Update: Polio this week – As of 6 March 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s Extract and bolded text]
– In the Democratic Republic of the Congo, all samples from 2012 AFP cases have now been fully cleared, and confirm that the country has not reported a WPV case in over one year (the last reported WPV case had onset of paralysis on 20 December 2011).

– Islamic scholars call for urgent action to complete polio eradication in Muslim communities: “Crippled children lead to a crippled Muslim Ummah” warned the Grand Imam of Al-Azhar, at a meeting in Cairo this week of Muslim scholars from several countries. As Muslim communities and countries everywhere have eradicated polio, the scholars reaffirmed their resolve to support the people, health workers and governments of the three remaining countries – Afghanistan, Nigeria and Pakistan. More at http://www.emro.who.int/media/news/polio-eradication-in-muslim-communities.html.

Nigeria
– One new WPV case was reported in the past week (WPV1 from Yobe), bringing in the total number of WPV cases for 2013 to 3. The total number of WPV cases for 2012 remains 122. The most recent WPV case had onset of paralysis on 31 January (from Yobe).

– No new cases of cVDPV2 were reported in the past week. The total number of cVDPV2 cases for 2012 remains eight. The most recent cVDPV2 case had onset of paralysis on 24 November 2012 (from Kebbi).

– Nationwide Immunization Plus Days (IPDs) were conducted using trivalent OPV on 2-5 March in 30 states, coordinated with activities in neighbouring Republic of Niger. IPDs have been postponed by one week in four southern states and the Federal Capital Territory because of the need for more time to adequately prepare for the round of immunization. IPDs have been postponed in Kano and Borno states due to security concerns. The security situation in the north remains fluid.

Pakistan
– The security situation continues to be monitored closely, in consultation with law enforcement agencies. Based on these security evaluations, immunization campaigns then proceed at local level as and when the situation allows. Immunization campaigns were conducted throughout February in key reservoir areas.

The Weekly Epidemiological Record (WER) for 8 March 2013, vol. 88, 10 (pp. 101–116) includes:
– Recommended composition of influenza virus vaccines for use in the 2013–2014 northern hemisphere influenza season
– Global report on Fukushima nuclear accident details health risks

http://www.who.int/entity/wer/2013/wer8810.pdf

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

6 March 2013 Novel coronavirus infection – update
The Ministry of Health in Saudi Arabia has informed WHO of a new confirmed case of infection with the novel coronavirus (NCoV).

The patient, a 69-year-old male, was hospitalized on 10 February 2013 and died on 19 February 2013. Preliminary investigation indicated that the patient had no contact with previously reported cases of NCoV infection and did not have recent history of travel.

To date, WHO has been informed of a global total of 14 confirmed cases of human infection with NCoV, including eight deaths. Of the total number, seven cases, including five deaths, have been reported from Saudi Arabia.

Based on the current situation and available information, WHO encourages all Member States (MS) to continue their surveillance for severe acute respiratory infections (SARI) and to carefully review any unusual patterns. WHO is currently working with international experts and countries where cases have been reported to assess the situation and review recommendations for surveillance and monitoring.

All MS are reminded to promptly assess and notify WHO of any new case of infection with NCoV along with information about potential exposures that may have resulted in infection and a description of the clinical course.

WHO does not advise special screening at points of entry with regard to this event nor does it recommend that any travel or trade restrictions be applied.

WHO continues to closely monitor the situation.

Public web consultation: WHO engagement with non-State actors
Background

In response to the request of the Executive Board of WHO (Decision EB132(11)) to conduct public web-based consultations on the draft principles and policies of engagement with non-State actors, the WHO Secretariat welcomes interested parties to provide comments on the issues and questions related to WHO’s engagement with non-State actors as outlined and described below.  Comments are invited from 6 March 2013 to 20 March 2013.

– PDF version of issues and questions
pdf, 131kb

http://www.who.int/about/who_reform/governance/non_state_consultation/en/index.html

Meeting: 5th Regional Pneumococcal Symposium
Sabin Vaccine Institute,  PAHO, JHU -IVAC), CDC
5-6 March 2013: Sao Paulo

This meeting convened “…health representatives from the Latin America and Caribbean (LAC) region to discuss and exchange ideas that may lead to the overcoming of financial, logistical, and political obstacles to pneumococcal prevention.” Research introduced at the meeting indicated that in the Latin American and Caribbean context the cost of illness is an important and significant economic burden, suggesting that more use of pneumococcal vaccines could be cost-effective in adults.

Dr. Fernando de la Hoz , a member of the Medical Faculty at the National University of Colombia and lead author of the study, said, “Further research is needed in order for health officials to fully grasp the potential impact of immunizing older populations in Latin America and the Caribbean. We know now that the vaccine is saving the lives of thousands of our region’s youngest citizens. The question is whether we should also be protecting their parents and grandparents.”

The study found that direct medical costs to treat bacteremic pneumonia ranged from USD $993 to USD $3,535 per person, and the cost of treatment for bacteremic meningitis was as high as USD $4,490 for elderly persons. The cost analysis concluded that these diseases pose sizable burdens in five countries studied: Argentina, Brazil, Chile, Colombia and Uruguay.

http://www.prnewswire.com/news-releases/new-study-suggests-potential-shift-in-burden-of-pneumococcal-disease-195297681.html

Meeting: Global Vaccine Summit
UNICEF, WHO, Global Polio Eradication Initiative, GAVI Alliance, Bill & Melinda Gates
Foundation.
24-25 April 2013; Abu Dhabi

Media Release Excerpt
“…The Summit will endorse the critical role that vaccines and immunization play in saving lives and protecting children for a lifetime. It aims to turn a spotlight on the importance of building and maintaining powerful routine immunization systems to keep all children healthy, no matter where they live.

“Despite tremendous progress, one child still dies every 20 seconds from a disease that could have been prevented by an existing vaccine. The Summit, held during World Immunization Week (April 24-30), will continue the momentum of the Decade of Vaccines — a vision and commitment to reach all people with the vaccines they need.

“The Global Vaccine Summit will showcase how the world is uniting to improve child health by developing better and more affordable vaccines, by providing access to existing and new vaccines, and by strengthening routine immunization…

“…At the summit, donors, global leaders and partners will demonstrate their support for the Global Polio Eradication Initiative’s Eradication and Endgame Strategic Plan 2013-2018, the first comprehensive plan to lay out all the critical elements needed to achieve eradication.  Ending polio is an early milestone in the global roadmap to save more than 20 million lives by 2020…”

http://www.prnewswire.com/news-releases/global-vaccine-summit-to-recognize-progress-in-immunizing-all-children-everywhere-195778611.html

American Journal of Infection Control
Vol 41 | No. 3 | March 2013 | Pages 189-284
http://www.ajicjournal.org/current

Article in Press
Impact of hospital policies on health care workers’ influenza vaccination rates
Mary Patricia Nowalk, PhD, RD; Chyongchiou Jeng Lin, PhD; Mahlon Raymund, PhD; Jamie Bialor, MPH, CHES, Richard K. Zimmerman, MD, MPH
published online 18 February 2013.

Abstract
Background
Overall annual influenza vaccination rate has slowly increased among health care workers but still remains below the national goal of 90%.

Methods
To compare hospitals that mandate annual health care worker (HCW) influenza vaccination with and without consequences for noncompliance, a 34-item survey was mailed to an infection control professional in 964 hospitals across the United States in 4 waves. Respondents were grouped by presence of a hospital policy that required annual influenza vaccination of HCWs with and without consequences for noncompliance. Combined with hospital characteristics from the American Hospital Association, data were analyzed using χ2 or Fisher exact tests for categorical variables and t tests for continuous variables.

Results
One hundred fifty hospitals required influenza vaccination, 84 with consequences (wear a mask, termination, education, restriction from patient care duties, unpaid leave) and 66 without consequences for noncompliance. Hospitals whose mandates have consequences for noncompliance included a broader range of personnel, were less likely to allow personal belief exemptions, or to require formal declination. The change in vaccination rates in hospitals with mandates with consequences (19.5%) was nearly double that of the hospitals with mandates without consequences (11%; P=.002). Presence of a state law regulating HCW influenza vaccination was associated with an increase in rates for mandates with consequences nearly 3 times the increase for mandates without consequences.

Conclusion
Hospital mandates for HCW influenza vaccination with consequences for noncompliance are associated with larger increases in HCW influenza vaccination rates than mandates without such consequences.

BMC Public Health
(Accessed 9 March 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Research article  
Economic analysis of pandemic influenza mitigation strategies for five pandemic severity categories
Joel K Kelso, Nilimesh Halder, Maarten J Postma, George J Milne BMC Public Health 2013, 13:211 (8 March 2013)

Abstract (provisional) [Open Access]
Background
The threat of emergence of a human-to-human transmissible strain of highly pathogenic influenza A(H5N1) is very real, and is reinforced by recent results showing that genetically modified A(H5N1) may be readily transmitted between ferrets. Public health authorities are hesitant in introducing social distancing interventions due to societal disruption and productivity losses. This study estimates the effectiveness and total cost (from a societal perspective, with a lifespan time horizon) of a comprehensive range of social distancing and antiviral drug strategies, under a range of pandemic severity categories.

Methods
An economic analysis was conducted using a simulation model of a community of ~30,000 in Australia. Data from the 2009 pandemic was used to derive relationships between the Case Fatality Rate (CFR) and hospitalization rates for each of five pandemic severity categories, with CFR ranging from 0.1% to 2.5%.

Results
For a pandemic with basic reproduction number R0 = 1.8, adopting no interventions resulted in total costs ranging from $441 per person for a pandemic at category 1 (CFR 0.1%) to $8,550 per person at category 5 (CFR 2.5%). For severe pandemics of category 3 (CFR 0.75%) and greater, a strategy combining antiviral treatment and prophylaxis, extended school closure and community contact reduction resulted in the lowest total cost of any strategy, costing $1,584 per person at category 5. This strategy was highly effective, reducing the attack rate to 5%. With low severity pandemics costs are dominated by productivity losses due to illness and social distancing interventions, whereas higher severity pandemic costs are dominated by healthcare costs and costs arising from productivity losses due to death.

Conclusions
For pandemics in high severity categories the strategies with the lowest total cost to society involve rigorous, sustained social distancing, which are considered unacceptable for low severity pandemics due to societal disruption and cost.

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

BMC Public Health
(Accessed 9 March 2013)
http://www.biomedcentral.com/bmcpublichealth/content

Research article  
Yellow fever vaccination coverage following massive emergency immunization campaigns in rural Uganda, May 2011: a community cluster survey
James Bagonza, Elizeus Rutebemberwa, Malimbo Mugaga, Nathan Tumuhamye, Issa Makumbi BMC Public Health 2013, 13:202 (7 March 2013)

Abstract (provisional) [Open Access]
Background
Following an outbreak of yellow fever in northern Uganda in December 2010, Ministry of Health conducted a massive emergency vaccination campaign in January 2011. The reported vaccination coverage in Pader District was 75.9%. Administrative coverage though timely, is affected by incorrect population estimates and over or under reporting of vaccination doses administered. This paper presents the validated yellow fever vaccination coverage following massive emergency immunization campaigns in Pader district.

Methods
A cross sectional cluster survey was carried out in May 2011 among communities in Pader district and 680 respondents were indentified using the modified World Health Organization (WHO) 40 x 17 cluster survey sampling methodology. Respondents were aged nine months and above. Interviewer administered questionnaires were used to collect data on demographic characteristics, vaccination status and reasons for none vaccination. Vaccination status was assessed using self reports and vaccination card evidence. Our main outcomes were measures of yellow fever vaccination coverage in each age-specific stratum, overall, and disaggregated by age and sex, adjusting for the clustered design and the size of the population in each stratum.

Results
Of the 680 survey respondents, 654 (96.3%, 95% CI 94.9 — 97.8) reported being vaccinated during the last campaign but only 353(51.6%, 95% CI 47.2 — 56.1) had valid yellow fever vaccination cards. Of the 280 children below 5 years, 269 (96.1%, 95% CI 93.7 — 98.7) were vaccinated and nearly all males 299 (96.9%, 95% CI 94.3 — 99.5) were vaccinated. The main reasons for none vaccination were; having travelled out of Pader district during the campaign period (40.0%), lack of transport to immunization posts (28.0%) and, sickness at the time of vaccination (16.0%).

Conclusions
Our results show that actual yellow fever vaccination coverage was high and satisfactory in Pader district since it was above the desired minimum threshold coverage of 80% according to World Health Organization. Massive emergency vaccination done following an outbreak of Yellow fever achieved high population coverage in Pader district. Active surveillance is necessary for early detection of yellow fever cases.

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

Globalization and Health
[Accessed 9 March 2013]
http://www.globalizationandhealth.com/

Debate
The health systems funding platform and World Bank legacy: the gap between rhetoric and reality
Brown SS, Sen K and Decoster K Globalization and Health 2013, 9:9 (6 March 2013)

Abstract (provisional) [Open Access]
Global health partnerships created to encourage funding efficiencies need to be approached with some caution, with claims for innovation and responsiveness to development needs based on untested assumptions around the potential of some partners to adapt their application, funding and evaluation procedures within these new structures. We examine this in the case of the Health Systems Funding Platform, which despite being set up some three years earlier, has stalled at the point of implementation of its key elements of collaboration. While much of the attention has been centred on the suspension of the Global Fund’s Round 11, and what this might mean for health systems strengthening and the Platform more broadly, we argue that inadequate scrutiny has been made of the World Bank’s contribution to this partnership, which might have been reasonably anticipated based on an historical analysis of development perspectives. Given the tensions being created by the apparent vulnerability of the health systems strengthening agenda, and the increasing rhetoric around the need for greater harmonization in development assistance, an examination of the positioning of the World Bank in this context is vital.

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

Health Affairs
March 2013; Volume 32, Issue 3
http://content.healthaffairs.org/content/current
Theme: Promoting Health & Wellness
[No specific relevant content on vaccines/immunization]

Survey Finds Public Support For Legal Interventions Directed At Health Behavior To Fight Noncommunicable Disease
Stephanie Morain and Michelle M. Mello
Health Aff March 2013 32:486-496; doi:10.1377/hlthaff.2012.0609

Abstract
The high prevalence of chronic diseases in the United States with lifestyle-related risk factors, such as obesity and tobacco use, has sparked interest in legal strategies to influence health behavior. However, little is known about the public’s willingness to accept these policies as legitimate, which in turn may affect compliance. We present results from a national survey of 1,817 US adults concerning the acceptability of different public health legal interventions that address noncommunicable, or chronic, diseases. We found that support for these new interventions is high overall; substantially greater among African Americans and Hispanics than among whites; and tied to perceptions of democratic representation in policy making. There was much support for strategies that enable people to exercise healthful choices—for example, menu labeling and improving access to nicotine patches—but considerably less for more coercive measures, such as insurance premium surcharges. These findings suggest that the least coercive path will be the smoothest and that support for interventions may be widespread among different social groups. In addition, the findings underscore the need for policy makers to involve the public in decision making, understand the public’s values, and communicate how policy decisions reflect this understanding.

http://content.healthaffairs.org/content/32/3/486.abstract

Health Economics, Policy and Law 
Volume 8 – Issue 02 – April 2013
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

NICE’s social value judgements about equity in health and health care
Koonal K. Shah, Richard Cookson, Anthony J. Culyer and Peter Littlejohns
Health Economics, Policy and Law / Volume 8 / Issue 02 / April 2013, pp 145 – 165
Copyright © Cambridge University Press 2012
DOI: http://dx.doi.org/10.1017/S1744133112000096 (About DOI), Published online: 01 May 2012

Abstract
The National Institute for Health and Clinical Excellence (NICE) routinely publishes details of the evidence and reasoning underpinning its recommendations, including its social value judgements (SVJs). To date, however, NICE’s SVJs relating to equity in the distribution of health and health care have been less specific and systematic than those relating to cost-effectiveness in the pursuit of improved total population health. NICE takes a pragmatic, case-based approach to developing its principles of SVJ, drawing on the cumulative experience of its advisory bodies in making decisions that command respect among its broad range of stakeholders. This paper aims to describe the SVJs about equity in health and health care that NICE has hitherto used to guide its decision making. To do this, we review both the general SVJs reported in NICE guidance on methodology and the case-specific SVJs reported in NICE guidance about particular health care technologies and public health interventions.

Health Economics, Policy and Law 
Volume 8 – Issue 02 – April 2013
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

Articles
Neglected infectious diseases: Are push and pull incentive mechanisms suitable for promoting drug development research?
Frank Mueller-Langer

Abstract
Infectious diseases are among the main causes of death and disability in developing countries, and they are a major reason for the health disparity between rich and poor countries. One of the reasons for this public health tragedy is a lack of lifesaving essential medicines, which either do not exist or badly need improvements. In this article, we analyse which of the push and pull mechanisms proposed in the recent literature may serve to promote research into neglected infectious diseases. A combination of push programmes that subsidise research inputs through direct funding and pull programmes that reward research output rather than research input may be the appropriate strategy to stimulate research into neglected diseases. On the one hand, early-stage (basic) research should be supported through push mechanisms, such as research grants or publicly financed research institutions. On the other hand, pull mechanisms, such as prize funds that link reward payments to the health impacts of effective medicines, have the potential to stimulate research into neglected diseases.

JAMA   
March 06, 2013, Vol 309, No. 9
http://jama.ama-assn.org/current.dtl

Viewpoint | March 6, 2013 ONLINE FIRST
Influenza Prevention Update – Examining Common Arguments Against Influenza Vaccination
Thomas R. Talbot, MD, MPH; H. Keipp Talbot, MD, MPH
JAMA. 2013;309(9):881-882. doi:10.1001/jama.2013.453.

Extract
Following last year’s season of low activity, influenza is surging across the country and as of January 5 has claimed the lives of 20 children.1 With influenza intensifying, it is important to review essential interventions that prevent influenza transmission at home, at work, and in health care facilities.

Several important actions should be performed by everyone to prevent the spread of this potentially deadly pathogen. Basic infection control practices such as regularly performing hand hygiene, observing respiratory hygiene and cough etiquette (“cover your cough”), and avoiding others and crowded areas when ill (social distancing) are important prevention methods for any contagious respiratory tract infection. Additional measures to limit transmission of influenza in health care settings are also essential. These include screening patients on arrival to assess for respiratory symptoms, placing a surgical mask on potentially infected individuals, using isolation precautions for those suspected of having or confirmed to have a respiratory tract infection, keeping infected patients away from other patients, and ensuring that visitors and health care personnel (HCP) do not visit or work while ill (ie, “presenteeism”)…2.

The Lancet  
Mar 09, 2013  Volume 381  Number 9869  p777 – 874  e8
http://www.thelancet.com/journals/lancet/issue/current

Comment
SARS legacy: outbreak reporting is expected and respected
David L Heymann, John S Mackenzie, Malik Peiris

Preview |
On March 15, 2003, WHO declared that the new disease it called severe acute respiratory syndrome (SARS) was a worldwide health threat. The disease emerged in late 2002, when an outbreak of atypical pneumonia began in Guangdong Province, China. It subsequently spread across the world via major air routes, reaching 29 countries on five continents. This international spread began when a doctor who had treated patients in China arrived in Hong Kong on Feb 21, 2003. His 1-day stay in a hotel led to infection of 15 others who carried the infection to hospitals within Hong Kong and in Vietnam, Canada, Singapore, the USA, the Philippines, and Australia.

The Lancet  
Mar 09, 2013  Volume 381  Number 9869  p777 – 874  e8
http://www.thelancet.com/journals/lancet/issue/current

Comment
The beginning of the end for serogroup B meningococcus?
Matthew D Snape, Andrew J Pollard

Preview
Widespread use of glycoconjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae, and serogroup C Neisseria meningitidis has resulted in a substantial decrease in childhood meningitis in industrialised countries, but the persisting threat posed by serogroup B Neisseria meningitidis (MenB) is an unwelcome anomaly. This organism’s external polysaccharide capsule is poorly immunogenic, sharing chemical and antigenic identity with human fetal neural-cell antigens, and is therefore unsuitable for use in a glycoconjugate vaccine.

The Lancet  
Mar 09, 2013  Volume 381  Number 9869  p777 – 874  e8
http://www.thelancet.com/journals/lancet/issue/current

Immunogenicity and safety of an investigational multicomponent, recombinant, meningococcal serogroup B vaccine (4CMenB) administered concomitantly with routine infant and child vaccinations: results of two randomised trials
Timo Vesikari, Susanna Esposito, Roman Prymula, Ellen Ypma, Igor Kohl, Daniela Toneatto, Peter Dull, Alan Kimura, for the EU Meningococcal B Infant Vaccine Study group
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2812%2961961-8/abstract

Summary
Background
Meningococcal serogroup B disease disproportionately affects infants. We assessed lot-to-lot consistency, safety and immunogenicity, and the effect of concomitant vaccination on responses to routine vaccines of an investigational multicomponent vaccine (4CMenB) in this population.

Methods
We did primary and booster phase 3 studies between March 31, 2008, and Aug 16, 2010, in 70 sites in Europe. We used two series of sponsor-supplied, computer-generated randomisation envelopes to allocate healthy 2 month-old infants to receive routine vaccinations (diphtheria-tetanus-acellular pertussis, inactivated poliovirus, hepatitis B plus Haemophilus influenzae type b, and seven-valent pneumococcal vaccine) at 2, 4, and 6 months of age alone, or concomitantly with 4CMenB or serogroup C conjugate vaccine (MenC) in: 1) an open-label, lot-to-lot immunogenicity and safety substudy of three 4CMenB lots compared with routine vaccines alone (1:1:1:1, block size eight); or 2) an observer-blind, lot-to-lot safety substudy of three 4CMenB lots compared with MenC (1:1:1:3, block size six). At 12 months, 4CMenB-primed children from either substudy were randomised (1:1, block size two) to receive 4CMenB booster, with or without measles-mumps-rubella-varicella (MMRV) vaccine. Immunogenicity was assessed by serum bactericidal assay with human complement (hSBA) against serogroup B test strains, and on randomly selected subsets of serum samples for routine vaccines; laboratory personnel were masked to assignment. The first coprimary outcome was lot-to-lot consistency (hSBA geometric mean ratio of all lots between 0·5 and 2·0), and the second was an immune response (hSBA titre ≥5) for each of the three strains. The primary outcome for the booster study was immune response to booster dose. Immunogenicity data for 4CMenB were for the modified intention-to-treat population, including all infants from the open-label substudy who provided serum samples. The safety population included all participants who contributed safety data after at least one dose of study vaccine. These trials are registered with ClinicalTrials.gov, numbers NCT00657709 and NCT00847145.

Findings
We enrolled 2627 infants in the open-label phase, 1003 in the observer-blind phase, and 1555 in the booster study. Lot-to-lot consistency was shown for the three 4CMenB lots, with the lowest 95% lower confidence limit being 0·74 and the highest upper limit being 1·33. Of 1181—1184 infants tested 1 month after three 4CMenB doses (all lots pooled), 100% (95% CI 99—100) had hSBA titres of 5 or more against strains selective for factor H binding protein and neisserial adhesin A, and 84% (82—86) for New Zealand outer-membrane vesicle. In a subset (n=100), 84% (75—91) of infants had hSBA titres of 5 or more against neisseria heparin binding antigen. At 12 months of age, waning titres were boosted by a fourth dose, such that 95—100% of children had hSBA titres of 5 or more for all antigens, with or without concomitant MMRV. Immune responses to routine vaccines were much the same with or without concomitant 4CMenB, but concomitant vaccination was associated with increased reactogenicity. 77% (1912 of 2478) of infants had fever of 38·5°C or higher after any 4CMenB dose, compared with 45% (295 of 659) after routine vaccines alone and 47% (228 of 490) with MenC, but only two febrile seizures were deemed probably related to 4CMenB.

Interpretation
4CMenB is immunogenic in infants and children aged 12 months with no clinically relevant interference with routine vaccines, but increases reactogenicity when administered concomitantly with routine vaccines. This breakthrough vaccine offers an innovative solution to the major remaining cause of bacterial meningitis in infant and toddlers.

Funding
Novartis Vaccines and Diagnostics.

Nature Medicine
March 2013, Volume 19 No 3 pp247-377
http://www.nature.com/nm/journal/v19/n3/index.html

Opinion
Bioethical accreditation or rating needed to restore trust in pharma
Jennifer E. Miller
Nature Medicine 19, 261 (2013)  doi:10.1038/nm0313-261
Published online – 06 March 2013

After years of decline in the public eye, drug companies should implement a bioethics accreditation or rating program to help appropriately restore the industry’s good name and improve its effectiveness in advancing global health and new treatments.

Extract
The pharmaceutical industry was once among the most admired industries on the planet. Today, it is heavily criticized and distrusted, with only 12% of people in the US believing that drug companies are generally honest and ethical, according to a Harris poll published late last year. Countless experts have raised this problem before, and drug companies have attempted numerous remedial strategies to address bioethical concerns and repair trust deficits.    Nonetheless, the mistrust persists, arguably weakening the effectiveness of these important institutions. Is there something new that companies can do to demonstrate the quality of their processes and genuinely earn back our trust? I believe there is.

The drug industry should voluntarily implement a bioethics accreditation, certification or rating system to help companies assess and improve the quality of their services and organizational processes. Such a system would also increase transparency, accountability and awareness of best practices, as well as appropriately improve public confidence where merited…

New England Journal of Medicine
March 7, 2013  Vol. 368 No. 10
http://www.nejm.org/toc/nejm/medical-journal

Review Article – Global Health
Governance Challenges in Global Health
Julio Frenk, M.D., M.P.H., Ph.D., and Suerie Moon, M.P.A., Ph.D.
N Engl J Med 2013; 368:936-942March 7, 2013DOI: 10.1056/NEJMra1109339

Extract
Global health is at the threshold of a new era. Few times in history has the world faced challenges as complex as those now posed by a trio of threats: first, the unfinished agenda of infections, undernutrition, and reproductive health problems; second, the rising global burden of noncommunicable diseases and their associated risk factors, such as smoking and obesity; and third, the challenges arising from globalization itself, such as the health effects of climate change and trade policies, which demand engagement outside the traditional health sector.1    These threats are evolving within a multifaceted and dynamic global context characterized by great diversity among societies in norms, values, and interests, as well as by large inequalities in the distribution of health risks and the resources to address them.

A robust response to this complex picture requires improved governance of health systems — certainly at the national level but also at a worldwide level in what could be thought of as the “global health system.” However, the concept of governance is still poorly understood despite its growing visibility in current debates about global health. In this article, we define and discuss the importance of good global governance for health, outline major challenges to such governance, and describe the necessary functions of a global health system…

Pediatrics
March 2013, VOLUME 131 / ISSUE 3
http://pediatrics.aappublications.org/current.shtml

Published online March 4, 2013
Article
Effect of Rotavirus Vaccine on Diarrhea Mortality in Different Socioeconomic Regions of Mexico
Paul A. Gastañaduy, MD, MPHa,b, Edgar Sánchez-Uribe, MDc, Marcelino Esparza-Aguilar, MD, MScc, Rishi Desai, MD, MPHa,b, Umesh D. Parashar, MBBS, MPHb, Manish Patel, MD, MScb, and Vesta Richardson, MDc

OBJECTIVE: In Mexico, declines in childhood diarrhea deaths have been documented during 2008–2010 after rotavirus vaccine introduction in 2007. Because of concerns about variation in rotavirus vaccine efficacy by socioeconomic status, we compared reductions in diarrhea mortality in the lesser developed southern region versus the more developed northern and central regions of Mexico.

METHODS: We obtained data from national vital statistics on diarrhea deaths among children aged <5 years from 2002 through 2011. We compared region-specific diarrhea mortality before (2003–2006) and after (2009–2011) vaccine introduction. Regional vaccine coverage was estimated from administrative data, and socioeconomic status was assessed by using the Human Development Index.

RESULTS: In northern, central, and southern Mexico, the 2007 Human Development Index was 0.84, 0.82, and 0.77, respectively, and by 2010 an estimated 99%, 84%, and 89% of children aged <12 months had completed rotavirus vaccination. Diarrhea mortality among children <5 years old declined from 8.3, 17.9, and 28.5 deaths per 100 000 children during 2003–2006 to 4.5, 8.1, and 16.2 in 2009–2011 in northern, central, and southern Mexico, respectively, corresponding to rate reductions of 45%, 55%, and 43%. No significant differences were observed in rate reductions between regions (P > .8).

CONCLUSIONS: After introduction of rotavirus vaccination, marked and sustained declines in diarrhea deaths were seen among children in all regions of Mexico, including in the least developed southern region with the highest baseline diarrhea mortality. This finding indicates equitable vaccine delivery to children with varying risk of mortality and reaffirms the beneficial effects of rotavirus vaccination against fatal diarrheal disease.

http://pediatrics.aappublications.org/content/early/2013/02/26/peds.2012-2797.abstract?sid=11b7a43a-2784-4fc3-a61b-c965a55dd28c

PLoS One
[Accessed 9 March 2013]
http://www.plosone.org/

Seroprevalence of Mumps in The Netherlands: Dynamics over a Decade with High Vaccination Coverage and Recent Outbreaks
Gaby Smits, Liesbeth Mollema, Susan Hahné, Hester de Melker, Irina Tcherniaeva, Sandra Waaijenborg, Rob van Binnendijk, Fiona van der Klis, Guy Berbers
Research Article | published 08 Mar 2013 | PLOS ONE 10.1371/journal.pone.0058234

Abstract
Here we present mumps virus specific antibody levels in a large cross-sectional population-based serosurveillance study performed in the Netherlands in 2006/2007 (n = 7900). Results were compared with a similar study (1995/1996) and discussed in the light of recent outbreaks. Mumps antibodies were tested using a fluorescent bead-based multiplex immunoassay. Overall seroprevalence was 90.9% with higher levels in the naturally infected cohorts compared with vaccinated cohorts. Mumps virus vaccinations at 14 months and 9 years resulted in an increased seroprevalence and antibody concentration. The second vaccination seemed to be important in acquiring stable mumps antibody levels in the long term. In conclusion, the Dutch population is well protected against mumps virus infection. However, we identified specific age- and population groups at increased risk of mumps infection. Indeed, in 2007/2008 an outbreak has occurred in the low vaccination coverage groups emphasizing the predictive value of serosurveillance studies.

PLoS One
[Accessed 9 March 2013]
http://www.plosone.org/

Influenza Virus Aerosols in Human Exhaled Breath: Particle Size, Culturability, and Effect of Surgical Masks
Donald K. Milton, M. Patricia Fabian, Benjamin J. Cowling, Michael L. Grantham, James J. McDevitt
Research Article | published 07 Mar 2013 | PLOS Pathogens 10.1371/journal.ppat.1003205

Abstract
The CDC recommends that healthcare settings provide influenza patients with facemasks as a means of reducing transmission to staff and other patients, and a recent report suggested that surgical masks can capture influenza virus in large droplet spray. However, there is minimal data on influenza virus aerosol shedding, the infectiousness of exhaled aerosols, and none on the impact of facemasks on viral aerosol shedding from patients with seasonal influenza.

We collected samples of exhaled particles (one with and one without a facemask) in two size fractions (“coarse”>5 µm, “fine”≤5 µm) from 37 volunteers within 5 days of seasonal influenza onset, measured viral copy number using quantitative RT-PCR, and tested the fine-particle fraction for culturable virus.

Fine particles contained 8.8 (95% CI 4.1 to 19) fold more viral copies than did coarse particles. Surgical masks reduced viral copy numbers in the fine fraction by 2.8 fold (95% CI 1.5 to 5.2) and in the coarse fraction by 25 fold (95% CI 3.5 to 180). Overall, masks produced a 3.4 fold (95% CI 1.8 to 6.3) reduction in viral aerosol shedding. Correlations between nasopharyngeal swab and the aerosol fraction copy numbers were weak (r = 0.17, coarse; r = 0.29, fine fraction). Copy numbers in exhaled breath declined rapidly with day after onset of illness. Two subjects with the highest copy numbers gave culture positive fine particle samples.

Surgical masks worn by patients reduce aerosols shedding of virus. The abundance of viral copies in fine particle aerosols and evidence for their infectiousness suggests an important role in seasonal influenza transmission. Monitoring exhaled virus aerosols will be important for validation of experimental transmission studies in humans.

Author Summary
The relative importance of direct and indirect contact, large droplet spray, and aerosols as modes of influenza transmission is not known but is important in devising effective interventions. Surgical facemasks worn by patients are recommended by the CDC as a means of reducing the spread of influenza in healthcare facilities. We sought to determine the total number of viral RNA copies present in exhaled breath and cough aerosols, whether the RNA copies in fine particle aerosols represent infectious virus, and whether surgical facemasks reduce the amount of virus shed into aerosols by people infected with seasonal influenza viruses. We found that total viral copies detected by molecular methods were 8.8 times more numerous in fine (≤5 µm) than in coarse (>5 µm) aerosol particles and that the fine particles from cases with the highest total number of viral RNA copies contained infectious virus. Surgical masks reduced the overall number of RNA copies by 3.4 fold. These results suggest an important role for aerosols in transmission of influenza virus and that surgical facemasks worn by infected persons are potentially an effective means of limiting the spread of influenza.

PLoS One
[Accessed 9 March 2013]
http://www.plosone.org/

Rapid and Scalable Plant-based Production of a Cholera Toxin B Subunit Variant to Aid in Mass Vaccination against Cholera Outbreaks
Krystal Teasley Hamorsky, J. Calvin Kouokam, Lauren J. Bennett, Keegan J. Baldauf, Hiroyuki Kajiura, Kazuhito Fujiyama, Nobuyuki Matoba
Research Article | published 07 Mar 2013 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0002046

Abstract
Introduction
Cholera toxin B subunit (CTB) is a component of an internationally licensed oral cholera vaccine. The protein induces neutralizing antibodies against the holotoxin, the virulence factor responsible for severe diarrhea. A field clinical trial has suggested that the addition of CTB to killed whole-cell bacteria provides superior short-term protection to whole-cell-only vaccines; however, challenges in CTB biomanufacturing (i.e., cost and scale) hamper its implementation to mass vaccination in developing countries. To provide a potential solution to this issue, we developed a rapid, robust, and scalable CTB production system in plants.

Methodology/Principal Findings
In a preliminary study of expressing original CTB in transgenic Nicotiana benthamiana, the protein was N-glycosylated with plant-specific glycans. Thus, an aglycosylated CTB variant (pCTB) was created and overexpressed via a plant virus vector. Upon additional transgene engineering for retention in the endoplasmic reticulum and optimization of a secretory signal, the yield of pCTB was dramatically improved, reaching >1 g per kg of fresh leaf material. The protein was efficiently purified by simple two-step chromatography. The GM1-ganglioside binding capacity and conformational stability of pCTB were virtually identical to the bacteria-derived original B subunit, as demonstrated in competitive enzyme-linked immunosorbent assay, surface plasmon resonance, and fluorescence-based thermal shift assay. Mammalian cell surface-binding was corroborated by immunofluorescence and flow cytometry. pCTB exhibited strong oral immunogenicity in mice, inducing significant levels of CTB-specific intestinal antibodies that persisted over 6 months. Moreover, these antibodies effectively neutralized the cholera holotoxin in vitro.

Conclusions/Significance
Taken together, these results demonstrated that pCTB has robust producibility in Nicotiana plants and retains most, if not all, of major biological activities of the original protein. This rapid and easily scalable system may enable the implementation of pCTB to mass vaccination against outbreaks, thereby providing better protection of high-risk populations in developing countries.

Author Summary
Cholera sporadically causes outbreaks in regions where safe water supply and sanitation systems are not sufficient. As currently available vaccines are only effective for 2 to 3 years, reactive mass vaccination has been proposed to reduce mortality during outbreaks. Cholera toxin B subunit (CTB), when combined with killed whole-cell bacteria, has been shown to provide superior short-term protection, but manufacturing challenges of the protein limit its availability for mass vaccination programs in developing countries. Our work presented herein developed a rapid, robust, and scalable bioproduction system in plants for a CTB variant, pCTB. The system allowed for the accumulation of pCTB at >1 g per kg of fresh leaf of tobacco-related plants within 5 days, which accounts for over 1000 doses of original CTB included in the World Health Organization-prequalified vaccine Dukoral. We further analyzed in depth the integrity of pCTB using a series of biochemical, biophysical, and immunological experiments, demonstrating that the plant-made protein is feasible as a cholera vaccine antigen. Thus, pCTB plus killed bacteria may be ideal for reactive vaccination against cholera outbreaks.

PLoS One
[Accessed 9 March 2013]
http://www.plosone.org/

Policy Resistance Undermines Superspreader Vaccination Strategies for Influenza
Chad R. Wells, Eili Y. Klein, Chris T. Bauch
Research Article | published 07 Mar 2013 | PLOS Computational Biology 10.1371/journal.pcbi.1002945

Abstract
Theoretical models of infection spread on networks predict that targeting vaccination at individuals with a very large number of contacts (superspreaders) can reduce infection incidence by a significant margin. These models generally assume that superspreaders will always agree to be vaccinated. Hence, they cannot capture unintended consequences such as policy resistance, where the behavioral response induced by a new vaccine policy tends to reduce the expected benefits of the policy. Here, we couple a model of influenza transmission on an empirically-based contact network with a psychologically structured model of influenza vaccinating behavior, where individual vaccinating decisions depend on social learning and past experiences of perceived infections, vaccine complications and vaccine failures. We find that policy resistance almost completely undermines the effectiveness of superspreader strategies: the most commonly explored approaches that target a randomly chosen neighbor of an individual, or that preferentially choose neighbors with many contacts, provide at best a relative improvement over their non-targeted counterpart as compared to when behavioral feedbacks are ignored. Increased vaccine coverage in super spreaders is offset by decreased coverage in non-superspreaders, and superspreaders also have a higher rate of perceived vaccine failures on account of being infected more often. Including incentives for vaccination provides modest improvements in outcomes. We conclude that the design of influenza vaccine strategies involving widespread incentive use and/or targeting of superspreaders should account for policy resistance, and mitigate it whenever possible.

Author Summary
Superspreaders are the small number of individuals responsible for the majority of infections. Theoretical models have shown how vaccinating superspreaders can be a highly efficient way to control disease. However, these models neglect behavior by assuming that superspreaders will always agree to be vaccinated. This is a problematic assumption for influenza vaccination, which is voluntary in most populations, and for which vaccine coverage is often suboptimal. We developed a model of seasonal influenza transmission on a network of individuals who make decisions about whether or not to get vaccinated based on known determinants of vaccine uptake, such as personal infection history, perceived vaccine risks, and social influences. We found that, because of feedbacks between disease spread and individual vaccinating behavior, attempts to boost vaccine coverage in superspreaders through the use of incentives or recruiting by social contacts are almost completely undermined by such feedbacks. For example, higher vaccine uptake in superspreaders reduces influenza incidence, which in the next season reduces the perceived need for vaccination among non-superspreaders, who then do not become vaccinated as much. Our results suggest that the design of potential strategies to reach influenza superspreaders should account for behavioral feedbacks, since they may blunt policy effectiveness.

From Google Scholar+: Dissertations, Theses, Selected Journal Articles

Virus-like particles: the future of microbial factories and cell-free systems as platforms for vaccine development
WA Rodríguez-Limas, K Sekar, KEJ Tyo – Current Opinion in Biotechnology, 2013
Vaccines based on virus-like particles have proved their success in human health. More than 25 years after the approval of the first vaccine based on this technology, the substantial efforts to expand the range of applications and target diseases are beginning to bear fruit. …

A Mobile Phone Application for Recording Vaccine Refusals
D Murphy, J Cremer, PM Polgreen – International Meeting on Emerging Diseases and …, 2013
Background: Although vaccines are a safe and effective approach for preventing morbidity and mortality, many people in developed countries are refusing vaccination for themselves and their children. Low vaccination rates are contributing to the re-emergence of vaccine …

Travel Characteristics and Yellow Fever Vaccine Usage Among US Global TravEpiNet Travelers Visiting Countries with Risk of Yellow Fever Virus Transmission, 2009 …
ES Jentes, P Han, MD Gershman, SR Rao… – The American Journal of …, 2013
Abstract Yellow fever (YF) vaccine-associated serious adverse events and changing YF epidemiology have challenged healthcare providers to vaccinate only travelers whose risk of YF during travel is greater than their risk of adverse events. We describe the travel …

Exploring Barriers and Facilitators to Participation of Male-to-Female Transgender Persons in Preventive HIV Vaccine Clinical Trials
MP Andrasik, R Yoon, J Mooney, G Broder, M Bolton… – Prevention Science, 2013
Abstract Observed seroincidence and prevalence rates in male-to-female (MTF) transgender individuals highlight the need for effective targeted HIV prevention strategies for this community. In order to develop an effective vaccine that can be used by transgender …

DBH gene as predictor of response in a cocaine vaccine clinical trial
TR Kosten, CB Domingo, SC Hamon, DA Nielsen – Neuroscience Letters, 2013
Abstract We examined a pharmacogenetic association of the dopamine β-hydroxylase (DBH) gene with a response to an anti-cocaine vaccine that was tested in a recent clinical trial. This gene is associated with cocaine-induced paranoia, which has a slower onset …

Increasing Human Papillomavirus Vaccine Acceptability by Tailoring Messages to Young Adult Women’s Perceived Barriers
MA Gerend, MA Shepherd, MLA Lustria – Sexually Transmitted Diseases, 2013
Background: Human papillomavirus (HPV) vaccination is a safe and effective primary prevention strategy for cervical cancer. Despite the need for effective HPV vaccination interventions, relatively few have been tested. Moreover, existing interventions have …

Foreign Affairs
http://www.foreignaffairs.com/
Accessed 9 March 2013

Essay
Own the Goals
March/April 2013
By John W. McArthur

Since their inception in 2000, The Millennium Development Goals have revolutionized the global aid business, using specific targets to help mobilize and guide development efforts. They have encouraged world leaders to tackle multiple dimensions of poverty simultaneously and provided a standard for judging performance. As their 2015 expiration looms, the time has come to bank those successes and focus on what comes next.

Le Monde
http://www.lemonde.fr/
Accessed 9 March 2013

Idées
Prévenir le cancer et protéger les futures générations de femmes !
Le Monde.fr | 08.03.2013 à 10h29 • Mis à jour le 09.03.2013 à 15h17
Par Seth Berkley, directeur exécutif GAVI ; Jacqueline Godet, présidente de la Ligue contre le cancer

Chaque année en France, 1 000 femmes décèdent d’un cancer du col de l’utérus. Dans le monde, elles sont 275 000, c’est une femme qui meurt toutes les deux minutes, en majorité dans les pays en développement . Des cancers et des décès qui peuvent quasiment tous, être évités. La journée internationale de la femme est aujourd’hui l’occasion de rappeler que la prévention est fondamentale en matière de lutte contre le cancer et particulièrement dans le cas du cancer du col de l’utérus. Il faut, par ailleurs, briser les peurs, les tabous et préjugés qui entourent la maladie afin que tous puissent accéder aux outils qui permettent de l’éviter ou de la dépister.

La principale cause du cancer du col de l’utérus est une infection due à des virus, les Papillomavirus Humains (VPH), transmis sexuellement. Dans leur vie, 80 % des femmes sont susceptibles de les rencontrer – il existe plus d’une centaine de génotypes différents – et en général, elles vont arriver à les éliminer naturellement. Si l’infection persiste, elle provoque le développement de lésions qui peuvent évoluer en cancer. Deux outils sont à la disposition des filles et des femmes : la vaccination et le dépistage, par frottis notamment.

Le vaccin contre le VPH est disponible depuis 2006. Il a été homologué par plus de 120 pays et plus d’une quarantaine l’ont introduit dans leurs programmes de vaccination nationaux comme le recommande l’OMS. Cette vaccination ne se substitue cependant pas au dépistage car elle ne protège que contre 70 % des types de VPH mais, elle constitue un outil complémentaire essentiel. Dans certaines situations, la vaccination est également le seul rempart contre le VPH pour les femmes car elles n’ont pas ou peu accès au dépistage.

Dans le monde, le cancer du col de l’utérus constitue le deuxième cancer le plus répandu chez les femmes. Environ 85 % des femmes qui meurent du cancer du col vivent dans les pays en développement. En Afrique sub-saharienne notamment, c’est la première cause de mortalité par cancer chez les femmes . La plupart d’entre elles n’ont en effet pas accès au dépistage, ni au traitement. Par ailleurs, les tabous sont un frein, si bien que la vaccination apparaît comme le seul moyen de les protéger, de leur permettre de devenir “actrice” de leur vie de femme.

GAVI soutient ainsi cette année huit pays parmi les plus pauvres de la planète dans des projets pilotes de vaccination qui doivent démontrer la capacité des pays bénéficiaires à introduire à l’échelle nationale les vaccins intégrés à d’autres interventions de santé publique. Des milliers de jeunes filles du Ghana, du Kenya ou encore du Niger et de Madagascar vont être immunisées. A l’horizon 2020, GAVI compte l’avoir introduit dans plus de 40 pays pauvres pour protéger plus de 30 millions d’adolescentes.

Le vaccin ne peut cependant se substituer au dépistage. La Ligue contre le cancer et l’Alliance des ligues francophones africaines et méditerranéennes (ALIAM) réaffirment qu’il est nécessaire d’agir conjointement en amont de la maladie en évitant et en dépistant les cancers. Il est indispensable aussi d’agir pendant et après la maladie.

En France, plus de 50 % des femmes ne sont pas ou trop peu souvent dépistées. Les femmes appartenant par ailleurs à un ménage modeste sont deux fois plus nombreuses à ne jamais avoir eu de frottis. La Haute Autorité de santé estime que le dépistage organisé permettrait d’atteindre en quelques années une couverture de 80 % des femmes, et ainsi de réduire de plus de 20 % le nombre de décès.

Au moment où en France se prépare un plan Cancer III, tous les acteurs concernés par la prévention des cancers et en particulier par la prévention des cancers féminins se mobilisent. Cette action doit viser à lutter contre les tabous et les préjugés concernant plus spécifiquement ceux liés au cancer du col de l’utérus et à réduire les inégalités pour protéger les femmes les plus vulnérables. En cette journée internationale de la femme, c’est notre appel pour les futures générations de femmes.

Seth Berkley, directeur exécutif GAVI ; Jacqueline Godet, présidente de la Ligue contre le cancer

http://www.lemonde.fr/idees/article/2013/03/08/prevenir-le-cancer-et-proteger-les-futures-generations-de-femmes_1845051_3232.html

Washington Post
http://www.washingtonpost.com/
Accessed 9 March 2013

Sequester spin: The White House’s vaccine statistics
Posted by Glenn Kessler at 06:00 AM ET, 03/08/2013
Rep. Andy Harris (R-Md.): “Let me get it straight. Under the president’s cut of $58 million to the [Section] 317 program, you think you could get around that to avoid cutting vaccines to children, but under a sequester, that the president blames on Republicans, you don’t know if you can do that?”

CDC Director Thomas R. Frieden: “We’re going to do everything we can to limit any damage that occurs because of the across-the-board cut, but it reduces our flexibility significantly.”

Harris: “Is it your testimony that under the president’s proposed cut of $58 million in his budget to the 317 program you could have avoided cuts to vaccines to children in Maryland?”

Frieden: “We believe that we could have maintained vaccination levels, yes.”
— exchange during congressional testimony, March 5, 2013

A colleague alerted us to this interesting exchange on Capitol Hill. Is this another case of sequester spin?

On the face of it, it looks suspicious. In the White House’s fiscal 2013 budget proposal,  the administration had sought a $58 million cut in funding for the Section 317 Immunization Program, which mainly gives grants to states and localities for child and some adult vaccinations, primarily those who do not have enough insurance to be fully vaccinated. (The program gets its name from the Vaccine Assistance Act, or Section 317 of the Public Health Service Act, which was enacted in 1962.)

Yet, in raising the alarm about the sequester, the administration has highlighted the decline in vaccinations that it claims would result from sequestration. The White House Web site displays an interactive map, which when you click on Maryland, it declares: “2,050 fewer children will get vaccines for diseases like measles and whooping cough.”  It’s even worse for Virginia: 3,530 children would supposedly be affected.

What’s going on here?…

Full analysis here: http://www.washingtonpost.com/blogs/fact-checker/post/sequester-spin-the-white-houses-vaccine-statistics/2013/03/07/798295e2-877a-11e2-98a3-b3db6b9ac586_blog.html

Twitter Watch (9 March 2013 – 17:47)
Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive.

UNICEF ‏@UNICEF
IN PHOTOS: Bringing measles & rubella #vaccines to children in Mongolia by foot, by car – and by reindeer. http://uni.cf/XW28az 
10:30 p.m. – Mar 8, 2013

PATH ‏@PATHtweets
The ‘iPods’ of poverty alleviation have likely been invented.~ Steve Davis http://ow.ly/iAqMH  @HarvardBiz
12:21 p.m. – Mar 8, 2013

PAHO/WHO ‏@pahowho
Video Message from Dr. Margaret Chan, Director @WHO for the International #WomensDay 2013: http://youtu.be/Mk_0mdV5J9I  cc: @un @un_Women #IWD2013
11:55 a.m. – Mar 8, 2013

UN Spokesperson ‏@UN_Spokesperson
#UNSG Ban Ki-moon’s message on International #Women‘s Day #IWD2013 #endVAW http://bit.ly/10qbAal 
7:12 a.m. – Mar 8, 2013

IAVI ‏@AIDSvaccine
Even a partially effective #HIV #vaccine could significantly reduce the number of new HIV infections among women http://bit.ly/10kW7It  #IWD
5:11 a.m. – Mar 8, 2013

Editor’s Notes:

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

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_2 March 2013_PDF

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

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

 Bloomberg Philanthropies announced a US$100 million donation to support polio eradication efforts in the context of the Global Polio Eradication Initiative’s (GPEI) six year plan. In making the announcement, Michael Bloomberg said, “It’s unthinkable that polio still exists in the world when we have the tools and technology to protect children from this preventable, debilitating disease. Now is the time to invest in making polio history. Doing so will protect future generations of children and pave the way for other life-saving interventions to reach the world’s most vulnerable populations. We are thrilled to join the Gates Foundation and other partners in the effort to end this disease once and for all.”

Full media release: http://www.prnewswire.com/news-releases/bloomberg-philanthropies-to-donate-100-million-to-help-global-initiative-to-end-polio-forever-193799251.html

Reuters reports that “top World Health Organization officials and Islamic leaders will meet in Egypt next week in an effort to stop attacks on polio workers, which are hampering the eradication of the virus in some countries with large Muslim populations.” WHO’s Assistant Director-General Bruce Aylward told Reuters in Canberra said, “Shooting health workers who are protecting kids from this crippling disease is against the Koran and everything Islam stands for…Muslim leaders have been great advocates of immunization and generally the support has always been there. In Cairo, we are meeting senior Islamic leaders to get a sense of what we can do, and ask them ‘how can you help us?’”

http://www.reuters.com/article/2013/03/01/us-polio-idUSBRE92005320130301

Update: Polio this week – As of 27 February 2013
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s Extract and bolded text]
– In Pakistan on 26 February, a police officer providing security to a polio vaccination team was shot and killed in Mardan, Khyber Pakhtunkhwa (KP). No vaccinators were harmed. The prevailing security situation in this district has been a challenge to polio eradication activities. – This is yet another example of the often dangerous circumstances faced by frontline workers, and those who protect them.
– Afghanistan and Nigeria have reported their first wild poliovirus cases of 2013

Afghanistan
– One new WPV case was reported in the past week, a WPV1 from Nangarhar, with onset of paralysis on 31 January. It is the first WPV case in the country for 2013. The total number of WPV cases for 2012 remains 37.

Nigeria
– Two new WPV cases were reported in the past week, both WPV1s from Federal Capital Territory (FCT) and Nasarawa, with onset of paralysis on 25 January and 29 January, respectively. These are the first WPV cases in the country for 2013. The total number of WPV cases for 2012 remains 122.
– The wards of Nasarawa State and Federal Capital Territory (FCT), with recently-confirmed WPV cases, have been covered by supplementary immunization activities using bivalent OPV.

Pakistan
– One new cVDPV2 case was reported in the past week, with onset of paralysis on 11 January (from Balochistan). It is the first cVDPV2 case in the country for 2013. The total number of cVDPV2 cases for 2012 remains 16.
– The security situation continues to be monitored closely, in consultation with law enforcement agencies. Based on these security evaluations, immunization campaigns then proceed at local level as and when the situation allows. Immunization campaigns were conducted throughout February in key reservoir areas.

The Weekly Epidemiological Record (WER) for 1 March 2013, vol. 88, 9 (pp. 89–100) includes:
– Framework for verifying elimination of measles and rubella
– Monthly report on dracunculiasis cases, January–December 2012

http://www.who.int/entity/wer/2013/wer8809.pdf

Global Immunization News February 2013 Issue
http://www.who.int/immunization/GIN_February_2013.pdf

Inside this issue:
– Burundi introducing Measles second dose
– Project Optimize Comes to an End in Guatemala
– Trinidad and Tobago rolls out HPV Vaccination Programme for Adolescent girls
– WHO and GAVI conduct a Joint Review of the Bhutan Health Trust Fund
– PAHO Revolving Fund Makes Influenza Vaccines More Available to Countries
– V3P Vaccine Product, Price and Procurement Project Entering Development Phase
– First Mobile Laboratory in Guinea
– Vaccine Procurement System Assessment in Ukraine

Meetings/Workshops
– Regional Consultation on the Introduction of New Vaccines in South East Asia
Excerpt
NEW GAVI POLICY ON FRAGILITY AND IMMUNIZATION
Introducing greater flexibility will enable GAVI to better respond to long and short term challenges faced by countries.
In December 2012, the GAVI Alliance Board approved a new policy on a country-by-country approach for GAVI in states that are fragile and face immunization challenges. The policy allows GAVI to work with its partners to strengthen its focus on countries that require more intensive support and attention.

What is the purpose of the policy?
Public, country and expert consultations show that there are a number of GAVI-eligible countries that face exceptional challenges over long periods of time, limiting their ability to access and implement GAVI support.

Working closely with partners and in-country stakeholders, the new policy allows GAVI to develop a tailored approach for each of these countries and to adjust our support to better relate to the specific country context.

The policy also recognises that there are countries that may experience time-limited man-made or natural emergencies. For these situations, GAVI will provide one-off flexibilities in order to help protect immunisation systems and existing GAVI support. After such an event has occurred, the country Government or an in-country partner (WHO or UNICEF) may submit a request to GAVI using the short template available on the GAVI web site.

When is the policy applied and how does it work?
The policy includes a framework that serves as a transparent tool for identifying a number of countries to receive long-term intensified support from the GAVI Alliance. The framework will be applied on an annual basis to ensure that GAVI responds to those countries most in need.

The new policy also offers guidance for countries that experience emergency situations, in which case a request can be submitted to GAVI by the country, WHO or UNICEF.

For countries that are not identified for a tailored approach, several other work streams are available within GAVI and across the Alliance to address specific challenges, e.g. focused support for countries with DTP3 coverage under 70%, equity or data quality challenges.

UN Secretary-General Ban Ki-moon announced the appointment of Ray Chambers of the United States as his Special Envoy for Malaria and for the Financing of the Health-Related Millennium Development Goals. The announcement noted that Mr. Chambers has served as the Secretary-General’s Special Envoy for Malaria since February 2008.  During that time, “visibility, awareness, and funding for malaria have increased exponentially, with more than $4 billion raised, over 400 million mosquito nets distributed and millions of treatment courses administered.  Yet, malaria continues to kill an African child every minute.  With a further push, deaths can be brought down to near zero by the end of 2015.”  In his new capacity and focus on financing, Mr. Chambers “will collaborate with United Nations agencies, funds and programmes to promote and secure increased investment by the public and private sectors to achieve the health-related Millennium Development Goals of child and maternal mortality, HIV/AIDS, malaria, tuberculosis and other diseases by the end of December 2015, the internationally agreed deadline for achieving the Goals.”

http://www.un.org/News/Press/docs//2013/sga1391.doc.htm

The Global Fund to Fight AIDS, Tuberculosis and Malaria today launched “a new funding model that allows it to invest more strategically, achieve greater impact, and engage implementers and partners more effectively. The new funding model provides countries that implement grants with more flexibility around when they apply for funds, as well as more predictability on the level of funding available, while still encouraging countries to clearly express how much funding they need to effectively treat and prevent HIV and AIDS, TB and Malaria.”  The Global Fund noted that up to US$1.9 billion may be available for the new funding model’s transition period, in 2013 and 2014. Full implementation of the new funding model will begin in early 2014 and will grant money in the 2014-2016 period. Based on the available funding, “47 countries may receive up to US$1.5 billion through renewals, grant extensions and redesigned programs that can rapidly make use of funds in 2013. As ‘interim applicants,’ these countries can immediately accelerate current programs that are highly effective.”    The new funding model “also encourages countries to strengthen national strategies by incorporating HIV and AIDS, tuberculosis and malaria treatment and prevention in a holistic, programmatic approach. Further, it supports countries in consolidating existing funding streams and redesigning grants as needed around coherent, strategic and high impact investments that are aligned with domestic and other external funding sources.”

http://www.theglobalfund.org/en/mediacenter/newsreleases/2013-02-28_Global_Fund_Launches_New_Funding_Model/

Consultative Report: Health in the Post-2015 Development Agenda
UN-WHO
March 2013  –  77 pages
http://www.worldwewant2015.org/health
Draft report – health in the post-2015 development agenda
http://www.worldwewant2015.org/file/311537/download/338636

Based on the comments received a revised draft report has been prepared, to be considered at the High Level Dialogue on health in the post-2015 development  which will take place in Botswana 5 and 6 of March 2013. This report can be seen at the link below, and a final report will be issued by the end of March. draft report

Policy Report: Renewing US Leadership: Policies to Advance Global Health Research
Global Health Technologies Coalition, PATH
March 2013

This research highlights recent scientific and policy achievements that have spurred the development of important health innovations such as vaccines, drugs, and diagnostics.

It also offers recommendations for how US policymakers can continue making critical investments to produce the next generation of global health tools—proposals that are especially timely given the looming US budget cuts that threaten decades of work to develop tools against major killers, including AIDS, tuberculosis, and malaria. The report makes recommendations in two areas: advancing global health research and maximizing US investments in research and development.

http://www.path.org/news/an130226-ghtc-report.php

Meeting: Eighth International Conference on Typhoid Fever and Other Invasive Salmonelloses
Dhaka, Bangladesh
1-2 March 2013

International and regional health experts will convene in to review progress on the control and prevention of typhoid fever, enteric fever (disease caused by typhoid or paratyphoid), and disease caused by invasive non-typhoidal salmonella, including news on the development/licensure of next generation vaccines. The is being organized by the Coalition against Typhoid (CaT) Secretariat, alongside its partners icddr,b,  the Bangladesh Pediatric Association (BPA) and the International Vaccine Institute (IVI).

Dr. Christopher Nelson, Director of the CaT Secretariat at Sabin Vaccine Institute, said, “This meeting will facilitate a vital conversation between clinicians, researchers and government leaders from around the world and across Asia. It is important to discuss the highly endemic rates of typhoid in the region and how typhoid vaccines can help control and prevent disease.”
www.typhoidconference.org.

About The Coalition against Typhoid (CaT)
The Coalition against Typhoid (CaT) is a global forum of scientists and immunization experts working to save lives and reduce suffering by advancing typhoid vaccination in high burden communities who is one amongst other leading alliances. By prioritizing typhoid on the global health agenda and developing a comprehensive work plan to combat this disease, the Coalition against Typhoid eagerly anticipates expanding access to these life-saving vaccines. Learn more about CaT at http://www.coalitionagainsttyphoid.org/
http://www.sabin.org/updates/pressreleases/international-conference-present-progress-typhoid-fever-control-and-prevention

WHO Euro: Intersectoral coordination and disease control at points of entry – critical to avert and control health crises
1 March 2013

European countries have identified intersectoral coordination and disease control at international airports, ports and ground crossings (points of entry) as critical to ensuring their effective implementation of the International Health Regulations (IHR). This would help avert and control health crises, such as the influenza pandemic and the recent outbreaks of foodborne disease and of measles affecting many European countries.

This was the main conclusion of over 100 participants from 50 IHR State Parties, who gathered in Luxembourg on 26–27 February 2013 to discuss the achievements and remaining challenges in the WHO European Region in improving preparedness for and response to health crises under the IHR.

The meeting addressed the IHR as a collective responsibility to foster global health security, including crisis preparedness and response. It is part of a global series of such implementation meetings taking place in all WHO regions.

http://www.euro.who.int/en/what-we-do/health-topics/emergencies/international-health-regulations/news/news/2013/03/intersectoral-coordination-and-disease-control-at-points-of-entry-critical-to-avert-and-control-health-crises

British Medical Journal
02 March 2013 (Vol 346, Issue 7897)
http://www.bmj.com/content/346/7897

Research
Risk of narcolepsy in children and young people receiving AS03 adjuvanted pandemic A/H1N1 2009 influenza vaccine: retrospective analysis
Elizabeth Miller, consultant epidemiologist1, Nick Andrews, senior statistician2, Lesley Stellitano, public health researcher13, Julia Stowe, research fellow14, Anne Marie Winstone, public health researcher13, John Shneerson, consultant physician5, Christopher Verity, consultant paediatric neurologist13
BMJ 2013;346:f794 (Published 26 February 2013)
http://www.bmj.com/content/346/bmj.f794

Abstract
Objective – To evaluate the risk of narcolepsy in children and adolescents in England targeted for vaccination with ASO3 adjuvanted pandemic A/H1N1 2009 vaccine (Pandemrix) from October 2009.

Design – Retrospective analysis. Clinical information and results of sleep tests were extracted from hospital notes between August 2011 and February 2012 and reviewed by an expert panel to confirm the diagnosis. Vaccination and clinical histories were obtained from general practitioners.

Setting – Sleep centres and paediatric neurology centres in England.

Participants – Children and young people aged 4-18 with onset of narcolepsy from January 2008.

Main outcome measures The odds of vaccination in those with narcolepsy compared with the age matched English population after adjustment for clinical conditions that were indications for vaccination. The incidence of narcolepsy within six months of vaccination compared with the incidence outside this period measured with the self controlled cases series method.

Results – Case notes for 245 children and young people were reviewed; 75 had narcolepsy (56 with cataplexy) and onset after 1 January 2008. Eleven had been vaccinated before onset; seven within six months. In those with a diagnosis by July 2011 the odds ratio was 14.4 (95% confidence interval 4.3 to 48.5) for vaccination at any time before onset and 16.2 (3.1 to 84.5) for vaccination within six months before onset. The relative incidence from the self controlled cases series analysis in those with a diagnosis by July 2011 with onset from October 2008 to December 2010 was 9.9 (2.1 to 47.9). The attributable risk was estimated as between 1 in 57 500 and 1 in 52 000 doses.

Conclusion – The increased risk of narcolepsy after vaccination with ASO3 adjuvanted pandemic A/H1N1 2009 vaccine indicates a causal association, consistent with findings from Finland. Because of variable delay in diagnosis, however, the risk might be overestimated by more rapid referral of vaccinated children.

Bulletin of the World Health Organization
Volume 91, Number 3, March 2013, 157-236
http://www.who.int/bulletin/volumes/91/3/en/index.html

Identifying high-risk areas for sporadic measles outbreaks: lessons from South Africa
Benn Sartorius, C Cohen, T Chirwa, G Ntshoe, A Puren & K Hofman
http://www.who.int/bulletin/volumes/91/3/12-110726-ab/en/index.html

Abstract
Objective
To develop a model for identifying areas at high risk for sporadic measles outbreaks based on an analysis of factors associated with a national outbreak in South Africa between 2009 and 2011.

Methods
Data on cases occurring before and during the national outbreak were obtained from the South African measles surveillance programme, and data on measles immunization and population size, from the District Health Information System. A Bayesian hierarchical Poisson model was used to investigate the association between the risk of measles in infants in a district and first-dose vaccination coverage, population density, background prevalence of human immunodeficiency virus (HIV) infection and expected failure of seroconversion. Model projections were used to identify emerging high-risk areas in 2012.

Findings
A clear spatial pattern of high-risk areas was noted, with many interconnected (i.e. neighbouring) areas. An increased risk of measles outbreak was significantly associated with both the preceding build-up of a susceptible population and population density. The risk was also elevated when more than 20% of infants in a populous area had missed a first vaccine dose. The model was able to identify areas at high risk of experiencing a measles outbreak in 2012 and where additional preventive measures could be undertaken.

Conclusion
The South African measles outbreak was associated with the build-up of a susceptible population (owing to poor vaccine coverage), high prevalence of HIV infection and high population density. The predictive model developed could be applied to other settings susceptible to sporadic outbreaks of measles and other vaccine-preventable diseases.

Development in Practice
Volume 23, Issue 1, 2013
http://www.tandfonline.com/toc/cdip20/current
Reaching beyond the health post: Community-based surveillance for polio eradication
Dora Curry, Filimona Bisrat, Ellen Coates & Penny Altman
pages 69-78  DOI:10.1080/09614524.2013.753410

Abstract
This article discusses the CORE Group Polio Project Ethiopia’s introduction of community-based surveillance (CBS) of acute flaccid paralysis (AFP) to support polio eradication. A USAID-funded collaboration among Ethiopian and US-based NGOs, the CGPP supports volunteers in education about AFP and encouraging case reporting. Volunteers also conduct active case searches, visiting community leaders likely to have contact with paralysis cases. The project’s methods strengthen communities’ awareness of AFP and their connection to the health system. Data indicate a near doubling of AFP reporting in project areas since the implementation of CBS, according to MOH-E (Ministry of Health, Ethiopia)/WHO statistics.

Eurosurveillance
Volume 18, Issue 9, 28 February 2013
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Research articles
The number of deaths among infants under one year of age in England with pertussis: results of a capture/recapture analysis for the period 2001 to 2011
A J van Hoek 1, H Campbell1, G Amirthalingam1, N Andrews2, E Miller1
Immunisation, Hepatitis and Blood Safety Department, Health Protection Agency, London, United Kingdom
Statistics Unit, Health Protection Services, Health Protection Agency, London, United Kingdom
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20414

Abstract
Pertussis activity in England in 2012 was at its highest level for more than 12 years, leading to an increased number of deaths, especially among infants who were too young to be vaccinated. To support decision making on the introduction of maternal immunisation as an outbreak response measure to prevent these early deaths, we analysed reported deaths amongst infants of less than one year of age during the period from 2001 to 2011 with a capture/recapture analysis. We used log linear regression to allow for interactions. Reported deaths were obtained from the Hospital Episode Statistics for England, death registered by the Office of National Statistics and the enhanced surveillance of laboratory-confirmed pertussis conducted by the Health Protection Agency. There were a total of 48 deaths recorded; of these 41 had a disease onset before being fully protected by vaccination. Around half of these deaths (23) were recorded in all three datasets and 10 in only one. Due to the high coverage of the datasets the estimated number of deaths missed was small with 1.6 (95% confidence interval (CI): 0.5–4.5) deaths. The total average incidence was 0.721 (95% CI: 0.705–0.763) per 100,000 maternities. We concluded that under ascertainment of deaths from diagnosed pertussis cases is small.

Forum for Development Studies
Volume 40, Issue 1, 2013
http://www.tandfonline.com/toc/sfds20/current
Frontline Vaccinators and Immunisation Coverage in Malawi
Lot Nyirenda & Rune Flikke
pages 27-46

Abstract
Access to health services for the poor, especially in the Global South, is a major challenge to achieving health targets like those under the millennium development goals. In Malawi, health surveillance assistants (HSAs) have been instrumental in bringing health services, including immunisation, to remote areas amidst an acute shortage of professional healthcare workers. On the basis of ethnographic fieldwork and historical sources, we describe and analyse the roles played by HSAs in delivering immunisation in Malawi. As frontline vaccinators, HSAs work under adverse conditions with low remuneration, rare upward career mobility and inadequate equipment. All the same, HSA immunisation services are generally considered satisfactory by supervisors as well as by caretakers/mothers among the local population. Without adequate resources for the supervision and continuous training of HSAs, however, the quality of immunisation and other services may be compromised. Unlike professional healthcare workers like nurses and doctors, HSAs undergo only limited training and can be easily replaced. Such a situation makes them vulnerable, a scenario which throws up a cruel paradox: in the HSAs’ vulnerability lies the key to the health system. Amidst high unemployment and poverty levels however, the admittedly low salaries help to retain HSAs and enable them have a better life than most Malawians who live below the poverty line. The Malawi case demonstrates that, rather than relying on unpaid volunteers, community health work can be sustainable if the workers have a secure salary mainstreamed within the public health sector.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 9, Issue 3    March 2013    Pages 447 – 719
http://www.landesbioscience.com/journals/vaccines/toc/volume/9/issue/3/

Special Issue: Vaccines, Immunisation and Immunotherapy
Based on the Eighth World Congress on Vaccines, Immunisation and Immunotherapy
Barcelona, Spain, June 5-7, 2012

Results of the rubella elimination program in Catalonia (Spain), 2002–2011
Irene Barrabeig, Nuria Torner, Ana Martínez, Gloria Carmona, Pilar Ciruela, Joan Batalla, Josep Costa, Sergi Hernández, Luis Salleras, Angela Domínguez and the Rubella Surveillance Group of Catalonia
Pages 642 – 648
http://dx.doi.org/10.4161/hv.23260
Abstract | PDF

REVIEW
Progress in the elimination of measles and congenital rubella in Central Italy
Angela Bechini, Miriam Levi, Sara Boccalini, Emilia Tiscione, Donatella Panatto, Daniela Amicizia and Paolo Bonanni
Pages 649 – 656
http://dx.doi.org/10.4161/hv.23261
Abstract | PDF

Surveillance of hospitalized and outpatient cases of pertussis in Catalonia from 2003 to 2009
Inma Crespo Fernández, Núria Soldevila, Gloria Carmona, Maria Rosa Sala, Pere Godoy, Angela Domínguez and the Pertussis Surveillance Group of Catalonia
Pages 667 – 670
http://dx.doi.org/10.4161/hv.23263
Abstract | Full Text | PDF

Epidemiology of two large measles virus outbreaks in Catalonia: What a difference the month of administration of the first dose of vaccine makes
Núria Torner, Andres Anton, Irene Barrabeig, Sara Lafuente, Ignasi Parron, César Arias, Neus Camps, Josep Costa, Ana Martínez, Roser Torra, Pere Godoy, Sofia Minguell, Glòria Ferrús, Carmen Cabezas, Ángela Domínguez, the Measles Elimination Program Surveillance Network of Catalonia and Spain
Pages 675 – 680
http://dx.doi.org/10.4161/hv.23265
Abstract | Full Text | PDF

Epidemiology of vaccine-preventable invasive diseases in Catalonia in the era of conjugate vaccines
Pilar Ciruela, Ana Martínez, Conchita Izquierdo, Sergi Hernández, Sonia Broner, Carmen Muñoz-Almagro, Àngela Domínguez and the Microbiological Reporting System of Catalonia Study Group
Pages 681 – 691
http://dx.doi.org/10.4161/hv.23266
Abstract | Full Text | PDF

RESEARCH PAPERS
Open Access Article
Effectiveness of the WC/rBS oral cholera vaccine in the prevention of traveler’s diarrhea: A prospective cohort study
Rosa López-Gigosos and 21 others
Pages 692 – 698
http://dx.doi.org/10.4161/hv.23267
Abstract | Full Text | PDF

Cost-effectiveness of new adult pneumococcal vaccination strategies in Italy
Sara Boccalini, Angela Bechini, Miriam Levi, Emila Tiscione, Roberto Gasparini and Paolo Bonanni
Pages 699 – 706
http://dx.doi.org/10.4161/hv.23268
Abstract | Full Text | PDF

Economic benefits of inactivated influenza vaccines in the prevention of seasonal influenza in children
Luis Salleras, Encarna Navas, Nuria Torner, Andreu A. Prat, Patricio Garrido, Núria Soldevila and Angela Domínguez
Pages 707 – 711
http://dx.doi.org/10.4161/hv.23269
Abstract | PDF

JAMA   
February 27, 2013, Vol 309, No. 8
http://jama.ama-assn.org/current.dtl

Why the Ethics of Parsimonious Medicine Is Not the Ethics of Rationing
Jon C. Tilburt, MD; Christine K. Cassel, MD
JAMA. 2013;309(8):773-774. doi:10.1001/jama.2013.368
http://jama.jamanetwork.com/article.aspx?articleid=1656264

Extract
The ethics of rationing health care resources has been debated for decades. Opponents of rationing are concerned that societal interests will supplant respect for individual patient choice and professional judgment. Advocates argue that injustices in the current system necessitate that physicians use resources prudently on behalf of society, even in their daily work with individual patients. The debate is important, potentially divisive, and unavoidable.

Various groups have championed the cause of medicine practiced leanly, consistent with the professional responsibility to use resources wisely. These initiatives, which champion “parsimonious medicine,” have highlighted the 20% of routine practices in US medicine that add no demonstrable value to health care but that persist in the inertia and rituals of clinical work.1 The specialty societies and the Choosing Wisely collaborative2 outline commonsense principles for avoiding unnecessary, wasteful care…

Journal of Infectious Diseases
Volume 207 Issue 7   April 1, 2013
http://www.journals.uchicago.edu/toc/jid/current

MAJOR ARTICLES AND BRIEF REPORTS
VIRUSES
Exposure to Influenza Virus Aerosols During Routine Patient Care
Werner E. Bischoff, Katrina Swett, Iris Leng, and Timothy R. Peters
J Infect Dis. (2013) 207(7): 1037-1046 doi:10.1093/infdis/jis773
http://jid.oxfordjournals.org/content/207/7/1037.abstract

Abstract
Background. Defining dispersal of influenza virus via aerosol is essential for the development of prevention measures.

Methods. During the 2010–2011 influenza season, subjects with influenza-like illness were enrolled in an emergency department and throughout a tertiary care hospital, nasopharyngeal swab specimens were obtained, and symptom severity, treatment, and medical history were recorded. Quantitative impaction air samples were taken not ≤0.305 m (1 foot), 0.914 m (3 feet), and 1.829 m (6 feet) from the patient’s head during routine care. Influenza virus was detected by rapid test and polymerase chain reaction.

Results. Sixty-one of 94 subjects (65%) tested positive for influenza virus. Twenty-six patients (43%) released influenza virus into room air, with 5 (19%) emitting up to 32 times more virus than others. Emitters surpassed the airborne 50% human infectious dose of influenza virus at all sample locations. Healthcare professionals (HCPs) were exposed to mainly small influenza virus particles (diameter, <4.7 µm), with concentrations decreasing with increasing distance from the patient’s head (P < .05). Influenza virus release was associated with high viral loads in nasopharyngeal samples (shedding), coughing, and sneezing (P < .05). Patients who reported severe illness and major interference with daily life also emitted more influenza virus (P < .05).

Conclusions. HCPs within 1.829 m of patients with influenza could be exposed to infectious doses of influenza virus, primarily in small-particle aerosols. This finding questions the current paradigm of localized droplet transmission during non–aerosol-generating procedures.

Journal of Infectious Diseases
Volume 207 Issue 7   April 1, 2013
http://www.journals.uchicago.edu/toc/jid/current

Combined Effects of Antenatal Receipt of Influenza Vaccine by Mothers and Pneumococcal Conjugate Vaccine Receipt by Infants: Results from a Randomized, Blinded, Controlled Trial
Saad B. Omer, Khalequ Zaman, Eliza Roy, Shams E. Arifeen, Rubhana Raqib, Laila Noory, Katherine Seib, Robert F. Breiman, and Mark C. Steinhoff
J Infect Dis. (2013) 207(7): 1144-1147 doi:10.1093/infdis/jit003
http://jid.oxfordjournals.org/content/207/7/1144.abstract

Abstract
A 2 × 2 factorial trial was performed to determine the efficacy of antennal influenza vaccination of mothers plus pneumococcal conjugate vaccination of their infants against respiratory illness during early infancy. The efficacy of trivalent inactivated influenza vaccine (TIV; delivered to mothers) plus 7-valent pneumococcal vaccine (PCV7; delivered to infants) was higher than the efficacy of TIV alone or PCV7 alone. During the period of the study in which influenza was circulating, the efficacy of TIV plus PCV7 was 72.4% (95% confidence interval, 30.2%–89.1%) against febrile respiratory illness and 66.4% (95% CI, 14.3%–86.9%) against medically attended acute respiratory illness. Clinical Trials registration NCT00142389.