Trends in the types and quality of childhood immunisation research output from Africa 1970-2010: mapping the evidence base

[PDF] Trends in the types and quality of childhood immunisation research output from Africa 1970-2010: mapping the evidence base
S Machingaidze, GD Hussey, CS Wiysonge – BMC Health Services Research, 2014

Background: Over the past four decades, extraordinary progress has been made in establishing and improving childhood immunization programmes around Africa. In order to ensure effective and sustainable positive growth of these childhood immunisations programmes, the development, adaptation and implementation of all interventions (programme activities, new vaccines, new strategies and policies) should be informed by the best available local evidence.

Methods: An assessment of the peer-reviewed literature on childhood immunization research published in English from 1970 to 2010 was conducted in PubMed and Africa-Wide databases. All study types were eligible for inclusion. A standard form was used to extract information from all studies identified as relevant and entered into a Microsoft Access database for analysis.

Results: Our initial search yielded 5,436 articles from the two databases, from which 848 full text articles were identified as relevant. Among studies classified as clinical research (417), 40% were clinical trials, 24% were burden of disease/epidemiology and 36% were other clinical studies. Among studies classified as operational research (431), 77% related to programme management, 18% were policy related and 5% were related to vaccine financing. Studies were conducted in 48 African countries with six countries (South Africa, The Gambia, Nigeria, Senegal, Guinea-Bissau and Kenya) accounting for 56% of the total research output. Studies were published in 152 different journals with impact factors ranging from 0.192 to 53.29; with a median impact factor of 3.572.

Conclusion: A similar proportion of clinical versus operational research output was found. However, an uneven distribution across Africa was observed with only six countries accounting for over half of the research output. The research conducted was of moderate to high quality, with 62% being published in journals with 2010 impact factors greater than two. Urgent attention should be given to the development of research capacity in low performing countries around Africa, with increased focus on the process of turning immunisations programme research evidence into policy and practice, as well as increased focus on issues relating to vaccine financing and sustainability in Africa.

Inside the world’s largest polio reservoir — the city of Peshawar

Al Jazeera
Accessed 15 February 2014

Inside the world’s largest polio reservoir
The city of Peshawar, in northwestern Pakistan, is a hotspot for the crippling virus.
Arsla Jawaid Last updated: 08 Feb 2014 14:43
Peshawar, Pakistan – Almost 60 years after Jonas Salk developed a vaccine for the polio virus, the crippling disease remains endemic in just three countries: Afghanistan, Pakistan, and Nigeria.

Of those, only Pakistan saw an increase in the number of cases reported last year, from 58 cases in 2012 to 93 in 2013. More than 90 percent of these were found to be genetically linked to a strain of the virus emanating from the northwestern city of Peshawar.

According to a statement released by the World Health Organization (WHO), all environmental sewage samples collected over the past six months in Peshawar have tested positive for the presence of poliovirus, making the urban centre of approximately four million the world’s “largest poliovirus reservoir”, or source of infection…

Vaccines and Global Health :: The Week in Review 8 Feb 2014

Vaccines and Global Health: 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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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

WHO Media Note: Measles deaths reach record lows with fragile gains toward global elimination

WHO Media Note: Measles deaths reach record lows with fragile gains toward global elimination
6 February 2014
New mortality estimates from WHO show that annual measles deaths have reached historic lows, dropping 78% from more than 562,000 in 2000 to 122,000 in 2012. During this time period, “an estimated 13.8 million deaths have been prevented by measles vaccination” and surveillance data showed that reported cases declined 77% from 853,480 to 226,722.

These gains are a result of global routine measles immunization coverage holding steady at 84% and 145 countries having introduced a routine second dose of measles vaccine to ensure immunity and prevent outbreaks. In addition to routine immunization, countries vaccinated 145 million children during mass campaigns against measles in 2012 and reached more than 1 billion since 2000, with the support of the Measles & Rubella Initiative.

Despite the impressive gains made, progress towards measles elimination remains uneven with some populations still unprotected. Measles continues to be a global threat, with five of six WHO regions still experiencing large outbreaks and with the Region of the Americas responding to many importations of measles cases. The African, Eastern Mediterranean and European regions are not likely to meet their measles elimination targets on time. The Region of the Americas has achieved measles elimination and continues to maintain this status while the Western Pacific region is approaching its target.

Routine measles vaccination coverage is an important progress indicator towards meeting Millennium Development Goal Four3 because of its potential to reduce child mortality and widely recognized as a marker of access to children’s health services…

   The Weekly Epidemiological Report (WER) for 7 February 2014, vol. 89, 6 (pp. 45–52) includes:
:: Global control and regional elimination of measles, 2000–2012

Polio Round-up: [to 8 February 2014]

Update: Polio this week – As of 5 February 2014
Global Polio Eradication Initiative
Full report:
[Editor’s extract and bolded text]
:: In a commentary piece published last week in the Lancet, WHO Regional Director for the Eastern Mediterranean Dr Ala Alwan, and WHO Assistant Director-General for Polio, Emergencies and Country Collaboration Dr Bruce Aylward, outline the challenges to meet the country’s health needs, and what WHO and its partners are doing to urgently support regional polio outbreak response activities. More.
:: Pakistan remains the only country with areas of uncontrolled transmission of polio, particularly in parts of Federally Administered Tribal Areas (FATA) and Khyber Pakhtunkhwa. More than 80% of cases in Pakistan since September are from these areas.
:: Three new WPV1 cases were reported in the past week, two from North Waziristan in FATA (with onset of paralysis on 10 and 16 January 2014), and one from greater Karachi, Sindh (with onset of paralysis on 31 December 2013). The total number of cases for 2013 is 93. The total number of cases in 2014 is seven. The most recent case had onset of paralysis on 16 January 2014 (WPV1 from North Waziristan)…
:: North Waziristan is the district with the largest number of children being paralyzed by poliovirus in the world (both wild and VDPV2). Immunization activities have been suspended by local leaders since June 2012. It is critical that children in all areas are vaccinated and protected from poliovirus. Immunizations in neighbouring high-risk areas are being intensified, to further boost population immunity levels in those areas and prevent further spread of this outbreak.
:: Since September, 67 WPV1 cases have been reported from Pakistan, 55 of them from FATA and Khyber Pakhtunkhwa. North Waziristan has had 35 of the country’s 93 WPV1 cases in 2013 and all seven WPV1 cases in 2014. Additionally, North Waziristan had 38 of the country’s 45 cVDPV2 cases in 2013, and one from 2014.
:: Peshawar is considered to be the main engine of transmission, alongside North Waziristan, due to large-scale population movements through Peshawar from across this region, and into other areas of Pakistan. The quality of operations must be urgently improved in Peshawar, and immunizations resumed in North Waziristan.
:: However, at the same time, concerning trends have been noted in greater Karachi, Sindh, in Quetta, Balochistan, and environmental positives isolates from every major city of Punjab confirm widespread virus circulation.

UN: Polio vaccination campaign begins at besieged Palestinian refugee camp in Syria
5 February 2014 – The United Nations agency assisting Palestinian refugees said today it has begun a large-scale polio vaccination campaign targeting thousands of children in the Yarmouk refugee camp in Damascus.

The UN Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) and its partners have been attempting for months to take desperately needed aid, particularly food and medicines, to Yarmouk, whose 18,000 residents have been trapped for months amid the ongoing conflict in Syria.

“We are pleased to announce that UNRWA has secured the formal authorization for the transfer of 10,000 polio vaccines to Yarmouk Camp in Damascus,” said Chris Gunness, a spokesperson for the Agency.

“This process has been completed without incident and the vaccination of thousands children in the camp is now underway”…

Pakistan: Government vows to eradicate polio in 2014
The International News
February 06, 2014   From Print Edition
UNITED NATIONS: Despite the security challenges, Ambassador Masood Khan has told a United Nations panel that Pakistan, under the leadership of Prime Minister Muhammad Nawaz Sharif, hopes to eradicate polio in 2014.

“We have come a long way in eliminating polio from the country,” he told the UNICEF Executive Board which opened this year’s first session on Tuesday.

“Almost 95 percent of the country is now polio free. More is needed, however, the Pakistani envoy said. “We are therefore now implementing an augmented National Emergency Action Plan (NEAP) to eradicate polio in 2014,” he told delegates.

“Prime Minister Muhammad Nawaz Sharif is leading the efforts to eradicate polio which threatens our future generations. To accomplish this mission, the prime minister has created a Polio Eradication Cell in his office and has designated a focal point to coordinate actions between the federal, provincial and local governments.”

The Pakistani envoy said President Mamnoon Hussain launched immunization programme in Khyber Pakhtunkhwa last month by convening a Grand Jirga where he secured the support of local community, specially Ulema and tribal leaders.

“Despite security challenges, our valiant polio workers continue to perform their tasks with devotion and dedication,” Masood Khan said. “We salute their perseverance and commitment. We condemn terrorist attacks against them. We pay a tribute to the volunteers who have lost their lives while eradicating the menace of polio from our country.”…

The Lawrence Ellison Foundation announced a planned gift of US$100 million over five years to support global polio eradication, noting that roughly US$20 million of that contribution was delivered in 2013. The donation will help fund the Global Polio Eradication Initiative’s (GPEI) $5.5 billion six-year plan to eradicate polio.

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

WHO: Global Alert and Response (GAR) – Disease Outbreak News
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 7 February 2014
On 3 February 2014, United Arab Emirates (UAE) notified WHO of an additional laboratory-confirmed case of Middle East Respiratory Syndrome coronavirus (MERS-CoV) infection…
Globally, from September 2012 to date, WHO has been informed of a total of 182 laboratory-confirmed cases of infection with MERS-CoV, including 79 deaths…

:: Human infection with avian influenza A(H7N9) virus – update 7 February 2014
On 5 February 2014, the National Health and Family Planning Commission (NHFPC) of China notified WHO of ten additional laboratory-confirmed cases of human infection with avian
influenza A(H7N9) virus… So far, there is no evidence of sustained human-to-human transmission.

The Chinese Government continues to take the following surveillance and control measures:
–       strengthen surveillance and situation analysis;
–       reinforce case management and treatment;
–       conduct risk communication with the public and release information;
–       strengthen international collaboration and communication; and
–       conduct scientific studies.

While the recent report of avian influenza A(H7N9) virus being detected in live poultry imported from the mainland to Hong Kong SAR, shows the potential for the virus to spread
through live poultry, at this time there is no indication that international spread of avian influenza A(H7N9) has occurred through humans or animals.

Further sporadic human cases of A(H7N9) infection are expected in affected and possibly neighbouring areas, especially given expected increases in the trade and transport of poultry associated with the Lunar New Year…

:: Human infection with avian influenza A(H7N9) virus – update 5 February 2014
:: Human infection with avian influenza A(H7N9) virus – update 5 February 2014

Dr Robert Newman appointed head of Policy and Performance at GAVI

GAVI Watch [to 8 February 2014]
:: Dr Robert Newman appointed head of Policy and Performance at GAVI Alliance Geneva

3 February 2014 – Dr Robert Newman has joined the GAVI Alliance as the new Managing Director of Policy and Performance. He will be responsible for ensuring GAVI retains its position as a leading performer in terms of results and value for money.

Dr Newman will be based at the Alliance’s Geneva headquarters and will report to the Executive Office. He will lead teams focused on ensuring the organisation is delivering on its strategic plan, market shaping and monitoring and evaluating the performance of its programmes.

“I am delighted to be joining GAVI, and be part of a dynamic and dedicated team working in partnership to deliver on a clear and compelling mission,” he said of his appointment. “As a paediatrician, it is a particular honour to become part of an organisation whose success is critical for the health of children around the world.”

“Robert’s appointment comes at a critical time for the GAVI Alliance as we look towards our next strategic period,” said Dr Seth Berkley. “The skills and experience that he will bring to GAVI will play an important part in helping us reach more children with lifesaving vaccines.”

Dr Newman succeeds Nina Schwalbe who is leaving GAVI to take up the position of Principal Advisor, Health, at UNICEF in New York….

Dr Newman joins GAVI from the World Health Organization, where he has spent the past four-and-a-half years as the director of the Global Malaria Programme. During his time at WHO, Dr Newman led a team that redefined the global fight against malaria with improved evidence collation and analysis and the creation of the Malaria Policy Advisory Committee to help guide countries by translating the latest research into public health policies…

EU alllocates US$431 M to boost UNICEF partnership


EU and UNICEF boost their partnership to improve child and maternal health and to save more children
NEW YORK, 4 February 2014 – The European Union announced today that it has allocated €320 million ($431 million) through UNICEF to improve the health and nutrition of children and women in 15 developing countries and to help speed progress in meeting the Millennium Development Goals.

MMWR – February 7, 2014 / Vol. 63 / No. 5

CDC/MMWR Watch [to 8 February 2014]

MMWR – February 7, 2014 / Vol. 63 / No. 5
:: Noninfluenza Vaccination Coverage Among Adults — United States, 2012
Walter W. Williams, MD1, Peng-Jun Lu, MD, PhD1, Alissa O’Halloran, MSPH1, Carolyn B. Bridges, MD1,Tamara Pilishvili, MPH2, Craig M. Hales3, MD, Lauri E. Markowitz, MD4 (Author affiliations at end of text)
Vaccinations are recommended throughout life to prevent vaccine-preventable diseases and their sequelae. Adult vaccination coverage, however, remains low for most routinely recommended vaccines (1) and well below Healthy People 2020 targets.* In October 2013, the Advisory Committee on Immunization Practices (ACIP) approved the adult immunization schedule for 2014 (2). With the exception of influenza vaccination, which is recommended for all adults each year, vaccinations recommended for adults target different populations based on age, health conditions, behavioral risk factors (e.g., injection drug use), occupation, travel, and other indications (2). To assess vaccination coverage among adults aged ≥19 years for selected vaccines, CDC analyzed data from the 2012 National Health Interview Survey (NHIS). This report summarizes the results of that analysis for pneumococcal, tetanus toxoid–containing (tetanus and diphtheria vaccine [Td] or tetanus and diphtheria with acellular pertussis vaccine [Tdap]), hepatitis A, hepatitis B, herpes zoster (shingles), and human papillomavirus (HPV) vaccines by selected characteristics (age, race/ethnicity,† and vaccination target criteria). Influenza vaccination coverage estimates for the 2012–13 influenza season have been published separately (3). Compared with 2011 (1), only modest increases occurred in Tdap vaccination among adults aged 19–64 years, herpes zoster vaccination among adults aged ≥60 years, and HPV vaccination among women aged 19–26 years; coverage among adults in the United States for the other vaccines did not improve. Racial/ethnic gaps in coverage persisted for all six vaccines and widened for Tdap, herpes zoster, and HPV vaccination. Increases in vaccination coverage are needed to reduce the occurrence of vaccine-preventable diseases among adults. The Community Preventive Services Task Force and other authorities have recommended that health-care providers incorporate vaccination needs assessment, recommendation, and offer of vaccination into routine clinical practice for adult patients (4,5)…

:: Global Control and Regional Elimination of Measles, 2000–2012

:: Advisory Committee on Immunization Practices Recommended Immunization Schedules for Persons Aged 0 Through 18 Years — United States, 2014

:: Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2014

European Medicines Agency updates guidance for annual strain change of seasonal influenza vaccines

European Medicines Agency Watch [to 8 February 2014]

European Medicines Agency updates guidance for annual strain change of seasonal influenza vaccines
The European Medicines Agency has published an update to its guidance for the annual strain change of influenza vaccines. This update ensures that EU requirements for the annual strain change reflect current knowledge, and is consistent with the approach taken by other    regulatory authorities globally.

The update introduces an improved system that allows strengthened and sustainable monitoring of an influenza vaccine’s performance over the years in a real-life setting.

From the influenza season 2014-2015 onwards, vaccine manufacturers will be required to submit for each vaccine appropriate measures for proactive surveillance of the safety and effectiveness to regulatory authorities for review. From the influenza season 2015-2016, with the new system in place, the Agency no longer requires routine submission of clinical trials for annual strain-change updates.

The Agency will publish interim guidance by March 2014 on the principles of safety monitoring commitments that should form part of the proactive surveillance

NIH, biopharma and HGOs launch Accelerating Medicines Partnership (AMP),

   The National Institutes of Health, 10 biopharmaceutical companies and several nonprofit organizations launched The Accelerating Medicines Partnership (AMP), described as “an unprecedented partnership to transform the current model for identifying and validating the most promising biological targets of disease for new diagnostics and drug development.”  The AMP “aims to distinguish biological targets of disease most likely to respond to new therapies and characterize biological indicators of disease, known as biomarkers. Through the Foundation for the NIH (FNIH), AMP partners will invest more than US$230 million over five years in the first projects, which focus on Alzheimer’s disease, type 2 diabetes, and the autoimmune disorders rheumatoid arthritis and systemic lupus erythematosus (lupus).

A critical and groundbreaking element of the partnership is the agreement that the data and analyses generated will be made publicly available to the broad biomedical community. The three- to five-year, milestone-driven pilot projects in these disease areas could set the stage for broadening AMP to other diseases and conditions.

Full media release:

Global Fund accepts recommendations to reprimand two international suppliers of mosquito nets

    The Global Fund said it accepted recommendations of its Sanctions Panel to reprimand two international suppliers of mosquito nets and to set mandatory terms for continued engagement in the future. The Sanctions Panel, composed of independent legal, compliance and ethics experts, recommended three conditions for continued engagement with the two suppliers, Vestergaard Frandsen and Sumitomo Chemical Co. First, each supplier must engage an independent compliance monitor to assess the supplier’s internal controls and then to verify the implementation of improvements and report back to the Global Fund by 30 June 2014, with a second progress update by the end of 2014. Second, each supplier would be obligated to make a contribution of 1 million long-lasting insecticide-treated nets to a Principal Recipient of a Global Fund grant. Third, each supplier would need to subscribe to an anti-bribery pact for manufacturers of long-lasting insecticide-treated nets, and commit to raising industry support for such a pact. Mark Dybul, the Executive Director of the Global Fund, accepted the recommendations and thanked the panel for determining an appropriate response and a constructive, forward-looking approach. The outcome is geared toward ensuring that all suppliers are held accountable for their actions and also toward encouraging ethical behavior.

The global Fund said that ach supplier has agreed to these conditions for continued engagement, and the Global Fund has lifted the suspension on their contracts

US HHS: The State of the National Vaccine Plan – 2013

US HHS: The State of the National Vaccine Plan – 2013
January 2014
The State of the National Vaccine Plan, the first of what will be an annual report, provides an overview of recent accomplishments and progress made by the U.S. Department of Health and Human Services and its partners that fall under the five goals of the 2010 National Vaccine Plan. The 2010 National Vaccine Plan provides a guiding vision for vaccines and immunization in the United States for the decade 2010–2020.

The report also includes expert commentaries by leaders within the government and from external stakeholder organizations. The commentaries, which can be found accompanying the progress report for each goal, discuss issues in vaccines and immunization that need continued attention moving forward.

Additionally, the report features an overview of the accomplishments and contributions of the National Vaccine Advisory Committee, which has been providing expert guidance to the U.S. Department of Health and Human Services on vaccine-related topics for 25 years.
Goal 1: Develop new and improved vaccines.
Goal 2: Enhance the vaccine safety system.
Goal 3: Support communications to enhance informed vaccine decision-making.
Goal 4: Ensure a stable supply of, access to, and better use of recommended vaccines in the United States.
Goal 5: Increase global prevention of death and disease through safe and effective vaccination.

–       Download The State of the National Vaccine Plan 2013 Annual Report [PDF]

Determinants and Coverage of Vaccination in Children in Western Kenya from a 2003 Cross-Sectional Survey

American Journal of Tropical Medicine and Hygiene
February 2014; 90 (2)

Determinants and Coverage of Vaccination in Children in Western Kenya from a 2003 Cross-Sectional Survey
Lisa M. Calhoun, Anna M. van Eijk, Kim A. Lindblade, Frank O. Odhiambo, Mark L. Wilson, Elizabeth Winterbauer, Laurence Slutsker, and Mary J. Hamel
Am J Trop Med Hyg 2014 90:234-241; Published online December 16, 2013, doi:10.4269/ajtmh.13-0127

This study assesses full and timely vaccination coverage and factors associated with full vaccination in children ages 12–23 months in Gem, Nyanza Province, Kenya in 2003. A simple random sample of 1,769 households was selected, and guardians were invited to bring children under 5 years of age to participate in a survey. Full vaccination coverage was 31.1% among 244 children. Only 2.2% received all vaccinations in the target month for each vaccination. In multivariate logistic regression, children of mothers of higher parity (odds ratio [OR] = 0.27, 95% confidence interval [95% CI] = 0.13–0.65, P ≤ 0.01), children of mothers with lower maternal education (OR = 0.35, 95% CI = 0.13–0.97, P ≤ 0.05), or children in households with the spouse absent versus present (OR = 0.40, 95% CI = 0.17–0.91, P ≤ 0.05) were less likely to be fully vaccinated. These data serve as a baseline from which changes in vaccination coverage will be measured as interventions to improve vaccination timeliness are introduced.

U.S. Physicians’ Perspective of Adult Vaccine Delivery

Annals of Internal Medicine
4 February 2014, Vol. 160. No. 3

U.S. Physicians’ Perspective of Adult Vaccine Delivery
Laura P. Hurley, MD, MPH; Carolyn B. Bridges, MD; Rafael Harpaz, MD, MPH; Mandy A. Allison, MD, MSPH; Sean T. O’Leary, MD; Lori A. Crane, PhD, MPH; Michaela Brtnikova, PhD; Shannon Stokley, MPH; Brenda L. Beaty, MSPH; Andrea Jimenez-Zambrano, MPH; Faruque Ahmed, PhD; Craig Hales, MD, MPH; and Allison Kempe, MD, MPH


Background: Adults are at substantial risk for vaccine-preventable disease, but their vaccination rates remain low.

Objective: To assess practices for assessing vaccination status and stocking recommended vaccines, barriers to vaccination, characteristics associated with reporting financial barriers to delivering vaccines, and practices regarding vaccination by alternate vaccinators.

Design: Mail and Internet-based survey.

Setting: Survey conducted from March to June 2012.

Participants: General internists and family physicians throughout the United States.

Measurements: A financial barriers scale was created. Multivariable linear modeling for each specialty was performed to assess associations between a financial barrier score and physician and practice characteristics.

Results: Response rates were 79% (352 of 443) for general internists and 62% (255 of 409) for family physicians. Twenty-nine percent of general internists and 32% of family physicians reported assessing vaccination status at every visit. A minority used immunization information systems (8% and 36%, respectively). Almost all respondents reported assessing need for and stocking seasonal influenza; pneumococcal; tetanus and diphtheria; and tetanus, diphtheria, and acellular pertussis vaccines. However, fewer assessed and stocked other recommended vaccines. The most commonly reported barriers were financial. Characteristics significantly associated with reporting greater financial barriers included private practice setting, fewer than 5 providers in the practice, and, for general internists only, having more patients with Medicare Part D. The most commonly reported reasons for referring patients elsewhere included lack of insurance coverage for the vaccine (55% for general internists and 62% for family physicians) or inadequate reimbursement (36% and 41%, respectively). Patients were most often referred to pharmacies/retail stores and public health departments.

Limitations: Surveyed physicians may not be representative of all physicians.

Conclusion: Improving adult vaccination delivery will require increased use of evidence-based methods for vaccination delivery and concerted efforts to resolve financial barriers, especially for smaller practices and for general internists who see more patients with Medicare Part D.

Primary Funding Source: Centers for Disease Control and Prevention.

Editors’ Notes


Vaccination rates in adults are low, even though more than 95% of Americans who die of vaccine-preventable disease each year are adults. General internists and family medicine physicians were surveyed about vaccine perceptions and practices.


Barriers related to vaccine delivery included lack of regular assessment of vaccine status, insufficient stocking of some vaccines, and financial disincentives for vaccination in the primary care setting. Use of electronic tools to record and prompt vaccination was low. Most physicians surveyed accepted vaccination outside of the medical home but believed communication between themselves and alternate vaccinators was suboptimal.


System changes are necessary to improve adult vaccination in the United States.

Chinese immigrant parents’ vaccination decision making for children: a qualitative analysis

BMC Public Health
(Accessed 8 February 2014)

Research article  
Chinese immigrant parents’ vaccination decision making for children: a qualitative analysis
Linda DL Wang, Wendy WT Lam, Joseph T Wu, Qiuyan Liao, Richard Fielding BMC Public Health 2014, 14:133 (7 February 2014)
Abstract (provisional)
While immunization coverage rates for childhood routine vaccines in Hong Kong are almost 100%, the uptake rates of optional vaccines remain suboptimal. Understanding parental decision-making for children’s vaccination is important, particularly among minority groups who are most vulnerable and underserved. This study explored how a subsample of new immigrant mothers from mainland China, a rapidly-growing subpopulation in Hong Kong, made decisions on various childhood and adolescent vaccines for their offspring, and identified key influences affecting their decision making.

Semi-structured in-depth interviews were conducted with 23 Chinese new immigrant mothers recruited by purposive sampling. All interviews were audio-taped, transcribed and analyzed using a Grounded Theory approach.

Participants’ conversation revealed five underlying themes which influenced parents’ vaccination decision-making: (1) Institutional factors, (2) Insufficient vaccination knowledge and advice, (3) Affective impacts on motivation, (4) Vaccination barriers, and (5) Social influences. The role of social norms appeared overwhelmingly salient influencing parents’ vaccination decision making. Institutional factors shaped parent’s perceptions of vaccination necessity. Fear of vaccine-targeted diseases was a key motivating factor for parents adopting vaccination. Insufficient knowledge about vaccines and targeted diseases, lack of advice from health professionals and, if provided, suspicions regarding the motivations for such advice were common issues. Vaccination cost was a major barrier for many new immigrant parents.

Social norms play a key role influencing parental vaccination decision-making. Insight gained from this study will help inform healthcare providers in vaccination communication and policymakers in future vaccination programme.

Editorial: No universal health coverage without strong local health system

Bulletin of the World Health Organization
Volume 92, Number 2, February 2014, 77-152

No universal health coverage without strong local health systems
Bruno Meessen a, Belma Malanda b & for the Community of Practice “Health Service Delivery”
a. Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
b. Brussels, Belgium.
Bulletin of the World Health Organization 2014;92:78-78A. doi:

Despite the current global and national momentum,1 universal health coverage could remain an empty promise unless it is focussed on the provision of quality essential services to everyone. And this, in turn, will not happen without strengthening local health systems.

Economic benefits of keeping vaccines at ambient temperature during mass vaccination: the case of meningitis A vaccine in Chad

Bulletin of the World Health Organization
Volume 92, Number 2, February 2014, 77-152

Economic benefits of keeping vaccines at ambient temperature during mass vaccination: the case of meningitis A vaccine in Chad
Patrick Lydon, Simona Zipursky, Carole Tevi-Benissan, Mamoudou Harouna Djingarey, Placide Gbedonou, Brahim Oumar Youssouf & Michel Zaffran
To evaluate the potential economic benefits of keeping a meningitis A vaccine at or near ambient temperature for up to 4 days during a mass vaccination campaign.

During a 10-day mass vaccination campaign against meningitis A in three regions of Chad in 2011, the costs associated with storage and transport of the vaccine in a traditional cold chain system were evaluated. A mathematical model was used to estimate the savings that could have been achieved if the vaccine had been stored at or near ambient temperature – in a “controlled temperature” chain – at the peripheral levels of the supply chain system.

The cost of the cold chain and associated logistics used in the campaign in Chad was 0.24 United States dollars (US$) per person vaccinated. In the modelled scenario for a controlled temperature chain, however, these costs dropped by 50% and were estimated to be only US$ 0.12 per person vaccinated.

The implementation of a “controlled temperature” chain at the most peripheral levels of the supply chain system – assuming no associated loss of vaccine potency, efficacy or safety – could result in major economic benefits and allow vaccine coverage to be extended in low-resource settings.

Diarrhoea-related hospitalizations in children before and after implementation of monovalent rotavirus vaccination in Mexico

Bulletin of the World Health Organization
Volume 92, Number 2, February 2014, 77-152

Diarrhoea-related hospitalizations in children before and after implementation of monovalent rotavirus vaccination in Mexico
Marcelino Esparza-Aguilar, Paul A Gastañaduy, Edgar Sánchez-Uribe, Rishi Desai, Umesh D Parashar, Vesta Richardson & Manish Patel
To assess, by socioeconomic setting, the effect of nationwide vaccination against species A rotavirus (RVA) on childhood diarrhoea-related hospitalizations in Mexico.

Data on children younger than 5 years who were hospitalized for diarrhoea in health ministry hospitals between 1 January 2003 and 31 December 2011 were collected from monthly discharge reports. Human development indexes were used to categorize the states where hospitals were located as having generally high, intermediate or low socioeconomic status. Annual rates of hospitalization for diarrhoea – per 10 000 hospitalizations for any cause – were calculated. Administrative data were used to estimate vaccine coverage.

In the states with high, intermediate and low socioeconomic status, coverage with a two-dose monovalent RVA vaccine – among children younger than 5 years – had reached 93%, 86% and 71%, respectively, by 2010. The corresponding median annual rates of hospitalization for diarrhoea – per 10 000 admissions – fell from 1001, 834 and 1033 in the “prevaccine” period of 2003–2006, to 597, 497 and 705 in the “postvaccine” period from 2008 to 2011, respectively. These decreases correspond to rate reductions of 40% (95% confidence interval, CI: 38–43), 41% (95% CI: 38–43) and 32% (95% CI: 29–34), respectively. Nationwide, RVA vaccination appeared to have averted approximately 16 500 hospitalizations for childhood diarrhoea in each year of the postvaccine period.

Monovalent RVA vaccination has substantially reduced childhood diarrhoea-related hospitalizations for four continuous years in discretely different socioeconomic populations across Mexico

A cocoon immunisation strategy against pertussis for infants: does it make sense for Ontario?

Volume 19, Issue 5, 06 February 2014

Research Articles
A cocoon immunisation strategy against pertussis for infants: does it make sense for Ontario?
by GH Lim, SL Deeks, NS Crowcroft
Pertussis deaths occur primarily among infants who have not been fully immunised. In Ontario, Canada, an adult booster dose was recently added to the publicly funded immunisation programme. We applied number-needed-to-treat analyses to estimate the number of adults that would need to be vaccinated (NNV) to prevent pertussis disease, hospitalisation and death among infants if a cocoon strategy were implemented. NNV=1/(PM X R) + 1/(PF X R), where PM,PF (proportion of infants infected by mothers, fathers) were sourced from several studies. Rates of disease, hospitalisation or death (R) were derived from Ontario’s reportable disease data and Discharge Abstract Database. After adjusting for under-reporting, the NNV to prevent one case, hospitalisation or death from pertussis was between 500–6,400, 12,000–63,000 and 1.1–12.8 million, respectively. Without adjustment, NNV increased to 5,000–60,000, 55,000–297,000 and 2.5–30.2 million, respectively. Rarer outcomes were associated with higher NNV. These analyses demonstrate the relative inefficiency of a cocoon strategy in Ontario, which has a well-established universal immunisation programme with relatively high coverage and low disease incidence. Other jurisdictions considering a cocoon programme should consider their local epidemiology.

Connected Health: Emerging Disruptive Technologies

Health Affairs
February 2014; Volume 33, Issue 2

Theme: Early Evidence, Future Promise Of Connected Health
Connected Health: Emerging Disruptive Technologies
John K. Iglehart
Health Aff February 2014 33:190; doi:10.1377/hlthaff.2014.0042

The explosion of knowledge through telecommunication is linking patients and providers separated by geography. This development, in turn, is increasing the potential of the health delivery system to achieve the “Triple Aim,” the watchwords of reform driving changes in public- and private-sector actions outlined seven years ago in Health Affairs by Donald Berwick, Thomas Nolan, and John Whittington: better care, better health, and reduced per capita costs.   This issue is largely devoted to papers that report early evidence and future promise of “connected health,” the umbrella term arrived at to lessen the confusion over the definitions of telemedicine, telehealth, and mHealth.

The importance of an array of emerging technologies and services is certain to grow as more people who reside in rural locales or areas of provider scarcity gain coverage and team-based care becomes a more prominent feature of the delivery landscape…

The End of Measles and Rubella…

JAMA Pediatrics
February 2014, Vol 168, No. 2

The Beginning of the End of Measles and Rubella
Mark Grabowsky, MD, MPH
Measles was first imported into the New World in the early 16th century by European colonists, often with devastating effects on native populations. Rubella importation followed and led to congenital rubella syndrome. It is estimated that during the following 5 centuries, more than 200 million people globally died of measles. Disease incidence fell rapidly after the availability of vaccines in the United States for measles in 1963 and rubella in 1969, and after the availability of a combined measles-rubella vaccine in 1971. As vaccination expanded into other countries of the Americas, the Pan American Health Organization established a goal to eliminate measles from the Western hemisphere by 2002 and rubella by 2010. By 2004, transmission had been interrupted in the United States. However, there has been concern that pockets of transmission persisted or that transmission could be reestablished if immunization coverage levels declined.

Elimination of Endemic Measles, Rubella, and Congenital Rubella Syndrome From the Western Hemisphere: The US Experience
Mark J. Papania, MD, MPH; Gregory S. Wallace, MD, MPH; Paul A. Rota, PhD; Joseph P. Icenogle, PhD; Amy Parker Fiebelkorn, MSN, MPH; Gregory L. Armstrong, MD; Susan E. Reef, MD; Susan B. Redd; Emily S. Abernathy, MS; Albert E. Barskey, MPH; Lijuan Hao, MD; Huong Q. McLean, PhD; Jennifer S. Rota, MPH; William J. Bellini, PhD; Jane F. Seward, MBBS
Importance  To verify the elimination of endemic measles, rubella, and congenital rubella syndrome (CRS) from the Western hemisphere, the Pan American Health Organization requested each member country to compile a national elimination report. The United States documented the elimination of endemic measles in 2000 and of endemic rubella and CRS in 2004. In December 2011, the Centers for Disease Control and Prevention convened an external expert panel to review the evidence and determine whether elimination of endemic measles, rubella, and CRS had been sustained.

Objective  To review the evidence for sustained elimination of endemic measles, rubella, and CRS from the United States through 2011.

Design, Setting, and Participants  Review of data for measles from 2001 to 2011 and for rubella and CRS from 2004 to 2011 covering the US resident population and international visitors, including disease epidemiology, importation status of cases, molecular epidemiology, adequacy of surveillance, and population immunity as estimated by national vaccination coverage and serologic surveys.

Main Outcomes and Measures  Annual numbers of measles, rubella, and CRS cases, by importation status, outbreak size, and distribution; proportions of US population seropositive for measles and rubella; and measles-mumps-rubella vaccination coverage levels.

Results  Since 2001, US reported measles incidence has remained below 1 case per 1 000 000 population. Since 2004, rubella incidence has been below 1 case per 10 000 000 population, and CRS incidence has been below 1 case per 5 000 000 births. Eighty-eight percent of measles cases and 54% of rubella cases were internationally imported or epidemiologically or virologically linked to importation. The few cases not linked to importation were insufficient to represent endemic transmission. Molecular epidemiology indicated no endemic genotypes. The US surveillance system is adequate to detect endemic measles or rubella. Seroprevalence and vaccination coverage data indicate high levels of population immunity to measles and rubella.

Conclusions and Relevance  The external expert panel concluded that the elimination of endemic measles, rubella, and CRS from the United States was sustained through 2011. However, international importation continues, and health care providers should suspect measles or rubella in patients with febrile rash illness, especially when associated with international travel or international visitors, and should report suspected cases to the local health department.

Effect of closure of live poultry markets on poultry-to-person transmission of avian influenza A H7N9

The Lancet  
Feb 08, 2014  Volume 383  Number 9916   p487 – 574  e11

Can closure of live poultry markets halt the spread of H7N9?
Guillaume Fournié, Dirk U Pfeiffer
Preview | Full Text | PDF
After isolation of avian influenza A H7N9 virus from live poultry markets (LPMs), and reports that several people who were infected with the virus had visited such markets a few days before disease onset, LPMs were suspected to be a main source of human exposure to H7N9 in China.1 After LPM closure was enforced in several Chinese cities, the incidence of H7N9 human cases rapidly reduced.2 In The Lancet, Hongjie Yu and colleagues3 quantify the risk of human infections before and after LPM closure in the Chinese cities of Nanjing, Shanghai, Hangzhou, and Huzhou.

Effect of closure of live poultry markets on poultry-to-person transmission of avian influenza A H7N9 virus: an ecological study
Hongjie Yu MD a, Joseph T 1 case PhD e , Dr Benjamin J Cowling PhD e , Qiaohong Liao MD a, Vicky J Fang MPhil e, Sheng Zhou MD a, Peng Wu PhD e, Hang Zhou MD a, Eric H Y Lau PhD e, Danhuai Guo PhD f, Michael Y Ni MPH e, Zhibin Peng MD a, Luzhao Feng MD a, Hui Jiang MD a, Huiming Luo MD b, Qun Li MD c, Zijian Feng MD c, Yu Wang PhD d, Dr Weizhong Yang MD d  Prof Gabriel M Leung MD e

Transmission of the novel avian influenza A H7N9 virus seems to be predominantly between poultry and people. In the major Chinese cities of Shanghai, Hangzhou, Huzhou, and Nanjing—where most human cases of infection have occurred—live poultry markets (LPMs) were closed in April, 2013, soon after the initial outbreak, as a precautionary public health measure. Our objective was to quantify the effect of LPM closure in these cities on poultry-to-person transmission of avian influenza A H7N9 virus.

We obtained information about every laboratory-confirmed human case of avian influenza A H7N9 virus infection reported in the four cities by June 7, 2013, from a database built by the Chinese Center for Disease Control and Prevention. We used data for age, sex, location, residence type (rural or urban area), and dates of illness onset. We obtained information about LPMs from official sources. We constructed a statistical model to explain the patterns in incidence of cases reported in each city on the basis of the assumption of a constant force of infection before LPM closure, and a different constant force of infection after closure. We fitted the model with Markov chain Monte Carlo methods.

85 human cases of avian influenza A H7N9 virus infection were reported in Shanghai, Hangzhou, Huzhou, and Nanjing by June 7, 2013, of which 60 were included in our main analysis. Closure of LPMs reduced the mean daily number of infections by 99% (95% credibility interval 93—100%) in Shanghai, by 99% (92—100%) in Hangzhou, by 97% (68—100%) in Huzhou, and by 97% (81—100%) in Nanjing. Because LPMs were the predominant source of exposure to avian influenza A H7N9 virus for confirmed cases in these cities, we estimated that the mean incubation period was 3·3 days (1·4—5·7).

LPM closures were effective in the control of human risk of avian influenza A H7N9 virus infection in the spring of 2013. In the short term, LPM closure should be rapidly implemented in areas where the virus is identified in live poultry or people. In the long term, evidence-based discussions and deliberations about the role of market rest days and central slaughtering of all live poultry should be renewed.

Ministry of Science and Technology, China; Research Fund for the Control of Infectious Disease; Hong Kong University Grants Committee; China—US Collaborative Program on Emerging and Re-emerging Infectious Diseases; Harvard Center for Communicable Disease Dynamics; and the US National Institutes of Health.

Perspective: Ending AIDS — Is an HIV Vaccine Necessary?

New England Journal of Medicine
February 6, 2014  Vol. 370 No. 6

Ending AIDS — Is an HIV Vaccine Necessary?
Anthony S. Fauci, M.D., and Hilary D. Marston, M.D., M.P.H.
N Engl J Med 2014; 370:495-498February 6, 2014DOI: 10.1056/NEJMp1313771
The numbers of AIDS-related deaths and new HIV infections have decreased dramatically, thanks to prevention and treatment tools. But to control the pandemic more quickly and sustain the success, a safe and at least moderately effective vaccine is essential.

Intussusception Risk after Rotavirus Vaccination

New England Journal of Medicine
February 6, 2014  Vol. 370 No. 6

Original Article
Intussusception Risk after Rotavirus Vaccination in U.S. Infants
W. Katherine Yih, Ph.D., M.P.H., Tracy A. Lieu, M.D., M.P.H., Martin Kulldorff, Ph.D., David Martin, M.D., M.P.H., Cheryl N. McMahill-Walraven, M.S.W., Ph.D., Richard Platt, M.D., Nandini Selvam, Ph.D., M.P.H., Mano Selvan, Ph.D., Grace M. Lee, M.D., M.P.H., and Michael Nguyen, M.D.
N Engl J Med 2014; 370:503-512 February 6, 2014 DOI: 10.1056/NEJMoa1303164

International postlicensure studies have identified an increased risk of intussusception after vaccination with the second-generation rotavirus vaccines RotaTeq (RV5, a pentavalent vaccine) and Rotarix (RV1, a monovalent vaccine). We studied this association among infants in the United States.

The study included data from infants 5.0 to 36.9 weeks of age who were enrolled in three U.S. health plans that participate in the Mini-Sentinel program sponsored by the Food and Drug Administration. Potential cases of intussusception and vaccine exposures from 2004 through mid-2011 were identified through procedural and diagnostic codes. Medical records were reviewed to confirm the occurrence of intussusception and the status with respect to rotavirus vaccination. The primary analysis used a self-controlled risk-interval design that included only vaccinated children. The secondary analysis used a cohort design that included exposed and unexposed person-time.

The analyses included 507,874 first doses and 1,277,556 total doses of RV5 and 53,638 first doses and 103,098 total doses of RV1. The statistical power for the analysis of RV1 was lower than that for the analysis of RV5. The number of excess cases of intussusception per 100,000 recipients of the first dose of RV5 was significantly elevated, both in the primary analysis (attributable risk, 1.1 [95% confidence interval, 0.3 to 2.7] for the 7-day risk window and 1.5 [95% CI, 0.2 to 3.2] for the 21-day risk window) and in the secondary analysis (attributable risk, 1.2 [95% CI, 0.2 to 3.2] for the 21-day risk window). No significant increase in risk was seen after dose 2 or 3. The results with respect to the primary analysis of RV1 were not significant, but the secondary analysis showed a significant risk after dose 2.

RV5 was associated with approximately 1.5 (95% CI, 0.2 to 3.2) excess cases of intussusception per 100,000 recipients of the first dose. The secondary analysis of RV1 suggested a potential risk, although the study of RV1 was underpowered. These risks must be considered in light of the demonstrated benefits of rotavirus vaccination. (Funded by the Food and Drug Administration.)

Original Article
Risk of Intussusception after Monovalent Rotavirus Vaccination
Eric S. Weintraub, M.P.H., James Baggs, Ph.D., Jonathan Duffy, M.D., M.P.H., Claudia Vellozzi, M.D., M.P.H., Edward A. Belongia, M.D., Stephanie Irving, M.H.S., Nicola P. Klein, M.D., Ph.D., Jason M. Glanz, Ph.D., Steven J. Jacobsen, M.D., Ph.D., Allison Naleway, Ph.D., Lisa A. Jackson, M.D., M.P.H., and Frank DeStefano, M.D., M.P.H.
N Engl J Med 2014; 370:513-519February 6, 2014DOI: 10.1056/NEJMoa1311738

Although current rotavirus vaccines were not associated with an increased risk of intussusception in large trials before licensure, recent postlicensure data from international settings suggest the possibility of a small increase in risk of intussusception after monovalent rotavirus vaccination. We examined this risk in a population in the United States.

Participants were infants between the ages of 4 and 34 weeks who were enrolled in six integrated health care organizations in the Vaccine Safety Datalink (VSD) project. We reviewed medical records and visits for intussusception within 7 days after monovalent rotavirus vaccination from April 2008 through March 2013. Using sequential analyses, we then compared the risk of intussusception among children receiving monovalent rotavirus vaccine with historical background rates. We further compared the risk after monovalent rotavirus vaccination with the risk in a concurrent cohort of infants who received the pentavalent rotavirus vaccine.

During the study period, 207,955 doses of monovalent rotavirus vaccine (including 115,908 first doses and 92,047 second doses) were administered in the VSD population. We identified 6 cases of intussusception within 7 days after the administration of either dose of vaccine. For the two doses combined, the expected number of intussusception cases was 0.72, resulting in a significant relative risk of 8.4. For the pentavalent rotavirus vaccine, 1,301,810 doses were administered during the study period, with 8 observed intussusception cases (7.11 expected), for a nonsignificant relative risk of 1.1. The relative risk of chart-confirmed intussusception within 7 days after monovalent rotavirus vaccination, as compared with the risk after pentavalent rotavirus vaccination, was 9.4 (95% confidence interval, 1.4 to 103.8). The attributable risk of intussusception after the administration of two doses of monovalent rotavirus vaccine was estimated to be 5.3 per 100,000 infants vaccinated.

In this prospective postlicensure study of more than 200,000 doses of monovalent rotavirus vaccine, we observed a significant increase in the rate of intussusception after vaccination, a risk that must be weighed against the benefits of preventing rotavirus-associated illness. (Funded by the Centers for Disease Control and Prevention.)

Epidemiology of Human Infections with Avian Influenza A(H7N9) Virus in China

New England Journal of Medicine
February 6, 2014  Vol. 370 No. 6

Original Article
Epidemiology of Human Infections with Avian Influenza A(H7N9) Virus in China
Qun Li, M.D., Lei Zhou, M.D., Minghao Zhou, Ph.D., Zhiping Chen, M.D., Furong Li, M.D., Huanyu Wu, M.D., Nijuan Xiang, M.D., Enfu Chen, M.P.H., Fenyang Tang, M.D., Dayan Wang, M.D., Ling Meng, M.D., Zhiheng Hong, M.D., Wenxiao Tu, M.D., Yang Cao, M.D., Leilei Li, Ph.D., Fan Ding, M.D., Bo Liu, M.D., Mei Wang, M.D., Rongheng Xie, M.D., Rongbao Gao, M.D., Xiaodan Li, M.D., Tian Bai, M.D., Shumei Zou, M.D., Jun He, M.D., Jiayu Hu, M.D., Yangting Xu, M.D., Chengliang Chai, M.D., Shiwen Wang, M.D., Yongjun Gao, M.D., Lianmei Jin, M.D., Yanping Zhang, M.D., Huiming Luo, M.D., Hongjie Yu, M.D., M.P.H., Jianfeng He, M.D., Qi Li, M.D., Xianjun Wang, M.D., Lidong Gao, M.D., Xinghuo Pang, M.D., Guohua Liu, M.D., Yansheng Yan, M.D., Hui Yuan, M.D., Yuelong Shu, Ph.D., Weizhong Yang, M.D., Yu Wang, M.D., Fan Wu, M.D., Timothy M. Uyeki, M.D., M.P.H., M.P.P., and Zijian Feng, M.D., M.P.H.
N Engl J Med 2014; 370:520-532February 6, 2014DOI: 10.1056/NEJMoa1304617

The first identified cases of avian influenza A(H7N9) virus infection in humans occurred in China during February and March 2013. We analyzed data obtained from field investigations to describe the epidemiologic characteristics of H7N9 cases in China identified as of December 1, 2013.
Full Text of Background…

Field investigations were conducted for each confirmed case of H7N9 virus infection. A patient was considered to have a confirmed case if the presence of the H7N9 virus was verified by means of real-time reverse-transcriptase–polymerase-chain-reaction assay (RT-PCR), viral isolation, or serologic testing. Information on demographic characteristics, exposure history, and illness timelines was obtained from patients with confirmed cases. Close contacts were monitored for 7 days for symptoms of illness. Throat swabs were obtained from contacts in whom symptoms developed and were tested for the presence of the H7N9 virus by means of real-time RT-PCR.
Full Text of Methods…

Among 139 persons with confirmed H7N9 virus infection, the median age was 61 years (range, 2 to 91), 71% were male, and 73% were urban residents. Confirmed cases occurred in 12 areas of China. Nine persons were poultry workers, and of 131 persons with available data, 82% had a history of exposure to live animals, including chickens (82%). A total of 137 persons (99%) were hospitalized, 125 (90%) had pneumonia or respiratory failure, and 65 of 103 with available data (63%) were admitted to an intensive care unit. A total of 47 persons (34%) died in the hospital after a median duration of illness of 21 days, 88 were discharged from the hospital, and 2 remain hospitalized in critical condition; 2 patients were not admitted to a hospital. In four family clusters, human-to-human transmission of H7N9 virus could not be ruled out. Excluding secondary cases in clusters, 2675 close contacts of case patients completed the monitoring period; respiratory symptoms developed in 28 of them (1%); all tested negative for H7N9 virus.
Full Text of Results…

Most persons with confirmed H7N9 virus infection had severe lower respiratory tract illness, were epidemiologically unrelated, and had a history of recent exposure to poultry. However, limited, nonsustained human-to-human H7N9 virus transmission could not be ruled out in four families.
Full Text of Discussion…

Health Care Systems in Low- and Middle-Income Countries

New England Journal of Medicine
February 6, 2014  Vol. 370 No. 6

Global Health
Health Care Systems in Low- and Middle-Income Countries
Anne Mills, D.H.S.A., Ph.D.
N Engl J Med 2014; 370:552-557 February 6, 2014 DOI: 10.1056/NEJMra1110897

Over the past 10 years, debates on global health have paid increasing attention to the importance of health care systems, which encompass the institutions, organizations, and resources (physical, financial, and human) assembled to deliver health care services that meet population needs. It has become especially important to emphasize health care systems in low- and middle-income countries because of the substantial external funding provided for disease-specific programs, especially for drugs and medical supplies, and the relative underfunding of the broader health care infrastructures in these countries.1 A functioning health care system is fundamental to the achievement of universal coverage for health care, which has been the focus of recent statements by advocacy groups and other organizations around the globe, including a declaration by the United Nations in 2012.2

Recent analyses have drawn attention to the weaknesses of health care systems in low- and middle-income countries. For example, in the 75 countries that account for more than 95% of maternal and child deaths, the median proportion of births attended by a skilled health worker is only 62% (range, 10 to 100%), and women without money or coverage for this service are much less likely to receive it than are women with the means to pay for it.3 Lack of financial protection for the costs of health care means that approximately 100 million people are pushed below the poverty line each year by payments for health care,4 and many more will not seek care because they lack the necessary funds.

In response to such deficiencies in the health care system, a number of countries and their partners in development have been introducing new approaches to financing, organizing, and delivering health care. This article briefly reviews the main weaknesses of health care systems in low- and middle-income countries, lists the most common responses to those weaknesses, and then presents three of the most popular responses for further review. These responses, which have attracted considerable controversy, involve the questions of whether to pay for health care through general taxation or contributory insurance funds to improve financial protection for specific sections of the population, whether to use financial incentives to increase health care utilization and improve health care quality, and whether to make use of private entities to extend the reach of the health care system.

This review draws on what is now quite an extensive literature on the deficiencies of health care systems1 and on the Health Systems Evidence database.5 However, the poor quality and uneven coverage of evidence on the strengthening of health care systems means that evidence of deficiencies is stronger than evidence of remedies. Moreover, the specific circumstances of individual countries strongly influence both decisions about which approaches might be relevant and their success, so any generalizations made from health systems research in particular countries must be carefully considered.6 It is unlikely that there is one single blueprint for an ideal health care system design or a magic bullet that will automatically remedy deficiencies. The strengthening of health care systems in low- and middle-income countries must be seen as a long-term developmental process….

Methods to Assess the Impact of Mass Oral Cholera Vaccination Campaigns under Real Field Conditions

PLoS One
[Accessed 8 February 2014]

Methods to Assess the Impact of Mass Oral Cholera Vaccination Campaigns under Real Field Conditions
Jacqueline Deen mail, Mohammad Ali, David Sack
Published: February 07, 2014
DOI: 10.1371/journal.pone.0088139

There is increasing interest to use oral cholera vaccination as an additional strategy to water and sanitation interventions against endemic and epidemic cholera. There are two internationally-available and WHO-prequalified oral cholera vaccines: an inactivated vaccine containing killed whole-cells of V. cholerae O1 with recombinant cholera toxin B-subunit (WC/rBS) and a bivalent inactivated vaccine containing killed whole cells of V. cholerae O1 and V. cholerae O139 (BivWC). The efficacy, effectiveness, direct and indirect (herd) protection conferred by WC/rBS and BivWC are well established. Yet governments may need local evidence of vaccine impact to justify and scale-up mass oral cholera vaccination campaigns. We discuss various approaches to assess oral cholera vaccine protection, which may be useful to policymakers and public health workers considering deployment and evaluation of the vaccine.

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH) December 2013

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH)
December 2013 Vol. 34, No. 6

Action on social determinants of health in the Americas
Acción en los determinantes sociales de la salud en las Américas

Measuring progress of collaborative action in a community health effort [Medición del progreso de las actividades de colaboración en una iniciativa de salud comunitaria]
Vicki L. Collie-Akers, Stephen B. Fawcett, and Jerry A. Schultz
 Indicadores de accesibilidad geográfica a los centros de atención primaria para la gestión de inequidades [Use of indicators of geographical accessibility to primary health care centers in addressing inequities]
Diana De Pietri, Patricia Dietrich, Patricia Mayo, Alejandro Carcagno y Ernesto de Titto

Health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks [Sistemas de salud en su contexto: revisión sistemática de la integración de los determinantes sociales de la salud en los marcos de los sistemas de salud]
Evan Russell, Bryce Johnson, Heidi Larsen, M. Lelinneth B. Novilla, Josefien van Olmen, and
R. Chad Swanson

Integrating social determinants of health in the universal health coverage monitoring framework [La integración de los determinantes sociales de la salud en el marco de la vigilancia de la cobertura universal de salud]
Jeanette Vega and Patricia Frenz
Synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the Americas [Sinergia para la equidad en salud: integración de los enfoques de la promoción de la salud y de los determinantes sociales de la salud dentro y fuera de la Región de las Américas]
Suzanne F. Jackson, Anne-Emanuelle Birn, Stephen B. Fawcett, Blake Poland, and Jerry A. Schultz

Urgent Need To Address Chronic Disease In Developing Countries

Accessed 8 February 2014

Urgent Need To Address Chronic Disease In Developing Countries
Geoffrey Kabat, Contributor
2 February 2014
As mortality rates from chronic disease decline in developed countries, developing countries are facing a double-barreled health threat. In addition to the burden of infectious diseases (malaria, tuberculosis, HIV-AIDS), changes in diet and lifestyle are driving increases in chronic diseases, including cancer, diabetes, and heart disease. The cancer burden in low-resource countries has doubled in the past 25 years and is projected to double again by 2030…

Opinion: Mandating Flu Shots Is the Moral Choice


Opinion: Mandating Flu Shots Is the Moral Choice
By Arthur Caplan
The battle over vaccination has taken a fascinating new twist in Rhode Island, where the Department of Health has proposed a policy under which all children between 6 months and 5 years of age would have to be vaccinated against the flu before entering daycare or preschool.

The twist: Along with the usual vaccination opponents, the ACLU has joined the fight — on the critics’ side. That is the side that favors letting people get sick, miss work and even die in the name of personal choice…

…That is why the proposed policy lets parents opt out of vaccination for medical or religious reasons as long as they keep their kids at home during flu outbreaks. Surely, protecting the health of others by requiring them to be vaccinated or stay home can be justified by trying to prevent the 37 deaths of children who have already died from the flu this season. Their liberty is permanently over.

The government telling parents what to do when it comes to their children’s health is hardly new. They do it a lot — from mandating car seats to banning lead paint and requiring childproof caps on drugs and pesticides. For parents who balk when it comes to science and safety, the state has a legitimate interest in overriding bad choices that can be fatal.

Connecticut, New Jersey and New York City all have the kind of preschool flu shot mandates   Rhode Island is trying to implement. The ACLU, parents, teachers unions and all the rest of us should be doing something about this. All should be making sure Rhode Island and the rest of the nation adopt mandatory flu vaccination policies.

Vaccines and Global Health: The Week in Review 1 Feb 2014

Vaccines and Global Health: 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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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

Polio in Syria – Jan 2014

The Lancet
Early Online Publication, 31 January 2014

Polio in Syria
R Bruce Aylward a, Ala Alwan b
“In war, truth is the first casualty.”
Aeschylus (525 BC — 45 BC)

Jan 31, 2014, marks the mid-point in the initial phase of the international emergency response1 to the ongoing Middle East polio outbreak, one of the most challenging and visible outbreaks the Global Polio Eradication Initiative has tackled since its launch 25 years ago.

The challenges have not been due to the scale or speed of this polio outbreak (figure). To date, 23 laboratory-confirmed cases of polio have been reported by the Government of Syria.2   Even accounting for missed cases, and the additional 13 cases confirmed from opposition-controlled areas but not yet reflected in figures from the Government of Syria, this outbreak is smaller than the explosive outbreaks of polio that left hundreds of people paralysed in countries such as Somalia, the Republic of the Congo, and Tajikistan in recent years.3 Nonetheless, within 24 hours of the region’s Ministers of Health declaring the outbreak an “emergency for all Member States”,4 the outlines of a massive multi-country emergency response were agreed; the Government of Syria approved fast-track registration of bivalent oral polio vaccine for the response and to facilitate its delivery across lines of control to all opposition-held areas. All parties in the crisis rapidly committed to ensure that all children were vaccinated.

Figure Full-size image (65K) Download to PowerPoint

Fully implementing this response plan, however, has required overcoming immense hurdles to reach every child amid the wreckage of Syria’s public infrastructure and health system, the active conflict and insecurity, the dearth of trust, and one of the largest refugee crises since World War 2. These challenges have been compounded by erroneous allegations that—rather than doing everything possible to protect all Syrian children and the huge international investment in global polio eradication—UN agencies, and WHO in particular, had “blocked a vaccination campaign”,5 were “obstructing the testing of polio samples”,6 and by extension disregarding fundamental humanitarian principles.

Every day, thousands of local and international public health workers, community members, and volunteers on all sides of this conflict risk their lives to deliver basic services, including and especially immunisation, to all Syrians. It is essential that the complexities of the environment in which they are working are properly understood and that where information is incomplete, or is not shared for security reasons, it is not replaced with speculation or accusation.

The context of this outbreak is important. With the exception of Egypt, which had its last case of indigenous polio in 2005, most of the Middle East has been free of the disease since the 1990s as the result of a concerted, regionally coordinated effort.7 Protecting this achievement from importations of wild poliovirus from Pakistan, Nigeria, and, until recently, India has been a priority. Recognising the increasing risk of polio (and other vaccine-preventable diseases) as the Syrian crisis intensified, WHO, UNICEF, and partners helped organise and support at least five immunisation campaigns within Syria between March, 2011, and the end of 2012. In the surrounding countries, mass campaigns with oral polio vaccine (OPV) were undertaken in areas of low routine immunisation coverage, while refugees who arrived at registration points or camps were to be systematically vaccinated by host governments or the United Nations High Commissioner for Refugees (UNHCR).8

In December, 2012, poliovirus of Pakistan origin was first detected in Cairo’s sewage. A mass immunisation response was implemented immediately and the entire region was put on alert.9 Recognising the particular vulnerability of Syrian children, surveillance was heightened across that country, including through WHO’s Early Warning, Alert and Response Network that now comprises more than 450 reporting sites, many of which are in opposition-controlled areas. At the same time, 1.5 million children were vaccinated against polio (and 1.3 million against measles) in all of Syria’s 14 governorates, including, by January, 2013, Deir al-Zour where activities were delayed by 1 month due to insecurity. Despite these efforts, the risk escalated as this wild poliovirus type 1 was found in Israeli sewage from February, 2013, and then in the occupied Palestinian territory in mid-2013.10 It was while additional, region-wide mass campaigns were being planned for November to December, 2013, that the first polio-paralysed children were reported in Syria.

Information from opposition-controlled areas rapidly led to WHO’s first international alert on the polio outbreak within Syria on Oct 19, 2013.11 Within 5 days a nationwide vaccination campaign was launched, this time reaching a reported 2 million Syrian children, including 600,000 from Raqua, Rural Damascus, and Deir al-Zour. Nonetheless, many communities, particularly in opposition-controlled and besieged areas, were unable to access vaccine. WHO consolidated information on the major coverage gaps, especially across northern Syria, and had frank discussions with the Government of Syria, partners, and surrounding countries on additional approaches to address these gaps in each subsequent campaign. Preliminary results from the most recent campaign in Syria suggest that nearly 3 million children were vaccinated, with OPV reaching most if not all districts, more than at any time in the past 2 years.12      Preliminary results, consistent from multiple sources, suggest that vaccine coverage was greater than 85% in all but three of Syria’s governorates, and that coverage was greater than 75% in two of those three. Substantial numbers of children are still unreached, however, including in besieged communities, and further efforts are required to ensure that all parties have the vaccine they need to immunise all Syrian children.

Collecting, reconciling, and disseminating comprehensive surveillance information has been as difficult as assessing vaccine availability and coverage. All humanitarian organisations and health authorities have been encouraged to ensure that any case of polio is immediately reported, properly investigated, and rapidly acted upon, irrespective of where it is detected. Substantial negotiations have been required on everything, from ensuring a common case investigation form to agreeing on laboratories from which results will be accepted and recorded by the Government of Syria in its national figures. WHO considers all results from all WHO-accredited laboratories in assessing the international risk posed by this outbreak and additional response requirements; WHO has neither the motive nor the means to block the testing of any specimens in any laboratory.

As with all of its humanitarian work, WHO is impartial in aiding communities on all sides of this crisis, despite the restraints placed on all humanitarian actors whether they operate from within Syria or from neighbouring countries. In Syria, we work with local health workers and authorities, local and international non-governmental organisations (NGOs), UN agencies, civil society groups, the Syrian Arab Red Crescent, and other humanitarian partners to reach all Syrians, throughout the country, with health interventions and services.13 Over the past 12 months, and under extremely difficult conditions, WHO has, for example, also distributed medicines and supplies to meet the needs of 4.6 million people, trained more than 2,500 health workers, and supported health services delivery through 36 local NGOs, in both government and opposition-controlled areas.14

The prospects for interrupting this polio outbreak in Syria and the Middle East are promising. As a result of high vaccination coverage rates historically, overall susceptibility to polio in Syria is relatively low and concentrated among children younger than 2 years. Syrians remain deeply concerned for the welfare of their children and demand for vaccination remains high; no party to the conflict has voiced opposition to the ongoing OPV campaigns. Furthermore, winter has arrived in Syria, bringing with it the low season for poliovirus transmission when the impact of mass vaccination with OPV is usually highest.

Halfway through the Syrian polio outbreak response, many critical programme indicators are improving, particularly in terms of access to vaccine, coverage, and surveillance performance. Addressing the remaining gaps in programme implementation in Syria is a deadly serious issue; compounding this challenge with inaccurate information unnecessarily complicates an already very difficult and dangerous operating environment.

RBA is WHO’s Assistant Director-General for Polio and Emergencies. AA is Regional Director of WHO’s Regional Office for the Eastern Mediterranean.


1 WHO, UNICEF. Global Polio Eradication Initiative. Strategic plan for polio outbreak response in the Middle East November, 2013. The Syrian Arab Republic, Iraq, Jordan, Lebanon, Turkey, West Bank and Gaza Strip. Geneva: World Health Organization, 2013. (accessed Jan 29, 2014).

2 Global Polio Eradication Initiative. Polio this week. (accessed Jan 30, 2014).

3 WHO. Wild poliovirus 2009—2014. (accessed Jan 30, 2014).

4 WHO. Escalating poliomyelitis emergency in the Eastern Mediterranean Region. Document EM/RC60/R.3. 60th Session of the Regional Committee for the Eastern Mediterranean, October, 2013. Geneva: World Health Organization, 2013.

5 Reuter C. An apolitical virus: strife fuels polio’s return to Middle East. Der Spiegel Nov 21, 2013.

6 Coutts AP, Fouad MF. Syria’s raging health crisis. The New York Times Jan 1, 2014.

7 Aylward RB. An ancient scourge triggers a modern emergency. East Mediterr Health J 2013; 19: 903-904. PubMed

8 UNHCR. Inter-agency regional response for Syrian refugees. Egypt, Iraq, Jordan, Lebanon, Turkey. (accessed Jan 29, 2014).

9 WHO. Global alert and response. Poliovirus detected from environmental samples in Egypt. Disease Outbreak News, Feb 11, 2013. Geneva: World Health Organization, 2013. (accessed Jan 29, 2014).

10 WHO. Global alert and response. Poliovirus detected from environmental samples in Israel and West Bank and Gaza Strip. Disease Outbreak News, Sept 20, 2013. Geneva: World Health Organization, 2013. (accessed Jan 30, 2014).

11 WHO. Global alert and response. Report of suspected polio cases in the Syrian Arab Republic. Disease Outbreak News, Oct 19, 2013. Geneva: World Health Organization, 2013. (accessed Jan 29, 2014).

12 Polio Control Task Force Syria. End polio in Syria. House-to-house polio vaccination campaign, first round final report. Jan 28, 2014. Polio Control Task Force Syria, 2014.

13 United Nations Office for the Coordination of Humanitarian Affairs. Syrian Arab Republic Humanitarian Assistance Response Plan (SHARP). (accessed Jan 30, 2014).

14 WHO. WHO Response to the Syria crisis in the country 2013. (accessed Jan 30, 2014).

a World Health Organization, CH-1211 Geneva 27, Switzerland

b World Health Organization, Regional Office for the Eastern Mediterranean, Nasr City, Cairo, Egypt

GPEI Update: Polio this week – As of 29 January 2014

Update: Polio this week – As of 29 January 2014
Global Polio Eradication Initiative
Full report:
[Editor’s extract and bolded text]
:: In the Syrian Arab Republic, seven new cases of wild poliovirus type 1 were reported in the past week. The reporting of new cases is a sign that surveillance for acute flaccid paralysis is improving in the country, as expected in an outbreak. The response continues country-wide and across the entire Middle East region, to reach more than 22 million children under the age of five years with oral polio vaccine (OPV).

:: Two new wild poliovirus type 1 (WPV1) cases were reported in the past week, bringing the total WPV1 cases for 2013 to 14, and one case reported in 2014 to date, with onset of paralysis on 14 January. The first 2014 case was reported from Alingar, Laghman province, Eastern Region.

:: Two new WPV1 cases were reported in the past week, one from Peshawar, Khyber Pakhtunkhwa with onset of paralysis on 31 December 2013 and one from North Waziristan, FATA with onset of paralysis on 4 January 2014. The total number of WPV1 cases for Pakistan in 2013 is now 92. The total number for WPV1 cases for Pakistan in 2014 is now 5. The most recent WPV1 case had onset of paralysis on 5 January (from North Waziristan, FATA).
:: Two new cVDPV2 cases were reported in the past week, both from North Waziristan. The total number of cVDPV2 cases is now 45 for 2013 and one for 2014. The most recent cVDPV2 case had onset of paralysis on 3 January (from North Waziristan).

Horn of Africa
:: In Somalia, one new WPV1 cases were reported in the past week. Onset of paralysis was in June 2013. This case was reported late due to a laboratory processing backlog.

Middle East
:: In Syria, seven new WPV1 cases were reported in the past week. The total number of WPV1 cases is now 23. The cases were reported from Aleppo, Deir-Al-Zour, Edleb and Hasakeh governorates, all with onset of paralysis in November and December 2013. The most recent case had onset of paralysis on 17 December and was reported from Mara, Edleb governorate. Before the outbreak wild poliovirus was last reported in Syria in 1999.

:: In the Middle East, a comprehensive outbreak response continues to be implemented across the region. A third large-scale supplementary immunization activity commenced on 5 January. Initial reporting indicates that over 2 million children were reached during this third SIA.

WHO and UNICEF are committed to working with all organizations and agencies providing humanitarian assistance to Syrians affected by the conflict. This includes vaccinating all Syrian children no matter where they are, whether in government or contested areas, or outside Syria.

:: The WHO/UNICEF Strategic Plan for Polio Outbreak Response in the Middle East outlines the action plan for Syria and neighbouring countries in response to the circulation of wild poliovirus following importation. The objective is to stop the outbreak in Syria by the end of March 2014 and prevent any further international spread.

GAVI Watch [to 1 February 2014]

GAVI Watch [to 1 February 2014]
:: Bangladesh launches country’s largest measles-rubella campaign to date targeting 52 million children. GAVI said Bangladesh Prime Minister Sheikh Hasina launched the campaign during a ceremony in Dhaka. GAVI is supporting the three-week campaign. Dr Seth Berkley, GAVI Alliance CEO, said, “This is the largest ever measles-rubella campaign launched to date with support from the GAVI Alliance. Investing in rubella will provide a much-needed boost to improving women’s and children’s health, and will help accelerate global progress in controlling two life-threatening diseases. GAVI plans to support 49 countries to introduce the combined measles-rubella vaccine immunizing close to 700 million boys and girls by 2020.”

This campaign is expected to reach more than 170,000 schools and 150,000 immunisation centers with a special attention to be given to children without homes and others who are difficult-to-reach….

:: India commits US$4 million to GAVI Alliance vaccine programmes
GAVI said the contribution, which will be spread over four years as part of the Government of India’s 12th Five Year Plan, “marks a milestone in the relationship between India and the GAVI Alliance. India has received support for its immunisation programme from GAVI since 2002. The announcement comes at a critical time as the GAVI Alliance is stepping up its efforts to save children’s lives and protect people’s health by increasing access to immunisation in the world’s poorest countries.”$-4-million-to-gavi-alliance-vaccine-programmes/

:: New GAVI Advisory Council in India Formed
Prominent Indian experts to support the GAVI Alliance in reducing child mortality through immunisation
The new council “will provide strategic advice and thought leadership to GAVI for its commitment to India” and involve “nine prominent Indians…(who) have agreed to support the goal of increasing access to immunisation and reducing child mortality across the country.

They will work with the GAVI Alliance, a public private partnership made up of members including the World Health Organization, UNICEF, the World Bank and the Bill & Melinda Gates Foundation, as members of the GAVI Advisory Council in India. The inaugural members of the Council are:

–       Baijayant Jay Panda, Member of Parliament, Lok Sabha

–       Nand Kishore Singh, Member of Parliament, Rajya Sabha

–       Harshavardhan Neotia, Chairman, Ambuja Neotia Group

–       Dr. Vishwajeet Kumar, CEO, Community Empowerment Lab

–       Shabana Azmi, actor, social activist

–       Bachi Karkaria, journalist

–       Yuvraj Singh, cricketer, child health and cancer activist

–       Sangitha Reddy, Executive Director, Apollo Hospitals Group

–       Dr C P Bansal, President, South Asia Paediatric Association

Dr Seth Berkley, CEO of the GAVI Alliance, said “GAVI needs India’s partnership and support to work with India to reduce child mortality.  These eminent personalities from different fields, will reinforce our efforts in the policy discourses on child health and advise the GAVI secretariat and partners on the challenges of immunisation and the introduction of new vaccines in India. I am delighted to be launching this council, and I sincerely welcome and am grateful for the acceptance of its inaugural members.”

PATH’s board elected four new board members,

PATH’s board of directors elected four new board members, described as “international business executives who come from a variety of private-sector backgrounds.” Dr. George Gotsadze, chair of PATH’s board of directors, commented, “As PATH sharpens our focus on improving the health and saving the lives of women and children in the world’s poorest places, we welcome the addition of these four outstanding new board members.  Their global experience and expertise in strategic business management, global health, and public-private partnership will strengthen PATH’s ability to take innovation to scale and increase our impact around the world.” The new members include Kofi Amegashie, MSc; David King, JD; Dr. Felix Olale, MD, PhD; and Raj Vattikuti, MS. Bios on these new members are available in the full announcement here:

WHO: South Sudan humanitarian medical assistance

WHO: Humanitarian Health Action
South Sudan humanitarian medical assistance

28 January 2014 — New figures indicate that 646 000 people have been internally displaced (IDPs) and another 123,400 people have fled to neighbouring countries. WHO supported vaccination of over 20,000 children in the IDP camps of Bor, Juba and Nimule. WHO continued to support health cluster partners with life-saving drugs and medical supplies to extend emergency health services to the affected population.
Read the Health Cluster Response Plan – January 2014
pdf, 964kb

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 1 February 2014]

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

:: Human infection with avian influenza A(H7N9) virus – update 31 January 2014

:: Human infection with avian influenza A(H7N9) virus – update 30 January 2014

:: Human infection with avian influenza A(H7N9) virus – update 29 January 2014

:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 27 January 2014

CDC/MMWR Watch [to 1 February 2014]

CDC/MMWR Watch [to 1 February 2014]

MMWR January 31, 2014 / Vol. 63 / No. 4
:: CDC Grand Rounds: Reducing the Burden of HPV-Associated Cancer and Disease

:: Rapidly Building Global Health Security Capacity — Uganda Demonstration Project, 2013

:: Strengthening Global Health Security Capacity — Vietnam Demonstration Project, 2013

:: Notes from the Field: Rotavirus Vaccine Administration Errors — United States, 2006–2013

Research Report : Assessing the Value of Biopharmaceutical Innovation in Key Therapy Areas in Middle Income Countries

Research Report : Assessing the Value of Biopharmaceutical Innovation in Key Therapy Areas in Middle Income Countries
Independent study conducted by Charles River Associates (CRA) commissionedinIFPMA.
January 2014,

The study demonstrates “that there is clear evidence that innovative medicines have delivered significant value by reducing healthcare costs and benefitting both patients and wider society. However, there remains enormous untapped potential of adopting innovative medicines more widely in middle-income countries (MICs). This can be achieved by national prioritization, investments in healthcare infrastructure and building better epidemiological and cost databases for effective evaluation of therapies.” The study examined the value of innovation in five key therapy areas: coronary heart disease (CHD), depression, diabetes, HIV/AIDS, and rotavirus infection.

In the case of rotavirus, the most common cause of severe diarrhoea among children in both industrialized and developing countries, Tim Wilsdon, CRA Vice President, said, “We compared the value that two recently-launched vaccines yielded in Brazil and Australia. The major benefit seen in both countries was a direct drop in hospitalization costs, but in Brazil we also witnessed a major decline in related mortality rates. So obviously both benefitted from these innovations, but given the nature of the disease burden the added value was greater for Brazil.”

Commenting on the study findings, Eduardo Pisani, IFPMA Director General, added that “We now have evidence that in MICs innovative therapies have the potential to create significant value that goes far beyond pricing and reimbursement. Both the social and economic benefits should be taken into account in any calculation of value.”…

[Full report] and [CRA key findings]

Timeliness of childhood vaccine uptake among children attending a tertiary health service facility-based immunisation clinic in Ghana

BMC Public Health
(Accessed 1 February 2014)

Research article  
Timeliness of childhood vaccine uptake among children attending a tertiary health service facility-based immunisation clinic in Ghana
Dennis Odai Laryea, Emmanuel Abbeyquaye Parbie, Ebenezer Frimpong BMC Public Health 2014, 14:90 (29 January 2014)
Abstract |

Childhood immunisation is a cost-effective activity in health. Immunisation of children has contributed to reducing child morbidity and mortality. In the last two decades, global deaths from vaccine-preventable illnesses have decreased significantly as a result of immunisation. Similar trends have been observed in Ghana following the introduction of the Expanded Programme on Immunisation. The administration of vaccines is based on the period of highest susceptibility among others. Ghana has long used the proportion of children receiving vaccines and the trends in vaccine preventable illness incidence as performance indicators for immunisation. The addition of timeliness of vaccine uptake as an additional performance indicator has been recommended. This study evaluated the timeliness of vaccine uptake among children immunised at the Komfo Anokye Teaching Hospital, Kumasi, Ghana.

The study was conducted at the Maternal and Child Health clinic of the hospital between February and March 2012. A representative sample of 259 respondents was selected by simple random sampling. Data collection was by a structured questionnaire and included the examination of Child Health records booklet. Data was entered into a Microsoft Office Access database and analysed using Epi Info Version 3.5.1 2008.

The majority of mothers attended antenatal clinics during pregnancy. An overwhelming majority of babies (98.8%) were delivered in a hospital. About 85% of babies were less than 12 months of age. Mean time taken to reach the clinic was 30 minutes. Vaccine uptake was generally timely for initial vaccines. The proportion of children receiving the vaccines later increased with latter vaccines. Overall, 87.3% of babies received vaccines on time with only 5.3% receiving vaccines beyond 28 days of the scheduled date. Children receiving immunisations services in the same facility as they were born were more likely to receive the BCG vaccine on time.

Vaccine uptake is mostly timely among respondents in the study. The BCG vaccine in particular was received on time among children born in the same facility as the immunisation clinic. There is the need to further examine the timeliness of vaccine uptake among children delivered outside health facilities in Ghana.

Japanese encephalitis: The virus and vaccines

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
February 2014  Volume 10, Issue 2

Japanese encephalitis: The virus and vaccines
Sang-Im Yun and Young-Min Lee
Japanese encephalitis (JE) is an infectious disease of the central nervous system caused by Japanese encephalitis virus (JEV), a zoonotic mosquito-borne flavivirus. JEV is prevalent in much of Asia and the Western Pacific, with over 4 billion people living at risk of infection. In the absence of antiviral intervention, vaccination is the only strategy to develop long-term sustainable protection against JEV infection. Over the past half-century, a mouse brain-derived inactivated vaccine has been used internationally for active immunization. To date, however, JEV is still a clinically important, emerging, and re-emerging human pathogen of global significance. In recent years, production of the mouse brain-derived vaccine has been discontinued, but three new cell culture-derived vaccines are available in various parts of the world. Here we review current aspects of JEV biology, summarize the four types of JEV vaccine, and discuss the potential of an infectious JEV cDNA technology for future vaccine development.

Commentary — Adult immunization: The need to address

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
February 2014  Volume 10, Issue 2

Adult immunization: The need to address
Bharti Mehta, Sumit Chawla, Vijay Kumar, Harashish Jindal and Bhumika Bhatt
Vaccination is recommended throughout life to prevent vaccine-preventable diseases and their sequel. The primary focus of vaccination programs has historically been directed to childhood immunizations. For adults, chronic diseases have been the primary focus of preventive and medical health care, though there has been increased emphasis on preventing infectious diseases. Adult vaccination coverage, however, remains low for most of the routinely recommended vaccines. Though adults are less susceptible to fall prey to traditional infectious agents, the probability of exposure to infectious agents has increased manifold owing to globalization and increasing travel opportunities both within and across the countries. Thus, there is an urgent need to address the problem of adult immunization. The adult immunization enterprise is more complex, encompassing a wide variety of vaccines and a very diverse target population. There is no coordinated public health infrastructure to support an adult immunization program as there is for children. Moreover, there is little coordination among adult healthcare providers in terms of vaccine provision. Substantial improvement in adult vaccination is needed to reduce the health consequences of vaccine-preventable diseases among adults. Routine assessment of adult patient vaccination needs, recommendation, and offer of needed vaccines for adults should be incorporated into routine clinical care of adults.

Commentary — Tuberculosis vaccine: Time to look into future

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
February 2014  Volume 10, Issue 2

Tuberculosis vaccine: Time to look into future
Sumit Chawla, Dinesh Garg, Ram Bilas Jain, Pardeep Khanna, Satvinder Singh Choudhary, Soumya Sahoo and Inderjeet Singh

Global burden of tuberculosis is nearly 12 million. As per the WHO Global TB Report 2013, there were an estimated 8.6 million incident cases of TB globally in 2012. Tuberculosis is an issue that affects development through its effect on the health of individuals and families. In humans, neither prior latent infection nor recovery from active TB confers reliable protection against reinfection or reactivation disease. The power of vaccines as a public health intervention lies in their ability to reduce onward transmission of disease as much as in their ability to protect vaccinated individuals; a feature generally referred to as “herd immunity.” MVA85A is a booster vaccine, used in con-junction with BCG as part of a prime-boost strategy. BCG serves as the prime vaccination and MVA85A as the boost, operating under the theory that the addition of MVA85A will produce a better immune response and more protection against TB than BCG vaccination alone. There is a critical need to raise the profile of TB vaccine research at the community, national, regional, and global levels in order to generate support and political will, increase investment, create an enabling and supportive environment for clinical trials, and lay the groundwork for acceptance and adoption of new TB vaccines once licensed.

Benefits of Antiretroviral Therapy in Africa

Journal of Infectious Diseases
Volume 209 Issue 4 February 15, 2014

Massive Benefits of Antiretroviral Therapy in Africa
Sten H. Vermund1,2
One of the most positive, life-affirming, and transformational public health efforts in modern history is the US President’s Emergency Plan for AIDS Relief (PEPFAR) [1–4]. This bilateral program (which involves the United States and individual partner nations) has had an unprecedented $44.3 billion appropriated from the US Congress from fiscal year 2004 through fiscal year 2012 (as of 31 March 2013), including over $7 billion to its multilateral partner, the Global Fund to Fight AIDS, Tuberculosis and Malaria [5]. Additional funds have been provided by other donor nations, typically through the Global Fund, and by national governments of low- and middle-income countries. These resources have gone toward the global effort to prevent human immunodeficiency virus (HIV) infection and to offer lifesaving antiretroviral therapy (ART)-based care to HIV-infected persons [6]. With its many partners, PEPFAR has directly supported >6 million persons, most in sub-Saharan Africa, among the >10 million persons estimated to have begun ART as of 2013. Since South African legal rulings and the change in government in 2009, the Government of South Africa has been an enthusiastic partner—with its people and with the global community—making up for lost time in the effort to address the epidemic and cooperate with its neighbors in southern Africa [7–9]. No nation has a higher number of infected persons than South Africa, and the southern African nations have the highest prevalence of HIV infection in the world, ranging to over half of the adult population in certain venues and age groups [10]. The Government of South Africa, with support from PEPFAR and the Global Fund, has supported the Herculean efforts of health workers, activists, and patients to reverse the …

Editor’s choice: The Survival Benefits of Antiretroviral Therapy in South Africa
Michael D. April, Robin Wood, Bethany K. Berkowitz, A. David Paltiel, Xavier Anglaret, Elena Losina, Kenneth A. Freedberg, and Rochelle P. Walensky
J Infect Dis. (2014) 209 (4): 491-499 doi:10.1093/infdis/jit584
Full Text (HTML)
Full Text (PDF)
Supplementary Data
Background.  We sought to quantify the survival benefits attributable to antiretroviral therapy (ART) in South Africa since 2004.

Methods. We used the Cost-Effectiveness of Preventing AIDS Complications–International model (CEPAC) to simulate 8 cohorts of human immunodeficiency virus (HIV)–infected patients initiating ART each year during 2004–2011. Model inputs included cohort-specific mean CD4+ T-cell count at ART initiation (112–178 cells/µL), 24-week ART suppressive efficacy (78%), second-line ART availability (2.4% of ART recipients), and cohort-specific 36-month retention rate (55%–71%). CEPAC simulated survival twice for each cohort, once with and once without ART. The sum of the products of per capita survival differences and the total numbers of persons initiating ART for each cohort yielded the total survival benefits.

Results.  Lifetime per capita survival benefits ranged from 9.3 to 10.2 life-years across the 8 cohorts. Total estimated population lifetime survival benefit for all persons starting ART during 2004–2011 was 21.7 million life-years, of which 2.8 million life-years (12.7%) had been realized by December 2012. By 2030, benefits reached 17.9 million life-years under current policies, 21.7 million life-years with universal second-line ART, 23.3 million life-years with increased linkage to care of eligible untreated patients, and 28.0 million life-years with both linkage to care and universal second-line ART.

Conclusions.  We found dramatic past and potential future survival benefits attributable to ART, justifying international support of ART rollout in South Africa.

Lancet Series: Health in the Arab world – a view from within

The Lancet  
Feb 01, 2014  Volume 383  Number 9915   p383 – 486  e9 – 10

Health in the Arab world: a view from within
Changing therapeutic geographies of the Iraqi and Syrian wars
Omar Dewachi, Mac Skelton, Vinh-Kim Nguyen, Fouad M Fouad, Ghassan Abu Sitta, Zeina Maasri, Rita Giacaman
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The health consequences of the ongoing US-led war on terror and civil armed conflicts in the Arab world are much more than the collateral damage inflicted on civilians, infrastructure, environment, and health systems. Protracted war and armed conflicts have displaced populations and led to lasting transformations in health and health care. In this report, we analyse the effects of conflicts in Iraq and Syria to show how wars and conflicts have resulted in both the militarisation and regionalisation of health care, conditions that complicate the rebuilding of previously robust national health-care systems.

Health and ecological sustainability in the Arab world: a matter of survival
Abbas El-Zein, Samer Jabbour, Belgin Tekce, Huda Zurayk, Iman Nuwayhid, Marwan Khawaja, Tariq Tell, Yusuf Al Mooji, Jocelyn De-Jong, Nasser Yassin, Dennis Hogan
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Discussions leading to the Rio+20 UN conference have emphasised the importance of sustainable development and the protection of the environment for future generations. The Arab world faces large-scale threats to its sustainable development and, most of all, to the viability and existence of the ecological systems for its human settlements. The dynamics of population change, ecological degradation, and resource scarcity, and development policies and practices, all occurring in complex and highly unstable geopolitical and economic environments, are fostering the poor prospects.

Health and contemporary change in the Arab world
Samer Jabbour
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In the past 10 years, but especially since the desperate act by Mohamed Bouazizi (a 26-year-old street vendor who set himself on fire on Dec 17, 2010, in protest against the confiscation of his cart and his humiliation by police) sparked popular uprisings in Tunisia that toppled President Zine El Abidine Ben Ali in January, 2011, huge ongoing changes have gripped several countries in the Arab world and affected almost all others. From the invasion and occupation of Iraq to the empowerment of previously silenced masses (claiming new spaces for dissent, toppling presidents, and redrafting constitutions), the separation of South Sudan, and persistent insecurities and violence in some countries, these changes affect every domain of social life and have important effects on health.

State formation and underdevelopment in the Arab world
Tariq Tell
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A revisionist view of Arab underdevelopment has gained popularity because of the hegemony of neoliberal beliefs over development policy in the region. It stresses the inadequacies of the Arab state and the shortcomings of the dirigiste (state-led) development policies associated with so-called Arab socialism, and was given popular support by President Gamal Abdel Nasser of Egypt who dominated the politics of the Arab world from 1952 to 1970.1,2 Little effort has been made to understand the historical forces that produced this turn to the state, and an internalist explanation of the lack of Arab progress is offered instead.

Importance of research networks: the Reproductive Health Working Group, Arab world and Turkey
Rita Giacaman, Asya Al-Ryami, Hyam Bashour, Jocelyn DeJong, Noha Gaballah, Atf Gherissi, Belgin Tekce, Huda Zurayk
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A meeting of the Reproductive Health Working Group’s Consultative Committee was due to take place at the Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon, on June 17–18, 2013. This Committee plans the activities of the Reproductive Health Working Group, Arab World and Turkey, a 25-year-old capacity-building research network for the Arab countries and Turkey. The Consultative Committee members are based in Egypt, Jordan, Lebanon, Oman, occupied Palestinian territory, Syria, Tunisia, and Turkey, where, with the exception of Oman, conflicts, wars, military occupation, insecurity, and uncertainty seem to be the norm these days.

Risk Factors for Transmission of Mumps in a Highly Vaccinated Population in Orange County, NY, 2009–2010

The Pediatric Infectious Disease Journal
February 2014 – Volume 33 – Issue 2 pp: 121-231,e29-e66

Risk Factors for Transmission of Mumps in a Highly Vaccinated Population in Orange County, NY, 2009–2010
Kutty, Preeta K.; McLean, Huong Q.; Lawler, Jacqueline; More

Background: In 2009–2010, we investigated a mumps outbreak among a highly vaccinated Orthodox Jewish population in a village in Orange County, NY, to identify risk factors associated with mumps transmission among persons with 2 doses of mumps-containing vaccine.

Methods: Demographic and epidemiologic characteristics were collected on students in grades 6–12 in 3 schools. A mumps case was defined as a student, who self-reported parotitis, orchitis, jaw swelling and/or a mumps-related complication or whose mumps illness was reported to the Orange County Health Department during September 1, 2009, to January 18, 2010. Log-binomial regression analyses were conducted separately for boys and girls as they attended different schools and had different hours of study.

Results: Of the 2503 students with 2 documented doses of mumps-containing vaccine, 320 (13%) developed mumps. Risk of mumps increased with increasing number of mumps cases in the class [≥8 vs. ≤3 cases: boys aRR=3.1; 95% confidence interval (CI): 2.0–5.0; girls aRR=2.6; 95% CI: 1.6–4.1] and household (>1 vs. 0 cases: boys aRR= 4.3 95% CI: 3.7–5.6; girls aRR= 10.1 95% CI: 7.1–14.3). Age at first dose, time since last dose, time between first and second dose, school, class size, number of hours at school per week and household size were not significantly associated with having mumps.

Conclusions: Two doses of mumps-containing vaccine may not be as effective in outbreak settings with multiple, prolonged and intense exposure. Additional studies are required to understand why such mumps outbreaks occur and how they can be prevented in the future.
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Prospective Nationwide Surveillance of Hospitalizations Due to Pertussis in Children, 2006–2010

The Pediatric Infectious Disease Journal
February 2014 – Volume 33 – Issue 2 pp: 121-231,e29-e66

Prospective Nationwide Surveillance of Hospitalizations Due to Pertussis in Children, 2006–2010
Heininger, Ulrich; Weibel, Daniel; Richard, Jean-Luc
Background: Frequency of pertussis is highly variable from country to country and it depends on multiple factors including case definitions and type of surveillance systems used. Many countries recently reported an increase of pertussis cases especially in infants and adolescents.

Methods: From April 2006 to March 2011, 15-year-old patients hospitalized with suspected or proven pertussis were reported to the Swiss Pediatric Surveillance Unit. Patients with ≥14 days of cough plus paroxysms, whooping or post-tussive vomiting fulfilled the clinical case definition of pertussis. For laboratory confirmation, Bordetella pertussis polymerase chain reaction was offered free of charge.

Results: Data were available from 159 of 173 reported cases and 130 (90% of them <12 months old) were eligible including 125 laboratory-confirmed B. pertussis infections. Rates per 100,000 population were 2.6 (<16 years) and 38.8 (<12 months), respectively. Most frequent complications were cyanosis (63%) and sleep disturbance (60%); 35 (27%) patients received intensive care and 1 patient died. Source of infection was known in 79 (61%) patients and was mainly a sibling, parent or both. Most patients were unimmunized (65%) or incompletely immunized (30%).

Conclusions: The high rate of pertussis hospitalization in young infants established in this surveillance project and the incomplete pertussis immunization status in almost all hospitalized patients require further efforts for improvement. In addition, introduction of pertussis immunizations for all adolescents (in 2013), young adults (in 2012) and pregnant women (in 2013) in Switzerland should increase indirect protection of vulnerable newborns and infants too young to be fully immunized.

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Cost-Effectiveness of Alternative Strategies for Annual Influenza Vaccination among Children Aged 6 Months to 14 Years in Four Provinces in China

PLoS One
[Accessed 1 February 2014]

Cost-Effectiveness of Alternative Strategies for Annual Influenza Vaccination among Children Aged 6 Months to 14 Years in Four Provinces in China
Lei Zhou, Sujian Situ, Zijian Feng, Charisma Y. Atkins, Isaac Chun-Hai Fung, Zhen Xu, Ting Huang, Shixiong Hu, Xianjun Wang, Martin I. Meltzer Research Article | published 31 Jan 2014 | PLOS ONE 10.1371/journal.pone.0087590

To support policy making, we developed an initial model to assess the cost-effectiveness of potential strategies to increase influenza vaccination rates among children in China.

We studied on children aged 6 months to 14 years in four provinces (Shandong, Henan, Hunan, and Sichuan), with a health care system perspective. We used data from 2005/6 to 2010/11, excluding 2009/10. Costs are reported in 2010 U.S. dollars.

In comparison with no vaccination, the mean (range) of Medically Attended Cases averted by the current self-payment policy for the two age groups (6 to 59 months and 60 months to 14 years) was 1,465 (23~11,132) and 792 (36~4,247), and the cost effectiveness ratios were $ 0 (-11-51) and $ 37 (6-125) per case adverted, respectively. In comparison with the current policy, the incremental cost effectiveness ratio (ICER) of alternative strategies, OPTION One-reminder and OPTION Two-comprehensive package, decreased as vaccination rate increased. The ICER for children aged 6 to 59 months was lower than that for children aged 60 months to 14 years.

The model is a useful tool in identifying elements for evaluating vaccination strategies. However, more data are needed to produce more accurate cost-effectiveness estimates of potential vaccination policies

Free-Riding Behavior in Vaccination Decisions: An Experimental Study

PLoS One
[Accessed 1 February 2014]

Free-Riding Behavior in Vaccination Decisions: An Experimental Study
Yoko Ibuka, Meng Li, Jeffrey Vietri, Gretchen B. Chapman, Alison P. Galvani Research Article | published 24 Jan 2014 | PLOS ONE 10.1371/journal.pone.0087164
Individual decision-making regarding vaccination may be affected by the vaccination choices of others. As vaccination produces externalities reducing transmission of a disease, it can provide an incentive for individuals to be free-riders who benefit from the vaccination of others while avoiding the cost of vaccination. This study examined an individual’s decision about vaccination in a group setting for a hypothetical disease that is called “influenza” using a computerized experimental game. In the game, interactions with others are allowed. We found that higher observed vaccination rate within the group during the previous round of the game decreased the likelihood of an individual’s vaccination acceptance, indicating the existence of free-riding behavior. The free-riding behavior was observed regardless of parameter conditions on the characteristics of the influenza and vaccine. We also found that other predictors of vaccination uptake included an individual’s own influenza exposure in previous rounds increasing the likelihood of vaccination acceptance, consistent with existing empirical studies. Influenza prevalence among other group members during the previous round did not have a statistically significant effect on vaccination acceptance in the current round once vaccination rate in the previous round was controlled for.