce racial disparities in HPV-related diseases and cervical cancers. However, current trends in the US indicate low uptake among all adolescents, with persistent disparities among minority and low-income adolescents despite largely positive views of vaccination among their parents. As Black, Hispanic, and Asian populations continue to grow in the US over the next 40 y, it is imperative that we not only improve HPV vaccination rates overall, but focus on high-risk populations to prevent an increase in cervical cancer disparities. This review discusses initiation and completion rates of the three-dose HPV vaccine series among adolescents in high-risk groups and describes cultural similarities and differences in motivation and barriers to vaccination. The goal of this review is to highlight factors leading to vaccination in different adolescent racial groups and to help guide the development of strategies to increase rates of vaccine initiation and completion among groups at the highest risk for developing cervical cancer.

Factors associated with HPV vaccination among adult women in Quebec

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 7   July 2013
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/7/

Short Report
Factors associated with HPV vaccination among adult women in Quebec
Marilou Kiely, Chantal Sauvageau, Eve Dubé, Genevieve Deceuninck and Philippe De Wals
http://dx.doi.org/10.4161/hv.24603

Abstract:
Background and objective: Human papillomavirus (HPV) infections are the most common sexually transmitted infections in North America and are associated with cervical cancer. A publicly-funded HPV immunization program was launched in the province of Quebec, Canada, in the fall of 2008.

The aim of this study was to explore factors associated with HPV immunization among young adult women not targeted by this program.

Methods: A questionnaire was mailed to 2400 24-y-old women randomly selected from the Quebec provincial health insurance database and 56% responded. Factors associated with vaccination status were analyzed using a multivariate logistic regression model.
Results: Few women had received at least one dose of HPV vaccine among the 1347 respondents. Age at first sexual intercourse ≥ 20 y, participating in cervical cancer screening, higher education level, being born in Quebec and some positive beliefs about HPV were associated with vaccination.
Conclusions: The rate of immunization in women who had to pay for the HPV vaccine was very low and was associated with characteristics that are generally associated with a lower risk for HPV infection and cervical cancer. Efforts are needed to reach at-risk adult women.

Delivery of immunogens to mucosal immune system using an oral inactivated cholera vaccine: A new approach for development of oral vaccine

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 7   July 2013
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/7/

Commentary
Delivery of immunogens to mucosal immune system using an oral inactivated cholera vaccine: A new approach for development of oral vaccines
Ali Azizi, Haitham Ghunaim, Danylo Sirskyj, Firouzeh Fallahi, Hoang Thanh Le and Ashok Kumar
http://dx.doi.org/10.4161/hv.24200
Abstract:
Oral vaccines have several attractive features; however, due to several challenges, to date, only a limited number of oral vaccines are licensed. Over the past two decades, several oral vehicle delivery systems have been developed to address these challenges and deliver antigens to the target cells in the mucosal immune system. While the size of vehicle delivery systems, the quantity of components in the vehicle formulation, the dose of administration, and even the type of animals species, are important aspects in development of a suitable oral vaccine, our results showed that entrapment of inactivated Vibrio cholera, a component in the structure of Dukoral vaccine into oral vehicle delivery systems, is able to induce a more rigorous humoral immune response in the systemic compartment. We further investigated the mechanism of Dukoral vaccine as a potential stimulator in induction of immune response by immunizing TLR-2-, TLR-4-, MyD88- and Trif-deficient mice. We are hopeful that these findings will lead to development of more precisely-designed oral vaccines in the future.

Understanding the interplay of factors informing vaccination behavior in three Canadian provinces

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 7   July 2013
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/7/

Research Paper
Understanding the interplay of factors informing vaccination behavior in three Canadian provinces
Franziska Boerner, Jennifer Keelan, Laura Winton, Cindy Jardine and S. Michelle Driedger

Abstract:
Arguably, the two most critical components in any response to a pandemic are effective risk communication and the rapid development of a vaccine. Despite the roll-out of a publicly-funded H1N1 vaccine program across the country, less than half of all Canadians were vaccinated during the 2009–10 pandemic. Using focus group data, this study examined vaccinating behaviors, the impact of public health messaging, and the public’s attitudes toward H1N1 and the H1N1 vaccine in three Canadian provinces. Drawing on vaccine risk communication literature, a framework was devised to identify and analyze the factors related to vaccine uptake and vaccine refusal. The most predictive factor for H1N1 vaccine uptake was a prior history of vaccinating against seasonal influenza. Other important factors included barriers to immunizing (access issues) and an individual’s perception of serious risk from contracting H1N1. Although critical gaps in the public’s understanding of influenza infections were identified, together with misinformation about vaccination effectiveness and safety, these factors were less frequently reported to be the core factors influencing an individual’s decision to vaccinate.

Influenza vaccines in low and middle income countries: A systematic review of economic evaluations

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 7   July 2013
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/7/

Review
Influenza vaccines in low and middle income countries: A systematic review of economic evaluations
Jördis J. Ott, Janna Klein Breteler, John S. Tam, Raymond C.W. Hutubessy, Mark Jit and Michiel R. de Boer

Abstract:
Objectives
Economic evaluations on influenza vaccination from low resource settings are scarce and have not been evaluated using a systematic approach. Our objective was to conduct a systematic review on the value for money of influenza vaccination in low- and middle-income countries.

Methods
PubMed and EMBASE were searched for economic evaluations published in any language between 1960 and 2011. Main outcome measures were costs per influenza outcome averted, costs per quality-adjusted life years gained or disability-adjusted life years averted, costs per benefit in monetary units or cost-benefit ratios.

Results
Nine economic evaluations on seasonal influenza vaccine met the inclusion criteria. These were model- or randomized-controlled-trial (RCT)-based economic evaluations from middle-income countries. Influenza vaccination provided value for money for elderly, infants, adults and children with high-risk conditions. Vaccination was cost-effective and cost-saving for chronic obstructive pulmonary disease patients and in elderly above 65 y from model-based evaluations, but conclusions from RCTs on elderly varied.

Conclusion
Economic evaluations from middle income regions differed in population studied, outcomes and definitions used. Most findings are in line with evidence from high-income countries highlighting that influenza vaccine is likely to provide value for money. However, serious methodological limitations do not allow drawing conclusions on cost-effectiveness of influenza vaccination in middle income countries. Evidence on cost-effectiveness from low-income countries is lacking altogether, and more information is needed from full economic evaluations that are conducted in a standardized manner.

The Paradox of Disease Prevention: Celebrated in Principle, Resisted in Practice

JAMA   
July 3, 2013, Vol 310, No. 1
http://jama.ama-assn.org/current.dtl

Special Communication
The Paradox of Disease Prevention: Celebrated in Principle, Resisted in Practice
Harvey V. Fineberg, MD, PhD

ABSTRACT
Prevention of disease is often difficult to put into practice. Among the obstacles: the success of prevention is invisible, lacks drama, often requires persistent behavior change, and may be long delayed; statistical lives have little emotional effect, and benefits often do not accrue to the payer; avoidable harm is accepted as normal, preventive advice may be inconsistent, and bias against errors of commission may deter action; prevention is expected to produce a net financial return, whereas treatment is expected only to be worth its cost; and commercial interests as well as personal, religious, or cultural beliefs may conflict with disease prevention. Six strategies can help overcome these obstacles: (1) Pay for preventive services. (2) Make prevention financially rewarding for individuals and families. (3) Involve employers to promote health in the workplace and provide incentives to employees to maintain healthy practices. (4) Reengineer products and systems to make prevention simpler, lower in cost, and less dependent on individual action. (5) Use policy to reinforce choices that favor prevention. (6) Use multiple media channels to educate, elicit health-promoting behavior, and strengthen healthy habits. Prevention of disease will succeed over time insofar as it can be embedded in a culture of health.

Consistent Condom Use Reduces the Genital Human Papillomavirus Burden Among High-Risk Men: The HPV Infection in Men Study

Journal of Infectious Diseases
Volume 208 Issue 3 August 1, 2013
http://jid.oxfordjournals.org/content/current

Consistent Condom Use Reduces the Genital Human Papillomavirus Burden Among High-Risk Men: The HPV Infection in Men Study
Christine M. Pierce Campbell1, Hui-Yi Lin1, William Fulp1, Mary R. Papenfuss1, Jorge J. Salmerón2, Manuel M. Quiterio2, Eduardo Lazcano-Ponce3, Luisa L. Villa4 and Anna R. Giuliano1
http://jid.oxfordjournals.org/content/208/3/373.abstract

Abstract
Background. Data supporting the efficacy of condoms against human papillomavirus (HPV) infection in males are limited. Therefore, we examined the effect of consistent condom use on genital HPV acquisition and duration of infection.

Methods. A prospective analysis was conducted within the HPV Infection in Men Study, a multinational HPV cohort study. Men who were recently sexually active (n = 3323) were stratified on the basis of sexual risk behaviors and partnerships. Using Cox proportional hazards regression, type-specific incidence of HPV infection and clearance were modeled for each risk group to assess independent associations with condom use.

Results. The risk of HPV acquisition was 2-fold lower among men with no steady sex partner who always used condoms, compared with those who never used condoms (hazard ratio, 0.54), after adjustment for country, age, race, education duration, smoking, alcohol, and number of recent sex partners. The probability of clearing an oncogenic HPV infection was 30% higher among nonmonogamous men who always used condoms with nonsteady sex partners, compared with men who never used condoms (hazard ratio, 1.29), after adjustment for country, age, race, education duration, marital status, smoking, alcohol, and number of recent sex partners. No protective effects of condom use were observed among monogamous men.

Conclusions. Condoms should be promoted in combination with HPV vaccination to prevent HPV infection in men.

Reduction in Human Papillomavirus (HPV) Prevalence Among Young Women Following HPV Vaccine Introduction in the United States, National Health and Nutrition Examination Surveys, 2003–2010

Journal of Infectious Diseases
Volume 208 Issue 3 August 1, 2013
http://jid.oxfordjournals.org/content/current

Reduction in Human Papillomavirus (HPV) Prevalence Among Young Women Following HPV Vaccine Introduction in the United States, National Health and Nutrition Examination Surveys, 2003–2010
Lauri E. Markowitz1, Susan Hariri1, Carol Lin1, Eileen F. Dunne1, Martin Steinau2, Geraldine McQuillan3 and Elizabeth R. Unger2
http://jid.oxfordjournals.org/content/208/3/385.abstract

Abstract
Background.  Human papillomavirus (HPV) vaccination was introduced into the routine immunization schedule in the United States in late 2006 for females aged 11 or 12 years, with catch-up vaccination recommended for those aged 13–26 years. In 2010, 3-dose vaccine coverage was only 32% among 13–17 year-olds. Reduction in the prevalence of HPV types targeted by the quadrivalent vaccine (HPV-6, -11, -16, and -18) will be one of the first measures of vaccine impact.

Methods. We analyzed HPV prevalence data from the vaccine era (2007–2010) and the prevaccine era (2003–2006) that were collected during National Health and Nutrition Examination Surveys. HPV prevalence was determined by the Linear Array HPV Assay in cervicovaginal swab samples from females aged 14–59 years; 4150 provided samples in 2003–2006, and 4253 provided samples in 2007–2010.

Results. Among females aged 14–19 years, the vaccine-type HPV prevalence (HPV-6, -11, -16, or -18) decreased from 11.5% (95% confidence interval [CI], 9.2–14.4) in 2003–2006 to 5.1% (95% CI, 3.8–6.6) in 2007–2010, a decline of 56% (95% CI, 38–69). Among other age groups, the prevalence did not differ significantly between the 2 time periods (P > .05). The vaccine effectiveness of at least 1 dose was 82% (95% CI, 53–93).

Conclusions. Within 4 years of vaccine introduction, the vaccine-type HPV prevalence decreased among females aged 14–19 years despite low vaccine uptake. The estimated vaccine effectiveness was high.

to promote certain behaviours. Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities

The Lancet  
Jul 06, 2013  Volume 382  Number 9886  p1 – 100
http://www.thelancet.com/journals/lancet/issue/current

Comment
Promise, and risks, of conditional cash transfer programmes
Lia CH Fernald
Preview
What do we know about how to help poor children in low-income and middle-income countries? Various approaches have worked—improved nutrition, reduced exposure to infection, and introduction of parenting or preschool programmes—but there is still a long way to go.1,2 Conditional cash transfer programmes try to go deeper than these other approaches and get at the root causes of poverty. These programmes use cash to help households deal with their most pressing financial needs and also as an incentive to promote certain behaviours.

Effect of a conditional cash transfer programme on childhood mortality: a nationwide analysis of Brazilian municipalities
Davide Rasella PhD a, Rosana Aquino MD a, Carlos AT Santos PhD a b, Rômulo Paes-Sousa MD c, Prof Mauricio L Barreto MD a d
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2960715-1/abstract

Summary
Background
In the past 15 years, Brazil has undergone notable social and public health changes, including a large reduction in child mortality. The Bolsa Familia Programme (BFP) is a widespread conditional cash transfer programme, launched in 2003, which transfers cash to poor households (maximum income US$70 per person a month) when they comply with conditions related to health and education. Transfers range from $18 to $175 per month, depending on the income and composition of the family. We aimed to assess the effect of the BFP on deaths of children younger than 5 years (under-5), overall and resulting from specific causes associated with poverty: malnutrition, diarrhoea, and lower respiratory infections.

Methods
The study had a mixed ecological design. It covered the period from 2004—09 and included 2853 (of 5565) municipalities with death and livebirth statistics of adequate quality. We used government sources to calculate all-cause under-5 mortality rates and under-5 mortality rates for selected causes. BFP coverage was classified as low (0·0—17·1%), intermediate (17·2—32·0%), high (>32·0%), or consolidated (>32·0% and target population coverage ≥100% for at least 4 years). We did multivariable regression analyses of panel data with fixed-effects negative binomial models, adjusted for relevant social and economic covariates, and for the effect of the largest primary health-care scheme in the country (Family Health Programme).

Findings
Under-5 mortality rate, overall and resulting from poverty-related causes, decreased as BFP coverage increased. The rate ratios (RR) for the effect of the BFP on overall under-5 mortality rate were 0·94 (95% CI 0·92—0·96) for intermediate coverage, 0·88 (0·85—0·91) for high coverage, and 0·83 (0·79—0·88) for consolidated coverage. The effect of consolidated BFP coverage was highest on under-5 mortality resulting from malnutrition (RR 0·35; 95% CI 0·24—0·50) and diarrhoea (0·47; 0·37—0·61).

Interpretation
A conditional cash transfer programme can greatly contribute to a decrease in childhood mortality overall, and in particular for deaths attributable to poverty-related causes such as malnutrition and diarrhoea, in a large middle-income country such as Brazil.

Funding
National Institutes of Science and Technology Programme, Ministry of Science and Technology, and Council for Scientific and Technological Development Programme (CNPq), Brazil.

Health Policy: Universal health coverage in Turkey: enhancement of equity

The Lancet  
Jul 06, 2013  Volume 382  Number 9886  p1 – 100
http://www.thelancet.com/journals/lancet/issue/current

Health Policy
Universal health coverage in Turkey: enhancement of equity
Rifat Atun, Sabahattin Aydın, Sarbani Chakraborty, Safir Sümer, Meltem Aran, Ipek Gürol, Serpil Nazlıoğlu, Şenay Özgülcü, Ülger Aydoğan, Banu Ayar, Uğur Dilmen, Recep Akdağ
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2813%2961051-X/abstract

Summary
Turkey has successfully introduced health system changes and provided its citizens with the right to health to achieve universal health coverage, which helped to address inequities in financing, health service access, and health outcomes. We trace the trajectory of health system reforms in Turkey, with a particular emphasis on 2003—13, which coincides with the Health Transformation Program (HTP). The HTP rapidly expanded health insurance coverage and access to health-care services for all citizens, especially the poorest population groups, to achieve universal health coverage. We analyse the contextual drivers that shaped the transformations in the health system, explore the design and implementation of the HTP, identify the factors that enabled its success, and investigate its effects. Our findings suggest that the HTP was instrumental in achieving universal health coverage to enhance equity substantially, and led to quantifiable and beneficial effects on all health system goals, with an improved level and distribution of health, greater fairness in financing with better financial protection, and notably increased user satisfaction. After the HTP, five health insurance schemes were consolidated to create a unified General Health Insurance scheme with harmonised and expanded benefits. Insurance coverage for the poorest population groups in Turkey increased from 2·4 million people in 2003, to 10·2 million in 2011. Health service access increased across the country—in particular, access and use of key maternal and child health services improved to help to greatly reduce the maternal mortality ratio, and under-5, infant, and neonatal mortality, especially in socioeconomically disadvantaged groups. Several factors helped to achieve universal health coverage and improve outcomes. These factors include economic growth, political stability, a comprehensive transformation strategy led by a transformation team, rapid policy translation, flexible implementation with continuous learning, and simultaneous improvements in the health system, on both the demand side (increased health insurance coverage, expanded benefits, and reduced cost-sharing) and the supply side (expansion of infrastructure, health human resources, and health services).

Invasive Pneumococcal Disease in Infants Younger Than 90 Days Before and After Introduction of PCV7

Pediatrics
July 2013, VOLUME 132 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Article
Invasive Pneumococcal Disease in Infants Younger Than 90 Days Before and After Introduction of PCV7
Liset Olarte, MDa, Krow Ampofo, MDa, Chris Stockmann, MSca, Edward O. Mason, PhDb, Judy A. Daly, PhDa, Andrew T. Pavia, MDa, and Carrie L. Byington, MDa
http://pediatrics.aappublications.org/content/132/1/e17.abstract

Abstract
BACKGROUND: Introduction of the heptavalent pneumococcal conjugate vaccine (PCV7) changed the epidemiology of invasive pneumococcal disease (IPD). We evaluated the changes that occurred after PCV7 introduction among Utah infants aged 1 to 90 days, too young to be fully immunized.

METHODS: We identified children <18 years with culture-confirmed IPD from 1997–2010. We analyzed demographic, clinical, and serotype data for infants aged 1–90 days. The pre– and post–vaccine introduction periods spanned 1997–2000 and 2001–2010, respectively.

RESULTS: Of 513 children with IPD, 36 were 1 to 90 days and accounted for 7% of IPD cases in both the pre– and post–vaccine introduction period. The pre–vaccine IPD incidence rate was 5.0 per 100 000 live births, and was unchanged in the post–vaccine introduction period. IPD caused by PCV7 serotypes decreased by 74% (from 2.2 to 0.58 per 100 000), whereas non-vaccine serotype IPD increased by 57% (from 2.8 to 4.4 per 100 000). Sixteen infants (44%) required intensive care, and 3 (8%) died. Bacteremia without focus (56%) and meningitis (44%) were the predominant syndromes in the pre– and post–vaccine introduction periods, respectively. In the post–vaccine introduction period, serotype 7F was the most common serotype among infants and was responsible for 50% of meningitis.

CONCLUSIONS: The incidence of IPD in Utah infants aged 1 to 90 days caused by PCV7 serotypes decreased after PCV7 introduction, but overall incidence was unchanged. In the post–vaccine introduction period, serotype 7F predominated in this age group and was associated with meningitis.

Effectiveness of Monovalent and Pentavalent Rotavirus Vaccine

Pediatrics
July 2013, VOLUME 132 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Article
Effectiveness of Monovalent and Pentavalent Rotavirus Vaccine
Margaret M. Cortese, MDa, Lilly Cheng Immergluck, MD, MSb,c, Melissa Held, MDd, Shabnam Jain, MD, MPHb,e, Trisha Chan, BSc, Alexandra P. Grizas, MPHf, Saadia Khizer, MD, MPHPb, Carol Barrett, MAd, Osbourne Quaye, PhDa, Slavica Mijatovic-Rustempasic, MSca, Rashi Gautam, PhDa, Michael D. Bowen, PhDa, Jessica Moore, MPHa, Jacqueline E. Tate, PhDa, Umesh D. Parashar, MBBS, MPHa, and Marietta Vázquez, MDf

Abstract
OBJECTIVE: Previous US evaluations have not assessed monovalent rotavirus vaccine (RV1, a G1P[8] human rotavirus strain) effectiveness, because of its later introduction (2008). Using case-control methodology, we measured the vaccine effectiveness (VE) of the 2-dose RV1 and 3-dose pentavalent vaccine (RV5) series against rotavirus disease resulting in hospital emergency department or inpatient care.

METHODS: Children were eligible for enrollment if they presented to 1 of 5 hospitals (3 in Georgia, 2 in Connecticut) with diarrhea of ≤10 days’ duration during January through June 2010 or 2011, and were born after RV1 introduction. Stools were collected; immunization records were obtained from providers and state electronic immunization information system (IIS). Case-subjects (children testing rotavirus antigen-positive) were compared with 2 control groups: children testing rotavirus negative and children selected from IIS.

RESULTS: Overall, 165 rotavirus-case subjects and 428 rotavirus-negative controls were enrolled. Using the rotavirus-negative controls, RV1 VE was 91% (95% confidence interval [CI] 80 to 95) and RV5 VE was 92% (CI 75 to 97) among children aged ≥8 months. The RV1 VE against G2P[4] disease was high (94%, CI 78 to 98), as was that against G1P[8] disease (89%, CI 70 to 96). RV1 effectiveness was sustained among children aged 12 through 23 months (VE 91%; CI 75 to 96). VE point estimates using IIS controls were similar to those using rotavirus-negative controls.

CONCLUSIONS: RV1 and RV5 were both highly effective against severe rotavirus disease. RV1 conferred sustained protection during the first 2 years of life and demonstrated high effectiveness against G2P[4] (heterotypic) disease.

Religious Exemptions for Immunization and Risk of Pertussis in New York State, 2000–2011

Pediatrics
July 2013, VOLUME 132 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Article
Religious Exemptions for Immunization and Risk of Pertussis in New York State, 2000–2011
Aamer Imdad, MDa, Boldtsetseg Tserenpuntsag, MD, DrPhb, Debra S. Blog, MD, MPHb, Neal A. Halsey, MDc, Delia E. Easton, PhDb, and Jana Shaw, MD, MPHa
http://pediatrics.aappublications.org/content/132/1/37.abstract

Abstract
OBJECTIVE: The objective of this study was to describe rates of religious vaccination exemptions over time and the association with pertussis in New York State (NYS).

METHODS: Religious vaccination exemptions reported via school surveys of the NYS Department of Health from 2000 through 2011 were reviewed by county, and the changes were assessed against incidence rates of pertussis among children reported to the NYS Department of Health Communicable Disease Electronic Surveillance System.

RESULTS: The overall annual state mean prevalence (± SD) of religious exemptions for ≥1 vaccines in 2000–2011 was 0.4% ± 0.08% and increased significantly from 0.23% in 2000 to 0.45% in 2011 (P = .001). The prevalence of religious exemptions varied greatly among counties and increased by >100% in 34 counties during the study period. Counties with mean exemption prevalence rates of ≥1% reported a higher incidence of pertussis, 33 per 100 000 than counties with lower exemption rates, 20 per 100 000, P < .001. In addition, the risk of pertussis among vaccinated children living in counties with high exemption rate increased with increase of exemption rate among exempted children (P = .008).

CONCLUSIONS: The prevalence of religious exemptions varies among NYS counties and increased during the past decade. Counties with higher exemption rates had higher rates of reported pertussis among exempted and vaccinated children when compared with the low-exemption counties. More studies are needed to characterize differences in the process of obtaining exemptions among NYS schools, and education is needed regarding the risks to the community of individuals opting out from recommended vaccinations.

Sick-Visit Immunizations and Delayed Well-Baby Visits

Pediatrics
July 2013, VOLUME 132 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Article
Sick-Visit Immunizations and Delayed Well-Baby Visits
Steve G. Robison, BS
http://pediatrics.aappublications.org/content/132/1/44.abstract

Abstract
OBJECTIVE: Giving recommended immunizations during sick visits for minor and acute illness such as acute otitis media has long been an American Academy of Pediatrics/Advisory Committee on Immunization Practice recommendation. An addition to the American Academy of Pediatrics policy in 2010 advised considering whether giving immunizations at the sick visit would discourage making up missed well-baby visits. This study quantifies the potential tradeoff between sick-visit immunizations and well-baby visits.

METHODS: This study was a retrospective cohort analysis with a case-control component of sick visits for acute otitis media that supplanted normal well-baby visits at age 2, 4, or 6 months. Infants were stratified for sick-visit immunization, no sick-visit immunization but quick makeup well-baby visits, or no sick-visit immunizations or quick makeup visits. Immunization rates and well-baby visit rates were assessed through 24 months of age.

RESULTS: For 1060 study cases, no significant difference was detected in immunization rates or well-baby visits through 24 months of age between those with or without sick-visit immunizations. Thirty-nine percent of infants without a sick-visit shot failed to return for a quick makeup well-baby visit; this delayed group was significantly less likely to be up-to-date for immunizations (relative risk: 0.66) and had fewer well-baby visits (mean: 3.8) from 2 through 24 months of age compared with those with sick-visit shots (mean: 4.7).

CONCLUSIONS: The substantial risk that infants will not return for a timely makeup well-baby visit after a sick visit should be included in any consideration of whether to delay immunizations.

Balancing Evidence and Uncertainty when Considering Rubella Vaccine Introduction

PLoS One
[Accessed 5 July 2013]
http://www.plosone.org/
Balancing Evidence and Uncertainty when Considering Rubella Vaccine Introduction
Justin Lessler, C. Jessica E. Metcalf
Research Article | published 05 Jul 2013 | PLOS ONE 10.1371/journal.pone.0067639

Abstract
Background
Despite a safe and effective vaccine, rubella vaccination programs with inadequate coverage can raise the average age of rubella infection; thereby increasing rubella cases among pregnant women and the resulting congenital rubella syndrome (CRS) in their newborns. The vaccination coverage necessary to reduce CRS depends on the birthrate in a country and the reproductive number, R0, a measure of how efficiently a disease transmits. While the birthrate within a country can be known with some accuracy, R0 varies between settings and can be difficult to measure. Here we aim to provide guidance on the safe introduction of rubella vaccine into countries in the face of substantial uncertainty in R0.

Methods
We estimated the distribution of R0 in African countries based on the age distribution of rubella infection using Bayesian hierarchical models. We developed an age specific model of rubella transmission to predict the level of R0 that would result in an increase in CRS burden for specific birth rates and coverage levels. Combining these results, we summarize the safety of introducing rubella vaccine across demographic and coverage contexts.

Findings
The median R0 of rubella in the African region is 5.2, with 90% of countries expected to have an R0 between 4.0 and 6.7. Overall, we predict that countries maintaining routine vaccination coverage of 80% or higher are can be confident in seeing a reduction in CRS over a 30 year time horizon.

Conclusions
Under realistic assumptions about human contact, our results suggest that even in low birth rate settings high vaccine coverage must be maintained to avoid an increase in CRS. These results lend further support to the WHO recommendation that countries reach 80% coverage for measles vaccine before introducing rubella vaccination, and highlight the importance of maintaining high levels of vaccination coverage once the vaccine is introduced.

Financing HIV Programming: How Much Should Low- And Middle-Income Countries and their Donors Pay?

PLoS One
[Accessed 5 July 2013]
http://www.plosone.org/
Financing HIV Programming: How Much Should Low- And Middle-Income Countries and their Donors Pay?
Omar Galárraga, Veronika J. Wirtz, Yared Santa-Ana-Tellez, Eline L. Korenromp
Research Article | published 05 Jul 2013 | PLOS ONE 10.1371/journal.pone.0067565

Abstract
Global HIV control funding falls short of need. To maximize health outcomes, it is critical that national governments sustain reasonable commitments, and that international donor assistance be distributed according to country needs and funding gaps. We develop a country classification framework in terms of actual versus expected national domestic funding, considering resource needs and donor financing. With UNAIDS and World Bank data, we examine domestic and donor HIV program funding in relation to need in 84 low- and middle-income countries. We estimate expected domestic contributions per person living with HIV (PLWH) as a function of per capita income, relative size of the health sector, and per capita foreign debt service. Countries are categorized according to levels of actual versus expected domestic contributions, and resource gap. Compared to national resource needs (UNAIDS Investment Framework), we identify imbalances among countries in actual versus expected domestic and donor contributions: 17 countries, with relatively high HIV prevalence and GNI per capita, have domestic funding below expected (median per PLWH $143 and $376, respectively), yet total available funding including from donors would exceed the need ($368 and $305, respectively) if domestic contribution equaled expected. Conversely, 27 countries have actual domestic funding above the expected (medians $294 and $149) but total (domestic+donor) funding does not meet estimated need ($685 and $1,173). Across the 84 countries, in 2009, estimated resource need totaled $10.3 billion, actual domestic contributions $5.1 billion and actual donor contributions $3.7 billion. If domestic contributions would increase to the expected level in countries where the actual was below expected, total domestic contributions would increase to $7.4 billion, turning a funding gap of $1.5 billion into a surplus of $0.8 billion. Even with imperfect funding and resource-need data, the proposed country classification could help improve coherence and efficiency in domestic and international allocations.

Policy Trap and Optimal Subsidization Policy under Limited Supply of Vaccines

PLoS One
[Accessed 5 July 2013]
http://www.plosone.org/

Policy Trap and Optimal Subsidization Policy under Limited Supply of Vaccines
Ming Yi, Achla Marathe
Research Article | published 01 Jul 2013 | PLOS ONE 10.1371/journal.pone.0067249

Abstract
We adopt a susceptible-infected-susceptible (SIS) model on a Barabási and Albert (BA) network to investigate the effects of different vaccine subsidization policies. The goal is to control the prevalence of the disease given a limited supply and voluntary uptake of vaccines. The results show a uniform subsidization policy is always harmful and increases the prevalence of the disease, because the lower degree individuals’ demand for vaccine crowds out the higher degree individuals’ demand. In the absence of an effective uniform policy, we explore a targeted subsidization policy which relies on a proxy variable instead of individuals’ connectivity. Findings show a poor proxy-based targeted program can still increase the disease prevalence and become a policy trap. The results are robust to general scale-free networks.