Sabin Vaccine Institute: …on the passing of Ciro de Quadros, MD, its Executive Vice President
Thursday, May 29, 2014
Dr. Ciro de Quadros, a public health hero and the Sabin Vaccine Institute’s Executive Vice President and Director of Vaccine Advocacy and Education, passed away peacefully yesterday at his home in Washington, DC, surrounded by his family.
:: To learn more about Ciro’s life and career, click here.
:: Statements from Sabin’s executive leadership team can be found here, and Sabin invites you to share your own memories of Ciro on the Sabin website.
:: Please see additional statements and memoriams here:
Pan American Health Organization (PAHO)
Ministry of Health of Mexico
Ministry of Health of Argentina

CDC/MMWR Watch [to 31 May 2014]
http://www.cdc.gov/mmwr/mmwr_wk.html

CDC Press Release: Measles cases in the United States reach 20-year high
May 29, 2014
CDC urges vaccination as summer travel season approaches
Excerpt
Two hundred and eighty-eight cases of measles were reported to the Centers for Disease Control and Prevention (CDC) in the United States between Jan. 1 and May 23, 2014. This is the largest number of measles cases in the United States reported in the first five months of a year since 1994. Nearly all of the measles cases this year have been associated with international travel by unvaccinated people.
“The current increase in measles cases is being driven by unvaccinated people, primarily U.S. residents, who got measles in other countries, brought the virus back to the United States and spread to others in communities where many people are not vaccinated,” said Dr. Anne Schuchat, assistant surgeon general and director of CDC’s National Center for Immunizations and Respiratory Diseases. “Many of the clusters in the U.S. began following travel to the Philippines where a large outbreak has been occurring since October 2013.”
Of the 288 cases, 280 (97 percent) were associated with importations from at least 18 countries. More than one in seven cases has led to hospitalization. Ninety percent of all measles cases in the United States were in people who were not vaccinated or whose vaccination status was unknown. Among the U.S. residents who were not vaccinated, 85 percent were religious, philosophical or personal reasons…

GPEI Update: Polio this week – As of 28 May 2014
Global Polio Eradication Initiative
Editor’s Excerpt – Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: A case of polio due to wild poliovirus type 1 (WPV1) was reported in the past week from Iraq, the second child to be paralyzed by polio in the country since the beginning of the Middle East outbreak last year. Countries are currently implementing the second phase of the regional outbreak response. A targeted mop-up campaign is currently ongoing in the area where the two cases in Iraq were found…
Pakistan
:: One new WPV1 case was reported in the past week from FR Bannu, Federally Administered Tribal Areas (FATA), with onset of paralysis on 2 May. The total number of WPV1 cases reported from Pakistan for 2014 is 67…
Middle East
:: A case of polio due to wild poliovirus type 1 (WPV1) was reported last week from Mada’in district in Baghdad-Resafa province, Iraq, with onset of paralysis on 7 April. This is the second child to be paralyzed by polio in the country since the beginning of the Middle East outbreak last year. A targeted mop-up campaign is currently ongoing in the area where the two cases in Iraq were found.
:: The total number of WPV1 cases reported from the Middle East is 38. In Syria, 36 cases are reported (35 in 2013 and 1 in 2014) with the most recent date of onset of paralyses on 21 January…

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 31 May 2014]
http://www.who.int/csr/don/en/

:: Ebola virus disease, West Africa – update 30 May 2014
:: Cholera outbreak, South Sudan 30 May 2014
:: Ebola virus disease, West Africa – update 28 May 2014
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 28 May 2014

GAVI Watch [to 31 May 2014]
http://www.gavialliance.org/library/news/press-releases/

:: Latest News: UN Secretary-General champions GAVI’s life-saving mission
Ban Ki-moon emphasizes investment in vaccines as key to achieving UN Millennium Development Goals
Excerpt
Toronto, Canada, 30 May 2014 – UN Secretary-General Ban Ki-moon has agreed to become a champion of the GAVI Alliance, supporting its mission to save children’s lives and protect people’s health by increasing access to immunisation.
He made the announcement during the high-level summit “Saving Every Woman, Every Child: Within Arm’s Reach,” emphasising his commitment to women and children’s health globally.
“I am proud to support the GAVI Alliance,” said Secretary-General Ban Ki-moon. “Immunisation continues to be an essential tool in moving us toward the UN Millennium Development Goals. An investment in immunisation is an investment in the health of all the world’s children, in our collective future. A successful replenishment of the GAVI Alliance is critical to the efforts of the Every Woman Every Child movement to improve the health of women and children around the world.”…

UNICEF Watch [to 31 May 2014]
http://www.unicef.org/media/media_71724.html

:: UNICEF, UNFPA stand behind Africa’s biggest anti child marriage push
ADDIS ABABA, Ethiopia, 29 May 2014 – UNICEF and the United Nations Population Fund (UNFPA) welcomed the first African Union campaign to end child marriage launched in Addis Ababa today.
:: Preventing newborn deaths must be a global priority: UNICEF
TORONTO, 29 May 2014 – Every minute, 10 babies die or are stillborn across the world, a staggering 5.5 million lives ended every year just as they start. The majority of those deaths are from preventable causes, including prematurity, childbirth complications and newborn infections.

WHO: Humanitarian Health Action [to 31 May 2014]
http://www.who.int/hac/en/

WHO helps bring medical supplies to besieged Syrian town of Douma for first time in 18 months
Excerpt
28 May 2014
WHO has helped to bring life-saving medicines and medical supplies to thousands of people in the besieged Syrian town of Douma for the first time in 18 months.
Two WHO trucks loaded with urgently needed supplies to support the Syrian Arab Red Crescent and the local health authorities reached the town in the East Ghouta area on Saturday as part of a UN inter-agency convoy.
It was the first time medical help had reached Douma since the siege of the area began in November 2012….

The Weekly Epidemiological Record (WER) for 30 May 2014, vol. 89, 22 (pp. 237–244) includes:
:: Progress towards polio eradication worldwide, 2013–2014
:: Anticipating epidemics
http://www.who.int/entity/wer/2014/wer8922.pdf?ua=1

WHO: New guidelines for planning and developing cancer registries
27 May 2014
The International Agency for Research on Cancer (IARC), WHO and the International Association of Cancer Registries (IACR) launched new guidelines for establishing cancer registries.
The publication, titled “Planning and developing population-based cancer registration in low- and middle-income settings”, provides essential guidance on the key steps in planning a registry, including accessing sources of information, monitoring the quality of the data, and reporting results.

Media Release: PATH Malaria Vaccine Initiative Names New Director of Research & Development
Excerpt
WASHINGTON, May 29, 2014 /PRNewswire-USNewswire/ — The PATH Malaria Vaccine Initiative (MVI) announced today that C. Richter (Rick) King, PhD, has been named Director of Research & Development (R&D). MVI drives the development of safe and effective vaccines to combat malaria. Malaria still kills more than 600,000 people worldwide, and half the world’s population remains at risk of contracting the disease.

Dr. King is an accomplished scientist with more than 25 years of experience in the public and private sectors, in both for-profit and nonprofit organizations. Most recently he served as Vice President of Vaccine Design for the International AIDS Vaccine Initiative (IAVI), within their Vaccine Design & Development Laboratory, a role he held for five years…

…Dr. King will lead work around transmission-blocking vaccines, a priority area of product development for MVI. He will also guide MVI’s portfolio of evaluation technology projects, which aim to refine or develop ways to assess vaccine efficacy prior to large-scale field trials…

…”Advancing new treatments and preventions have been a life-long passion,” said Dr. King, “and I am excited to be on the cutting edge of the malaria vaccine development field. I can’t wait to get started.”…

European Medicines Agency Watch [to 31 May 2014]
http://www.ema.europa.eu/ema/

European Medicines Agency welcomes publication of the Clinical Trials Regulation
28/05/2014
Excerpt
The European Medicines Agency (EMA) welcomes the publication of the Clinical Trials Regulation in the Official Journal of the European Union (EU). This legislation will open up a new era for the conduct of clinical trials in the EU, ensuring that Europe remains an attractive centre for clinical research. This will foster European competitiveness and innovative capacity, and facilitate swifter development of new medicines for patients. In addition to simplifying clinical trial approvals, the Regulation foresees transparency on the conduct of trials in the European Economic Area, from the point of their authorisation to the publication of the results of those clinical trials.
Whilst authorisation and oversight of clinical trials remains the competence of Member States, the new legislation mandates the Agency to prepare the IT platforms to support sponsors and experts in the Member States in carrying out their roles in relation to the authorisation of trials, their supervision, safety reporting and compliance activities, as well as to enable public access to information on clinical trials.
EMA policy on publication and access to clinical trial data
The new Regulation provides for the first time a direct legal basis for the release of clinical trial results. This is directly in line with the Agency’s commitment to increased transparency of these data, through its draft policy on proactive publication and access to clinical trial data. This policy, currently in the process of being finalised, will provide a bridge until the new legislation comes into force, which can be no earlier than mid-2016.

Summit: Saving Every Woman and Every Child – Within Arm’s Reach
Government of Canada
28-30 May 2014
Toronto, Canada
Overview
The Summit will focus on reducing the preventable deaths of newborns, mothers and children under the age of five in developing countries. It will bring together global leaders and Canadian experts to galvanize support for the next phase of efforts and ensure that maternal, newborn and child health remains a global priority.

Canada is a world leader in the global effort to reduce maternal and child mortality, and improve the health of mothers and children in the world’s poorest countries. As part of the G8 Muskoka Initiative, Canada is providing $2.85 billion in funding between 2010 and 2015 to improve the health and save the lives of women and children in developing countries.

The Summit will build consensus on how to scale-up progress on maternal, newborn and child health. The critical issues include:
:: accelerating progress on maternal health
:: reducing newborn mortality
:: saving lives through immunization
:: scaling up nutrition as a foundation for healthy lives
:: building civil registration and vital statistics systems
:: building new partnerships with the private sector to leverage innovation and financing

WHO: Sixty-seventh World Health Assembly [WHA]
[Editor’s Note: The Sixty-seventh World Health Assembly concluded on Saturday, 31 May. Key interviews, video, the WHA Journal and all documentation available here: http://www.who.int/mediacentre/events/2014/wha67/en/.

News release: World Health Assembly closes
24 May 2014 | GENEVA – The Sixty-seventh World Health Assembly closed today, after adopting more than 20 resolutions on public health issues of global importance.
“This has been an intense Health Assembly, with a record-breaking number of agenda items, documents and resolutions, and nearly 3,500 registered delegates,” said Dr Margaret Chan, WHO’s Director-General. “This is a reflection of the growing number of complexity of health issues, and your deep interest in addressing them.”

A number of the Health Assembly resolutions were approved today on the following issues.
:: Antimicrobial drug resistance
The delegates recognized their growing concern of antimicrobial resistance and urged governments to strengthen national action and international collaboration. This requires sharing information on the extent of resistance and the use of antibiotics in humans and animals. It also involves improving awareness among health providers and the public of the threat posed by resistance, the need for responsible use of antibiotics, and the importance of good hand hygiene and other measures to prevent infections.
The resolution urges Member States to strengthen drug management systems, to support research to extend the lifespan of existing drugs, and to encourage the development of new diagnostics and treatment options.
As requested in the resolution, WHO will develop a draft global action plan to combat antimicrobial resistance, including antibiotic resistance for presentation to the World Health Assembly for approval next year.

:: Implementation of the International Health Regulations (2005)
Yellow fever is a disease specified in the International Health Regulations (2005) for which countries may require proof of vaccination from travellers as a condition of entry under certain circumstances, and may take certain measures if an arriving traveller does not have this certificate in his possession.
The Health Assembly adopted revised provisions on yellow fever vaccination or revaccination under the International Health Regulations (2005). These include extending the validity of a certificate of vaccination against yellow fever from 10 years to the extent of the life of the vaccinated person. The revised provisions are based on the recommendations of the Strategic Advisory Group of Experts (SAGE) on immunization following its scientific review and analysis of evidence.
Member States reaffirmed their strong and continuous commitment to the implementation of International Health Regulations (2005).
:: Public health impacts of exposure to mercury and mercury compounds: the role of WHO and ministries of public health in the implementation of the Minamata Convention
The World Health Assembly requested the WHO Secretariat provide expert advice to help health ministries implement the Minamata Convention on Mercury. Most mercury is released as a result of human activity, such as burning coal and waste and mining for mercury, gold and other metals. WHO considers mercury one of the top ten chemicals or groups of chemicals of major public health concern.
The 2013 Minamata Convention aims to “protect human health and the environment from anthropogenic emissions and releases of mercury and mercury compounds”. The legally binding convention will enter into force when 50 countries have ratified it. It encourages countries to identify and better protect people who are at particular risk from mercury and highlights the need to provide effective health services for everyone who has been affected by exposed to mercury.

:: Addressing the global challenge of violence, in particular against women and girls
Across the world, each year, nearly 1.4 million people lose their lives to violence. Women and girls experience specific forms of violence that are often hidden. Globally, 1 in 3 women experience physical and/or sexual violence at least once in her life. For every person who dies as a result of violence, many more are injured and suffer from a range of adverse physical and mental health outcomes.
Member States will work to strengthen the role of the health system in addressing violence. WHO will develop a global plan of action to strengthen the role of national health systems within a multi-sectoral response to address interpersonal violence, in particular against women and girls, and against children.

:: Follow up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage
The Recife Political Declaration was formulated and adopted by participants of the Third Global Forum on Human Resources for Health, in November 2013. Rooted in the right to health approach, the Recife Declaration recognizes the centrality of human resources for health in the drive towards universal health coverage. It commits governments to creating the conditions for the inclusive development of a shared vision with other stakeholders and reaffirms the role of the WHO Global Code of Practice on the International Recruitment of Health Personnel as a guide for action to strengthen the health workforce and health systems.

:: Follow-up of the report of the Consultative Expert Working Group on Research and Development: Financing and Coordination
The Heath Assembly approved a resolution that significantly advances the quest for innovative, sustainable solutions for financing and coordinating health research and development (R&D) for diseases that disproportionately affect developing countries. The decision provides a firm go-ahead on the implementation of innovative health R&D demonstration projects.
By virtue of this decision, WHO will take the first steps to establish at the Special Programme for Research and Training in Tropical Diseases (TDR) a pooled fund for voluntary contributions towards R&D for diseases of the poor. WHO Member States have emphasised the importance of inclusive coordination of these new developments.

:: Access to essential medicines
WHO’s strategy to help countries improve access to essential medicines was approved. Key principles include selecting a limited range of medicines on the basis of the best evidence available, efficient procurement, affordable prices, effective distribution systems, and rational use. The WHO Essential medicines list was recognized as a valuable tool that enables countries to identify a core set of medicines which need to be available to provide quality medical care.

:: Regulatory system strengthening
Effective medicines regulation ensures that medicines and medical products are of the required quality, safety and efficacy; medicines are appropriately manufactured, stored, distributed and dispensed; illegal manufacturing and trade is controlled and prevented; health professionals and patients have the necessary information to enable them to use medicines rationally; promotion and advertising is regulated and fair; and access to medicines is not hindered by unjustified regulatory work.
In order to improve the regulation of medical products globally and ensure that medical products are of assured quality, more emphasis needs to be placed on regulatory strengthening, and promoting collaboration in regulatory systems.
The WHA mandated WHO, in cooperation with national regulators, to continue its important role globally in medicines regulation through establishing necessary norms and standards, supporting regulatory capacity-building and strengthening safety monitoring programmes. Through its Prequalification programme, WHO is requested to continue to ensures the quality, safety and efficacy of selected priority essential medicines, diagnostics and vaccines. A new development endorsed by Member States is the future progressive transition of prequalification to networks of strengthened regulatory authorities.

:: Health intervention and technology assessment in support of universal health coverage
Many countries currently lack the capacity to assess the merits of health technology. Health technology assessment (HTA) involves systematically evaluating the properties, effects, and/or impacts of different health technologies. Its main purpose is to inform technology-related policy-making in health care, and thus improve the uptake of cost-effective new technologies and prevent the uptake of technologies that are of doubtful value for the health system. Wasteful spending on medicines and other technologies has been identified as a major cause of inefficiencies in health service delivery.
Following the adoption of a resolution on HTA at the Health Assembly, WHO will support capacity-building for health technology assessment in countries. It will provide tools and guidance to prioritize health technologies and intensify networking and information exchange among countries to support priority setting.

:: Health in the post-2015 development agenda
Member States approved a resolution on health in the post-2015 development agenda, stressing the need for ongoing engagement in the process of setting the agenda. This includes a need to complete the unfinished work of the health Millennium Development Goals, newborn health, as well as an increased focus on noncommunicable diseases, mental health and neglected tropical diseases. The resolution also stresses the importance of universal health coverage and the need to strengthen health systems.
Accountability through regular assessment of progress by strengthening civil registration, vital statistics and health information systems are crucial. Member States emphasized the importance of having health at the core of the post-2015 development agenda.

:: Newborn health: draft action plan
The first-ever global plan to end preventable newborn deaths and stillbirths by 2035 calls for all countries to aim for fewer than 10 newborn deaths per 1000 live births and less than 10 stillbirths per 1000 total births by 2035.
Every year almost 3 million babies die in the first month of life and 2.6 million babies are stillborn (die in the last 3 months of pregnancy or during childbirth). Most of these deaths could be prevented by cost-effective interventions.
The Plan’s goals will require every country to invest in high-quality care before, during and after childbirth for every pregnant woman and newborn and highlights the urgent need to record all births and deaths.

SUMMARY OF THE SESSION: GLOBAL VACCINE ACTION PLAN, ITEM 12.2
WHO 67th WORLD HEALTH ASSEMBLY
Geneva, 21st May 2014
Fifty-four speakers including 50 representatives from Member States[1], one observer[2], civil society organizations[3] and the GAVI Alliance took the floor during the discussion on the Global Vaccine Action Plan (GVAP).
Delegates commended the Strategic Advisory Group of Experts (SAGE) on immunization for an excellent assessment report[4] and took note of the recommendations, particularly on the need to improve data quality.
While Member States acknowledged WHO’s fundamental role in facilitating the rollout of the GVAP, they also highlighted the need for all stakeholders, particularly national governments to play a leading role in making the needed investments in immunization and in monitoring programme performance.
Delegates highlighted several issues that must be addressed if the global immunization goals are to be achieved including:
:: Sustainable access to vaccines — especially the newer vaccines — at affordable prices for all countries, especially the middle-income countries who are not eligible for funding support from the GAVI Alliance;
:: Technology transfer to facilitate local manufacture of vaccines as a means of ensuring vaccine security;
:: Guidance to improve data quality including the use of new technologies like electronic registries;
:: Assistance on risk communication and management to address misinformation in some countries and communities on the need for immunization and its impact on vaccination coverage; and
:: Support countries to review the evidence and conduct economic analysis leading to informed decisions based on local priorities and needs.
In its response, the WHO secretariat, while taking note of all the issues raised by the delegates also reminded the Assembly that the GVAP progress report indicated that the world was not on track to achieve some of the key immunization goals for the decade and urged for more concerted action by all immunization stakeholders.
[1] Brazil; Cote d’Ivoire; Jamaica; Malaysia; Bahrain; Colombia; Thailand; Lebanon; Republic of Korea; China; Ecuador; Burundi; Indonesia; Japan; Vietnam; Russia; Iraq; Kenya; Surinam; Congo; Oman; Spain; Togo; Mexico; Namibia; Maldives; Morocco; South Africa; Germany; Mongolia; Algeria; Iran; India; Egypt; Barbados; Burkina-Faso; Jordan; Costa Rica; UAE; Uruguay; Tunisia; USA; Ethiopia; Trinidad-Tobago; Grenada; Azerbaijan; Malawi; Libya; Argentina; Tanzania.
[2] Taipei
[3] International Pharmacists Federation and MSF
[4] WHA 67, Document A67/12, http://apps.who.int/gb/ebwha/pdf_files/WHA67/A67_12-en.pdf

WHA 67 – Selected Documentation
A67/6 – Framework of engagement with non-State actors
A67/11 – Draft global strategy and targets for tuberculosis prevention, care and control after 201
A67/12 – Global vaccine action plan
A67/15 A67/15 Add.1 – Maternal, infant and young child nutrition
A67/16 – Disability: Draft WHO global disability action plan 2014–2021: Better health for all people with disability
A67/19 – Monitoring the achievement of the health-related Millennium Development Goals
A67/20 – Monitoring the achievement of the health-related Millennium Development Goals
A67/21 A67/21 Corr.1 – Newborn health: draft action plan/ Every newborn: an action plan to end preventable deaths
A67/22 – Addressing the global challenge of violence in particular against women and girls
A67/23 – Multisectoral action for a life course approach to healthy ageing
A67/30 – Access to essential medicines
A67/33 – Health intervention and technology assessment in support of universal health coverage
A67/33 – Health intervention and technology assessment in support of universal health coverage
A67/34 – Follow-up of the Recife Political Declaration on Human Resources for Health: renewed commitments towards universal health coverage
A67/35 A67/35 Add.1 – Implementation of the International Health Regulations (2005)
A67/36 A67/36 Add.1 – Pandemic Influenza Preparedness: sharing of influenza viruses and access to vaccines and other benefits
A67/37 – Smallpox eradication: destruction of variola virus stocks
A67/38 – Poliomyelitis: intensification of the global eradication initiative
A67/39 – Antimicrobial drug resistance
A67/39 Add.1 – Draft global action plan on antimicrobial resistance
Resolution: WHA67.1
Global strategy and targets for tuberculosis prevention, care and control after 2015

American Journal of Infection Control
Vol 42 | No. 6 | June 2014 | Pages 585-696
http://www.ajicjournal.org/current

Understanding health care personnel’s attitudes toward mandatory influenza vaccination
Reda A. Awali, MD, MPH, Preethy S. Samuel, PhD, Bharat Marwaha, MD, Nazir Ahmad, MD, Puneet Gupta, MBBS, Vinod Kumar, MBBS, Joseph Ellsworth, BS, Elaine Flanagan, BSN, MSA, Mark Upfal, MD, Jim Russell, RN, BSN, Carol Kaplan, BS, Keith S. Kaye, MD, MPH, Teena Chopra, MD, MPH
Abstract
Background
This study investigated the factors influencing influenza vaccination rates among health care personnel (HCP) and explored HCP’s attitudes toward a policy of mandatory vaccination.
Methods
In September 2012, a 33-item Web-based questionnaire was administered to 3,054 HCP employed at a tertiary care hospital in metropolitan Detroit.
Results
There was a significant increase in the rate of influenza vaccination, from 80% in the 2010-2011 influenza season (before the mandated influenza vaccine) to 93% in 2011-2012 (after the mandate) (P < .0001). Logistic regression showed that HCP with a history of previous influenza vaccination were 7 times more likely than their peers without this history to receive the vaccine in 2011-2012. A pro-mandate attitude toward influenza vaccination was a significant predictor of receiving the vaccine after adjusting for demographics, history of previous vaccination, awareness of the hospital’s mandatory vaccination policy, and patient contact while providing care (P = .01).
Conclusions
The increased rate of influenza vaccination among HCP was driven by both an awareness of the mandatory policy and a pro-mandate attitude toward vaccination. The findings of this study call for better education of HCP on the influenza vaccine along with enforcement of a mandatory vaccination policy.

BMC Public Health
(Accessed 31 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
School nurses’ attitudes and experiences regarding the human papillomavirus vaccination programme in Sweden: a population-based survey
Maria Grandahl, Tanja Tydén, Andreas Rosenblad, Marie Oscarsson, Tryggve Nevéus and Christina Stenhammar
Author Affiliations
BMC Public Health 2014, 14:540 doi:10.1186/1471-2458-14-540
Published: 31 May 2014
Abstract (provisional)
Background
Sweden introduced a school-based human papillomavirus (HPV) vaccination programme in 2012, and school nurses are responsible for managing the vaccinations. The aim of the present study was to investigate the attitudes and experiences of school nurses regarding the school-based HPV vaccination programme 1 year after its implementation.
Methods
Data were collected using a web-based questionnaire in the spring of 2013, and 83.1% (851/1024) of nurses responded.
Results
There were strong associations between the nurses’ education about the HPV vaccine and their perceived knowledge about the vaccine and a favourable attitude towards vaccination (both p < 0.001). School nurses who received a high level of education were more likely to have a positive attitude to HPV vaccination compared with nurses with little education about HPV vaccination (adjusted odds ratio [OR] = 9.8; 95% confidence interval [CI]:3.797-25.132). Nurses with high perceived knowledge were more likely to have a positive attitude compared with those with a low level of perceived knowledge (OR = 2.5; 95% CI: 1.299-4.955). If financial support from the government was used to fund an additional school nurse, nurses were more likely to have a positive attitude than if the financial support was not used to cover the extra expenses incurred by the HPV vaccination (OR = 2.1; 95% CI:1.051-4.010). The majority, 648 (76.1%), had been contacted by parents with questions about the vaccine, mostly related to adverse effects. In addition, 570 (66.9%) stated that they had experienced difficulties with the vaccinations, and 337 (59.1%) of these considered the task to be time-consuming.
Conclusions
A high level of education and perceived good knowledge about HPV are associated with a positive attitude of school nurses to the HPV vaccination programme. Thus, nurses require adequate knowledge, education, skills and time to address the questions and concerns of parents, as well as providing information about HPV. Strategic financial support is required because HPV vaccination is a complex and time-consuming task.

BMC Public Health
(Accessed 31 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
HIV vaccine acceptability among high-risk drug users in Appalachia: a cross-sectional study
April M Young, Ralph J DiClemente, Daniel S Halgin, Claire E Sterk and Jennifer R Havens
Author Affiliations
BMC Public Health 2014, 14:537 doi:10.1186/1471-2458-14-537
Published: 30 May 2014
Abstract (provisional)
Background
A vaccine could substantially impact the HIV epidemic, but inadequate uptake is a serious concern. Unfortunately, people who use drugs, particularly those residing in rural communities, have been underrepresented in previous research on HIV vaccine acceptability. This study examined HIV vaccine acceptability among high-risk drug users in a rural community in the United States.
Methods
Interviewer-administered questionnaires included questions about risk behavior and attitudes toward HIV vaccination from 433 HIV-negative drug users (76% with history of injection) enrolled in a cohort study in Central Appalachia. HIV vaccine acceptability was measured on a 4-point Likert scale. Generalized linear mixed models were used to determine correlates to self-report of being “very likely” to receive a 90% effective HIV vaccine (i.e. “maximum vaccine acceptability”, or MVA). Adjusted odds ratios (AORs) and corresponding 95% confidence intervals (CIs) are reported.
Results
Most (91%) reported that they would accept a preventive HIV vaccine, but concerns about cost, dosing, transportation constraints, vaccine-induced seropositivity, and confidentiality were expressed. Cash incentives, oral-administration, and peer/partner encouragement were anticipated facilitators of uptake. In multivariate analysis, men were significantly less likely to report MVA (AOR: 0.33, CI: 0.21 – 0.52). MVA was more common among participants who believed that they were susceptible to HIV (AOR: 2.31, CI: 1.28 – 4.07), that an HIV vaccine would benefit them (AOR: 2.80, CI: 1.70 – 4.64), and who had positive experiential attitudes toward HIV vaccination (AOR: 1.85, CI: 1.08 – 3.17). MVA was also more common among participants who believed that others would encourage them to get vaccinated and anticipated that their behavior would be influenced by others’ encouragement (AOR: 1.81, 95% 1.09 – 3.01).
Conclusions
To our knowledge, this study was among the first to explore and provide evidence for feasibility of HIV vaccination in a rural, high-risk population in the United States. This study provides preliminary evidence that gender-specific targeting in vaccine promotion may be necessary to promoting vaccine uptake in this setting, particularly among men. The data also underscore the importance of addressing perceived risks and benefits, social norms, and logistical constraints in efforts to achieve widespread vaccine coverage in this high-risk population.

Eurosurveillance
Volume 19, Issue 21, 29 May 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Rapid communications
Middle East respiratory syndrome coronavirus (MERS-CoV) infections in two returning travellers in the Netherlands, May 2014
M Kraaij – Dirkzwager1, A Timen1, K Dirksen2, L Gelinck3, E Leyten3, P Groeneveld4, C Jansen3, M Jonges5, S Raj6, I Thurkow7, R van Gageldonk-Lafeber8, A van der Eijk6, M Koopmans5,6, on behalf of the MERS-CoV outbreak investigation team of the Netherlands9
National Institute for Public Health and the Environment (RIVM) National Coordination Centre for Communicable Disease Control, Bilthoven, the Netherlands
Public Health Service The Hague, The Hague, the Netherlands
Medical Centre Haaglanden, The Hague, the Netherlands
Isala Klinieken Zwolle, Zwolle, the Netherlands
National Institute for Public Health and the Environment (RIVM) Centre for Infectious Disease Research, Diagnostics and Screening, Bilthoven, the Netherlands
Erasmus MC, Rotterdam, the Netherlands
Public Health Service Ijsselland, Zwolle, the Netherlands
National Institute for Public Health and the Environment (RIVM), Centre for Infectious Diseases, Epidemiology and Surveillance, Bilthoven, the Netherlands
Summary
Two patients, returning to the Netherlands from pilgrimage in Medina and Mecca, Kingdom of Saudi Arabia, were diagnosed with Middle East respiratory syndrome coronavirus (MERS-CoV) infection in May 2014. The source and mode of transmission have not yet been determined. Hospital-acquired infection and community-acquired infection are both possible.

Globalization and Health
[Accessed 31 May 2014]
http://www.globalizationandhealth.com/

Research
Scaling up antiretroviral treatment and improving patient retention in care: lessons from Ethiopia, 2005-2013
Yibeltal Assefa, Achamyeleh Alebachew, Meskele Lera, Lut Lynen, Edwin Wouters and Wim Van Damme
Abstract (provisional)
Background
Antiretroviral treatment (ART) was provided to more than nine million people by the end of 2012. Although ART programs in resource-limited settings have expanded treatment, inadequate retention in care has been a challenge. Ethiopia has been scaling up ART and improving retention (defined as continuous engagement of patients in care) in care. We aimed to analyze the ART program in Ethiopia.
Methods
A mix of quantitative and qualitative methods was used. Routine ART program data was used to study ART scale up and patient retention in care. In-depth interviews and focus group discussions were conducted with program managers.
Results
The number of people receiving ART in Ethiopia increased from less than 9,000 in 2005 to more than 439, 000 in 2013. Initially, the public health approach, health system strengthening, community mobilization and provision of care and support services allowed scaling up of ART services. While ART was being scaled up, retention was recognized to be insufficient. To improve retention, a second wave of interventions, related to programmatic, structural, socio-cultural, and patient information systems, have been implemented. Retention rate increased from 77% in 2004/5 to 92% in 2012/13.
Conclusion
Ethiopia has been able to scale up ART and improve retention in care in spite of its limited resources. This has been possible due to interventions by the ART program, supported by health systems strengthening, community-based organizations and the communities themselves. ART programs in resource-limited settings need to put in place similar measures to scale up ART and retain patients in care.

Global Public Health
Volume 9, Issue 5, 2014
http://www.tandfonline.com/toc/rgph20/.Uq0DgeKy-F9#.U4onnCjDU1w

Locating global health in social medicine
Seth M. Holmesab*, Jeremy A. Greenec & Scott D. Stoningtonde
DOI: 10.1080/17441692.2014.897361
pages 475-480
Abstract
Global health’s goal to address health issues across great sociocultural and socioeconomic gradients worldwide requires a sophisticated approach to the social root causes of disease and the social context of interventions. This is especially true today as the focus of global health work is actively broadened from acute to chronic and from infectious to non-communicable diseases. To respond to these complex biosocial problems, we propose the recent expansion of interest in the field of global health should look to the older field of social medicine, a shared domain of social and medical sciences that offers critical analytic and methodological tools to elucidate who gets sick, why and what we can do about it. Social medicine is a rich and relatively untapped resource for understanding the hybrid biological and social basis of global health problems. Global health can learn much from social medicine to help practitioners understand the social behaviour, social structure, social networks, cultural difference and social context of ethical action central to the success or failure of global health’s important agendas. This understanding – of global health as global social medicine – can coalesce global health’s unclear identity into a coherent framework effective for addressing the world’s most pressing health issues.

Religious coping among women with obstetric fistula in Tanzania
Melissa H. Watta*, Sarah M. Wilsonab, Mercykutty Josephc, Gileard Masengac, Jessica C. MacFarlanea, Olola Onekoc & Kathleen J. Sikkemaab
DOI: 10.1080/17441692.2014.903988
pages 516-527
Abstract
Religion is an important aspect of Tanzanian culture, and is often used to cope with adversity and distress. This study aimed to examine religious coping among women with obstetric fistulae. Fifty-four women receiving fistula repair at a Tanzanian hospital completed a structured survey. The Brief RCOPE assessed positive and negative religious coping strategies. Analyses included associations between negative religious coping and key variables (demographics, religiosity, depression, social support and stigma). Forty-five women also completed individual in-depth interviews where religion was discussed. Although participants utilised positive religious coping strategies more frequently than negative strategies (p < .001), 76% reported at least one form of negative religious coping. In univariate analysis, negative religious coping was associated with stigma, depression and low social support. In multivariate analysis, only depression remained significant, explaining 42% of the variance in coping. Qualitative data confirmed reliance upon religion to deal with fistula-related distress, and suggested that negative forms of religious coping may be an expression of depressive symptoms. Results suggest that negative religious coping could reflect cognitive distortions and negative emotionality, characteristic of depression. Religious leaders should be engaged to recognise signs of depression and provide appropriate pastoral/spiritual counselling and general psychosocial support for this population.

Generating political priority for newborn survival in three low-income countries
Stephanie L. Smitha*, Jeremy Shiffmanb & Abigail Kazembec
Free access
DOI: 10.1080/17441692.2014.904918
pages 538-554
Abstract
Deaths to babies in their first 28 days of life now account for more than 40% of global under-5 child mortality. High neonatal mortality poses a significant barrier to achieving the child survival Millennium Development Goal. Surmounting the problem requires national-level political commitment, yet only a few nation-states have prioritised this issue. We compare Bolivia, Malawi and Nepal, three low-income countries with high neonatal mortality, with a view to understanding why countries prioritise or neglect the issue. The three have had markedly different trajectories since 2000: attention grew steadily in Nepal, stagnated then grew in Malawi and grew then stagnated in Bolivia. The comparison suggests three implications for proponents seeking to advance attention to neglected health issues in low-income countries: the value of (1) advancing solutions with demonstrated efficacy in low-resource settings, (2) building on existing and emerging national priorities and (3) developing a strong network of domestic and international allies. Such actions help policy communities to weather political storms and take advantage of policy windows.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 31 May 2014]

Scoping Review
Surveillance-response systems: the key to elimination of tropical diseases
Ernest Tambo, Lin Ai, Xia Zhou, Jun-Hu Chen, Wei Hu, Robert Bergquist, Jia-Gang Guo, Jürg Utzinger, Marcel Tanner and Xiao-Nong Zhou
Author Affiliations
Infectious Diseases of Poverty 2014, 3:17 doi:10.1186/2049-9957-3-17
Published: 27 May 2014
Abstract (provisional)
Tropical diseases remain a major cause of morbidity and mortality in developing countries. Although combined health efforts brought about significant improvements over the past 20 years, communities in resource-constrained settings lack the means of strengthening their environment in directions that would provide less favourable conditions for pathogens. Still, the impact of infectious diseases is declining worldwide along with progress made regarding responses to basic health problems and improving health services delivery to the most vulnerable populations. The London Declaration on Neglected Tropical Diseases (NTDs), initiated by the World Health Organization’s NTD roadmap, set out the path towards control and eventual elimination of several tropical diseases by 2020, providing an impetus for local and regional disease elimination programmes. Tropical diseases are often patchy and erratic, and there are differing priorities in resources-limited and endemic countries at various levels of their public health systems. In order to identify and prioritize strategic research on elimination of tropical diseases, the ‘1st Forum on Surveillance-Response System Leading to Tropical Diseases Elimination’ was convened in Shanghai in June 2012. Current strategies and the NTD roadmap were reviewed, followed by discussions on how to identify and critically examine prevailing challenges and opportunities, including inter-sectoral collaboration and approaches for elimination of several infectious, tropical diseases. A priority research agenda within a ‘One Health-One World’ frame of global health was developed, including the establishment of (i) a platform for resource-sharing and effective surveillance-response systems for Asia Pacific and Africa with an initial focus on elimination of lymphatic filariasis, malaria and schistosomiasis; (ii) development of new strategies, tools and approaches, such as improved diagnostics and antimalarial therapies; (iii) rigorous validation of surveillance-response systems; and (iv) designing pilot studies to transfer Chinese experiences of successful surveillance-response systems to endemic countries with limited resources.

JAMA
May 28, 2014, Vol 311, No. 20
http://jama.jamanetwork.com/issue.aspx

Viewpoint
Commitment Devices – Using Initiatives to Change Behavior
Todd Rogers, PhD1; Katherine L. Milkman, PhD2; Kevin G. Volpp, MD, PhD3
Initial text
Unhealthy behaviors are responsible for a large proportion of health care costs and poor health outcomes.1 Surveys of large employers regularly identify unhealthy behaviors as the most important challenge to affordable benefits coverage. For this reason, employers increasingly leverage incentives to encourage changes in employees’ health-related behaviors. According to one survey, 81% of large employers provide incentives for healthy behavior change.2 In this Viewpoint, we discuss the potential and limitations of an approach that behavioral science research has shown can be used to influence health behaviors but that is distinct from incentives: the use of commitment devices…

Journal of Immigrant and Minority Health
Volume 16, Issue 3, June 2014
http://link.springer.com/journal/10903/16/3/page/1

HPV Awareness and Vaccine Acceptability in Hispanic Women Living Along the US-Mexico Border
Jennifer Molokwu Norma P. Fernandez Charmaine Martin
Abstract
Despite advances in prevention of cervical cancer in the US, women of Hispanic origin still bear an unequal burden in cervical cancer incidence, morbidity and mortality. Our objective was to determine the HPV vaccine knowledge and acceptability in a group of mostly Hispanic females. In this cross sectional survey, 62 % of participants heard of HPV; 34.9 % identified HPV as a cause of cervical cancer. 63 % of participants reported willingness to receive vaccine and 77 % were willing to vaccinate daughters. Those with previous abnormal PAPs were more likely to have heard of HPV and Vaccine. No other factors examined showed association with willingness to get vaccine or administer to daughters. Knowledge level remains low in this high risk population. Willingness to receive vaccine is high despite lack of access to care. Increased targeted community based education and vaccination programs may be useful in closing disparity in cervical cancer morbidity.

The Lancet
May 31, 2014 Volume 383 Number 9932 p1861 – 1944 e16 – 18
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Polio eradication: the CIA and their unintended victims
The Lancet
Preview
On May 2, 2011, President Barack Obama announced that the US Central Intelligence Agency (CIA) had located and killed Osama Bin Laden. The agency organised a fake hepatitis vaccination campaign in Abottabad, Pakistan, in a bid to obtain DNA from the children of Bin Laden, to confirm the presence of the family in a compound and sanction the rollout of a risky and extensive operation. Release of this information has had a disastrous effect on worldwide eradication of infectious diseases, especially polio.

Offline: WHO offers a new future for sustainable development
Richard Horton
Preview |
WHO has made its definitive statement about the future it envisions for the post-2015 era of sustainable development. At a standing-room only technical briefing during last week’s World Health Assembly, WHO’s Director-General, Dr Margaret Chan, launched the agency’s much anticipated position. Dr Chan emphasises at every possible opportunity that WHO is a member-state organisation and can act only at the request of those member states. This loyalty to intergovernmental decision-making, underlining WHO’s role as a technical secretariat, has, not surprisingly, made Dr Chan popular among countries.

Rethinking the foundations of global governance for health: the youth response
Unni Gopinathan, Daniel Hougendobler, Nick Watts, Cristóbal Cuadrado, Renzo R Guinto, Alexandre Lefebvre, Saveetha Meganathan, Waruguru Wanjau, Jacob Jorem, Nilofer Khan Habibullah, Peter Asilia, Usman Ahmad Mushtaq
Preview |
In its recent report, The Lancet–University of Oslo Commission on Global Governance for Health declared that health “should be adopted as a universal value and a shared social and political objective for all”.1 This rallying cry is simple, compelling, and—most importantly—widely appealing. It provides a firm foothold for a renewed call for strengthened global governance. The Commission’s report, which builds upon the evidence base on social determinants of health,2 offers a normative framework for evaluating global governance by assessing the impacts of various sectors on health.

Blood pressure and incidence of twelve cardiovascular diseases: lifetime risks, healthy life-years lost, and age-specific associations in 1•25 million people
Dr Eleni Rapsomaniki PhD a b, Prof Adam Timmis FRCP a d, Julie George PhD a b, Mar Pujades-Rodriguez PhD a b, Anoop D Shah MRCP a b, Spiros Denaxas PhD a b, Ian R White PhD h, Prof Mark J Caulfield MD a e, Prof John E Deanfield FRCP a c, Prof Liam Smeeth FRCGP a f, Prof Bryan Williams FRCP a g, Prof Aroon Hingorani FRCP a b, Prof Harry Hemingway FRCP a b
Summary
Background
The associations of blood pressure with the different manifestations of incident cardiovascular disease in a contemporary population have not been compared. In this study, we aimed to analyse the associations of blood pressure with 12 different presentations of cardiovascular disease.
Methods
We used linked electronic health records from 1997 to 2010 in the CALIBER (CArdiovascular research using LInked Bespoke studies and Electronic health Records) programme to assemble a cohort of 1•25 million patients, 30 years of age or older and initially free from cardiovascular disease, a fifth of whom received blood pressure-lowering treatments. We studied the heterogeneity in the age-specific associations of clinically measured blood pressure with 12 acute and chronic cardiovascular diseases, and estimated the lifetime risks (up to 95 years of age) and cardiovascular disease-free life-years lost adjusted for other risk factors at index ages 30, 60, and 80 years. This study is registered at ClinicalTrials.gov, number NCT01164371.
Findings
During 5•2 years median follow-up, we recorded 83 098 initial cardiovascular disease presentations. In each age group, the lowest risk for cardiovascular disease was in people with systolic blood pressure of 90—114 mm Hg and diastolic blood pressure of 60—74 mm Hg, with no evidence of a J-shaped increased risk at lower blood pressures. The effect of high blood pressure varied by cardiovascular disease endpoint, from strongly positive to no effect. Associations with high systolic blood pressure were strongest for intracerebral haemorrhage (hazard ratio 1•44 [95% CI 1•32—1•58]), subarachnoid haemorrhage (1•43 [1•25—1•63]), and stable angina (1•41 [1•36—1•46]), and weakest for abdominal aortic aneurysm (1•08 [1•00—1•17]). Compared with diastolic blood pressure, raised systolic blood pressure had a greater effect on angina, myocardial infarction, and peripheral arterial disease, whereas raised diastolic blood pressure had a greater effect on abdominal aortic aneurysm than did raised systolic pressure. Pulse pressure associations were inverse for abdominal aortic aneurysm (HR per 10 mm Hg 0•91 [95% CI 0•86—0•98]) and strongest for peripheral arterial disease (1•23 [1•20—1•27]). People with hypertension (blood pressure ≥140/90 mm Hg or those receiving blood pressure-lowering drugs) had a lifetime risk of overall cardiovascular disease at 30 years of age of 63•3% (95% CI 62•9—63•8) compared with 46•1% (45•5—46•8) for those with normal blood pressure, and developed cardiovascular disease 5•0 years earlier (95% CI 4•8—5•2). Stable and unstable angina accounted for most (43%) of the cardiovascular disease-free years of life lost associated with hypertension from index age 30 years, whereas heart failure and stable angina accounted for the largest proportion (19% each) of years of life lost from index age 80 years.
Interpretation
The widely held assumptions that blood pressure has strong associations with the occurrence of all cardiovascular diseases across a wide age range, and that diastolic and systolic associations are concordant, are not supported by the findings of this high-resolution study. Despite modern treatments, the lifetime burden of hypertension is substantial. These findings emphasise the need for new blood pressure-lowering strategies, and will help to inform the design of randomised trials to assess them.
Funding
Medical Research Council, National Institute for Health Research, and Wellcome Trust.

Nature
Volume 509 Number 7502 pp533-656 29 May 2014
http://www.nature.com/nature/current_issue.html

Global health: Deadly dinners
Polluting biomass stoves, used by one-third of the global population, take a terrible toll. But efforts to clean them up are failing.
Meera Subramanian

Nature | Comment
Policy: An intergovernmental panel on antimicrobial resistance
Mark Woolhouse & Jeremy Farrar
22 May 2014
Drug-resistant microbes are spreading. A coordinated, global effort is needed to keep drugs working and develop alternatives, say Mark Woolhouse and Jeremy Farrar.
Excerpt from full text
Last month, the World Health Organization (WHO) produced a global map1 of antimicrobial resistance, warning that a ‘post-antibiotic’ world could soon become a reality. In some ways, it already has.
Drugs that were once lifesavers are now worthless. Chloramphenicol, once a physician’s first choice against typhoid, is no longer effective in many parts of the world. Strains of extensively drug-resistant tuberculosis (TB), methicillin-resistant Staphylococcus aureus (MRSA), multidrug-resistant Escherichia coli and Klebsiellapneumoniae are serious threats to public health. Plasmodium falciparum (the parasite that causes the most dangerous form of malaria) is developing resistance to all known classes of anti¬malarial drug, threatening the remarkable progress that has been made against the disease. HIV is increasingly resistant to first-line antiviral drugs. Every class of antibiotic is increasingly compromised by resistance, as are many antivirals, antiparasitic and antifungal drugs.
It could get worse: routine medical care, surgery, cancer treatment, organ transplants and industrialized agriculture would be impossible in their present form without antimicrobials. And the treatment of many infectious human and livestock diseases now relies on just one or two drugs.
Resistance has spread around the world. MRSA has spread between continents2, as have resistant strains of TB, malaria, HIV and pneumococci. Genes conferring resistance to β-lactams — antibiotics used against a broad range of infections, including E. coli and K. pneumoniae — have spread to bacterial populations worldwide, probably originating in the Indian subcontinent3. Numerous drug-resistant malaria strains have spread from southeast Asia to Africa.

New England Journal of Medicine
May 29, 2014 Vol. 370 No. 22
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Embracing Oral Cholera Vaccine — The Shifting Response to Cholera
Jean William Pape, M.D., and Vanessa Rouzier, M.D.
N Engl J Med 2014; 370:2067-2069 May 29, 2014 DOI: 10.1056/NEJMp1402837
Cholera, a rapidly dehydrating diarrheal disease, is caused by ingestion of Vibrio cholerae, serogroup O1 or O139. The World Health Organization (WHO) estimates that 1.4 billion people were at risk for cholera in 2012.1 More than 90% of reported cases occur in Africa, and most of the remainder occur in southern Asia. In 2010, only 10 months after it was hit by a major earthquake, Haiti experienced the most severe cholera epidemic of the past century, with 699,579 cases and 8539 related deaths reported as of February 11, 2014. This was the first time cholera had been documented in Haiti, despite the occurrence of devastating outbreaks in the Caribbean in the 19th century and in Latin America between 1991 and 2001 (see
Cholera is a disease of poverty, linked to poor sanitation and a lack of potable water.

Establishment of an adequate sanitation and potable-water system is the most definitive way to prevent and limit its spread. However, the cost of instituting adequate sanitation systems, one of the United Nations Millennium Development Goals, is prohibitive for the countries that are affected by cholera: it would cost an estimated $2.2 billion, for example, to adequately improve access to water and sanitation in Haiti. Water, sanitation, and hygiene (WASH) practices are the cornerstones of cholera prevention and control. The promotion of WASH practices, the creation of rehydration centers, use of antibiotics, and training of health personnel during the first months of the Haitian epidemic led to a dramatic reduction in cholera-associated mortality, from 4% to 1.5%.2 Yet a survey in the slums of Port-au-Prince showed that although people were aware of hand-washing methods, they did not have soap and water to implement them. What role should oral cholera vaccine (OCV) play, in combination with WASH practices, in epidemic conditions?

The three currently licensed OCVs are formulations of killed V. cholerae cells. Two of them, Dukoral and Shanchol, have been prequalified by the WHO for purchase by United Nations agencies. The third one, mORCVAX, is licensed and produced exclusively in Vietnam. For all three vaccines, there is evidence of safety and efficacy (66 to 85%) after two doses, with inferred herd protection and immunity lasting up to 5 years (in the case of Shanchol). Dukoral includes a cholera toxin B subunit requiring administration with a buffer, and it costs $3.64 to $6.00 per dose. Shanchol does not require a buffer and costs $1.85 per dose. Despite the evidence of safety and efficacy, international agencies cited several reasons for not including OCV in the prevention package during the 2010 Haitian epidemic.2

First, there was a limited number of OCV doses available worldwide. Second, Shanchol, the cheaper and easier-to-administer vaccine, could not be purchased by United Nations agencies until it received WHO approval in 2011. Third, there was concern that OCV implementation would compete with other WASH interventions in countries with fragile health systems.

After sustained lobbying by multiple institutions and organizations, a pilot intervention was initiated in Haiti using OCV with other WASH measures to control the outbreak (“reactive vaccination”). An urban project was conducted by the Haitian Group for the Study of Kaposi’s Sarcoma and Opportunistic Infections (GHESKIO), and a rural project was conducted by Partners in Health, both in collaboration with the Haitian Ministry of Health. The outcomes showed that OCV can be effectively employed as part of a comprehensive cholera-control program: 91% of 97,774 participants received two vaccine doses during a 90-day period.3,4

The WHO has since changed its policy and promotes OCV use in outbreaks worldwide.5 During the past 3 years, more than 1.6 million doses of Shanchol have been administered in Asia, Africa, and the Caribbean. A remaining challenge to OCV implementation was the lack of field evidence for its effectiveness early in an epidemic. The matched case–control study in Guinea, reported on by Luquero et al. in this issue of the Journal (pages 2111–2120), clearly illustrates the role OCV can play in countering cholera epidemics, with greater than 86% protection after administration of two doses.

Although the global stockpile of Shanchol is growing — the WHO has 2 million doses, and the Global Alliance for Vaccines and Immunization (GAVI) has pledged support for 20 million doses over the next 5 years — the world will need millions more doses. Moreover, many questions remain. For instance, how should priorities be set for use of the stockpile when there are multiple simultaneous epidemics (requiring reactive vaccination), other high-risk situations (e.g., encampments of refugees who could benefit from preemptive vaccination), and regions where cholera is endemic and peaks in incidence are expected during the rainy season? Risk evaluation and cost-effectiveness will certainly be important considerations.

In addition, because of their study’s small sample size, Luquero et al. could not test the efficacy of one versus two doses of OCV. A one-dose regimen would reduce the cost and logistic constraints for national scale-up programs. A collaborative double-blind, placebo-controlled study that the International Vaccine Institute and the International Center for Diarrheal Disease Research, Bangladesh, are conducting in Dhaka may provide this information.

Another question is whether OCV can be stored at room temperature so that the cold-chain requirement can be bypassed. In the study by Luquero et al., the vaccine was refrigerated during storage, but the cold chain was not maintained in the field. It will be important to determine how long the vaccine can retain its efficacy at room temperature.

Furthermore, can Shanchol be used in pregnancy and in children younger than 1 year of age? Although WHO recommendations suggest targeting pregnant women at high risk for cholera, the manufacturer has not approved use of the vaccine in pregnancy, and there are no guidelines for children under 1 year old.

Since 2010, some major obstacles preventing the use of OCV have been overcome. Shanchol, the cheapest and easiest-to-administer vaccine, is being stockpiled. OCV has been used in 13 countries on three continents (Asia, Africa, and the North American Caribbean) and in three risk settings. The study by Luquero et al. provides further evidence in favor of using OCV in emerging outbreaks.

Original Article
Use of Vibrio cholerae Vaccine in an Outbreak in Guinea
Francisco J. Luquero, M.D., M.P.H., Lise Grout, D.V.M., M.P.H., Iza Ciglenecki, M.D., Keita Sakoba, M.D., Bala Traore, M.D., Melat Heile, N.P., Alpha Amadou Diallo, M.Sc., Christian Itama, M.D., Anne-Laure Page, Ph.D., Marie-Laure Quilici, Ph.D., Martin A. Mengel, M.D., Jose Maria Eiros, M.D., Ph.D., Micaela Serafini, M.D., M.P.H., Dominique Legros, M.D., M.P.H., and Rebecca F. Grais, Ph.D.
N Engl J Med 2014; 370:2111-2120 May 29, 2014 DOI: 10.1056/NEJMoa1312680
Abstract
The use of vaccines to prevent and control cholera is currently under debate. Shanchol is one of the two oral cholera vaccines prequalified by the World Health Organization; however, its effectiveness under field conditions and the protection it confers in the first months after administration remain unknown. The main objective of this study was to estimate the short-term effectiveness of two doses of Shanchol used as a part of the integrated response to a cholera outbreak in Africa.
Full Text of Background…
Methods
We conducted a matched case–control study in Guinea between May 20 and October 19, 2012. Suspected cholera cases were confirmed by means of a rapid test, and controls were selected among neighbors of the same age and sex as the case patients. The odds of vaccination were compared between case patients and controls in bivariate and adjusted conditional logistic-regression models. Vaccine effectiveness was calculated as (1−odds ratio)×100.
Full Text of Methods…
Results
Between June 8 and October 19, 2012, we enrolled 40 case patients and 160 controls in the study for the primary analysis. After adjustment for potentially confounding variables, vaccination with two complete doses was associated with significant protection against cholera (effectiveness, 86.6%; 95% confidence interval, 56.7 to 95.8; P=0.001).
Full Text of Results…
Conclusions
In this study, Shanchol was effective when used in response to a cholera outbreak in Guinea. This study provides evidence supporting the addition of vaccination as part of the response to an outbreak. It also supports the ongoing efforts to establish a cholera vaccine stockpile for emergency use, which would enhance outbreak prevention and control strategies. (Funded by Médecins sans Frontières.)
Full Text of Discussion…
Read the Full Article…

PLoS One
[Accessed 31 May 2014]
http://www.plosone.org/

Research Article
Identifying the Science and Technology Dimensions of Emerging Public Policy Issues through Horizon Scanning
Miles Parker mail, Andrew Acland, Harry J. Armstrong, Jim R. Bellingham, Jessica Bland, Helen C. Bodmer, Simon Burall, Sarah Castell, Jason Chilvers, David D. Cleevely, David Cope, Lucia Costanzo, James A. Dolan, [ … ], William J. Sutherland , [ view all ]
Abstract
Public policy requires public support, which in turn implies a need to enable the public not just to understand policy but also to be engaged in its development. Where complex science and technology issues are involved in policy making, this takes time, so it is important to identify emerging issues of this type and prepare engagement plans. In our horizon scanning exercise, we used a modified Delphi technique [1]. A wide group of people with interests in the science and policy interface (drawn from policy makers, policy adviser, practitioners, the private sector and academics) elicited a long list of emergent policy issues in which science and technology would feature strongly and which would also necessitate public engagement as policies are developed. This was then refined to a short list of top priorities for policy makers. Thirty issues were identified within broad areas of business and technology; energy and environment; government, politics and education; health, healthcare, population and aging; information, communication, infrastructure and transport; and public safety and national security.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 31 May 2014)

Editorial
The Role of Open Access in Reducing Waste in Medical Research
Paul Glasziou mail
Published: May 27, 2014
DOI: 10.1371/journal.pmed.1001651
[Full text]
Twenty years ago an editorial by Doug Altman in the BMJ [1], “The Scandal of Poor Medical Research”, decried the poor design and reporting of research, stating that “huge sums of money are spent annually on research that is seriously flawed through the use of inappropriate designs, unrepresentative samples, small samples, incorrect methods of analysis, and faulty interpretation”. Since then, change has been gradual, while the list of problems has lengthened, and documentation of their magnitude has accumulated. Recent years, however, have seen a crescendo of concern. Public awareness has been accelerated with the publication of Ben Goldacre’s Bad Pharma [2], which clearly articulated the problems posed by biased non-publication and reporting of pharmaceutical research. Wider awareness of these issues helped spark the AllTrials campaign (http://www.alltrials.net/), which asks for “all trials registered; all results reported”. Of course, the problems of poor design and reporting, as well as selective non-publication, extend well beyond drug trials to most areas of research: drug and non-drug, basic and applied, interventional and observational, animal and human. A 2009 paper in The Lancet [3] estimated that three problems—flawed design, non-publication, and poor reporting—together meant over 85% of research funds were wasted, implying a global total loss of over US$100 billion per year. This year, a follow-up series [4] more extensively documented this wastage, confirming the earlier estimate, but adding details and a series of more explicit recommendations for action.

The waste sounds bad, but the reality is worse. The estimate that 85% of research is wasted referred only to activities prior to the point of publication. Much waste clearly occurs after publication: from poor access, poor dissemination, and poor uptake of the findings of research. The development of open access to research [5] is important to reduce this post-publication waste. Poor access—including paywalls, restrictions on re-publication and re-use, etc.—limits both researcher-to-researcher and researcher-to-clinician communications. As PLOS Medicine editorial leaders pointed out in a PubMed Commons response to the Lancet series [6], open access is more than free access and includes “free, immediate access online; unrestricted distribution and re-use rights in perpetuity for humans and technological applications; author(s) retains rights to attribution; papers are immediately deposited in a public online archive, such as PubMed Central” [7]. Globally, the most important access problem is arguably due to language barriers, and with the growth of research in non-English-speaking countries, particularly China, this problem is likely to grow. Language barriers make even free-access research unusable, but by eliminating restrictions on re-publication and re-use, open access can at least reduce barriers to translation.

Solving the problems of pre-publication waste and post-publication access could hugely accelerate medical research. Even the complete solution of these problems, however, would be insufficient to close the research–practice gap. Paradoxically, the plethora of research is itself a barrier to its use. A recent analysis of trials and reviews by specialty found an unmanageable scatter of research [8]. For example, in neurology the annual output was 2,770 trials across 896 journals, and 547 systematic reviews across 292 journals. So, in addition to access, clever systems of synthesis, filtering, findability, and usability are needed if the users of research are to cope with this information deluge [9]. The enormous marketing budgets of pharmaceutical companies demonstrate the importance they place on investing resources in getting the message of their research to decision makers. Unfortunately, little such investment is made in non-commercial research, and this research is consequently neglected. This concern has led to the development of different approaches given names such as “evidence-based medicine”, “knowledge translation”, and “implementation science”.

To get full value from research investment, we need to reduce both the annual US$100 billion of pre-publication (research production) waste and the unquantified cost of post-publication (research dissemination) barriers (Figure 1). Open access will not in itself fix the problems of poor research question selection, poor study design, selective non-publication, or poor or biased reporting, but these can be ameliorated considerably through appropriate editorial policies and peer review processes. Open-access medical journals must maintain particularly high standards for these processes in order to avoid merely increasing access to a biased selection of (often flawed) research. At the same time, improving research quality but keeping access restricted would mean continued waste in the use and uptake of good science.

“As the system encourages poor research,” wrote Altman in 1994 [1], “it is the system that should be changed. We need less research, better research, and research done for the right reasons.” To that must be added a need for research that is communicated effectively to those who need it. If over a 100 billion dollars of medical research money were being wasted by corruption, the public and political outcry would be overwhelming. That resources of this magnitude are being wasted through incompetence and inattention should be seen as a similar scandal. Badly designed and poorly thought through systems of research and dissemination subtract massively from global human health: they demand attention—and action.

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

Editorial
Ten Global “Hotspots” for the Neglected Tropical Diseases
Peter J. Hotez mail
Published: May 29, 2014
DOI: 10.1371/journal.pntd.0002496
Initial text
Since the founding of PLOS Neglected Tropical Diseases more than six years ago, I have written about the interface between disease and geopolitics. The neglected tropical diseases (NTDs) are the world’s most common infections of people living in poverty [1]. Where they are widespread in affected communities and nations, NTDs can be highly destabilizing and ultimately may promote conflict and affect international and foreign policy [2]. Many of the published papers in this area were recently re-organized in a PLOS “Geopolitics of Neglected Tropical Diseases” collection that was posted on our website in the fall of 2012, coinciding with the start of our sixth anniversary [3]. From this information, a number of new and interesting findings emerged about the populations who are most vulnerable to the NTDs, including the extreme poor who live in the large, middle-income countries and even some wealthy countries (such as the United States) that comprise the Group of Twenty (G20) countries [4], as well as selected Aboriginal populations [5]. Together, the PLOS “Geopolitics of Neglected Tropical Diseases” collection and the G20 analyses identified more than a dozen areas of the world that repeatedly show up as ones where NTDs disproportionately affect the poorest people living at the margins. Here, I summarize what I view as ten of the worst global “hotspots” where NTDs predominate (Figure 1). They represent regions of the world that will require special emphasis for NTD control and elimination if we still aspire to meet Millennium Development Goals (MDGs) and targets by 2015; they are regions that may need to be highlighted again as we consider post-MDG aspirations and new Sustainable Development Goals (SDGs).

Viewpoints
The Gulf Coast: A New American Underbelly of Tropical Diseases and Poverty
Peter J. Hotez, Kristy O. Murray, Pierre Buekens
PLOS Neglected Tropical Diseases: published 15 May 2014 | info:doi/10.1371/journal.pntd.0002760

Building Endogenous Capacity for the Management of Neglected Tropical Diseases in Africa: The Pioneering Role of ICIPE
Daniel K. Masiga, Lilian Igweta, Rajinder Saini, James P. Ochieng’-Odero, Christian Borgemeister
PLOS Neglected Tropical Diseases: published 15 May 2014 | info:doi/10.1371/journal.pntd.0002687

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

AIDS Research and Human Retroviruses
May 2014, ahead of print.
The Immune Space: A Concept and Template for Rationalizing Vaccine Development
Dr. Amapola Manrique, Dr. Elizabeth Adams, Dr. Dan Barouch, Dr. Patricia E Fast, Dr. Barney Graham, Dr. Jerome H. Kim, Dr. James Kublin, Margaret McCluskey, Dr. Giuseppe Pantaleo, Dr. Harriet L. Robinson, Dr. Nina Russell, William Snow, and Dr. Margaret I. Johnston.
doi:10.1089/AID.2014.0040.
ABSTRACT
Empirical testing of candidate vaccines has led to the successful development of a number of lifesaving vaccines. The advent of new tools to manipulate antigens and new methods and vectors for vaccine delivery has led to a veritable explosion of potential vaccine designs. As a result, selection of candidate vaccines suitable for large-scale efficacy testing has become more challenging. This is especially true for diseases such as dengue, HIV, and tuberculosis where there is no validated animal model or correlate of immune protection. Establishing guidelines for the selection of vaccine candidates for advanced testing has become a necessity. A number of factors could be considered in making these decisions, including, for example, safety in animal and human studies, immune profile, protection in animal studies, production processes with product quality and stability, availability of resources, and estimated cost of goods. The “immune space template” proposed here provides a standardized approach by which the quality, level, and durability of immune responses elicited in early human trials by a candidate vaccine can be described. The immune response profile will demonstrate if and how the candidate is unique relative to other candidates, especially those that have preceded it into efficacy testing and thus, what new information concerning potential immune correlates could be learned from an efficacy trial. A thorough characterization of immune responses should also provide insight into a developer’s rationale for the vaccine’s proposed mechanism of action. HIV vaccine researchers plan to include this general approach in up-selecting candidates for the next large efficacy trial. This “immune space” approach may also be applicable to other vaccine development endeavors where correlates of vaccine-induced immune protection remain unknown.

Quality in Primary Care
Volume 22, Number 3, June 2014
http://www.ingentaconnect.com/content/rmp/qpc/2014/00000022/00000003
Immunisation errors reported to a vaccine advice service: intelligence to improve practice
Lang, Sarah1; Ford, Karen J2; John, Tessa2; Pollard, Andrew J3; McCarthy, Noel D4
Abstract:
Background: The success of immunisation programmes depends on the quality with which they are administered. The Vaccine Advice for CliniCians Service (VACCSline) is an advice service to support immunisers and promote excellence in immunisation practice, through specialist guidance and local education, covering a catchment population of two million people. All enquiries are recorded onto a database and categorised. Vaccine error is selected when a vaccine has not been prepared or administered according to national recommendations or relevant expert guidance.
Method: All enquiries from 2009 to 2011, categorised on the VACCSline database as ‘vaccine error’ were analysed and subjected to a detailed free-text review.
Results: Of 4301 enquiries, 158 (3.7%) concerned vaccine errors. The greatest frequency of errors, 145 (92.9%) concerned immunisations delivered in primary care services; 92% of all errors occurred during either vaccine selection and preparation or history checking and scheduling. Administration of the wrong vaccine was the most frequent error recorded in 33.3% of reports. A shared first letter of the vaccine name was noted to occur in 13 error reports in which the incorrect vaccine was inadvertently administered. Consultations involving pairs of siblings were associated with various errors in seven enquiries. Failure to revaccinate after spillage (seven reports) showed a widespread knowledge gap in this area.
Conclusion: Advice line enquiries provide intelligence to alert immunisers to the errors that are commonly reported and may serve to highlight processes that predispose to errors, thus informing immuniser training and updating

American Journal of Obstetrics and Gynecology
Available online 22 May 2014
Utilization of the combined tetanus-diphtheria and pertussis vaccine during pregnancy
Ilona T. Goldfarb, MD, MPH1, , Sarah Little, MD, MPH2, Joelle Brown1, Laura E. Riley, MD1
Abstract
Objective
A recent increase in pertussis cases prompted the Advisory Committee on Immunization Practices to recommend administering the Tdap vaccine during each pregnancy. We sought to describe uptake of Tdap and identify predictors of vaccination in pregnancy.
Study Design
We conducted a retrospective study of all women delivering at a university hospital between February and June 2013. Demographic, pregnancy, and vaccination data were abstracted from the medical record. The relationship between maternal age, parity, gestational age, race/ethnicity, marital status, prenatal provider/site, insurance, influenza vaccination status, and Tdap vaccine was described by univariate analysis. Independent predictors were identified by multivariable logistic regression.
Results
In our cohort of 1467 women, 1194 (81.6%) received a Tdap vaccine. After adjusting for potential confounders, three factors were found to be independent predictors of receiving the vaccine. Patients were more likely to receive Tdap if they had been vaccinated against influenza during this pregnancy (aOR 1.7, 95% CI 1.4, 2.3). Black women were less likely to receive Tdap when compared to other women (aOR 0.42, 95% CI 0.27,0.67). Also, women who delivered preterm were less likely to receive the Tdap vaccine (aOR 0.33, 95% CI 0.22,0.48).
Conclusion
A high overall Tdap vaccination rate was observed following implementation of the ACIP guidelines. Black women, however, had significantly lower vaccine uptake than other women. Further research is needed to understand and minimize this disparity. Women who delivered prematurely also had a decreased rate of Tdap vaccination; vaccinating earlier should be considered to better capture this population.

Al Jazeera
http://www.aljazeera.com/Services/Search/?q=vaccine
Accessed 31 May 2014

The Last Drops
Will health workers in Pakistan overcome political and religious tensions to vaccinate children against polio?
VIDEO: 47:17
Excerpt from text overview
…Pakistan is one of the last countries never to have ended polio despite concerted vaccination efforts from local, national and international organisations.
Teams of women ‘vaccinators’ in Pakistan struggle to achieve full coverage in a country wracked by ideological violence. Their commitment is unfailing even as they face attacks from the Taliban, as well as fearful communities that don’t trust the source of the vaccines.
Determined and patient, these women go from door to door to try and get all the children protected.
A polio worker who lost two members of her family to the violence said:
“We should make an effort that people who don’t want the drops, who think that this is not right, we need to make them aware. If they become aware, we won’t have to work so hard for the coming generations. This disease, if God wills it, can be eradicated from this country.”…

New York Times
http://www.nytimes.com/

The Opinion Pages | Editorial
The C.I.A.’s Deadly Ruse in Pakistan
By THE EDITORIAL BOARD
MAY 26, 2014
The use of a sham vaccination program in the government’s hunt for Osama bin Laden has produced a lethal backlash in Pakistan where dozens of public health workers have been murdered and fearful parents are shunning polio vaccine for their children.

Leaders of a dozen American schools of public health raised an alarm with the Obama administration 16 months ago and finally got a response this month when the White House promised that the C.I.A. will no longer use phony immunization programs in its spying operations.

The fakery — one of an assortment of intelligence stratagems before the successful raid that killed bin Laden — should never have been used in a world where hardworking health care agencies depend on the trust of local communities.

The C.I.A.’s ruse involved phony door-to-door solicitations by a physician promising to deliver hepatitis B immunizations; his real purpose was to confirm bin Laden’s suspected hiding place. The ploy helped fuel a militant backlash against immunization workers, and as many as 60 health workers and police officers have since been killed.

Meanwhile, polio is on the rise, with Pakistan accounting for 66 of the 82 cases reported so far this year by the World Health Organization. Last year, there were 93 cases of polio in Pakistan, where the health organization warns that the disease is endemic, as it is in Afghanistan and Nigeria.

The C.I.A. can no longer seek to “obtain or exploit DNA or other genetic material” gathered this way, according to a promise from the Obama administration. That is small comfort for those suffering the aftereffects of this ruse.

Convincing wary parents to accept polio vaccination — and finding health workers willing to risk violence — has been made more difficult than ever.

Washington Post
http://www.washingtonpost.com/
Accessed 31 May 2014

The Post’s View
As measles cases increase, a sharp call for vaccinations
By Editorial Board, Published: May 29
EVEN WHEN there are significant gains against infectious diseases, there can be reversals. In 2000, measles was considered all but eliminated in the United States. For a while, there were only about 60 cases a year, mostly brought in from overseas. Now, the number of cases and outbreaks in the United States is rising again. The Centers for Disease Control and Prevention reported Thursday that there have already been more cases this year, 288, than in any full year this century.

Measles is a highly infectious respiratory disease caused by a virus that affects young children, with fever, runny nose, cough and a distinctive rash. Infrequently, it leads to more serious complications. There have been no deaths in the United States for a while, but in 2012 measles caused an estimated 122,000 deaths worldwide. That’s far fewer than in the past, thanks to a global campaign to vaccinate more than a billion children in high-risk countries.

In the United States, a vigorous effort at immunization in recent years brought measles almost to a standstill. After an epidemic from 1989 to 1991 resulted in 55,000 cases and more than 100 deaths, largely because of lack of immunization among poor and uninsured children, a federal program approved in 1994, Vaccines for Children, resulted in much wider coverage. More than 90 percent of the children in the United States are immunized.

Most of the recent measles cases in the United States arrived with travelers. For example, California reported 58 cases from January through April 18 this year, the highest number for that period in 19 years. According to the CDC, 93 percent of the California cases are linked to importation of the disease. The Philippines has seen an ongoing outbreak.

Sometimes a single traveler can ignite a wildfire of infections. In 2013, a 17-year-old who had not been vaccinated returned to an orthodox Jewish community in Brooklyn from the United Kingdom, leading to an outbreak that affected 58 people; most were in three extended families that had declined the measles vaccine. This year, an outbreak in Ohio has reached 68 cases, apparently sparked by Amish missionaries, unvaccinated, who had visited the Philippines.

The measles vaccine has been in use for half a century and is safe, inexpensive and effective. Some parents suspicious of vaccines have decided against immunization; in other cases, people are simply ignorant of the risks of inaction. Not all 50 states have the toughest immunization laws and standards. Thus, in some vulnerable pockets of the United States, a single person can touch off an outbreak. A nation’s borders provide no ironclad defense against viruses and bacteria. But measles can be stopped with comprehensive and proper immunization.

WHO: Sixty-seventh World Health Assembly [WHA]
[Editor’s Note: The Sixty-seventh World Health Assembly concluded today, Saturday, 24 May. Closing remarks by DG Margaret Chan are included below followed by news releases issued during the WHA. Key interviews, video, the WHA Journal and all documentation available here: http://www.who.int/mediacentre/events/2014/wha67/en/. The Week in Review will summarize key WHA developments in next week’s issue]

Closing remarks at the Sixty-seventh World Health Assembly
Dr Margaret Chan, Director-General of the World Health Organization
24 May 2014 Geneva, Switzerland
[Full text, Editor’s text bolding]

Mister President, Excellences, honourable ministers, distinguished delegates, ladies and gentlemen,

This has been an intense Assembly, with a record-breaking number of agenda items, documents, and resolutions, and nearly 3,500 registered delegates. This is a reflection of the growing number and complexity of health issues, and your deep interest in addressing them.

Delegates journeyed from different parts of the world to Geneva eager to share their experiences, ideas, concerns, and specific needs for WHO support. Doing so takes time, and we did not have enough time.

Thanks to your President, with his commitment and constant engagement, the skills of the committee chairs, and your own discipline, you were able to complete an especially heavy agenda. I congratulate all concerned, including our Regional Directors, the Deputy Director-General, and WHO staff, especially our all-night backroom staff. I also thank the interpreters.

This Assembly was big in a second sense. From the very first day, it was clear that Member States are deeply concerned about two big trends with major consequences for health: climate change and the rise of antimicrobial resistance.

For antimicrobial resistance, you have given WHO some important work to do in leading the response. As the Intergovernmental Panel on Climate Change concluded, strengthening basic health services and extending their coverage is an essential route to resilience. This is precisely what we are doing. Your deliberations during this session have taken us some steps forward.

You had some other deep concerns. You are worried about the costs of new vaccines and medicines. Many of you described these costs, especially for hepatitis C medicines, as “astronomical”.

You are worried about the anti-vaccine movement and the impact this has on the demand for vaccines, but also on social perceptions of autism spectrum disorders.

You have brought these problems to our attention, and you have asked us to take action. We will do so.

You want to do everything possible to protect the integrity of this Organization from undue influence and conflicts of interest. You looked long and hard at the most appropriate arrangements for securing this protection. These issues will be taken forward by the Regional Committees, which offer one of the most inclusive ways to engage further discussion.

You are deeply concerned about the rise of noncommunicable diseases, the challenges of early detection, and the crippling costs of long-term care. You are determined to do more for prevention.

You are likewise concerned about some striking changes in the communicable disease situation, notably the setback for polio eradication and the continuing surge in the number of MERS cases.

For polio, I thank you for the tremendous spirit of solidarity and determination demonstrated during discussion of this item.

For MERS, cases now clearly involve transmission within hospital settings, and are spreading beyond the Eastern Mediterranean Region. The very limited onward transmission following imported cases is a good sign of high levels of vigilance and preparedness.

Given these concerns, it comes as no surprise that you want health to have a prominent and correctly positioned place in the post-2015 development agenda.

Finally, you have asked WHO to do much more, but you have also demonstrated the good use of existing WHO instruments for practical support to countries, from the WHO Framework Convention on Tobacco Control, the International Health Regulations, and the Model Lists of Essential Medicines, right down to the designation of Baby-Friendly Hospitals as a way to boost exclusive breastfeeding.

As I conclude, let me wish all of you a safe journey home as we continue to work together to lift the standards of health care around the world.
Thank you.

67th WHA News Releases:
:: World Health Assembly progress on noncommunicable diseases and traditional medicine 23 May 2014
:: World Health Assembly approves resolution on hepatitis and mechanism to coordinate noncommunicable disease response 22 May 2014
:: World Health Assembly approves monitoring framework for maternal and child nutrition 21 May 2014
:: World Health Assembly guest speakers focus on gender-based violence and newborn health 20 May 2014
:: World Health Assembly opens: Director-General announces new initiative to end childhood obesity 19 May 2014
:: Sixty-seventh World Health Assembly opens in Geneva 18 May 2014

GAVI Watch [to 24 May 2014]
http://www.gavialliance.org/library/news/press-releases/

:: Press Release: GAVI Alliance sets out opportunity to save up to six million lives through immunisation
Fully funded Alliance programmes would enable developing countries to protect a further 300 million children with vaccines by 2020
[Excerpt, Editor’s text bolding]
Brussels, 20 May 2014 – The GAVI Alliance today called on donors to back ambitious plans to immunise an additional 300 million children against potentially fatal diseases between 2016 and 2020 and save a further five to six million lives.

By investing together in a healthy future, Alliance partners can build on the unprecedented success which has put developing countries on track to immunise close to half a billion additional children between 2000 and 2015, saving approximately six million lives. Additional investments for the 2016-2020 period could double the total number of lives saved through GAVI-supported vaccines since 2000.

An acceleration is necessary because, despite an unprecedented increase in vaccine programmes in developing countries, 1.5 million children die each year of vaccine-preventable diseases and one in five children worldwide do not receive a full course of even the most basic vaccines.

The GAVI Alliance today set out an investment case that demonstrates how donors can support the world’s poorest countries to secure and expand their immunisation programmes, which protect children against illnesses such as pneumococcal disease and rotavirus, the leading vaccine-preventable causes of pneumonia and diarrhoea, between 2016 and 2020.

The economic benefits of fully funded, sustainable vaccine programmes would result in US $80 to $100 billion in gains for developing countries through increased productivity and reductions in the cost of treating illnesses that would have been prevented through immunisation.

As GAVI-supported countries grow more prosperous, they can assume greater responsibility for their immunisation programmes. Between 2011 and 2015, countries have contributed approximately US$ 470 million. This will grow to US$ 1.2 billion in the 2016-20 period, making developing countries one of the largest contributors to the Alliance. By 2020, it is projected that 22 countries will have graduated and taken over full financing of their GAVI-supported vaccines, marking a new era of increased sustainability…

…The overwhelming benefits of investing in the Alliance were set out at a meeting hosted today in Brussels by European Development Commissioner Andris Piebalgs. The meeting was opened with a keynote speech from José Manuel Barroso, President of the European Commission, who demonstrated the EU’s long-term commitment to supporting the GAVI Alliance to save lives through immunisation by pledging an additional €175 million for the period 2014-2020…

…The GAVI Alliance is today asking donors to invest an additional US$ 7.5 billion to support developing countries’ immunisation programmes from 2016 to 2020. These commitments would be added to the US$ 2 billion already available to GAVI for the period to ensure that Alliance-supported programmes are fully funded up to 2020…
:: Statement: Germany to host key GAVI Alliance replenishment event

Voice of America News: CIA: Vaccination Programs Won’t be Used for Spying
May 20, 2014 2:55 AM
Excerpt
The White House has pledged that the CIA will no longer use vaccination programs as a cover for spying operations, three years after the agency used the ruse in Pakistan before the U.S. raid that killed Osama bin Laden.
A White House spokesperson said President Barack Obama’s top counterterrorism adviser, Lisa Monaco, responded to a letter from the deans of about a dozen prominent public health schools last week who were concerned the ruse could cause serious consequences to public health efforts.
Monaco told the deans the CIA has agreed it would no longer use vaccination programs or workers for intelligence purposes. The CIA also agreed not to use genetic materials obtained through such programs…

WHO: Statement on the United States Government’s announcement on vaccination campaigns
20 May 2014
[Full text]
WHO and UNICEF appreciate the commitment by the United States Government to stop making operational use of immunization campaigns.
Immunization averts approximately 2 to 3 million deaths each year and is an essential tool in public health. Humanitarian workers and programmes, especially life-saving vaccination campaigns, should never be used by any government for intelligence or military purposes.

Polio [to 24 May 2014]

GPEI Update: Polio this week – As of 21 May 2014
Global Polio Eradication Initiative
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: The 67th World Health Assembly, the WHO’s highest decision-making body, is meeting this week in Geneva. The report of the polio eradication programme to the Assembly is available here, and is scheduled to be discussed on Friday. On the sidelines of WHA, Bruce Aylward, WHO Assistant Director-General for Polio and Emergencies, discussed polio eradication at the World Health +SocialGood digital event on Monday. The recorded discussion can be watched here (start at 1:04:00).
:: In a statement published on 13 May, the Government of Pakistan announced that it had initiated implementation of the Temporary Recommendations to reduce the international spread of wild poliovirus as recently issued by WHO. Health facilities across Pakistan are now vaccinating prospective travelers and issuing the required vaccination certificates.
:: An Extraordinary Technical Advisory Group on Polio convened for the WHO Americas Region has agreed with the objectives of the polio endgame, including the phased removal of oral polio vaccine from the routine immunization schedule.
Nigeria
:: Two new cVDPV2 cases were reported in the past week from Damboa LGA, Borno state. The most recent cVDPV2 case had onset of paralysis on 20 April. The total number of cVDPV2 cases for 2014 is three, and for 2013 is four.
Pakistan
:: Five new WPV1 cases were reported in the past week from the Federally Administered Tribal Areas (FATA), including three cases from North Waziristan, one from South Waziristan, and one from Khyber agency, bringing the total number of WPV1 cases reported from Pakistan for 2014 to 66. The most recent WPV1 case had onset of paralysis on 1 May (from Khyber agency).

Polio issue to be raised at Taliban talks
Business Recorder (Pakistan)
May 23, 2014
MUSHTAQ GHUMMAN
Excerpt
Government has decided to take up polio immunisation with Taliban in the ongoing peace talks and incentives vaccination program in focused areas through Benazir Income Support Program (BISP), official sources told Business Recorder. This decision was taken at a recent meeting of Federal Cabinet presided over by Prime Minister Nawaz Sharif.
“Take up polio immunisation in the ongoing talks with militants as the key challenge to polio eradication is the resistance to polio vaccination in North and South Waziristan. All children leaving the tribal areas should be vaccinated at checkposts and permanent transit points,” the sources quoted the Prime Minister as saying in the meeting.
Official documents reveal that the Prime Minister – from the outset of briefing – stated that vigorous work was required for polio eradication as the prestige of the country was at stake. He informed the Cabinet that the Governor Khyber Pakhtunkhwa and the Chief of the Army Staff had been directed to provide security to vaccinators…

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 24 May 2014]
http://www.who.int/csr/don/en/
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 23 May 2014
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 22 May 2014
:: Human infection with avian influenza A(H7N9) virus – update 22 May 2014

UNICEF Watch [to 24 May 2014]
http://www.unicef.org/media/media_71724.html

:: Cholera cases rapidly multiplying in South Sudan
JUBA, South Sudan, 19 May 2014 – The caseload of cholera is rapidly increasing in South Sudan and the deadly, highly contagious disease appears to be spreading, UNICEF said today.

:: UNICEF fears the worst for hundreds of thousands of children in South Sudan
OSLO, 18 May 2014 – On the eve of the Oslo Humanitarian Pledging Conference, UNICEF warned that hundreds of thousands of children in South Sudan’s three most conflict-affected states are at imminent risk of death and disease, including the threat of cholera.

The Weekly Epidemiological Record (WER) for 23 May 2014, vol. 89, 21 (pp. 221–236) includes:
:: Meeting of the Strategic Advisory Group of Experts on immunization, April 2014 – conclusions and recommendations
http://www.who.int/entity/wer/2014/wer8921.pdf?ua=1

Global Fund Watch [to 24 May 2014]

:: News Release: WHO and Global Fund Strengthen Partnership
20 May 2014
GENEVA – The World Health Organization and the Global Fund today strengthened their long established partnership with a new technical agreement to support countries in developing more strategic investments in the fight against HIV, tuberculosis and malaria.
Margaret Chan, Director-General, WHO, and Mark Dybul, Executive Director of the Global Fund, both stressed the importance of expanding partnerships to let country-led programs maximize the impact of health investments.
“This renewed partnership between WHO and the Global Fund will allow us to increase impact and reach more people by working together more closely with countries,” said Dr. Chan…
…Under the agreement, WHO will provide technical assistance to Global Fund applicants under the new funding model ahead of the submission of their grant applications, or concept notes. The new funding model promotes opportunities for health interventions with a bigger impact, so robust concept notes and sound national strategic plans in specific geographic areas are strongly encouraged.
“The new funding model captures the promise of partnership that is our core belief,” said Dr. Dybul. “This agreement gives us a clear focus, and reinvigorates the spirit of working together.”
Country Coordinating Mechanisms and civil society organizations can apply for WHO technical assistance. WHO will provide assistance through its country or regional offices and with the Roll Back Malaria and STOP TB partnerships…
:: Announcement: Luxembourg Signs Multi-Year Contribution to Global Fund
22 May 2014
Excerpt
Luxembourg and the Global Fund today signed a multi-year contribution agreement for €7.5 million (US$10.2 million) for 2014-2016, signaling joint commitment to efforts to defeat AIDS, tuberculosis and malaria.
The agreement was signed at the Global Fund offices in Geneva by Romain Schneider, Minister of Development Cooperation and Humanitarian Action, and Mark Dybul, Executive Director of the Global Fund.
“The Global Fund is a key partner in realizing our new health sector strategy,” said Minister Schneider. “We appreciate the alignment of the Global Fund’s strategy and the new funding model on national priorities and strategies…

Industry Watch [to 24 May 2014]
Selected media releases and other selected content from industry.

Media Release: GSK announces new commitment to improve access to vaccines with 5-year price freeze for countries graduating from GAVI Alliance support
20 May 2014
Excerpt
…Speaking today at a European Commission/GAVI Alliance event in Brussels, Sir Andrew Witty, CEO of GSK paid tribute to the GAVI Alliance leadership and its partners including governments, donors, charities and vaccine manufacturers which together have enabled millions of children in the world’s poorest countries to receive innovative, life-saving vaccines.
Sir Andrew Witty said: “The achievements of the GAVI Alliance are remarkable with 6 million lives saved since its formation in 2000. Successful vaccination programmes have no doubt also helped countries to develop in this time. For countries that are doing well and are moving out of GAVI, I’m pleased that we are able to offer governments a price freeze to help ensure that children continue to be protected by national immunisation programmes. At the same time, GSK remains fully committed to supporting GAVI to expand and accelerate access to vaccines for children in the countries that still require the support of the Alliance.”
By 2020, 22 countries with growing economies will graduate from GAVI support. This process allows GAVI to focus resources on the poorest countries, while enabling governments to take increasing responsibility and ownership for vaccination programmes over time. GSK is the first company to commit to maintaining lowest prices for five years as countries take this step, enabling governments to plan for financing the full cost of their immunisation programmes.
“Sustainability is a central pillar in the long-term success of GAVI Alliance-supported vaccine programmes,” said Dr Seth Berkley, CEO of the GAVI Alliance. “GSK is taking strong steps towards supporting developing countries whose growing economies mean they are no longer eligible for Alliance support and is leading the way in longer-term access to low prices for rotavirus, pneumococcal and human papillomavirus vaccines for these countries.”..
GSK is one of the largest contributors of vaccines to the GAVI Alliance, supplying innovative vaccines, such as those for rotavirus, pneumococcal disease and cervical cancer, at significantly reduced prices to help accelerate access in developing countries. GSK has committed to provide more than 850 million vaccine doses that will help protect up to 300 million children and young girls in the developing world by 2024. GSK delivers over 2 million vaccines each day; over a year, 80% of our vaccine doses go to developing countries…

Report: Towards a Sustainable, Intersectoral Approach to Viral Hepatitis
The International Federation of Pharmaceutical Manufacturers and Associations (IFPMA)
20 May 2014
Excerpt from Announcement
The IFPMA published today a new report and recommendations on Hepatitis encouraging a comprehensive approach to fighting this silent epidemic…
Hepatitis B and C (HBV, HCV) are devastating viral diseases which are more common than HIV/AIDS. The virus progresses very slowly over the years. As a result many patients are unaware they are infected until serious complications emerge. 15-30% of people with chronic HCV infection will develop cirrhosis; HCV is the major cause of liver cancer. Viral hepatitis is responsible for 1.6 million deaths each year causing individual suffering and putting a huge cost to society in terms of lost productivity and cost of healthcare services.
Eduardo Pisani, IFPMA Director General, commented, “We have devoted substantial efforts to developing prevention and treatment options and are making all necessary efforts to bring up solutions that further increase cure rates and reduce treatment duration and toxicity. However, treatment is only part of the picture. Experience our industry gained through health partnerships in low- and middle-income countries makes it clear that to address hepatitis we need a comprehensive approach that combines research, prevention, screening and care. We need to act together to stop this silent epidemic”…
Full announcement: http://www.ifpma.org/news/news-releases/news-details/article/stop-silent-epidemic-research-based-pharmac.html

American Journal of Preventive Medicine
Volume 46, Issue 6, p543-660, e53-e60 June 2014
http://www.ajpmonline.org/current

Influenza Vaccination Coverage Among Adult Survivors of Pediatric Cancer
Rohit P. Ojha, DrPH, Tabatha N. Offutt-Powell, DrPH, James G. Gurney, PhD
DOI: http://dx.doi.org/10.1016/j.amepre.2014.01.007
Abstract
Background
A large proportion of long-term survivors of childhood cancer have treatment-related adverse cardiac and pulmonary late-effects, with related mortality. Consequently, this population of approximately 379,000 individuals in the U.S. is at high risk of complications from influenza infections.
Purpose
To estimate influenza vaccination coverage overall and among subgroups of adult survivors of pediatric cancer aged 18−64 years and to compare coverage with the general adult U.S. population.
Methods
Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed in 2013 using binomial regression to estimate influenza vaccination coverage differences (CDs) and corresponding 95% confidence limits (CLs) between adult survivors of pediatric cancer and the general U.S. population. Analyses were stratified by demographic characteristics and adjusted for design effects, non-coverage, and non-response.
Results
Influenza vaccination coverage was 37% for adult pediatric cancer survivors overall and 31% for the general adult U.S. population (CD=6.3%, 95% CL=0.04%, 13%). Dramatically lower coverage was observed for non-Hispanic black survivors (6%) than for non-Hispanic blacks in the general U.S. population (26%; CD=−18%, 95% CL=−25%, −11%).
Conclusions
Although influenza vaccination coverage was modestly higher among adult survivors of pediatric cancer than the general U.S. population, coverage was less than desirable for a population with a high prevalence of cardiopulmonary conditions and early mortality, and far lower than the Healthy People 2010 goal of 60% or Healthy People 2020 goal of 80% for the general population.

Annals of Internal Medicine
20 May 2014, Vol. 160. No. 10
http://annals.org/issue.aspx

Original Research | 20 May 2014
Health and Economic Benefits of Early Vaccination and Nonpharmaceutical Interventions for a Human Influenza A (H7N9) Pandemic: A Modeling Study
Nayer Khazeni, MD, MS; David W. Hutton, MS, PhD; Cassandra I.F. Collins, MPH; Alan M. Garber, MD, PhD; and Douglas K. Owens, MD, MS
Article and Author Information
Ann Intern Med. 2014;160(10):684-694. doi:10.7326/M13-2071
Abstract
Background:
Vaccination for the 2009 pandemic did not occur until late in the outbreak, which limited its benefits. Influenza A (H7N9) is causing increasing morbidity and mortality in China, and researchers have modified the A (H5N1) virus to transmit via aerosol, which again heightens concerns about pandemic influenza preparedness.
Objective:
To determine how quickly vaccination should be completed to reduce infections, deaths, and health care costs in a pandemic with characteristics similar to influenza A (H7N9) and A (H5N1).
Design:
Dynamic transmission model to estimate health and economic consequences of a severe influenza pandemic in a large metropolitan city.
Data Sources:
Literature and expert opinion.
Target Population:
Residents of a U.S. metropolitan city with characteristics similar to New York City.
Time Horizon:
Lifetime.
Perspective:
Societal.
Intervention:
Vaccination of 30% of the population at 4 or 6 months.
Outcome Measures:
Infections and deaths averted and cost-effectiveness.
Results of Base-Case Analysis:
In 12 months, 48 254 persons would die. Vaccinating at 9 months would avert 2365 of these deaths. Vaccinating at 6 months would save 5775 additional lives and $51 million at a city level. Accelerating delivery to 4 months would save an additional 5633 lives and $50 million.
Results of Sensitivity Analysis:
If vaccination were delayed for 9 months, reducing contacts by 8% through nonpharmaceutical interventions would yield a similar reduction in infections and deaths as vaccination at 4 months.
Limitation:
The model is not designed to evaluate programs targeting specific populations, such as children or persons with comorbid conditions.
Conclusion:
Vaccination in an influenza A (H7N9) pandemic would need to be completed much faster than in 2009 to substantially reduce morbidity, mortality, and health care costs. Maximizing non-pharmaceutical interventions can substantially mitigate the pandemic until a matched vaccine becomes available.
Primary Funding Source:
Agency for Healthcare Research and Quality, National Institutes of Health, and Department of Veterans Affairs.

BMC Public Health
(Accessed 24 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
“Knowledge and attitudes of spanish adolescent girls towards human papillomavirus infection: where to intervene to improve vaccination coverage”
Pedro Navarro-Illana, Javier Diez-Domingo, Esther Navarro-Illana, José Tuells, Sara Alemán and Joan Puig-Barberá
Author Affiliations
BMC Public Health 2014, 14:490 doi:10.1186/1471-2458-14-490
Published: 22 May 2014
Abstract (provisional)
Background
HPV vaccine coverage is far from ideal in Valencia, Spain, and this could be partially related to the low knowledge about the disease and the vaccine, therefore we assessed these, as well as the attitude towards vaccination in adolescent girls, and tried to identify independently associated factors that could potentially be modified by an intervention in order to increase vaccine coverage.
Methods
A cross sectional study was conducted in a random selection of schools of the Spanish region of Valencia. We asked mothers of 1278 girls, who should have been vaccinated in the 2011 campaign, for informed consent. Those that accepted their daughters’ participation, a questionnaire regarding the Knowledge of HPV infection and vaccine was passed to the girls in the school.
Results
833 mothers (65.1%) accepted participation. All their daughters’ responded the questionnaire. Of those, 89.9% had heard about HPV and they associated it to cervical cancer. Only 14% related it to other problems like genital warts. The knowledge score of the girls who had heard about HPV was 6.1/10. Knowledge was unrelated to the number of contacts with the health system (Pediatrician or nurse), and positively correlated with the discussions with classmates about the vaccine. Adolescents Spanish in origin or with an older sister vaccinated, had higher punctuation. 67% of the girls thought that the vaccine prevented cancer, and 22.6% felt that although prevented cancer the vaccine had important safety problems. 6.4% of the girls rejected the vaccine for safety problems or for not considering themselves at risk of infection. 71.5% of the girls had received at least one vaccine dose. Vaccinated girls scored higher knowledge (p = 0.05).
Conclusion
Knowledge about HPV infection and vaccine was fair in adolescents of Valencia, and is independent to the number of contacts with the health system, it is however correlated to the conversations about the vaccine with their peers and the vaccination status. An action to improve HPV knowledge through health providers might increase vaccine coverage in the adolescents.

BMC Public Health
(Accessed 24 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
What have we learned about communication inequalities during the H1N1 pandemic: a systematic review of the literature
Leesa Lin, Elena Savoia, Foluso Agboola and Kasisomayajula Viswanath
Author Affiliations
BMC Public Health 2014, 14:484 doi:10.1186/1471-2458-14-484
Published: 21 May 2014
Abstract (provisional)
Background
During public health emergencies, public officials are busy in developing communication strategies to protect the population from existing or potential threats. However, population’s social and individual determinants (i.e. education, income, race/ethnicity) may lead to inequalities in individual or group-specific exposure to public health communication messages, and in the capacity to access, process, and act upon the information received by specific sub-groups- a concept defined as communication inequalities.
The aims of this literature review are to: 1) characterize the scientific literature that examined issues related to communication to the public during the H1N1 pandemic, and 2) summarize the knowledge gained in our understanding of social determinants and their association with communication inequalities in the preparedness and response to an influenza pandemic.
Methods
Articles were searched in eight major communication, social sciences, and health and medical databases of scientific literature and reviewed by two independent reviewers by following the PRISMA guidelines. The selected articles were classified and analyzed in accordance with the Structural Influence Model of Public Health Emergency Preparedness Communications.
Results
A total of 118 empirical studies were included for final review. Among them, 78% were population-based studies and 22% were articles that employed information environment analyses techniques. Consistent results were reported on the association between social determinants of communication inequalities and emergency preparedness outcomes. Trust in public officials and source of information, worry and levels of knowledge about the disease, and routine media exposure as well as information-seeking behaviors, were related to greater likelihood of adoption of recommended infection prevention practices. When addressed in communication interventions, these factors can increase the effectiveness of the response to pandemics.
Conclusions
Consistently across studies, a number of potential predictors of behavioral compliance to preventive recommendations during a pandemic were identified. Our findings show the need to include such evidence found in the development of future communication campaigns to ensure the highest rates of compliance with recommended protection measures and reduce communication inequalities during future emergencies.

British Medical Journal
24 May 2014 (Vol 348, Issue 7959)
http://www.bmj.com/content/348/7959

Editorial
Delayed publication of vaccine trials
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3259 (Published 16 May 2014)
Christopher W Jones, attending physician1, Timothy F Platts-Mills, assistant professor2
Excerpt
Why are we waiting? Sponsors, authors, and editors all contribute to delays
Among medical interventions to improve human health, vaccination has been and remains one of the most important.1 Given the huge number of deaths from influenza pandemics in recent history, the ability to rapidly develop effective vaccines for new strains of influenza is particularly critical. Making and testing a new influenza vaccine that can be administered to the public takes six months or less.2 For example, the pandemic A/H1N1 2009 influenza strain was first identified in April of 2009; four vaccines were approved by the US Food and Drug Administration in September. After the approval of a vaccine, however, important questions remain regarding dosage, effectiveness, and safety. These questions are best answered by randomized clinical trials, and getting complete results from these trials to policy makers, clinicians, and the general public in a timely manner is essential.
The problems of delayed publication and non-publication of clinical trials have been described in a variety of settings.3 4 5 In this issue of The BMJ, Manzoli and colleagues (doi:10.1136/bmj.g3058) examine delays to publication and non-publication for the vitally important area of vaccine trials.6…

Research
Non-publication and delayed publication of randomized trials on vaccines: survey
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3058 (Published 16 May 2014)
Cite this as: BMJ 2014;348:g3058
Lamberto Manzoli, associate professor12, Maria Elena Flacco, resident physician13, Maddalena D’Addario, resident physician45, Lorenzo Capasso, PhD student12, Corrado De Vito, assistant professor6, Carolina Marzuillo, assistant professor6, Paolo Villari, professor6, John P A Ioannidis, professor78
Accepted 24 April 2014
Abstract
Objective
To evaluate the extent of non-publication or delayed publication of registered randomized trials on vaccines, and to investigate potential determinants of delay to publication.
Design
Survey.
Data sources
Trials registry websites, Scopus, PubMed, Google.
Study selection
Randomized controlled trials evaluating the safety or the efficacy or immunogenicity of human papillomavirus (HPV), pandemic A/H1N1 2009 influenza, and meningococcal, pneumococcal, and rotavirus vaccines that were registered in ClinicalTrials.gov, Current Controlled Trials, WHO International Clinical Trials Registry Platform, Clinical Study Register, or Indian, Australian-New Zealand, and Chinese trial registries in 2006-12. Electronic databases were searched up to February 2014 to identify published manuscripts containing trial results. These were reviewed and classified as positive, mixed, or negative. We also reviewed the results available in ClinicalTrials.gov.
Main outcome measures
Publication status of trial results and time from completion to publication in peer reviewed journals.
Data synthesis
Cox proportional hazards regression was used to evaluate potential predictors of publication delay.
Results
We analysed 384 trials (85% sponsored by industry). Of 355 trials (404,758 participants) that were completed, 176 (n=151,379) had been published in peer reviewed journals. Another 42 trials (total sample 62 \,765) remained unpublished but reported results in ClinicalTrials.gov. The proportion of trials published 12, 24, 36, and 48 months after completion was 12%, 29%, 53%, and 73%, respectively. Including results posted in ClinicalTrials.gov, 48 months after study completion results were available for 82% of the trials and 90% of the participants. Delay to publication between non-industry and industry sponsored trials did not differ, but non-industry sponsored trials were 4.42-fold (P=0.008) more likely to report negative or mixed findings. Negative results were reported by only 2% of the published trials.
Conclusions
Most vaccine trials are published eventually or the results posted in ClinicalTrials.gov, but delays to publication of several years are common. Actions should focus on the timely dissemination of data from vaccine trials to the public.

Clinical Infectious Diseases (CID)
Volume 58 Issue 11 June 1, 2014
http://cid.oxfordjournals.org/content/current

Editorial Commentary: Pertussis Is Less Severe in Vaccinated Than in Unvaccinated Patients
Jussi Mertsola
Author Affiliations
Department of Pediatrics, Turku University Hospital and Turku University, Finland
Correspondence: Jussi Mertsola, MD, PhD, Department of Paediatrics and Adolescent Medicine, Turku University Hospital, 20520 Turku, Finland (See the Major Article by Barlow et al on pages 1523–9.)
Extract
After the introduction of vaccines against pertussis, there was a dramatic decrease of the disease, and the problem was considered to have been solved. But it was not. Recently, large outbreaks have occurred in the United States, in several European countries, and in Australia [1, 2]. It is evident that there are still many unresolved questions in pertussis, the first of which is that we do not know enough about the exact pathogenesis of this infection and the real appearance of Bordetella pertussis organisms in vivo. We also do not know much about the intracellular living of the bacteria and possible transition between the virulent and nonvirulent phenotypes in the mucosal environment in the lungs. Perhaps we should again pay more attention to the old questions of molecular mimicry [3]. The infection cascade is very complex, and immunity is multifactorial. During and after the development of the acellular vaccine, the main focus has been on the extracellular living of B. pertussis and humoral immunity. In pertussis, the function of Th1 and Th17 cells seems to be very important [4]. Surprisingly, even some 100 years after the discovery of B. pertussis, we do not even understand the exact mechanism behind the typical paroxysmal cough in whooping cough.
Young infants are most vulnerable if they get B. pertussis infection. Historically, pertussis has been a serious killer, and recent outbreaks show that infants have a real risk of death and complications even today [1, 2]. One of the main problems is how to induce immunity against pertussis in young infants. The situation was so alarming in California in 2012 and in the United Kingdom that vaccinations against tetanus, diphtheria, and pertussis…

Vaccinated Children and Adolescents With Pertussis Infections Experience Reduced Illness Severity and Duration, Oregon, 2010–2012
Russell S. Barlow, Laura E. Reynolds, Paul R. Cieslak, and Amy D. Sullivan
Clin Infect Dis. (2014) 58 (11): 1523-1529 doi:10.1093/cid/ciu156
Abstract
We examined how vaccination status influenced the course of illness among persons infected with Bordetella pertussis in Oregon between 2010 and 2012. Our analyses provide evidence that vaccinated individuals have decreased disease severity and reduced illness duration.