Science Translational Medicine
12 March 2014 vol 6, issue 227
http://stm.sciencemag.org/content/current

POLICY
Meeting the Demand for Pediatric Clinical Trials
Edward M. Connor, William E. Smoyer, Jonathan M. Davis, Anne Zajicek, Linda Ulrich, Mary Purucker, and Steven Hirschfeld
12 March 2014: 227fs11
Abstract
The bid for high-quality, cost-effective pediatric clinical trials requires robust research and regulatory playgrounds and an appropriately trained workforce.

Vaccine
Volume 32, Issue 16, Pages 1775-1896 (1 April 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

National Immunization Commission: Strengthening evidence-based decision making in Argentina
Pages 1778-1780
Daniel Stecher, Alejandra Gaiano, Cristián Biscayart, Angela Gentile, Silvia Gonzalez Ayala, Eduardo López, Pablo Bonvehí, Pablo Yedlin, Cara Janusz, Carla Vizzotti
Abstract
In Argentina, the National Technical Advisory Group on Immunizations is represented by the National Immunization Commission (CoNaIn), an organization created by the Ministry of Health in 2000. Recently, the Argentine government has decided to prioritize vaccination as a state policy, emphasizing this strategy as a sign of social equity so CoNaIn was restructured to increase its capacity to formulate sound and evidence-based recommendations. The commission shall consist of a group of immunization experts, representatives of scientific societies, the immunization program and the Ministry of Health. Its functions include the formulation of recommendations on the introduction of vaccines into the immunization program. The recommendations are based on technical, programmatic and social criteria. This decision-making process transparent with the support and advice of experts and scientific societies and guided by available evidence decisions help strengthen the Ministry of Health immunization policy generating greater confidence and support from the population and health professionals.

Vaccine
Volume 32, Issue 16, Pages 1775-1896 (1 April 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Breastfeeding after maternal immunisation during pregnancy: Providing immunological protection to the newborn: A review
Review Article
Pages 1786-1792
Kirsten Maertens, Sara De Schutter, Tessa Braeckman, Lesley Baerts, Pierre Van Damme, Ingrid De Meester, Elke Leuridan
Abstract
Vaccination during pregnancy results in an augmentation of disease specific maternal antibodies. Immunoglobulin G (IgG) is mainly transferred through the placenta during the third trimester of pregnancy, while secretory Immunoglobulin A (sIgA) is passed through breast milk.    At birth, newborns are partially protected against infectious diseases by these antibodies.

This review aims to provide an overview of the effect of vaccination during pregnancy on the immunological protection of the newborn by the presence of disease specific sIgA antibodies in breast milk and their possible protective function against disease.

Our search produced 11 relevant papers; 1 on pertussis, 7 on pneumococcus, 2 on influenza and 1 on meningococcus.

All of the studies in this review that measured disease specific antibodies in breast milk (n = 8 papers), stressed the beneficial effect of maternal vaccination during pregnancy on the amount of disease specific sIgA in breast milk. Only a few studies demonstrated a potential protective effect, particularly with influenza vaccines. In an era where maternal vaccination is increasingly considered as a valuable strategy to protect both the mother and infant, further research is needed to assess the effect on breast milk sIgA and to understand the potentially beneficial effects to the infant.

Vaccine
Volume 32, Issue 16, Pages 1775-1896 (1 April 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Rising rates of vaccine exemptions: Problems with current policy and more promising remedies
Review Article
Pages 1793-1797
Catherine Constable, Nina R. Blank, Arthur L. Caplan
Abstract
Parents of school-age children are increasingly claiming nonmedical exemptions to refuse vaccinations required for school entry. The resultant unvaccinated pockets in many areas of the country have been linked with outbreaks of vaccine-preventable diseases. Many states are now focused on reducing rates of nonmedical exemptions by making exemption processes more restrictive or burdensome for the exemptor. These strategies, however, pose ethical problems and may ultimately be inadequate. A shift to strategies that raise the financial liabilities of exemptors may lead to better success and prove ethically more sound. Potential areas of reform include tax law, health insurance, and private school funding programs. We advocate an approach that combines this type of incentive with more effective vaccination education.

Vaccine
Volume 32, Issue 16, Pages 1775-1896 (1 April 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Measles resurgence in southern Africa: Challenges to measles elimination
Original Research Article
Pages 1798-1807
Messeret E. Shibeshi, Balcha G. Masresha, Sheilagh B. Smit, Robin J. Biellik, Jennifer L. Nicholson, Charles Muitherero, Nestor Shivute, Oladapo Walker, Katsande Reggis, James L. Goodson
Abstract
Introduction
In seven southern African countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland and Zimbabwe), following implementation of a measles mortality reduction strategy starting in 1996, the number of annually reported measles cases decreased sharply to less than one per million population during 2006–2008. However, during 2009–2010, large outbreaks occurred in these countries. In 2011, a goal for measles elimination by 2020 was set in the World Health Organization (WHO) African Region (AFR). We reviewed the implementation of the measles control strategy and measles epidemiology during the resurgence in the seven southern African countries.

Methods
Estimated coverage with routine measles vaccination, supplemental immunization activities (SIA), annually reported measles cases by country, and measles surveillance and laboratory data were analyzed using descriptive analysis.

Results
In the seven countries, coverage with the routine first dose of measles-containing vaccine (MCV1) decreased from 80% to 65% during 1996–2004, then increased to 84% in 2011; during 1996–2011, 79,696,523 people were reached with measles vaccination during 45 SIAs. Annually reported measles cases decreased from 61,160 cases to 60 cases and measles incidence decreased to <1 case per million during 1996–2008. During 2009–2010, large outbreaks that included cases among older children and adults were reported in all seven countries, starting in South Africa and Namibia in mid-2009 and in the other five countries by early 2010. The measles virus genotype detected was predominantly genotype B3.

Conclusion
The measles resurgence highlighted challenges to achieving measles elimination in AFR by 2020. To achieve this goal, high two-dose measles vaccine coverage by strengthening routine immunization systems and conducting timely SIAs targeting expanded age groups, potentially including young adults, and maintaining outbreak preparedness to rapidly respond to outbreaks will be needed.

Vaccine
Volume 32, Issue 16, Pages 1775-1896 (1 April 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Impact of measles national vaccination coverage on burden of measles across 29 Member States of the European Union and European Economic Area, 2006–2011
Original Research Article
Pages 1814-1819
E. Colzani, S.A. McDonald, P. Carrillo-Santisteve, M.C. Busana, P. Lopalco, A. Cassini
Abstract
Background
Challenges in reaching good vaccination coverage against measles emerged in several European Union/European Economic Area Member States (EU/EEA MS) leading to progressive accumulation of susceptible individuals and outbreaks. The Burden of Communicable Diseases in Europe (BCoDE) project developed a methodology for measuring the burden of communicable diseases expressed in Disability-Adjusted Life Years (DALYs) in the EU/EEA MS. The aim of this study was to compare national vaccination coverage and burden of measles across EU/EEA MS.

Methods
Country-specific data on measles national vaccination coverage 2006–2011 from 29 EU/EEA MS (MCV1) were retrieved from Centralized Information System for Infectious Diseases (CISID). DALYs were calculated for each country separately using a disease progression model with a single input parameter (annual measles incidence, adjusted for under-estimation). A software application was used to compute estimated DALYs according to country-specific and year-specific population age-distributions (data retrieved from Eurostat). Log-linear mixed-effect regression modeling approach was used to investigate a linear relation between natural logarithm-transformed DALYs and coverage.

Results
The reported annual vaccination coverage ranged from 72.6% to 100%. The estimated national annual burden ranged from 0 to 30.6 DALYs/100,000. Adjusting for year, there was a significant negative relationship between coverage and burden. For a given country there was a decrease in log-transformed DALYs/100,000 of 0.025 (95% confidence interval: −0.047 to −0.003) for every percentage increase in vaccination coverage. The largest effect of calendar time on estimated burden of measles was observed for the year 2011, the smallest was for the year 2007.

Conclusions
This study shows that the degree of success of national measles vaccination programs, when measured by the coverage obtained, is significantly associated with overall impact of measles across EU/EEA MS. In EU/EEA MS each percentage point increase in national vaccination coverage seems to lead to early significant reduction of overall burden of measles

Vaccine
Volume 32, Issue 15, Pages 1641-1774 (26 March 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/15

Cost-effectiveness of vaccination against herpes zoster and postherpetic neuralgia: a critical review
Review Article
Pages 1645-1653
Kosuke Kawai, Emmanuelle Preaud, Florence Baron-Papillon, Nathalie Largeron, Camilo J. Acosta
Abstract
Objective
The objective of this study was to systematically review cost-effectiveness studies of vaccination against herpes zoster (HZ) and postherpetic neuralgia (PHN).

Methods
We searched MEDLINE and EMBASE databases for eligible studies published prior to November 2013. We extracted information regarding model structure, model input parameters, and study results. We compared the results across studies by projecting the health and economic impacts of vaccinating one million adults over their lifetimes.

Results
We identified 15 cost-effectiveness studies performed in North America and Europe. Results ranged from approximately US$10,000 to more than US$100,000 per quality-adjusted life years (QALY) gained. Most studies in Europe concluded that zoster vaccination is likely to be cost-effective. Differences in results among studies are largely due to differing assumptions regarding duration of vaccine protection and a loss in quality of life associated with HZ and to a larger extent, PHN. Moreover, vaccine efficacy against PHN, age at vaccination, and vaccine cost strongly influenced the results in sensitivity analyses.

Conclusion
Most studies included in this review shows that vaccination against HZ is likely to be cost-effective. Future research addressing key model parameters and cost-effectiveness studies in other parts of the world are needed.

Vaccine
Volume 32, Issue 15, Pages 1641-1774 (26 March 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/15

Methodological quality of systematic reviews on influenza vaccination
Original Research Article
Pages 1678-1684
Cornelius Remschmidt, Ole Wichmann, Thomas Harder
Abstract
Background
There is a growing body of evidence on the risks and benefits of influenza vaccination in various target groups. Systematic reviews are of particular importance for policy decisions. However, their methodological quality can vary considerably.

Objectives
To investigate the methodological quality of systematic reviews on influenza vaccination (efficacy, effectiveness, safety) and to identify influencing factors.

Methods
A systematic literature search on systematic reviews on influenza vaccination was performed, using MEDLINE, EMBASE and three additional databases (1990–2013). Review characteristics were extracted and the methodological quality of the reviews was evaluated using the assessment of multiple systematic reviews (AMSTAR) tool. U-test, Kruskal–Wallis test, chi-square test, and multivariable linear regression analysis were used to assess the influence of review characteristics on AMSTAR-score.

Results
Fourty-six systematic reviews fulfilled the inclusion criteria. Average methodological quality was high (median AMSTAR-score: 8), but variability was large (AMSTAR range: 0–11). Quality did not differ significantly according to vaccination target group. Cochrane reviews had higher methodological quality than non-Cochrane reviews (p = 0.001). Detailed analysis showed that this was due to better study selection and data extraction, inclusion of unpublished studies, and better reporting of study characteristics (all p < 0.05). In the adjusted analysis, no other factor, including industry sponsorship or journal impact factor had an influence on AMSTAR score.

Conclusions
Systematic reviews on influenza vaccination showed large differences regarding their methodological quality. Reviews conducted by the Cochrane collaboration were of higher quality than others. When using systematic reviews to guide the development of vaccination recommendations, the methodological quality of a review in addition to its content should be considered.

Vaccine
Volume 32, Issue 15, Pages 1641-1774 (26 March 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/15

Socioecological and message framing factors influencing maternal influenza immunization among minority women
Original Research Article
Pages 1736-1744
Paula M. Frew, Diane S. Saint-Victor, Lauren E. Owens, Saad B. Omer
Abstract
Objective
A suboptimal level of seasonal influenza vaccination among pregnant minority women is an intractable public health problem, requiring effective message resonance with this population. We evaluated the effects of randomized exposure to messages which emphasize positive outcomes of vaccination (“gain-frame”), or messages which emphasize negative outcomes of forgoing vaccination (“loss-frame”). We also assessed multilevel social and community factors that influence maternal immunization among racially and ethnically diverse populations.

Study design
Minority pregnant women in metropolitan Atlanta were enrolled in the longitudinal study and randomized to receive intervention or control messages. A postpartum questionnaire administered 30 days postpartum evaluated immunization outcomes following baseline message exposure among the study population. We evaluated key outcomes using bivariate and multivariate analyses.

Results
Neither gain- [OR = 0.5176, (95% CI: 0.203,1.322)] nor loss-framed [OR = 0.5000, 95% CI: (0.192,1.304)] messages were significantly associated with increased likelihood of immunization during pregnancy. Significant correlates of seasonal influenza immunization during pregnancy included healthcare provider recommendation [OR = 3.934, 95% CI: (1.331,11.627)], use of hospital-based practices as primary source of prenatal care [OR = 2.584, 95% CI: (1.091,6.122)], and perceived interpersonal support for influenza immunization [OR = 3.405, 95% CI: (1.412,8.212)].

Conclusion
Dissemination of vaccine education messages via healthcare providers, and cultivating support from social networks, will improve seasonal influenza immunization among pregnant minority women.

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

Journal of Immigrant and Minority Health
March 2014
http://link.springer.com/journal/10903
Low Human Papillomavirus (HPV) Vaccine Knowledge Among Latino Parents in Utah
Deanna Kepka, Echo L. Warner, Anita Y. Kinney, Michael G. Spigarelli, Kathi Mooney
http://link.springer.com/article/10.1007/s10903-014-0003-1
Abstract
Latinas have the highest incidence of cervical cancer, yet Latino parents/guardians’ knowledge about and willingness to have their children receive the human papillomavirus (HPV) vaccine is unknown. Latino parents/guardians (N = 67) of children aged 11–17 were recruited from two community organizations to complete a survey, including HPV vaccine knowledge, child’s uptake, demographic characteristics, and acculturation. Descriptive statistics and correlates of parents’ HPV knowledge and uptake were calculated using Chi square tests and multivariable logistic regression. Receipt of at least one dose of the HPV vaccine was moderate for daughters (49.1 %) and low for sons (23.4 %). Parents/guardians reported limited knowledge as the main barrier to vaccine receipt. Among parents/guardians with vaccinated daughters, 92.6 % did not know the vaccine requires three doses. Adjusting for income, low-acculturated parents were more likely than high-acculturated parents to report inadequate information (OR 8.59, 95 % CI 2.11–34.92). Interventions addressing low knowledge and children’s uptake of the HPV vaccine are needed among Latino parents/guardians.

Special Focus Newsletters
Rotaflash  March 14, 2014
:: GACVS review of intussusception data provides reassurance that the benefits of rotavirus vaccines still outweigh risks
WHO recommendation for universal rotavirus vaccination remains unchanged

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 with the current issue date

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– Email Summary: Vaccines and Global health : The Week in Review is published as a single email summary, scheduled for release each Saturday eveningbefore midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.
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– pdf version:  A pdf of the current issues is available here: Vaccines and Global Health_The Week in Review_8 Mar 2014

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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– Support:  If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary. Thank you…
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

GAVI Watch [to 8 March 2014]
http://www.gavialliance.org/library/news/press-releases/
:: The GAVI Alliance announced that it will support HPV vaccination programmes in Rwanda, Uganda and Uzbekistan “aiming to protect 1.5 million girls against the cause of cervical cancer.” The first GAVI-supported national rollouts of the vaccine will begin in Uganda and Uzbekistan in 2015 while Rwanda will switch from a vaccine manufacturer’s donation to GAVI Alliance support this year to secure the sustainability of its existing national programme. The three countries “have developed detailed plans to ensure that girls aged 10 – 12 years are vaccinated with HPV vaccine in schools and also that those who are not in the classroom are reached in communities through outreach by health workers.”
Full announcement – 8 March 2014: http://www.gavialliance.org/library/news/press-releases/2014/1-5-million-girls-set-to-benefit-from-vaccine-against-cervical-cancer/#

:: GAVI noted that The Obama Administration has requested a record US$200 million in its fiscal year 2015 budget to support the GAVI Alliance, the largest amount the United States has ever requested for the Alliance.
Full announcement: http://www.gavialliance.org/library/news/press-releases/2014/us-presidents-budget-proposes-record-usd-200-million-to-the-gavi-alliance/

Statement: Message from WHO Director-General on International Women’s Day
WHO Director-General, Dr Margaret Chan
7 March 2014

[Full text; Editor’s bolded text]
On this day, WHO joins others in celebrating women’s achievements. These achievements are inspiring, and they can inspire change. In health development, as in many other areas, women are agents of change. They are the driving force that creates better lives for families, communities and, increasingly, the countries they have been elected to govern.

As I have learned from my discussions with parliaments in several countries, women are increasingly winning top leadership roles, in rich and poor countries alike, and this helps shape entire societies in broadly beneficial ways. Every time a women excels in a high-profile position, her achievement lifts the social status of women everywhere.

To inspire change, all women need to be free to achieve their full potential. This means freedom from all forms of discrimination, freedom to pursue all opportunities, including education, freedom to earn and spend their own income, and freedom to follow the career paths they decide they want.

The health sector can do much to free women by ensuring they have access to all the health services they need, including sexual and reproductive health services. Participants at last year’s London Summit on Family Planning achieved a breakthrough commitment to halve the number of girls and women in developing countries who want modern contraceptives but have no access. This commitment will give 120 million additional women the right to decide whether, when, and how many children they want to have. This, too, is freedom.

Throughout history, women have been associated with care and compassion. Worldwide, up to 80% of health care is provided in the home, almost always by women. This should inspire our admiration, but it should also underscore the need for change. Most of this work is unsupported, unrecognized, and unpaid.

   Polio is on the verge of eradication largely thanks to the millions of women – from vaccinators to administrators to medical doctors and mothers – who have made the vaccination and protection of children their life’s mission. On this International Women’s Day, let me thank these women for a level of dedication that can improve the world in a permanent way.

   The Global Fund said it is “expanding action on gender equality and emphasising the importance of saving the lives of women and girls through increased high-impact, gender-responsive investments to tackle HIV, TB and malaria.” As it observes International Women’s Day, 8 March, the Global Fund cited the health needs of women and girls as a central part of gender equality work that is essential to have significant impact on responses to AIDS, tuberculosis and malaria. Discussions on gender equality were highlighted at a Board Meeting of the Global Fund that concluded on 7 March. Board delegations “were briefed on the new Action Plan of the Global Fund Gender Equality Strategy. Women and men from diverse communities in India, Indonesia, Malawi, Myanmar and Zimbabwe spoke of their experiences with the Global Fund and urged leaders to translate words into action. Over 50 representatives from donor governments, technical agencies and affected women met to determine strategy on concrete steps toward gender equality and to target the world’s health investments towards the populations who need them most…”

Separately, the Board of the Global Fund approved strategic, financial and operational components of a new approach to funding that “offers more predictability, more flexibility, more inclusive country dialogue and a greater impact to defeat AIDS, TB and malaria”… “opening the way for its full implementation to begin this month.”     Full text of announcements:
:: http://www.theglobalfund.org/en/mediacenter/newsreleases/2014-03-07_Gender_Equality_Central_to_Global_Fund_Next_Steps/
:: http://www.theglobalfund.org/en/mediacenter/newsreleases/2014-03-07_Global_Fund_Board_Moves_Forward_on_New_Funding_Model/

IWD 2014: An AIDS Vaccine as a Force for Women’s Equality
Posted by Margaret G. McGlynn, President and CEO, the International AIDS Vaccine Initiative
on Friday, March 7th 2014

Excerpt
We’ve come a long way in 104 years of marking International Women’s Day. But far too many women remain left behind in far too many parts of the world.

In sub-Saharan Africa, AIDS is the leading killer of women of reproductive age. Limited education, economic and social dependence on men, and gender-based violence severely restrict women’s power over their own health. Imagine what an AIDS vaccine could change for African women and their children. Photo Credit: Frederic Courbet

In Africa, a vicious cycle of HIV and AIDS and gender inequity continues to thwart women’s hopes for a healthy and productive life. AIDS is the number-one killer of women of reproductive age in sub-Saharan Africa and the world, and women account for more than half of the people living with HIV in low- and middle-income countries. It’s a human tragedy and an economic one.  Beyond the epidemic’s direct costs, women are a driving force behind Africa’s economy, and their productivity loss takes a toll. Women own nearly one-third of firms in sub-Saharan Africa and grow at least 80 percent of the food.

Inequity in daily life explains much of the disproportional impact of HIV on women. Limited education, economic and social dependence on men, and gender-based violence severely restrict African women’s power over their own lives and health. An effective and widely available AIDS vaccine will help break through many of the related social and cultural barriers…

Full text: http://blog.usaid.gov/2014/03/iwd-2014-an-aids-vaccine-as-a-force-for-womens-equality/

GPEI Independent Monitoring Board: Letter to WHO Director-General
26 February 2014
Full text: More
Excerpts [Editor’s bolded text]
“…The current situation in Pakistan is a powder key that could ignite widespread polio transmission. The number of cases in this country is going in the wrong direction…the adequacy of the government’s plans will be in full public view at our May meeting and at the subsequent World Health Assembly…”

“..At our suggestion, the program has identified a Red List of the countries most vulnerable to a polio outbreak. In the IMB’s view, when a country is placed on the Red List, all possible means must be used to get it out of this precarious situation as swiftly as possible. As the ongoing outbreak in the Horn of Africa demonstrates, the program softens its focus on such countries at its peril…We are deeply worried about the present situation in the Ukraine, which was very vulnerable even before the recent civil conflict, and recommend that the country be included in the program’s Red List.

“Since our October meeting, a new outbreak has emerged in Syria. The program has done a commendable job of responding to this outbreak, within the constraints of a major conflict. Protecting children from this scourge should be part of a core humanitarian response. We suggest that when humanitarian emergencies occur in countries where the reintroduction (or export) of poliovirus is possible, the GPEI seek to work with the United Nations – OCHA – as a key partner, and that OCHA be asked to include polio vaccination as a priority of the health clusters under the Humanitarian Reform system…”

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GPEI Update: Polio this week – As of 5 March 2014
Global Polio Eradication Initiative
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
[Editor’s extract and bolded text]
:: On 28 February, UNICEF concluded its tender process which makes accessible sufficient quantities of affordable inactivated polio vaccine (IPV) to support country introductions. The vaccine will now be available to GAVI-supported countries for as little as EUR0.75 per dose (approximately US$1 at current exchange rate) in ten-dose vials. The introduction of IPV globally, prior to a phased removal of oral polio vaccines (OPV), is a major element of the comprehensive plan to end all polio disease. More than 120 countries have yet to introduce IPV, more than half of which are eligible for GAVI support. The conclusion of UNICEF’s tender ensures that affordable IPV will be made available, removing a major obstacle to global introduction. More.
:: On 27 February, the world’s leading Islamic scholars, led by the Grand Imam of the Holy Mosque of Mecca, stated that protection against diseases is obligatory and admissible under Islamic Shariah, and that any actions which do not support these preventive measures and cause harm to humanity are un-Islamic. The scholars adopted a strong ‘Jeddah Declaration’ and a focused six-month Plan of Action to address critical challenges facing polio eradication efforts in the few remaining polio-endemic parts of the Islamic world: a ban on vaccinations and lack of access to children in some areas, deadly attacks on health workers, and misconceptions by communities about mass vaccination campaigns. More.
:: The Independent Monitoring Board (IMB) issued its letter to the heads of the GPEI partner agencies, following the group’s additional meeting two weeks ago, and ahead of the group’s next regularly meeting on 6-7 May. The IMB reviewed the current global epidemiology, and expressed concern by the persistent shortfall in funds, seemingly due to significant delays in some donors following through on their pledges. More.
:: In Nigeria, the first wild poliovirus type 1 (WPV1) case of 2014 has been reported, from Kano state. It is the first WPV1 case in the country since December. Since September 2013, seven WPV1 cases have been reported, five from Kano. Together with Borno (the location of the last previous case from December), Kano state holds the key to a polio-free Nigeria.

Nigeria
:: One new WPV1 case was reported in the past week, the first in 2014. The case had onset of paralysis on 1 February, from Gaya Local Government Area (LGA), Kano. The total number of WPV cases for 2013 remains 53 (all WPV1).
:: A full case investigation of this latest WPV1 case has been launched. Technical support to Gaya LGA and surrounding areas was maximised for this week’s national Immunization Plus Days (IPDs – 1-4 March, with bivalent OPV), to ensure high-quality implementation, supervision and monitoring.
:: The IMB underscored that stopping polio transmission in 2014 is potentially feasible, though far from certain. The group welcomed the country’s determination to succeed this year, but warned Nigeria needed continuity and unwavering commitment particularly in the face of election-related distraction. The IMB underscored that the governors of Kano and Borno are vital figures in global polio eradication, and should be strongly supported and encouraged to apply their unique influence at this critical time.

Pakistan
:: Three new WPV1 cases were reported in the past week, all from Federally Administered Tribal Areas (FATA – two from North Waziristan and one from FR Bannu). The total number of cases for 2014 is now 24. The total number of cases for 2013 remains 93..
:: The IMB expressed particular concern at the polio situation in Pakistan, concluding that the country risked being the last place on earth in which polio exists, if current trend continues. While commending some new initiatives, the IMB cautioned that authorities needed to fully grasp the fundamental seriousness of the situation.
:: North Waziristan is the district with the largest number of children being paralyzed by poliovirus in the world (both wild and cVDPV2). 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.
:: The densely populated Peshawar valley is considered to be the main ‘engine’ of poliovirus 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 and in Quetta, Balochistan. Environmental positives isolates from every major city of Punjab confirm widespread virus circulation

Horn of Africa
:: One new WPV1 case was reported from Somalia in the past week, with onset of paralysis on 8 August 2013 from Middle Shabelle. The case was reported late due to laboratory processing backlog.

Middle East
:: One new WPV1 case was reported in the past week (onset of paralysis on 1 October 2013 from Deir Al Zour). The total number of laboratory-confirmed WPV1 cases is 25. The most recent case had onset of paralysis on 17 December and was reported from Mara, Edleb governorate.
:: Additionally, there are 13 cases confirmed from contested areas but not yet reflected in official figures.
:: In the Middle East, a comprehensive outbreak response continues to be implemented across the region. The most recent SIAs in Syria were held in early January and early February. Initial reporting indicates that over three million children were reached during both SIAs, with OPV reaching most if not all districts, and coverage attaining more than 85% in all but three governorates.

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Cross border movements threaten Afghan polio eradication efforts – IRIN

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Polio-free certification: WHO South-East Asia

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7th Meeting of the South-East Asia Regional Certification Commission for Polio Eradication (SEA-RCCPE) – New Delhi, India, 27 March 2014
The WHO South-East Asia Region has been maintaining its polio-free status for the last 3 years. After the last wild polio case was reported from India on 13 January 2011, the Region is firmly on track for polio-free certification in March 2014.
In order to ensure all the requirements for certification of polio eradication are met by the Member States, a review of the annual updates of respective national documentation including phase-1 wild poliovirus laboratory containment will be conducted during the 7th meeting of the SEA-RCCPE. This review will take place in the WHO Regional Office in New Delhi, India on 27 March 2014….
http://www.searo.who.int/entity/immunization/topics/polio/eradication/sea-polio-free/en/

MSF responds to inactivated polio vaccine price announcement
http://www.msfaccess.org/content/msf-responds-inactivated-polio-vaccine-price-announcement

Industry Watch  [to 8 March 2014]
Selected media releases and other selected content from industry.

Inactivated Polio Vaccines Broadly Available for the World’s Children in the Drive toward Polio Eradication
Excerpt
Lyon, France, – February 28, 2014 – Sanofi Pasteur announced “its further commitment to the international community’s efforts to complete polio eradication. UNICEF, the organization that procures the vaccine to meet global needs, announced it will purchase significant quantities of Inactivated Polio Vaccine (IPV) from Sanofi Pasteur and make it available based on country needs and vaccination plans. To achieve the goal of polio eradication by 2018, the World Health Organization (WHO) recommends that by end 2015, all children receive routinely at least one dose of IPV in over 120 countries that solely use Oral Polio Vaccine.”

In order to support rapid and widespread adoption of IPV, Sanofi Pasteur – the world’s largest producer of IPV – and the Bill & Melinda Gates Foundation ”have developed a joint price support mechanism, including a financial contribution from both organizations. This mechanism allows Sanofi Pasteur to offer IPV at a price of €0.75 per dose (approximately US$ 1) to 73 of the world’s poorest countries. The GAVI Alliance, a global immunisation partnership, will make IPV available for inclusion in routine immunisation schedules in these countries.”

This announcement “underscores Sanofi Pasteur’s commitment to offer unparalleled volumes of high-quality IPV across a broad range of countries and economic situations at differential prices in an unprecedented, global rollout.”

Sanofi Pasteur “has made significant investments in modern technology to produce very large quantities of IPV — up to 300 million doses a year. As well as this substantial investment in production capacity, Sanofi Pasteur support to IPV now includes development of a five-dose vial presentation (as well as the standard ten-dose vial presentation) to reduce wastage, a massive regulatory and licensing program in about 100 countries and expert contributions on scientific, program and technical questions.” Sanofi Pasteur has been a partner of the Global Polio Eradication Initiative for over 20 years…

Full text of media release: http://www.reuters.com/article/2014/02/28/idUSnHUGdxHX+73+ONE20140228

PATH named Katherine (Kate) Wilson to lead its Digital Health Solutions group. She will “build on PATH’s work using innovative digital technologies to develop and improve health solutions worldwide. In addition, she will serve as a global thought leader on digital health and will establish, maintain, and build connections with stakeholders and partners around the world for PATH.” PATH said it Digital Health Solutions group “strengthens health system performance through the design and deployment of effective, scalable, and sustainable digital health solutions and by encouraging use of those systems to impact health.”

Full Announcement: http://www.path.org/news/press-room/671/

The Weekly Epidemiological Report (WER) for 7 March 2014, vol. 89, 10 (pp. 93–104) includes:
:: Recommended composition of influenza virus vaccines for use in the 2014–2015 northern hemisphere influenza season
http://www.who.int/entity/wer/2014/wer8910.pdf?ua=1

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

:: Human infection with avian influenza A(H7N9) virus – update 7 March 2014
7 March 2014 – On 4 March 2014, the Centre for Health Protection (CHP) of the Department of Health, Hong Kong SAR, China, notified WHO of an additional laboratory-confirmed case of human infection with avian influenza A(H7N9) virus…
…The overall risk assessment has not changed…The previous report of avian influenza A(H7N9) virus detection in live poultry exported from mainland China to Hong Kong SAR shows the potential for the virus to spread through movement of live poultry, at this time there is no indication that international spread of avian influenza A(H7N9) has occurred. However as the virus infection does not cause signs of disease in poultry, continued surveillance is needed.
Further sporadic human cases of avian influenza A(H7N9) infection are expected in affected and possibly neighbouring areas…

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

:: Human infection with avian influenza A(H7N9) virus – update 3 March 2014

WHO: Humanitarian Health Action
http://www.who.int/hac/en/index.html

South Sudan humanitarian medical assistance
5 March 2014 — According to UNOCHA since the 15 December 2013 over 908 000 people have been displaced by violence. There are 705 800 IDP’s within South Sudan and 202 500 South Sudanese refugees in neighbouring countries. The cholera vaccination campaigns continued in Mingkaman and Tomping IDP camps and the number of new measles cases is declining in all the major IDP sites. Cases of suspected meningitis was reported in four states.
Read the latest situation report – 5 March 2014
pdf, 600kb

Keynote lecture: Research for Universal Health Coverage
WHO Director-General Dr Margaret Chan
Global vaccine and immunization research forum
Bethesda, Maryland – 5 March 2014
Full text: http://www.who.int/dg/speeches/2014/research-uhc/en/

Excerpt
Distinguished conference participants, experts in science and public health, representatives of sister UN agencies and industry, ladies and gentlemen,

WHO is proud to join the Bill and Melinda Gates Foundation and the National Institutes of Allergy and Infectious Diseases as an organizer of this event. The combination of cutting-edge science, down-to-earth public health experience, and well-conceived and generous funding is unbeatable.

The Forum further benefits from the engagement of industry and its commitment to develop new vaccines and constantly improve existing ones, with a particular focus on the needs of users in remote and understaffed areas…

…Last month, I travelled to India to celebrate the country’s remarkable polio-free status for the past three years. India’s success tells the world there is no such thing as impossible.

This has been the spirit of EPI during its four decades of evolution. This is the spirit of the Decade of Vaccines and the cutting-edge science being presented during this Forum.

This is the spirit of the Bill and Melinda Gates Foundation: set ever higher goals and use research to make them feasible.

Immunization, like universal coverage, is a magnet for solidarity that transcends borders and sectors. It has compelling public and political appeal, and is an especially rewarding investment for national governments and donors.

And it still has tremendous unrealized potential.

In a sense, immunization programmes have matured to the point where they can now take a great leap ahead. And in this sense, we are just getting started as we aim ever higher.

Thank you.

The Global Crisis of Drug-Resistant Tuberculosis and Leadership of China and the BRICS: Challenges and Opportunities: Summary of a Joint Workshop by the Institute of Medicine and the Institute of Microbiology, Chinese Academy of Sciences
Steve Olson, Rebecca A. English, and Anne B. Claiborne, Rapporteurs; Forum on Drug Discovery, Development, and Translation; Board on Health Sciences Policy; Institute of Medicine
https://download.nap.edu/login.php?record_id=18346&page=%2Fdownload.php%3Frecord_id%3D18346

Description
Multidrug-resistant tuberculosis (TB) is caused by bacteria resistant to isoniazid and rifampicin, the two most effective first-line anti-TB drugs, originally developed and introduced in the 1950 and 1960s. Since 2008, the Forum on Drug Discovery, Development, and Translation of the Institute of Medicine has hosted or co-hosted six domestic and international workshops addressing the global crisis of drug-resistant TB, with special attention to the BRICS countries – Brazil, Russia, India, China, and South Africa.

The Global Crisis of Drug-Resistant Tuberculosis and Leadership of China and the BRICS is the summary of a workshop convened to address the current status of drug-resistant TB globally and in China. This report considers lessons learned from high burden countries; highlights global challenges to controlling the spread of drug-resistant strains; and discusses innovative strategies to advance and harmonize local and international efforts to prevent and treat drug-resistant TB. Additionally, the report examines the problem of MDR TB and emergent TB strains that are potentially untreatable with drugs available and considers the critical leadership role of the BRICS countries in addressing the threats and opportunities in drug-resistant TB.

American Journal of Tropical Medicine and Hygiene
March 2014; 90 (3)
http://www.ajtmh.org/content/current

Editorial
Economic Burden of West Nile Virus in the United States
Alan D. T. Barrett
Am J Trop Med Hyg 2014 90:389-390; Published online February 10, 2014, doi:10.4269/ajtmh.14-0009
Full Text

Initial and Long-Term Costs of Patients Hospitalized with West Nile Virus Disease
J. Erin Staples*, Manjunath B. Shankar, James J. Sejvar, Martin I. Meltzer and Marc Fischer
Author Affiliations
Arboviral Diseases Branch, Centers for Disease Control and Prevention, Fort Collins, Colorado; Prion and Health Office, Centers for Disease Control and Prevention, Atlanta, Georgia; Division of Preparedness and Emerging Infections, Centers for Disease Control and Prevention, Atlanta, Georgia
http://www.ajtmh.org/content/90/3/402.abstract
Abst
There are no published data on the economic burden for specific West Nile virus (WNV) clinical syndromes (i.e., fever, meningitis, encephalitis, and acute flaccid paralysis [AFP]). We estimated initial hospital and lost-productivity costs from 80 patients hospitalized with WNV disease in Colorado during 2003; 38 of these patients were followed for 5 years to determine long-term medical and lost-productivity costs. Initial costs were highest for patients with AFP (median $25,117; range $5,385–$283,381) and encephalitis (median $20,105; range $3,965–$324,167). Long-term costs were highest for patients with AFP (median $22,628; range $624–$439,945) and meningitis (median $10,556; range $0–$260,748). Extrapolating from this small cohort to national surveillance data, we estimated the total cumulative costs of reported WNV hospitalized cases from 1999 through 2012 to be $778 million (95% confidence interval $673 million–$1.01 billion). These estimates can be used in assessing the cost-effectiveness of interventions to prevent WNV disease.
Disclaimer: The findings and conclusions of this report are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention.

Importance of Cholera and Other Etiologies of Acute Diarrhea in Post-Earthquake Port-au-Prince, Haiti
Macarthur Charles, Glavdia G. Delva, Jethro Boutin, Karine Severe, Mireille Peck, Marie Marcelle abou, Peter F. Wright, and Jean W. Pape
Am J Trop Med Hyg 2014 90:511-517; Published online January 20, 2014, doi:10.4269/ajtmh.13-0514
Abstract

Pre-Travel Preparation of US Travelers Going Abroad to Provide Humanitarian Service, Global TravEpiNet 2009–2011
Rhett J. Stoney, Emily S. Jentes, Mark J. Sotir, Phyllis Kozarsky, Sowmya R. Rao, Regina C. LaRocque, Edward T. Ryan, and the Global TravEpiNet Consortium
Am J Trop Med Hyg 2014 90:553-559; Published online January 20, 2014, doi:10.4269/ajtmh.13-0479
href=”http://www.ajtmh.org/content/90/3/553.abstract”>Abstract

Effects of Malnutrition on Children’s Immunity to Bacterial Antigens in Northern Senegal
Lobna Gaayeb, Jean B. Sarr, Cecile Cames, Claire Pinçon, Jean-Baptiste Hanon, Mamadou O. Ndiath, Modou Seck, Fabien Herbert, Andre B. Sagna, Anne-Marie Schacht, Franck Remoue,
Gilles Riveau, and Emmanuel Hermann
Am J Trop Med Hyg 2014 90:566-573; Published online January 20, 2014, doi:10.4269/ajtmh.12-0657
Abstract

BMC Public Health
(Accessed 8 March 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Factors associated with non-utilization of child immunization in Pakistan: evidence from the Demographic and Health Survey 2006-07
Ayesha Siddiqa Bugvi, Rahla Rahat, Rubeena Zakar, Muhammad Zakria Zakar, Florian Fischer, Muazzam Nasrullah and Riffat Manawar
Author Affiliations
BMC Public Health 2014, 14:232  doi:10.1186/1471-2458-14-232
Published: 6 March 2014
http://www.biomedcentral.com/1471-2458/14/232/abstract

Abstract (provisional)
Background
The proportion of incompletely immunized children in Pakistan varies from 37-58%, and this has recently resulted in outbreaks of measles and polio. The aim of this paper is to determine the factors associated with incomplete immunization among children aged 12-23?months in Pakistan.

Methods
Secondary analysis was conducted on nationally representative cross-sectional survey data from the Pakistan Demographic and Health Survey, 2006-07. The analysis was limited to ever-married mothers who had delivered their last child during the 23?months immediately preceding the survey (n?=?2,435). `Complete immunization? was defined as the child having received twelve doses of five vaccines, and `incomplete immunization? was defined if he/she had missed at least one of these twelve doses. The association between child immunization status and determinants of non-utilization of vaccines was assessed by calculating unadjusted and adjusted odds ratios (AOR) with 95% confidence intervals using a multivariable binary logistic regression.

Results
The findings of this research showed that nearly 66% of children were incompletely immunized against seven preventable childhood diseases. The likelihood of incomplete immunization was significantly associated with the father?s occupation as a manual worker (AOR = 1.47; 95% CI: 1.10-1.97), lack of access to information (AOR = 1.35; 95% CI: 1.09-1.66), non-use of antenatal care (AOR = 1.33; 95% CI: 1.07-1.66), children born in Baluchistan region (AOR = 1.74; 95% CI: 1.12-2.70) and delivery at home (AOR = 1.39; 95% CI: 1.14-1.69).

Conclusions
Despite governmental efforts to increase rates of immunization against childhood diseases, the proportion of incompletely immunized children in Pakistan is still high. Targeted interventions are needed to increase the immunization rates in Pakistan. These interventions need to concentrate on people with low socioeconomic and educational status in order to improve their knowledge of this topic.

BMC Public Health
(Accessed 8 March 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
From the parents’ perspective: a user-satisfaction survey of immunization services in Guatemala
Lissette Barrera, Silas Pierson Trumbo, Pamela Bravo-Alcántara, Martha Velandia-González and M Carolina Danovaro-Holliday
Author Affiliations
BMC Public Health 2014, 14:231  doi:10.1186/1471-2458-14-231
Published: 6 March 2014
http://www.biomedcentral.com/1471-2458/14/231/abstract

Abstract (provisional)
Background
Immunization coverage levels in Guatemala have increased over the last two decades, but national targets of >=95% have yet to be reached. To determine factors related to undervaccination, Guatemala’s National Immunization Program conducted a user-satisfaction survey of parents and guardians of children aged 0-5 years. Variables evaluated included parental immunization attitudes, preferences, and practices; the impact of immunization campaigns and marketing strategies; and factors inhibiting immunization.

Methods
Based on administrative coverage levels and socio-demographic indicators in Guatemala’s 22 geographical departments, five were designated as low-coverage and five as high-coverage areas. Overall, 1194 parents and guardians of children aged 0-5 years were interviewed in these 10 departments. We compared indicators between low- and high-coverage areas and identified risk factors associated with undervaccination.

Results
Of the 1593 children studied, 29 (1.8%) were determined to be unvaccinated, 458 (28.8%) undervaccinated, and 1106 (69.4%) fully vaccinated. In low-coverage areas, children of less educated (no education: RR = 1.49, p = 0.01; primary or less: 1.39, p = 0.009), older (aged >39 years: RR =1.31, p = 0.05), and single (RR = 1.32, p = 0.03) parents were more likely to have incomplete vaccination schedules. Similarly, factors associated with undervaccination in high-coverage areas included the caregiver’s lack of education (none: RR = 1.72, p = 0.0007; primary or less: RR = 1.30, p = 0.05) and single marital status (RR = 1.36, p = 0.03), as well as the child’s birth order (second: RR = 1.68, p = 0.003). Although users generally approved of immunization services, problems in service quality were identified. According to participants, topics such as the risk of adverse events (47.4%) and next vaccination appointments (32.3%) were inconsistently communicated to parents. Additionally, 179 (15.0%) participants reported the inability to vaccinate their child on at least one occasion. Compared to high-coverage areas, participants in low-coverage areas reported poorer service, longer wait times, and greater distances to health centers. In high-coverage areas, participants reported less knowledge about the availability of services.

Conclusions
Generally, immunization barriers in Guatemala are related to problems in accessing and attaining high-quality immunization services rather than to a population that does not adequately value vaccination. We provide recommendations to aid the country in maintaining its achievements and addressing new challenges.

BMC Public Health
(Accessed 8 March 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Vaccination coverage of children aged 12-23 months in Gaziantep, Turkey: comparative results of two studies carried out by lot quality technique: what changed after family medicine?
Birgul Ozcirpici, Neriman Aydin, Ferhat Coskun, Hakan Tuzun and Servet Ozgur
Author Affiliations
BMC Public Health 2014, 14:217  doi:10.1186/1471-2458-14-217
Published: 3 March 2014
http://www.biomedcentral.com/1471-2458/14/217/abstract

Abstract (provisional)
Background
Health care systems in many countries are changing for a variety of reasons. Monitoring of community-based services, especially vaccination coverage, is important during transition periods to ensure program effectiveness. In 2005, Turkey began a transformation from a “socialization of health services” system to a “family medicine” system. The family medicine system was implemented in the city of Gaziantep, in December, 2010.

Methods
Two descriptive, cross-sectional studies were conducted in Gaziantep city center; the first study was before the transition to the family medicine system and the second study was one year after the transition. The Lot Quality Technique methodology was used to determine the quality of vaccination services. The population studied was children aged 12-23 months. Data from the two studies were compared in terms of vaccination coverage and lot service quality to determine whether there were any changes in these parameters after the transition to a family service system.

Results
A total of 93.7% of children in Gaziantep were fully vaccinated before the transition. Vaccination rates decreased significantly to 84.0% (p <0.005) after the family medicine system was implemented. The number of unacceptable vaccine lots increased from 5 lots before the transition to 21 lots after the establishment of the family medicine system.

Conclusions
The number of first doses of vaccine given was higher after family medicine was implemented; however, the numbers of second, third, and booster doses, and the number of children fully vaccinated were lower than before transition. Acceptable and unacceptable lots were not the same before and after the transition. Different health care personnel were employed at the lots after family medicine was implemented. This result suggests that individual characteristics of the health care personnel working in a geographic area are as important as the socioeconomic and cultural characteristics of the community.

British Medical Journal
08 March 2014 (Vol 348, Issue 7948)
http://www.bmj.com/content/348/7948

Research
Effectiveness of quadrivalent human papillomavirus vaccine for the prevention of cervical abnormalities: case-control study nested within a population based screening programme in Australia
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g1458 (Published 4 March 2014)
Elizabeth Crowe, public health physician12, Nirmala Pandeya, biostatistician1, Julia M L Brotherton, public health physician and medical epidemiologist3, Annette J Dobson, iostatistician1, Stephen Kisely, public health physician4, Stephen B Lambert, public health physician56, David C Whiteman, cancer epidemiologist17
http://www.bmj.com/content/348/bmj.g1458

Abstract
Objective
To measure the effectiveness of the quadrivalent human papillomavirus (HPV) vaccine against cervical abnormalities four years after implementation of a nationally funded vaccination programme in Queensland, Australia.

Design
Case-control analysis of linked administrative health datasets.

Setting
Queensland, Australia.

Participants
Women eligible for free vaccination (aged 12-26 years in 2007) and attending for their first cervical smear test between April 2007 and March 2011. High grade cases were women with histologically confirmed high grade cervical abnormalities (n=1062) and “other cases” were women with any other abnormality at cytology or histology (n=10 887). Controls were women with normal cytology (n=96 404).

Main outcome measures
Exposure odds ratio (ratio of odds of antecedent vaccination (one, two, or three vaccine doses compared with no doses) among cases compared with controls), vaccine effectiveness ((1−adjusted odds ratio)×100), and number needed to vaccinate to prevent one cervical abnormality at first screening round. We stratified by four age groups adjusted for follow-up time, year of birth, and measures of socioeconomic status and remoteness. The primary analysis concerned women whose first ever smear test defined their status as a case or a control.

Results
The adjusted odds ratio for exposure to three doses of HPV vaccine compared with no vaccine was 0.54 (95% confidence interval 0.43 to 0.67) for high grade cases and 0.66 (0.62 to 0.70) for other cases compared with controls with normal cytology, equating to vaccine effectiveness of 46% and 34%, respectively. The adjusted numbers needed to vaccinate were 125 (95% confidence interval 97 to 174) and 22 (19 to 25), respectively. The adjusted exposure odds ratios for two vaccine doses were 0.79 (95% confidence interval 0.64 to 0.98) for high grade cases and 0.79 (0.74 to 0.85) for other cases, equating to vaccine effectiveness of 21%.

Conclusion
The quadrivalent HPV vaccine conferred statistically significant protection against cervical abnormalities in young women who had not started screening before the implementation of the vaccination programme in Queensland, Australia.

Eurosurveillance
Volume 19, Issue 9, 06 March 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Surveillance and outbreak reports
Epidemiology of tuberculosis in big cities of the European Union and European Economic Area countries
by G de Vries, RW Aldridge, JA Caylà, WH Haas, A Sandgren, NA van Hest, I Abubakar, the Tuberculosis in European Union Big Cities Working Group

Perspectives
Tuberculosis control in big cities and urban risk groups in the European Union: a consensus statement
N A van Hest1, R W Aldridge2, G de Vries3, A Sandgren4, B Hauer5, A Hayward2, W Arrazola de Oñate6, W Haas5, L R Codecasa7, J A Caylà8, A Story9, D Antoine10, A Gori11, L Quabeck12, J Jonsson13, M Wanlin6, À Orcau8, A Rodes14, M Dedicoat15, F Antoun16, H van Deutekom17, S T Keizer17, I Abubakar18
Date of submission: 26 February 2013
http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20728

In low-incidence countries in the European Union (EU), tuberculosis (TB) is concentrated in big cities, especially among certain urban high-risk groups including immigrants from TB high-incidence countries, homeless people, and those with a history of drug and alcohol misuse. Elimination of TB in European big cities requires control measures focused on multiple layers of the urban population. The particular complexities of major EU metropolises, for example high population density and social structure, create specific opportunities for transmission, but also enable targeted TB control interventions, not efficient in the general population, to be effective or cost effective. Lessons can be learnt from across the EU and this consensus statement on TB control in big cities and urban risk groups was prepared by a working group representing various EU big cities, brought together on the initiative of the European Centre for Disease Prevention and Control. The consensus statement describes general and specific social, educational, operational, organisational, legal and monitoring TB control interventions in EU big cities, as well as providing recommendations for big city TB control, based upon a conceptual TB transmission and control model.

Health Policy and Planning
Volume 29 Issue 2 March 2014
http://heapol.oxfordjournals.org/content/current

Impact of user fees on maternal health service utilization and related health outcomes: a systematic review
Susie Dzakpasu1, Timothy Powell-Jackson2 and Oona M.R. Campbell1
Author Affiliations
1Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK and 2Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
Accepted December 21, 2012.
http://heapol.oxfordjournals.org/content/29/2/137.abstract

Abstract
Objective
To assess the evidence of the impact of user fees on maternal health service utilization and related health outcomes in low- and middle-income countries, as well as their impact on inequalities in these outcomes.

Methods
Studies were identified by modifying a search strategy from a related systematic review. Primary studies of any design were included if they reported the effect of fee changes on maternal health service utilization, related health outcomes and inequalities in these outcomes. For each study, data were systematically extracted and a quality assessment conducted. Due to the heterogeneity of study methods, results were examined narratively.

Findings
Twenty studies were included. Designs and analytic approaches comprised: two interrupted time series, eight repeated cross-sectional, nine before-and-after without comparison groups and one before-and-after in three groups. Overall, the quality of studies was poor. Few studies addressed potential sources of bias, such as secular trends over time, and even basic tests of statistical significance were often not reported. Consistency in the direction of effects provided some evidence of an increase in facility delivery in particular after fees were removed, as well as possible increases in the number of managed delivery complications. There was little evidence of the effect on health outcomes or inequality in accessing care and, where available, the direction of effect varied.

Conclusion
Despite the global momentum to abolish user fees for maternal and child health services, robust evidence quantifying impact remains scant. Improved methods for evaluating and reporting on these interventions are recommended, including better descriptions of the interventions and context, looking at a range of outcome measures, and adopting robust analytical methods that allow for adjustment of underlying and seasonal trends, reporting immediate as well as longer-term (e.g. at 6 months and 1 year) effects and using comparison groups where possible.

Health Policy and Planning
Volume 29 Issue 2 March 2014
http://heapol.oxfordjournals.org/content/current

Estimates of performance in the rate of decline of under-five mortality for 113 low- and middle-income countries, 1970–2010
Stéphane Verguet and Dean T. Jamison
Author Affiliations
Department of Global Health, University of Washington, Seattle, WA, USA
Accepted December 21, 2012.
http://heapol.oxfordjournals.org/content/29/2/151.abstract

Abstract
Background
Measuring country performance in health has focused on assessing predicted vs observed levels of outcomes, an indicator that varies slowly over time. An alternative is to measure performance in terms of the rate of change in how a selected outcome compares to what would be expected given contextual determinants. Rates of change in health indicators can prove more sensitive than levels to changes in social, intersectoral or health policy context. It is thus similar to the growth rate of gross domestic product in the economic context. We assess performance in the rate of change (decline) of under-five mortality for 113 low- and middle-income countries.

Methods
For 1970–2010, we study the evolution in rates of decline of under-five mortality. For each decade, we define performance as the average of the difference between the observed rate of decline and a rate of decline predicted by a model controlling for the contextual factors of income, female education levels, decade and geographical location.

Results
In the 1970s, the top performer in the rate of decline of under-five mortality was Costa Rica. In the 2000s, the top performer was Turkey. Overall, performance in rates of decline correlated little with performance in levels of under-five mortality. A major transition in performance between decades suggests a change in underlying determinants and we report the magnitude of these transitions. For example, heavily AIDS impacted countries, such as Botswana, experienced major drops in performance between the 1980s and the 1990s and some, including Botswana, experienced major compensatory improvements between the 1990s and the 2000s.

Conclusions
Rate-based measures of country performance in health provide a starting point for assessments of the importance of health system, social and intersectoral determinants of performance.

Health Policy and Planning
Volume 29 Issue 2 March 2014
http://heapol.oxfordjournals.org/content/current

Achieving comprehensive childhood immunization: an analysis of obstacles and opportunities in The Gambia
Sarah Payne1, John Townend3, Momodou Jasseh3, Yamundow Lowe Jallow4 and Beate Kampmann2,3
Author Affiliations
1School of Public Health, Imperial College London, Norfolk Place, London W2 1PG, UK, 2Department of Paediatrics, St Mary’s Campus, Imperial College of Science, Technology & Medicine, Norfolk Place, London W2 1PG, UK, 3MRC-Unit, Atlantic Road, Fajara, The Gambia, West Africa and 4Ministry of Health and Social Welfare Government of The Gambia, The Quadrangle Banjul, The Gambia
Accepted January 11, 2013.
http://heapol.oxfordjournals.org/content/29/2/193.abstract

Abstract
Introduction
Immunization is a vital component in the drive to decrease global childhood mortality, yet challenges remain in ensuring wide coverage of immunization and full immunization, particularly in low- and middle-income countries. This study assessed immunization coverage and the determinants of immunization in a semi-rural area in The Gambia.

Methods
Data were drawn from the Farafenni Health and Demographic Surveillance System. Children born within the surveillance area between January 2000 and December 2010 were included. Main outcomes assessed included measles, BCG and DTP vaccination status and full immunization by 12 months of age as reported on child healthcards. Predictor variables were evaluated based on a literature review and included gender, ethnicity, area of residence, household wealth and mother’s age.

Results
Of the 7363 children included in the study, immunization coverage was 73% (CI 72–74) for measles, 86% (CI 86–87) for BCG, 79% (CI 78–80) for three doses of DTP and 52% (CI 51–53) for full immunization. Coverage was significantly associated with area of residence and ethnicity, with children in urban areas and of Mandinka ethnicity being least likely to be fully immunized.

Conclusions
Despite high levels of coverage of many individual vaccines, delivery of vaccinations later in the schedule and achieving high coverage of full immunization remain challenges, even in a country with a committed childhood immunization programme, such as The Gambia. Our data indicate areas for targeted interventions by the national Expanded Programme of Immunization.

JAMA Pediatrics
March 2014, Vol 168, No. 3
http://archpedi.jamanetwork.com/issue.aspx

Original Investigation | March 2014
Risk of Fever After Pediatric Trivalent Inactivated Influenza Vaccine and 13-Valent Pneumococcal Conjugate Vaccine
Melissa S. Stockwell, MD, MPH1,2,3; Karen Broder, MD4; Philip LaRussa, MD1; Paige Lewis, MSPH4; Nadira Fernandez, MD1; Devindra Sharma, MSN, MPH4; Angela Barrett1; Jose Sosa, MD1; Claudia Vellozzi, MD, MPH4
Author Affiliations
JAMA Pediatr. 2014;168(3):211-219. doi:10.1001/jamapediatrics.2013.4469.

Importance  An observational study found an increased risk of febrile seizure on the day of or 1 day after vaccination (days 0-1) with trivalent inactivated influenza vaccine (TIV) in the 2010-2011 season; risk was highest with simultaneous vaccination with TIV and 13-valent pneumococcal vaccine (PCV13) in children who were 6 to 23 months old. Text messaging is a novel method for surveillance of adverse events after immunization that has not been used for hypothesis-driven vaccine safety research.

The Lancet  
Mar 08, 2014   Volume 383  Number 9920  p845 – 926
http://www.thelancet.com/journals/lancet/issue/current

Editorial
An inspired change—stopping sexual violence against women
The Lancet
Preview |
International Women’s Day, this year themed Inspiring Change, falls on March 8. For more than a century, this event has marked women’s achievements in a world where the sexes are far from equal in many countries. In promoting the education, health, and success of women, the Day has addressed the distressing but key topic of violence against women more than once

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
March 2014  Volume 92, Issue 1  Pages 1–166
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-0009/currentissue

Review Article
Social Media and Internet-Based Data in Global Systems for Public Health Surveillance: A Systematic Review
EDWARD VELASCO1, TUMACHA AGHENEZA1, KERSTIN DENECKE2, GÖRAN KIRCHNER1, TIM ECKMANNS1
Article first published online: 6 MAR 2014
DOI: 10.1111/1468-0009.12038
http://onlinelibrary.wiley.com/doi/10.1111/1468-0009.12038/abstract
Abstract
Context
The exchange of health information on the Internet has been heralded as an opportunity to improve public health surveillance. In a field that has traditionally relied on an established system of mandatory and voluntary reporting of known infectious diseases by doctors and laboratories to governmental agencies, innovations in social media and so-called user-generated information could lead to faster recognition of cases of infectious disease. More direct access to such data could enable surveillance epidemiologists to detect potential public health threats such as rare, new diseases or early-level warnings for epidemics. But how useful are data from social media and the Internet, and what is the potential to enhance surveillance? The challenges of using these emerging surveillance systems for infectious disease epidemiology, including the specific resources needed, technical requirements, and acceptability to public health practitioners and policymakers, have wide-reaching implications for public health surveillance in the 21st century.

Methods
This article divides public health surveillance into indicator-based surveillance and event-based surveillance and provides an overview of each. We did an exhaustive review of published articles indexed in the databases PubMed, Scopus, and Scirus between 1990 and 2011 covering contemporary event-based systems for infectious disease surveillance.

Findings
Our literature review uncovered no event-based surveillance systems currently used in national surveillance programs. While much has been done to develop event-based surveillance, the existing systems have limitations. Accordingly, there is a need for further development of automated technologies that monitor health-related information on the Internet, especially to handle large amounts of data and to prevent information overload. The dissemination to health authorities of new information about health events is not always efficient and could be improved. No comprehensive evaluations show whether event-based surveillance systems have been integrated into actual epidemiological work during real-time health events.

Conclusions
The acceptability of data from the Internet and social media as a regular part of public health surveillance programs varies and is related to a circular challenge: the willingness to integrate is rooted in a lack of effectiveness studies, yet such effectiveness can be proved only through a structured evaluation of integrated systems. Issues related to changing technical and social paradigms in both individual perceptions of and interactions with personal health data, as well as social media and other data from the Internet, must be further addressed before such information can be integrated into official surveillance systems.

Nature   
Volume 507 Number 7490 pp8-134  6 March 2014
http://www.nature.com/nature/current_issue.html

Outlook: Vaccines
Produced with support from: newventurefund, UNICEF, GAVI
:: Vaccines  Herb Brody

:: The age of vaccines  Tony Scully

:: Infectious disease: Beating the big three  Katherine Bourzac

:: Logistics: Keeping cool  Neil Savage

:: Drug development: Searching for patterns  Tom Paulson

:: Production: Vaccines from the East  Priya Shetty

:: Polio: The eradication endgame  Cassandra Willyard

:: Perspective: Elimination round  Andrew W. Artenstein & Gregory A. Poland

:: Public health: An injection of trust  Michael Eisenstein

:: Perspective: Ill prepared for a pandemic  Klaus Stöhr

.
A predictive fitness model for influenza
Marta Łuksza & Michael Lässig
A computational approach for predicting the future evolution of the human influenza virus, based on population-genetic data of previous strains, is presented; this model holds promise for improving vaccine strain selection for seasonal influenza.

New England Journal of Medicine
March 6, 2014  Vol. 370 No. 10
http://www.nejm.org/toc/nejm/medical-journal

Review Article
Global Health: Global Supply of Health Professionals
N. Crisp and L. Chen
Free Full Text

Excerpt
There is a global crisis of severe shortages and marked maldistribution of health professionals that is exacerbated by three great global transitions — demographic changes, epidemiologic shifts, and redistribution of the disability burden. Each of these transitions exerts a powerful force for change in health care systems, the roles of health professionals, and the design of health professional education.1-5 Every country will have to respond to these global pressures for change.

There are many other reasons that it is important to think globally about the education and role of health professionals.6 The knowledge base of the profession is global in scope, and there is increasing cross-national transfer of technology, expertise, and services. Health professionals are migrating in what is now effectively a global market for their talent, while patients are also traveling for treatment. One quarter of the doctors in the United States come from abroad, and the “medical tourism” market for travel to such countries as Thailand and Singapore is growing at a rate of 20% annually.7,8 All people worldwide are threatened by risks such as global infectious epidemics and climate change. Health professionals globally are interlinked and interdependent, facing shared challenges

PLoS One
[Accessed 8 March 2014]
http://www.plosone.org/

Research Article
Incentives for Reporting Disease Outbreaks
Ramanan Laxminarayan mail, Julian Reif, Anup Malani
Published: March 06, 2014
DOI: 10.1371/journal.pone.0090290
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0090290
Abstract
Background
Countries face conflicting incentives to report infectious disease outbreaks. Reports of outbreaks can prompt other countries to impose trade and travel restrictions, which has the potential to discourage reporting. However, reports can also bring medical assistance to contain the outbreak, including access to vaccines.

Methods
We compiled data on reports of meningococcal meningitis to the World Health Organization (WHO) from 54 African countries between 1966 and 2002, a period is marked by two events: first, a large outbreak reported from many countries in 1987 associated with the Hajj that resulted in more stringent requirements for meningitis vaccination among pilgrims; and second, another large outbreak in Sub-Saharan Africa in 1996 that led to a new international mechanism to supply vaccines to countries reporting a meningitis outbreak. We used fixed-effects regression modeling to statistically estimate the effect of external forcing events on the number of countries reporting cases of meningitis to WHO.

Findings
We find that the Hajj vaccination requirements started in 1988 were associated with reduced reporting, especially among countries with relatively fewer cases reported between 1966 and 1979. After the vaccine provision mechanism was in place in 1996, reporting among countries that had previously not reported meningitis outbreaks increased.

Interpretation
These results indicate that countries may respond to changing incentives to report outbreaks when they can do so. In the long term, these incentives are likely to be more important than surveillance assistance in prompt reporting of outbreaks.

PLoS Neglected Tropical Diseases
February 2014
http://www.plosntds.org/article/browseIssue.action

From Innovation to Application
Resource Planning for Neglected Tropical Disease (NTD) Control Programs: Feasibility Study of the Tool for Integrated Planning and Costing (TIPAC)
Olivier J. Wouters, Philip W. Downs mail, Kathryn L. Zoerhoff, Kathryn R. Crowley, Hannah Frawley, Jennifer Einberg, Brian K. Chu, Molly A. Brady, Roland Oscar, Mireille Jeudi, Anne-Marie Desormeaux, Karleen Coly, Abdel N. Direny,  [ … ], Aya Yajima
Published: February 27, 2014
DOI: 10.1371/journal.pntd.0002619
http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0002619;jsessionid=0A6EAED973FE58156CF54531355875C4

Excerpt
Neglected tropical diseases (NTDs) cause significant morbidity and mortality worldwide and impose a large economic burden on endemic countries [1]. In 2006, the United States Agency for International Development (USAID) founded the NTD Control Program to target five NTDs in African, Asian, and Latin American countries, namely, lymphatic filariasis (LF), onchocerciasis, schistosomiasis, soil-transmitted helminthiases (STH), and trachoma; the three targeted STH infections are ascariasis, hookworm, and trichuriasis. The NTD Control Program supported national NTD control and elimination programs’ efforts to integrate and scale up delivery of preventive chemotherapy (PC) [2]. PC is the administration of safe, single-dose drugs, either alone or in combination, as a public health intervention against targeted NTDs. Administration is characterized by population-based diagnosis, population-based treatment, and implementation at regular intervals. PC can be delivered as universal chemotherapy (i.e., mass drug administration [MDA]), where the entire population of an area is targeted; targeted chemotherapy, where only high-risk groups (e.g., school age children) are targeted; or selective chemotherapy, where only screened individuals found or suspected to be infected are targeted [3]. Between October 2006 and March 2012, the program provided 589 million NTD treatments through the collaborative efforts of ministries of health, implementing partners, funders, and pharmaceutical donation programs.

The implementation of integrated NTD programs at the full national scale remains an important objective in many endemic countries [4]–[8]. Several theoretical frameworks for integration have been proposed; most protocols stress the importance of long-term commitments and concerted efforts of partnerships to realize NTD control and elimination objectives [9]–[14]. However, there is currently a paucity of economic evidence on the costs of integrated PC delivery for NTDs, primarily due to the significant variation in program structures and operations [14]. Given the scarce resources and substantial costs associated with NTD control and elimination, there is therefore a need to accurately determine the cost of program implementation. It is also important to delineate funding commitments to ensure that additional assistance is used to complement available resources, rather than duplicate or replace previous efforts.

To allow governments to more easily enumerate costs and funding commitments for NTD control and elimination, the NTD Control Program developed the Tool for Integrated Planning and Costing (TIPAC). The TIPAC, a versatile planning and costing instrument, is designed to be used by members of a NTD program at the national level. For countries with decentralized political structures, the TIPAC can also be implemented at a subnational administrative level. NTD program and financial managers are the primary users of the tool; the involvement of other personnel, including representatives from partner organizations and ministries of education, improves the accuracy and completeness of the TIPAC data…

PNAS – Proceedings of the National Academy of Sciences of the United States
of America
http://www.pnas.org/content/early/
(Accessed 8 March 2014)

A priority-setting aid for new vaccine candidates
Charles Phelpsa,b, Guruprasad Madhavanc,1, Kinpritma Sanghac, Rino Rappuolid, Rita R. Colwelle,f, Rose Marie Martinezc, Patrick Kelleyc, and Lonnie King
Author Affiliations
Abstract
Policy and investment decisions regarding new health technologies are often complex. They require a careful balancing of multiple perspectives and differing objectives. On some occasions, policymakers or analysts approaching these decisions have access to cost-effectiveness or cost-benefit analyses to help guide their decisions, but almost invariably such analyses are inadequate.

Recent advances in decision-support systems have offered ways to embed a range of different preferences and parameters into formal modeling structures, known as multicriteria decision analysis. The Institute of Medicine (IOM) has released a software tool called SMART Vaccines, short for Strategic Multi-Attribute Ranking Tool for Vaccines. This early-stage prototype—the use of which needs to be evaluated by interested parties—is grounded on multiattribute utility theory (see screenshot in Fig. 1). The software and associated reports in the Ranking Vaccines series can be downloaded free of charge from http://www.nap.edu/smartvaccines (1, 2).

Science        
7 March 2014 vol 343, issue 6175, pages 1049-1168
http://www.sciencemag.org/current.dtl

Report
Altitudinal Changes in Malaria Incidence in Highlands of Ethiopia and Colombia
A. S. Siraj1, M. Santos-Vega2, M. J. Bouma3, D. Yadeta4, D. Ruiz Carrascal5,6, M. Pascual2,7,†
Author Affiliations
1Department of Geography and the Environment, University of Denver, 235 Boettcher West, 2050 East Iliff Avenue Denver, CO 80208-0710, USA.
2Department of Ecology and Evolutionary Biology, University of Michigan, 2019 Kraus Natural Sciences Building, 830 North University, Ann Arbor, MI 48109-1048, USA.
3London School of Hygiene and Tropical Medicine, University of London, London WC1 E7HT, UK.
4Oromia Regional Health Bureau, Post Office Box 24341, Addis Ababa, Ethiopia.
5International Research Institute for Climate and Society, Columbia University in the City of New York, Lamont-Doherty Earth Observatory Post Office Box 1000, 61 Route 9W, Monell Building, Palisades, NY 10964-1000, USA.
6Escuela de Ingenieria de Antioquia, km 02+200 Vía al Aeropuerto José María Córdova, Envigado, Antioquia, Colombia.
7Howard Hughes Medical Institute, Chevy Chase, MD 20815-6789, USA.
http://www.sciencemag.org/content/343/6175/1154.abstract

Abstract
Editor’s Summary
The impact of global warming on insect-borne diseases and on highland malaria in particular remains controversial. Temperature is known to influence transmission intensity through its effects on the population growth of the mosquito vector and on pathogen development within the vector. Spatiotemporal data at a regional scale in highlands of Colombia and Ethiopia supplied an opportunity to examine how the spatial distribution of the disease changes with the interannual variability of temperature. We provide evidence for an increase in the altitude of malaria distribution in warmer years, which implies that climate change will, without mitigation, result in an increase of the malaria burden in the densely populated highlands of Africa and South America…

Vaccine
Volume 32, Issue 14, Pages 1523-1640 (20 March 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Special Theme: Sexually transmitted infections: Vaccine development for global health
16 articles focused on a range of STIs and vaccine prospects and performance.

Vaccine
Volume 32, Issue 14, Pages 1523-1640 (20 March 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Available online 2 March 2014
Review
Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012
Heidi J. Larson, Caitlin Jarrett, Elisabeth Eckersberger, David M.D. Smith, Pauline Paterson
http://www.sciencedirect.com/science/article/pii/S0264410X14001443
Highlights
:: Vaccine hesitancy is a complex issue driven by a variety of context-specific factors.
:: Most studies were conducted in Europe and the Americas, with a two-fold increase in research on this topic during the period 2007–2012.
:: Determinants examined are mostly from classic models (e.g., Health Belief Model) which do not adequately account for contextual influences.

Abstract
Vaccine “hesitancy” is an emerging term in the literature and discourse on vaccine decision-making and determinants of vaccine acceptance. It recognizes a continuum between the domains of vaccine acceptance and vaccine refusal and de-polarizes previous characterization of individuals and groups as either anti-vaccine or pro-vaccine.

The primary aims of this systematic review are to: 1) identify research on vaccine hesitancy; 2) identify determinants of vaccine hesitancy in different settings including its context-specific causes, its expression and its impact; and 3) inform the development of a model for assessing determinants of vaccine hesitancy in different settings as proposed by the Strategic Advisory Group of Experts Working Group (SAGE WG) for dealing with vaccine hesitancy.

A broad search strategy, built to capture multiple dimensions of public trust, confidence and hesitancy around vaccines, was applied across multiple databases. Peer-reviewed studies were selected for inclusion if they focused on childhood vaccines [≤7 years of age], used multivariate analyses, and were published between January 2007 and November 2012.

Our results show a variety of factors as being associated with vaccine hesitancy but they do not allow for a complete classification and confirmation of their independent and relative strength of influence. Determinants of vaccine hesitancy are complex and context-specific – varying across time, place and vaccines.

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

Q&A with WHO: Cholera vaccine stockpile – a new tool to avoid needless suffering
Thomson Reuters Foundation – Mon, 3 Mar 2014 11:20 AM
Alisa Tang
Excerpt
The World Health Organization (WHO) has activated for the first time a new cholera vaccine emergency stockpile to protect hundreds of thousands displaced by conflict in South Sudan and living in temporary camps.

Although there is currently no outbreak of cholera – an acute diarrhoeal infection caused by ingestion of contaminated food or water – the risk is high due to poor sanitary conditions and overcrowding, the WHO said.

With WHO coordinating the campaign, Médecins Sans Frontières (MSF) on Feb. 22 started vaccinations for 94,000 people in Minkaman camp in Awerial county, and the humanitarian organisation Medair was to vaccinate an additional 43,000 in camps in South Sudan’s capital, Juba.

Two oral doses of the cholera vaccine are required for an individual to be protected. The campaign begins with an initial round of vaccinations followed after a required 14-day interval by a second round.

William Perea, the WHO’s coordinator for the control of epidemic diseases, spoke to Thomson Reuters Foundation by phone from Geneva about the emergency stockpile – which is managed by WHO, the International Federation of the Red Cross and Red Crescent Societies (IFRC), MSF and UNICEF – as a tool to fight cholera…

Special Focus Newsletter/Projects
The Vaccine Confidence Project :: Confidence Commentary from Dr Heidi Larson
“Why we need “\’science understanding the public’ more than just ‘public understanding of science’: the case of vaccines”
London School of Hygiene and Tropical Medicine
www.vaccineconfidence.org

BMC Health Services Research
2014, 14:111
http://www.biomedcentral.com/bmchealthservres/content
Research article
Urban settings do not ensure access to services: findings from the immunisation programme in Kampala Uganda
Juliet N Babirye, Ingunn MS Engebretsen, Elizeus Rutebemberwa, Juliet Kiguli and Fred Nuwaha
Published: 6 March 2014
Author Affiliations
http://www.biomedcentral.com/1472-6963/14/111/abstract
Abstract (provisional)
Background
Previous studies on vaccination coverage in developing countries focus on individual- and community-level barriers to routine vaccination mostly in rural settings. This paper examines health system barriers to childhood immunisation in urban Kampala Uganda.
Methods
Mixed methods were employed with a survey among child caretakers, 9 focus group discussions (FGDs), and 9 key informant interviews (KIIs). Survey data underwent descriptive statistical analysis. Latent content analysis was used for qualitative data.
Results
Of the 821 respondents in the survey, 96% (785/821) were mothers with a mean age of 26 years (95% CI 24-27). Poor geographical access to immunisation facilities was reported in this urban setting by FGDs, KIIs and survey respondents (24%, 95% CI 21-27). This coupled with reports of few health workers providing immunisation services led to long queues and long waiting times at facilities. Consumers reported waiting for 3-6 hours before receipt of services although this was more common at public facilities. Only 33% (95% CI 30-37) of survey respondents were willing to wait for three or more hours before receipt of services. Although private-for-profit facilities were engaged in immunisation service provision their participation was low as only 30% (95% CI 27-34) of the survey respondents utilised these facilities. The low participation could be due to lack of financial support for immunisation activities at these facilities. This in turn could explain the rampant informal charges for services in this setting. Charges ranged from US$ 0.2 to US$4 and these were more commonly reported at private (70%, 95% CI 65-76) than at public (58%, 95% CI 54-63) facilities. There were intermittent availability of vaccines and transport for immunisation services at both private and public facilities.
Conclusions
Complex health system barriers to childhood immunisation still exist in this urban setting; emphasizing that even in urban areas with great physical access, there are hard to reach people. As the rate of urbanization increases especially in sub-Saharan Africa, governments should strengthen health systems to cater for increasing urban populations.

Journal of Epidemiology and Community Health
Online First doi:10.1136/jech-2013-203272
Commentary
International institutional legitimacy and the World Health Organization
Jennifer Prah Ruger
http://jech.bmj.com/content/early/2014/03/05/jech-2013-203272.extract
Extract
The global health community continues to look to the World Health Organization (WHO) to solve current global health governance (GHG) problems. Until the 1990s, nation-states and multilateral organisations with state members governed international health, and WHO played a prominent role, coordinating worldwide efforts such as smallpox eradication with a few partner organisations. WHO also provided international reporting and handled disease outbreaks through the International Health Regulations. The world still sees WHO as the leading global health governor, and proposals abound to reform it,1–4 to use its treaty abilities more regularly and to give it enforcement powers—all in the absence of real institutional alternatives.

But today’s WHO is a compromised institution; some interrogate its relevance altogether2 and WHO Director-General Margaret Chan herself questions WHO’s ability to respond to global health challenges.5 On a theoretical level, WHO lacks a substantive justice oriented conception of international institutional legitimacy. On a more pragmatic plane, WHO is riddled with budgetary weaknesses, power politics and diminishing reputation and effectiveness. WHO’s early successes were laudable and the organisation has the potential to make an impact on future global health problems, but the institution lacks a number of key ingredients of success: coordination capacity, authority, accountability, fairness, a master global health plan, effectiveness and credible compliance mechanisms.

While WHO reforms could help it do its job better, a new vision, based on a substantive conception of justice and legitimacy, and associated reforms in the broader GHG system will more effectively and efficiently serve GHG functions and the WHO itself. WHO Director-General Margaret Chan states “[t]he level of WHO engagement should not be governed by the size of a health problem. Instead it should be governed by the extent to which WHO can have an impact on the problem. Others may be positioned to do a …

Communication, Somali culture and decision-making about the human papillomavirus (HPV) Vaccine
Dailey, Phokeng 2014-02
28th Edward F. Hayes Graduate Research Forum. Ohio State University
http://hdl.handle.net/1811/59265
Abstract
The current study uses a multiple goals theoretical perspective to explore how Somali immigrant families in the United States make decisions regarding whether to vaccinate their children against human papillomavirus (HPV). A focus was placed on the communication goals of parents in HPV vaccine discussions with their child and health care provider. 16 semi-structured interviews were audiotaped, transcribed, and analyzed using a grounded theory approach. Key themes were the implications of the vaccine for early sexual activity, confusion between HPV and human immunodeficiency virus (HIV), the perception that the HPV vaccine is unnecessary, uncertainty about the vaccine’s efficacy and side effects, avoidance of parent-child communication about the vaccine, and a preference for framing the vaccine as a health promotion behavior. Framing the threat of HPV in the context of initiation of sexual activity, uncertainty regarding vaccine efficacy, and anticipated regret account for the inconsistency in HPV vaccine uptake among Somali parents. Health care providers should consider talking about HPV as a distal versus an immediate threat and HPV vaccine uptake as a health-promotion rather than a sexually transmitted infection (STI) prevention behavior.

Trends in HPV Vaccination of US Adolescent Females: How Policies, Education, and Health Care Providers Influence Immunization Rates
Grant, Jennifer Lyn (2013)
Dissertation (88 pages)
Program: Laney Graduate School, Health Services and Research Health Policy
Permanent url: http://pid.emory.edu/ark:/25593/f4mjs
Abstract
In my first paper, The Impact of State Immunization Financing Policies on HPV Vaccination Rates among US Adolescent Females, I examine the impact of expanded enrollment eligibility for The Vaccines for Children (VFC) program on HPV vaccine series initiation and completion among US adolescent girls. The VFC program provides certain vaccines at a reduced or no cost to eligible children. It was designed to help ensure all children receive recommended vaccinations on schedule, even if their parents are not be able to afford them. Specifically, I hypothesized that adolescent girls living in states in which all recommended vaccines were provided free of cost to all children in the state would be more likely to initiate and complete the HPV vaccine series than their peers living in states with more restricted VFC eligibility requirements.

In my second paper, Maternal Educational Inequalities in HPV Vaccine Utilization among US adolescent females- The relative roles of economics and awareness, I evaluate the relative influences of household-level socioeconomic status, specific health knowledge, and general healthcare utilization and timeliness in mediating the relationship between maternal educational attainment and HPV vaccine utilization among adolescent girls.

In my third and final paper, Factors Associated with Health Care Provider Recommendation of the Human Papillomavirus Vaccine and effect of provider recommendation on vaccine series initiation and completion, I examine the relative influences of adolescent and household sociodemographic characteristics and characteristics of their health-seeking behavior on the likelihood of receiving a health care provider recommendation of the HPV vaccine for US Adolescent girls. I also estimate the effect of provider recommendation on vaccine series initiation and completion

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 with the current issue date

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– Email Summary: Vaccines and Global health : The Week in Review is published as a single email summary, scheduled for release each Saturday eveningbefore midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.
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– pdf version: A pdf of the current issues is available here: Vaccines and Global Health_The Week in Review_1 Mar 2014

– Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links: We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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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 Briefing: Health situation in Syria
Dr Margaret Chan, Director-General of the World Health Organization
Briefing to the UN General Assembly
25 February 2014

Full text [Editor’s bolded text]

Mr President, Secretary-General, distinguished delegates, ladies and gentlemen,

I am speaking to you with a heavy heart. In March, the Syrian crisis will enter its fourth year. The long duration of the conflict has created a crisis for health. The health needs of the Syrian people are enormous, as is their suffering.

In the course of this conflict, more than 100,000 people have been killed, and more than 600,000 have been injured.

At least 6.5 million Syrians have been internally displaced, often crowded together under unsanitary conditions that favour the spread of disease. Another 2.3 million have fled to Lebanon, Jordan, Turkey, Iraq, and Egypt, creating a heavy burden on these countries.

Health needs have skyrocketed at a time when domestic capacity to respond has been decimated. The country’s previously excellent health system has collapsed in a significant number of areas.

More than half the country’s public hospitals have been damaged, often following direct attacks, and many no longer function. The number of doctors, nurses, and other health workers still at work has dropped by more than half.

A once vibrant pharmaceutical manufacturing industry has nearly ceased operations, resulting in severe shortages of drugs. Many patients with chronic diseases, like heart disease, cancer, and diabetes, are not being treated.

Immunization programmes, which reached 90% of children before the conflict, have been disrupted, leaving young children vulnerable to entirely preventable diseases. Safe childbirth is no longer readily accessible, placing pregnant women with life-threatening complications at heightened risk of losing their lives.

The suffering of the Syrian people is reflected in increased mental health disorders, food shortages, undernutrition, and an increase in sexual violence.

   The steep drop in childhood immunization opened the door for vaccine-preventable diseases to return to Syria. And they did, including polio.

   The first cases of polio in Syria since 1999 were reported in October 2013. This marked a significant added threat to Syria’s children, but also a setback to the global initiative to eradicate polio. Most significantly, it confirmed the renewed vulnerability of the Syrian people to diseases that had long disappeared from the country.

   Since detection of the polio cases in October, four mass vaccination campaigns have been conducted in Syria. The most recent campaigns, undertaken in January and February of this year, appear to have reached all districts in all governorates. Preliminary results indicate that immunization coverage was higher than 80% in all but two governorates.

   However, to control the outbreak, efforts on a similarly massive scale need to be sustained during three to four additional campaigns extending until at least June. The future of many Syrian children, and a worldwide eradication effort, are at stake.

Ladies and gentlemen,

Last year, life-saving medicines and supplies reached nearly 5 million Syrians. Much more needs to be done, despite the challenges.

All of these efforts to address the deteriorating health situation are being conducted under extremely difficult and dangerous conditions. Despite the greatest possible will to provide assistance, lack of access to people in need, wherever they reside, remains the most critical barrier to improving the health situation in Syria.

I began my intervention with a heavy heart, and conclude with a heartfelt plea. All parties in the conflict must respect the integrity and neutrality of health facilities.

They must ensure the protection of health workers and patients, in line with their obligations under international humanitarian law.

Thank you.

Joint GPEI-GAVI statement on the Availability and Price of Inactivated Polio Vaccine
Excerpt
The Global Polio Eradication Initiative (GPEI) and the GAVI Alliance “welcome the conclusion of UNICEF’s tender process, which makes accessible sufficient quantities of affordable inactivated polio vaccine (IPV) to support country introductions, in line with the ambitious timeline of GPEI’s Eradication and Endgame Strategic Plan 2013-2018.” The vaccine will now be available to GAVI-supported countries for as little as EUR 0.75 per dose (approximately USD 1.00 per dose at current exchange rates) in ten-dose vials. For middle-income countries, 10-dose presentations will be available through UNICEF from July 2014 at a price of EUR 1.49-2.40 (approximately USD 2.04-3.28 at current exchange rates). In addition, the awards by UNICEF include a price of USD 1.90 per dose for IPV in five-dose vials and USD 2.80 for IPV in single-dose vials. These vaccine presentations are accessible to both GAVI- supported and middle-income countries.

Further reductions in the cost of IPV are being pursued for the medium-term (i.e., post-2018) through continued efforts to develop and license new products.

As recommended by the World Health Organization’s Strategic Advisory Group of Experts on Immunization (SAGE) and endorsed by the World Health Assembly, the introduction of IPV globally – prior to a phased removal of the oral polio vaccine (OPV) during 2016-2018 – is a major element of the comprehensive plan to end all polio disease and secure a polio-free future.

Introduction of IPV will also help accelerate eradication of the remaining polioviruses by boosting global immunity.

GPEI’s plan calls for the introduction of IPV into routine immunisation programmes globally by the end of 2015. More than 120 countries have yet to introduce IPV, more than half of which are eligible for GAVI support.

Today’s publication of prices following conclusion of the UNICEF tender ensures that affordable IPV will be made available, removing a major obstacle to global introduction…With this tender completed, more than 120 countries can now move forward with their plans to introduce at least one dose of IPV into their routine immunisation schedules.
Full text: http://www.gavialliance.org/library/news/statements/2014/joint-gpei-gavi-statement-on-the-availability-and-price-of-inactivated-polio-vaccine/

GPEI Update: Polio this week – As of 26 February 2014
Global Polio Eradication Initiative
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s extract and bolded text]
:: Seven new cases (six wild poliovirus type 1 – WPV1 – and one circulating vaccine-derived poliovirus type 2 – cVDPV2) are reported this week from Federally Administered Tribal Areas and Khyber Pakhtunkhwa in Pakistan. This area is largely considered the ‘engine’ for polio transmission in the country.

Pakistan
:: Six new WPV1 cases were reported in the past week, five from North Waziristan, FATA and one from Peshawar, Khyber Pakhtunkhwa (KP). The total number of cases for 2013 remains 93. :: The total number of cases in 2014 is now 21. The most recent case had onset of paralysis on 10 February (WPV1 from Peshawar).
:: One new cVDPV2 case was reported in the past week, from FR Bannu, FATA, with onset of paralysis on 27 January. It is the most recent cVDPV2 case in the country. The total number of cVDPV2 cases for 2013 is 45, and four for 2014.
:: North Waziristan is the district with the largest number of children being paralyzed by poliovirus in the world (both wild and cVDPV2). 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.
:: The densely populated Peshawar valley is considered to be the main ‘engine’ of poliovirus 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 and in Quetta, Balochistan. Environmental positives isolates from every major city of Punjab confirm widespread virus circulation.

Horn of Africa
:: One new WPV1 case was reported from Somalia in the past week, with onset of paralysis on 19 June 2013. The case was reported late due to laboratory processing backlog.
:::The total number of WPV1 cases in the Horn of Africa is now 216 (193 from Somalia, 14 from Kenya and nine from Ethiopia). The most recent WPV1 case in the region had onset of paralysis on 20 December 2013 (from Bari, Somalia).
:: Outbreak response across the Horn of Africa is continuing. Recommendations from the recently held Horn of Africa Technical Advisory Group (TAG) are now actively being incorporated into outbreak response planning. The TAG had underscored that the initial response to the outbreak was appropriate, however expressed grave concern that gaps in SIA quality and surveillance remained in key infected areas of the region. Consequently, the group concluded there is a serious risk of the outbreak continuing and of further spread both within and beyond countries of the Horn of Africa. The group recommended that infected countries should focus efforts on high-risk and infected areas, by conducting high-quality SIAs no more than four weeks apart.

Associated Press: Bombs Kill 11 Pakistan Police Guarding Polio Teams
Two Bombs Struck Minutes Apart
March 1, 2014 7:16 a.m. ET
PESHAWAR, Pakistan—Two bombs minutes apart struck tribal police assigned to guard polio workers in northwest Pakistan on Saturday, killing 11, police said.
Police official Nawabzada Khan said the first of the two bombs struck an escort vehicle in the Lashora village of Jamrud tribal region in Khyber Pakhtunkhwa province. It wounded six officers, but caused no deaths.

Mr. Khan said minutes later, another roadside bomb struck a convoy of tribal police officers dispatched there to transport victims of the first attack, killing 11 officers and wounding six. He said gunmen also opened fire on officers, triggering a shootout that was still going on.

A government administrator named Nasir Khan said a hunt had been launched to trace and arrest the attackers. He confirmed 11 deaths and 12 injuries.

No one claimed responsibility for the two separate bombings, but antipolio teams or their guards have been frequently targeted in Pakistan by Islamic militants, who say the campaigns are a tool for spying and claim the vaccine makes boys sterile…

The Weekly Epidemiological Report (WER) for 28 February 2014, vol. 89, 9 (pp. 73–92) includes:
:: Polio vaccines: WHO position paper, January 2014
http://www.who.int/entity/wer/2014/wer8909.pdf?ua=1

  IVI announced the resignation of Dr. Alejandro Cravioto effective April 30, 2014. Dr. Cravioto will step down as Chief Scientific Officer on February 28, 2014 and will support IVI as a Senior Scientific Consultant until April 30th. Separately, IVI said its Board of Trustees has begun an executive recruitment search for IVI’s next Director General. IVI has retained the global search firm Russell Reynolds Associates to assist in the process with a deadline for applications of 17 March 2014.

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

:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 28 February 2014
On 3 and 15 February 2014, the Ministry of Health of Saudi Arabia announced two additional   laboratory-confirmed cases of Middle East Respiratory Syndrome coronavirus (MERS-CoV) infection… WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

:: Human infection with avian influenza A(H7N9) virus – update 27 February 2014
…The overall risk assessment has not changed…
:: Human infection with avian influenza A(H7N9) virus – update 27 February 2014
:: Human infection with avian influenza A(H7N9) virus – update 24 February 2014

Industry Watch  [to 1 March 2014]
Selected media releases and other selected content from industry.

:: Gardasil: New 2-dose Schedule Granted Positive CHMP Opinion for Europe’s Leading HPV Vaccine
Press release | 27 February 2014
Sanofi Pasteur MSD announced today that its quadrivalent HPV vaccine, Gardasil® has received a positive opinion from the European Medicines Agency’s Committee for Medicinal Products for Human Use (CHMP) for the use of a two-dose schedule in 9 to and including 13 year old adolescent girls and boys.

:: Novartis provides second US university with Bexsero to help protect students and staff against potentially deadly meningitis B disease
– FDA granted special use of Bexsero for nearly 20,000 UCSB students and staff in response to outbreak; the vaccine is licensed in Europe, Australia and Canada
– Novartis is pursuing a US license that would allow immediate public health response to outbreaks and make Bexsero available to American families
– MenB is an unpredictable disease, easily misdiagnosed, can kill within 24 hours and leaves those affected with serious lifelong disabilities
http://www.prnewswire.com/news-releases/novartis-provides-second-us-university-with-bexsero-to-help-protect-students-and-staff-against-potentially-deadly-meningitis-b-disease-246858901.html\
CAMBRIDGE, Mass., Feb. 24, 2014 /PRNewswire/ — Novartis announced today that its meningococcal serogroup B (MenB) vaccine, Bexsero® (Meningococcal Group B Vaccine [rDNA, component, adsorbed]), will be used as part of a vaccination program at the University of California Santa Barbara (UCSB) that began today and will end on March 7. In the last three months, the Food and Drug Administration (FDA) has approved the use of Bexsero twice in response to MenB outbreaks at US college campuses1. More than 5,000 students were vaccinated at Princeton University and 20,000 students will be offered vaccination at UCSB2.
Bexsero is the only licensed broad coverage vaccine approved in Europe, Canada and Australia to help protect against invasive meningococcal disease caused by serogroup B. It was approved for use in the US under a treatment Investigational New Drug (IND) designation…

:: Pfizer Announces Positive Top-Line Results Of Landmark Community-Acquired Pneumonia Immunization Trial In Adults (CAPiTA) Evaluating Efficacy Of Prevenar 13
Data to Be Presented at 9th International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD) on March 12, 2014
February 24, 2014 07:00 AM Eastern Standard Time
NEW YORK–(BUSINESS WIRE)–Pfizer Inc. (NYSE:PFE) today announced that the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA), the landmark study of approximately 85,000 subjects evaluating the efficacy of Prevenar 13* (pneumococcal polysaccharide conjugate vaccine [13-valent, adsorbed]) in adults 65 years of age and older, achieved its primary clinical objective and both secondary clinical objectives. CAPiTA is the largest double-blind, randomized, placebo-controlled vaccine efficacy trial ever conducted in adults.
“We are pleased with the outcome of the CAPiTA study, which demonstrated that Prevenar 13 can prevent vaccine-type pneumococcal community-acquired pneumonia in adults”
The primary objective of the study was to demonstrate efficacy of Prevenar 13 against a first episode of vaccine-type community-acquired pneumonia (CAP). The CAPiTA study also met both secondary objectives, which were efficacy against (i) a first episode of non-bacteremic/non-invasive vaccine-type CAP and (ii) a first episode of vaccine-type invasive pneumococcal disease (IPD).
Vaccine-type CAP (VT-CAP) was defined as CAP caused by any S. pneumoniae serotype included in the vaccine. Non-bacteremic/non-invasive VT-CAP was defined as CAP in which vaccine-type S. pneumoniae caused the pneumonia, but was not detected concurrently in the bloodstream or any other normally sterile site. Vaccine-type IPD was defined as a case in which vaccine-type S. pneumoniae was present in the bloodstream or any other normally sterile site, with or without pneumonia.
http://www.businesswire.com/news/home/20140224005899/en/Pfizer-Announces-Positive-Top-Line-Results-Landmark-Community-Acquired#.UxJGFYUt6F8